key: cord-343865-wbd0hqqc authors: singh, ajay; naik, b. naveen; soni, shiv lal; puri, g. d. title: real-time remote surveillance of doffing during covid-19 pandemic: enhancing safety of health care workers date: 2020-05-12 journal: anesth analg doi: 10.1213/ane.0000000000004940 sha: doc_id: 343865 cord_uid: wbd0hqqc nan to the editor t he global epidemiological crisis of coronavirus disease 2019 (covid-19) hints for strategic inspection, resource management, and responsiveness in infection control. worldwide a significant number of health care workers (hcws) have been infected till to date with asia-pacific region reporting 35 deaths and over 4000 quarantined cases, as on april 3, 2020. 1 hcws across the nation are anxious, unsure of personal protective equipment (ppe) availability, and whether it will provide enough protection or not. with alarming covid-19 case numbers, an overlooked facet of the ppe scarcity is whether hcws can use it properly without self-contamination. effective use of ppe by hcws is an integral part of covid-19 prevention in the health care setting. world health organization recommendations emphasize the importance of appropriate use of ppe, which requires correct and rigorous behavior from health care workers, particularly while doffing. 2 hospitals are scrambling to efficiently train a large number of noncritical care staff at short notice through simulation, webinars, and online courses on proper ppe donning and doffing practices. but experience from past infectious outbreak highlights the higher self-contamination rates as high as 46%-90% among hcws during doffing. 3, 4 even when hcws presume that they are trained enough, several factors may contribute to self-contamination during doffing-difficulty differentiating between dirty (outside) and clean (inside) surfaces, poorly fitting ppes, forceful movements, incorrect doffing sequence, and inconsistent ppe training. 5 therefore, an observer should watch the doffing process and alert hcw on any possible breach in safety. two-way audio-visual communication system with closed circuit television (cctv) cameras in the doffing area has the potential to ensure hcw safety from the offsite location through a trained observer, qualified to guide round the clock (figure) . observer follows the predefined checklist based on the centers for disease control and prevention (cdc) guideline for doffing, focusing on the visual screen. he will communicate, visually inspect, protect, and guide hcws through the protocols of doffing ppe. apart from adherence to the process of donning and doffing, the observer will ensure the disposal of used ppe from the doffing area. two-way audio-visual communication (with cctv cameras) in doffing area has the following advantages: • limits the risk of direct physical contact of the observer with potentially contaminated ppe of hcw. • limits ppe wastage. • allays hcw anxiety. • the low-cost surveillance system. asia-pacific health workers risk all to fight covid-19 rational use of personal protective equipment (ppe) for coronavirus disease (covid-19): interim guidance use of personal protective equipment among health care personnel: results of clinical observations and simulations alternative doffing strategies of personal protective equipment to prevent self-contamination in the health care setting healthcare workers' strategies for doffing personal protective equipment key: cord-334808-ds5yrr4w authors: liawrungrueang, wongthawat; sornsa-ard, tuanrit; niramitsantiphong, anugoon title: response to: management of traumatic spinal fracture in the coronavirus disease 2019 situation date: 2020-05-12 journal: asian spine j doi: 10.31616/asj.2020.0194.r1 sha: doc_id: 334808 cord_uid: ds5yrr4w nan we appreciate the letter regarding our manuscript titled "management of traumatic spinal fracture in the coronavirus disease 2019 situation [1] . " we would like to thank the reader/s for reading our article. our reply to the comment is as follows: comment: "i read your paper in the asian spine journal. i found your paper very interesting and your algorithm very informing. i am wondering what your institute uses specifically for "full personal protective equipment (ppe)" for the high risk patients, i.e., national institute for occupational safety and health-approved (n95) respirator, face shield, etc. " our reply: in this review article, the authors concluded that an algorithm could help make decisions about surgical interventions for spine injuries in patients who are at risk for coronavirus disease 2019 (covid-19) to prevent surgeons and nurses from contracting the virus. in this situation, where the health care professionals are in contact with a high-risk patient, the surgeons and nurses could use full ppe suits (fig. 1a) . the authors recommended full ppe that is composed of fluid-resistant legs with shoe coverings, goggles, safety glasses, a face shield, a double layer of gloves, and a surgical mask that can be used with a standard n95 respirator [1] . a standard n95 respirator protects the wearer from exposure to airborne particles (e.g., dust, mist, fumes, fibers, and bioaerosols, such as viruses and bacteria) or respiratory system [2] . an impermeable gown that covers from the neck to at least the mid-thigh is the standard centers for disease control and prevention guideline [3, 4] . by anesthesiologists (b) , and intraoperative standard with full ppe according to centers for disease control and prevention guidelines (c). ppe, personal protective equipment. c for a high-risk patient who needs emergency spine surgery, the surgeon could co-manage the airway with the anesthesiologists [5] and the covid-19 team [1] (fig. 1b) . the operative room should be prepared with full ppe and a standardized surgical suit (fig. 1c) , and a postoperative isolation room or isolation surgical intensive care unit should be used. the authors want to establish a prototype to help protect health care professionals [1] . the authors preferred that this algorithm be revised or modified according to the updated knowledge about prevention, novel treatment, and laboratory testing technology for covid-19. finally, all the authors hope that the journal's readers will use this algorithm as a prototype and that is can be modified to develop a better protocol. the authors designed this algorithm for the management of traumatic spinal fractures during the covid-19 situation because we believe in the philosophy of prince mahidol of songkla's that states "true success is not in the learning, but in its application to the benefit of mankind. " no potential conflict of interest relevant to this article was reported. liawrungrueang w. management of traumatic spinal fracture in the coronavirus disease 2019 situation 3m personal safety division. surgical n95 vs. standard n95: which to consider? mn): 3m personal safety division what healthcare personnel should know about caring for patients with confirmed or possible co-vid-19 infection strategies for optimizing the supply of n95 respirators centers for disease control and prevention personal protective equipment (ppe) for both anesthesiologists and other airway managers: principles and practice during the covid-19 pandemic thank you to chanon sukjaroen, md for the picture he provided of him wearing a full ppe suit. thank you to amornchai kritnikornkul, md and prapon piamanant, md for the picture they provided showing co-management and following the authors' algorithm. thank you to the institutional ethics review board at nakornping hospital for proof of this picture and this letter. tuanrit sornsa-ard: https://orcid.org/0000-0003-4021-1278 wongthawat liawrungrueang: https://orcid.org/0000-0002-4491-6569 key: cord-348038-9v16k6gi authors: bagnasco, annamaria; zanini, milko; hayter, mark; catania, gianluca; sasso, loredana title: covid 19—a message from italy to the global nursing community date: 2020-05-08 journal: j adv nurs doi: 10.1111/jan.14407 sha: doc_id: 348038 cord_uid: 9v16k6gi during these difficult times, it is not easy to learn all the nursing lessons from the covid-19 epidemic in italy. it is not easy because at the time of writing italian nurses are in the middle of this emergency that shows no sign of diminishing. whatever is said today can change completely after only 24 hours. as a global community we have only known about this virus for a few months, but it has invaded lives, hospitals and homes, subverting habits, practices, and protocols. some of the lessons learned will emerge later after reflection and retrospective analysis. however, some things are now so evident that sharing them now is vital to help prepare those who are getting ready to face this emergency. dent that sharing them now is vital to help prepare those who are getting ready to face this emergency. the first lesson is the vital importance of personal protective equipment (ppe)-both in terms of amount and suitability. in italy the lack of suitable ppe, in particular, appropriate masks-as the ordinary surgical masks are of no use-has played a key role in spreading the infection among health workers. this lack of appropriate protection for those working on the front lines translates into a drastic daily loss of health professionals. it has been estimated that one tenth of those in italy who are covid-19 positive are physicians and nurses, but this could be underestimated due to the presence of infected professionals who are without symptoms (anelli et al., 2020; sorbello et al., 2020) . it is to their enormous credit that many nurses continue to provide care conscious that the minimum levels of protection cannot be guaranteed. with the global pandemic now accelerating in areas of the world yet to see italian levels of infection, it is vital that ppe equipment is procured and delivered to the covid-19 front-line critical care environments. protecting staff-as well as being an ethical duty of healthcare providers-is also essential to prevent reductions in skilled staff due to illness when they are needed more than ever. time is precious in this pandemic-italy did not see it coming-many other areas of the world can. the importance of ppe for staff cannot be emphasized enough. learn also from italian nurses' experiences of the harm long-term use of ppe: facial lesions and sores produced by the pressure and sweat caused by masks and goggles worn far beyond the usual time frame in normal clinical practice. further research will be needed on this-with the manufacturers of ppe being involved. but in the immediate situation healthcare providers can advise on self-care for those staff having to wear ppe for protracted periods (suen et al., 2020) . to help limit face lesions caused by the pressure of masks and goggles, the italian national institute of health (istituto superiore di sanità) organized online courses for health professionals to help them deal with this issue, among others related to keeping safe against covid-19. more ergonomic masks, goggles and ppe will need to be available in the future. another very challenging issue, especially at the beginning of the outbreak, has been the antigen or viral testing of front-line staff, unfortunately in most cases this was not possible due to the very rapid spread of covid-19 infections, because there were not enough testing kits available and places where these analyses could be conducted (paterlini, 2020) . we also recognize that the lack of antibody testing resulted in an inability to tell who had had the infection but now had immunity-and could therefore safely return to work. more recently, some italian regions are starting to conduct tests on all front-line staff and on the entire population, but it has taken several precious weeks of time to implement this. so, this is another important lesson for the global community. an additional emotional burden facing nurses is the fear of introducing the virus into their own homes and exposing family members to covid-19. it is important that nurses and other health professionals are trained in the correct procedures to manage uniforms and other belongings to minimize such a risk. if possible, staff should be encouraged and supported to use alternative accommodation to reduce the risk of family transmission. policy makers need to ensure they provide appropriate logistic and financial support to help with this course of action. this also creates a sense of isolation for healthcare workers who are already highly stressed. it highlights that this epidemic is wreaking a huge emotional toll on all healthcare professionals in italy. the long-term support needs of these staff can be planned later-but the importance of trying to provide some psychological support for staff-including the opportunity to speak about their experiences and fears-if only briefly-should be an important part of the acute response to covid-19. front-line covid-19 care giving is exhausting-especially over long hours-at some point replacement staff will be needed to enable others to take some rest and restore their energy. many of these replacements may be returning to practice or unfamiliar with critical care environments-the importance of training and providing ppe for these staff should not be neglected due to the urgency of the need to plug gaps in the care teams. to healthcare providers and policy makers in areas at the start of their covid-19 epidemic, our message is to plan for the replacement of staff in critical care areasthink about how this will be done, how they can be prepared and how you plan to recall recently retired nurses back to the hospitals. the peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.14407 and encouragement, to ensure that such choices are solidly rooted in noble values. one last but very important lesson from the epidemic is the need to plan for the possibility of caring for patients in their own homes. we have learnt that hospitalization is not necessary for everyone and can even be harmful. home care may be a more viable option. moreover, this would enable to reduce hospital stay and facilitate the fast discharge of recovering patients, thus increasing the availability of beds and other hospital resources. however, to take care of patients at home community nurses and general practitioners must have all the equipment and instruments they need in order to be able to do their job properly. therefore, it is important to educate large numbers of primary and community-based health professionals who, with all the necessary equipment and means, and in collaboration with general practitioners, can take care of patients directly in their own homes. it is also vital that this also included ensuring the infection control measures are in place to protect others living in the same dwelling. to conclude, 2020 is the year of the nurse, celebrating the bicentenary of the birth of our colleague florence nightingale, but it will surely be remembered also as the year of the covid-19 pan we thank dr giuseppe aleo, phd and lecturer of scientific english from the department of health sciences of the university of genoa for translating this editorial into english. covid-19: over 300 italian doctors and scientists call for more testing società italiana di anestesia analgesia rianimazione e terapia intensiva (siaarti) airway research group, and the european airway management society comparing mask fit and usability of traditional and nanofibre n95 filtering facepiece respirators before and after nursing procedures key: cord-319865-g3qxu6uv authors: frountzas, maximos; nikolaou, christina; schizas, dimitrios; toutouzas, konstantinos g. title: personal protective equipment against covid-19: vital for surgeons, harmful for patients? date: 2020-09-21 journal: am j surg doi: 10.1016/j.amjsurg.2020.09.014 sha: doc_id: 319865 cord_uid: g3qxu6uv nan in the beginning of 2020, the world scientific community faced the novel coronavirus sars-cov-2 or covid-19, which presented a mortality of 0.25-3% and an intensive care unit (icu) admission rate of 20%. the outburst of this rna-virus was so huge, that in march 2020 the world health organization (who) declared a global pandemic, which led to a mandated lockdown for almost one quarter of earth's population [1] . the surgical community was generally affected during covid-19 outburst, as in many countries most elective surgical procedures were postponed, due to high demand for ventilators and specialized medical staff in intensive care units (icus) [2] . all surgical societies published specific criteria about high-risk surgical procedures and management of oncologic patients with alternative treatment options, such as chemotherapy or radiotherapy, after discussion by virtual tumor boards, that included surgeons, medical oncologists and radiologists [3] . moreover, additional preventive measures against covid-19, such as preoperative testing or patient decolonization, took place when resources were available [4] . operating room (or) was considered as a high-risk place for covid-19 transmission, due to consecutive aerosol generating procedures (agps). tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation and manual ventilation before intubation were considered as high-risk agps. moreover, due to the increased risk for covid-19 transmission during pneumoperitoneum creation for laparoscopy, a dilemma between laparoscopy and laparotomy had to be answered even for operations that laparoscopy is strongly indicated [5] . previous experience with sars showed a potential viral load of these procedures and increased risks for viral transmission. in addition, most of rnaviruses had been identified inside the human gastrointestinal (gi) tract in the past [6] . because of the possible contact with increased covid-19 load during open and laparoscopic gi surgery, such procedures were classified as high-risk agps, despite the decreased aerosol generation. therefore, the society of american gastrointestinal and endoscopic surgeons (sages), followed by most gi surgical communities all over the world, suggested the following ppe during gi surgery of a confirmed or highly suspected covid-19 patient [7] : surgical gowns, caps and shoe covers for skin and clothing protection. gloves for hand protection. the previous recommendations were so strong, that a global consensus emerged after the initial statement of the royal college of surgeons of england: surgical procedures were forbidden where adequate ppe was unavailable [8] . however, the wide use of ppe by healthcare workers during covid-19 outburst demonstrated a few side effects of prolonged ppe wearing, especially in emergency departments and icus. for example, in a study of 158 healthcare workers that used n95 masks and goggles, 81% developed de novo ppe-associated headaches. in addition, 91.3% of the healthcare workers with a primary headache in the past, reported that the prolonged (over 4 hours) use of ppe during covid-19 outburst worsened their headaches and affected their job performance [9] . moreover, another study of 43 healthcare workers, that used ppe for 8.76 ± 2.31 hours per day during management of covid-19 patients, outlined various ppe-induced dermatoses, such as pressure injury, contact dermatitis, pressure urticaria and exacerbation of pre-existing skin diseases. irritant contact dermatitis (icd) (39.5%) followed by friction dermatitis (25.5%) were the most common dermatoses reported. goggles were the most common type of ppe causing dermatoses (51.9%), followed by n95 masks (30.8%). most workers presented pruritus (67.4%) and erythema (53.5%). unfortunately, 21% of medical staff suffered from work absenteeism due to one of the dermatoses, leading to a significant decrease in human resources during a crucial "medical battle" [10] . six months after the initial shock from covid-19 outburst, containment measures, such as lockdowns and quarantines, have been gradually quitted, while the medical community seems to be organized against this public threat. several pharmaceutical therapeutic agents have been used against covid-19, while all efforts have been guided towards construction of a safe and effective vaccine [11] . however, a lot of countries are about to face a second outburst of covid-19. τhe expected socioeconomic consequences of a possible second global lockdown show that it is not a possible option [12] . consequently, the number of required surgeries for j o u r n a l p r e -p r o o f covid-19 patients would be increased in the next months. as a result, surgeons and or staff are expected to be more exposed to ppe during surgery. either in the case of a second lockdown or not, the safety of ppe use against covid-19 for surgeons should be investigated. all parts of ppe increase surgeon's body temperature and sweating, leading to an impairment of surgeon's comfort, especially during prolonged and complicated surgical procedures. as mentioned above, ppe seems to be associated with important side effects, like dermatoses and headaches for healthcare workers. the ppe-associated discomfort and side effects during surgery may increase surgeons' anxiety and fatigue while performing difficult operations. patients diagnosed with covid-19 are frail, due to the multi-organ dysfunction that is usually caused, requiring the highest surgical performance in the operating room. therefore, ppe's effect on surgeon's comfort and psychological status should be investigated in future studies. a comparison between surgeons wearing different quality ppe parts in terms of intraoperative comfort, anxiety and fatigue during certain operations for patients without covid-19, is proposed. for example, the comparison between face shields and goggles or between ffp masks and caprs could highlight the different impact of two similar ppe parts on surgical parameters, without undermining surgeon's protection. in addition, the frequency of alternative treatments due to surgeons' reluctance to operate in ppe would be a very interesting parameter for future studies. ppe against covid-19 during surgery may be actually life-saving for a surgeon, but is it really safe for a patient? is there something that the surgical community could do to improve surgical conditions and patient's safety? this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. none of the authors have conflicts to disclose. systematic review of recommended operating room practice during the covid-19 pandemic elective surgery cancellations due to the covid-19 pandemic: global predictive modelling to inform surgical recovery plans international guidelines and recommendations for surgery during covid-19 pandemic: a systematic review pre-operative covid-19 testing and decolonization surgery during the covid-19 pandemic: a comprehensive overview and perioperative care precautions for operating room team members during the covid-19 pandemic personal protective equipment and covid-19: a review for surgeons surgery during the covid-19 pandemic: operating room suggestions from an international delphi process headaches associated with personal protective equipment-a cross-sectional study amongst frontline healthcare workers during covid-19 (happe study) personal protective equipment induced facial dermatoses in healthcare workers managing covid-19 cases early treatment of covid-19 patients with hydroxychloroquine and azithromycin: a retrospective analysis of 1061 cases in marseille, france the socio-economic implications of the coronavirus pandemic (covid-19): a review we have taken a significant and active part in the preparation of the article, and we have read and approved the final version. we are willing to discuss it in detail.in consideration of the american journal of surgery reviewing and editing our submission, the authors undersigned hereby transfer, assign, or otherwise conveys all copyright ownership to the american journal of surgery represent that they own all rights in the material submitted. the authors further confirm that the article is original, that it is not under consideration by another journal in any language, and that it has not been previously published, in whole or in part, in another journal in any language. there is no conflict of interests relevant to the study reported in this article. key: cord-351527-u12obtvp authors: harvey, jessica title: perspectives covid-19 and ppe in context: an interview with china date: 2020-05-30 journal: j public health (oxf) doi: 10.1093/pubmed/fdaa077 sha: doc_id: 351527 cord_uid: u12obtvp the author aims to depict the current covid-19 pandemic and personal protective equipment (ppe) crisis in the uk. the current situation is put into context exploring the history of global outbreaks of infectious disease and what has been learnt. these lessons are then applied and weighed against the recent response to coronavirus. an in depth interview with a uk biomedical sme based in shanghai, china is reported in order to inform future procurement of ppe. it is hoped that an appreciation of the dynamic nature of the market will allow adaptations to be made in order to secure reliable supply chains moving forwards. in 2014 barack obama made a speech in which he predicted a future pandemic and encouraged a collaborative approach in planning for such an event. the ebola epidemic in west africa started the same year, continuing for 2 years. ebola has its natural host origin in the fruit bat which is in common with covid-19 which is found living in horseshoe bats. 1 exposure to these animal vectors alongside novel mutations in the viral genome has enabled transmission to humans. 2 according to jones et al. in the nejm lessons could have been learnt. 3 the article highlighted how historically the first reaction to a pandemic has been denial. could this be that the anticipation of disseminated communicable disease is so feared that the initial reaction is one of non-acceptance, somewhat like the first stage of grief in kübler-ross's model? 4 if so, how can we move towards earlier acceptance of the risk and work towards a more cohesive response to ensure preparedness? whilst the current viral pandemic is exceptional in its impact on global health and the economy, a recognition that shared decision-making is required will embolden future coordination. intense concern regarding individual protection on a national scale using personal protective equipment (ppe) has been at the forefront of the public health agenda in the uk. it is emphasised that if used appropriately, ppe can prevent transmission. there has been a distinct lack of clarity in how ppe is procured once the pandemic stores dried up. whether it be via the nhs supply chain or private means, a greater understanding of the process is required to assist in breaking down the problems encountered in order to ensure a seamless supply. in an interview with a uk small to medium enterprise (sme) based in shanghai. i enquired of the director on the dynamics of the market in china, who are the main exporters of ppe. 'in january...no foreign entity was allowed to buy or export ppe. china eased restrictions on us buying ppe around the end of february, after which we had a lot of suppliers approaching us for ppe sales'. subsequently, as china opened its doors again, the demand for ppe swelled. 'around the beginning of march, we saw a surge in demand from us and eu sources, affecting the market and stock availability. they were buying in large quantities and product lead times increased to around 7 days (from 1). in addition, the time taken to transport product ex-china has increased-previously our freight forwarder could move express items to the uk within 3 working days direct from our chinese factories by air. international flight restrictions combined with an increased demand for express deliveries have pushed this to 2 weeks-plus as orders are forced to queue for space on the limited flights, compounding lead times.' regarding access to protective gowns which have been found wanting in supply, 'yes, we have availability but there is a shortage of non-woven material in china used in the manufacture of the gowns. we currently charge £7.00 per gown due to an increase in supply costs -this is up from a pre pandemic price of about £0.80 for a full sterile surgical gown. we expect the fabric shortage to ease in may and prices might go down to about £3.00 per gown. we are advising our customers to seriously consider ordering with a buffer of 1-3 months worth of stock as lead time for ppe such as gowns and aprons is now up to 30 days including shipping to the uk even via express air freight. we came up with a scheme offering a full refund for ppe returned unused after three months if a customer buys the excess/buffer stock'. i enquired about the factories and whether it was business as usual now. 'as of the last week of april, many ppe suppliers have been mandated to produce solely for the chinese government providing for orders of facemasks, visors and gowns. however, there are a large number of ppe suppliers in chinathe benefit of smaller companies like ours is our flexibility, and we switch to new suppliers as necessary'. what is your production capacity? 'the key challenge is not capacity but lead time. under the extensive lead times currently required (and increasing) and the inherent uncertainty in the situation we are advising our customers, including nhs and care homes, to put in orders now and plan to stock up for the near future'. what is your lead time? '3-7days for product to be ready for shipping; 21 days for shipping by express air freight, 30-40 days for shipping by sea'. i understand you have supplied mainly gp surgeries. what problems have you encountered in corresponding with the uk? 'a lack of understanding of just how dynamic the market and procurement of ppe is. there is no shortage of procuring the products if done along the right channels, however there is a huge bottleneck in getting the ppe out of china and it would be prudent to not wait for demand in the uk to become urgent before ordering'. have you had any problems dealing with the chinese suppliers? 'stricter regulations recently enforced by china add to bureaucracy but should have the positive effect of preventing low quality ppe and testing kits being exported'. does the nhs make any specific requirements of ppe compared to chinese health service? 'nhs tend to ask for brand names as opposed to device/ppe requirements, limiting scope of what can be supplied and these favoured brands vary by trust. also, all orders are "urgent"-we suggest our customers to plan ahead when ordering at least a month in advance to reduce their costs. new rules imposed by the chinese government mean that ppe for the international market is subject to stricter quality requirements compared to the products meant for the local chinese health service. we abide by these rules and supervise and ensure all our products have a 100% inspection rate, ce certificate and most importantly our suppliers have to have a government licence to manufacture and export ppe'. what is your experience of being involved with the competitive bidding market? 'we have been bidding for nhs tenders for the last four years and are very used to the competitive market. we know we are very competitive when it comes to price however one cannot help but see that buyers find comfort in purchasing brands with which they are familiar whilst limiting their choice and product availability'. what could the uk do to improve working relations with smes supplying ppe looking forwards? 'sme's are agile and can react to ever changing situations, such as in a pandemic, where there are so many factors at play. we have a shorter chain of command meaning if a new supplier is identified we can evaluate and approve a supplier in a relatively short time. smaller overheads mean lower costs for the nhs and less pressure on already restricted budgets'. this invaluable insight into how an sme can navigate the market with somewhat more flexibility could have the potential to improve communications ensuring more timely adaptations to what is a dynamic supply chain. unilateral procurement has been necessary by individual trusts that have also been identifying neighbouring trusts in need, but ideally this would eventually be adequately provided on a national scale. with the uk's exit from the european union (eu), this will become essential as emphasised by flear et al . in the context of a pandemic, they stress the importance of defining the precise roles of key players in the field. 5 the relative reliance the uk had on the eu was recently demonstrated by the catastrophic leap for independence by not joining the eu medical supplies consortium which may have meant missing out on ppe supplies. in anticipation of departure from the single market which includes the joint procurement agreement and the european medicines agency, clear lines of communication and establishment of flexible supply chains will be vital to navigate the future impact of infectious disease. 5 no competing interests. cross-species virus transmission and the emergence of new epidemic diseases perspective history in a crisis -lessons for covid-19 on grief and grieving: finding the meaning of grief through the five stages of loss key: cord-315358-22srds0e authors: kovacs, george; sowers, nicholas; campbell, samuel; french, james; atkinson, paul title: just the facts: airway management during the coronavirus disease 2019 (covid-19) pandemic date: 2020-03-30 journal: cjem doi: 10.1017/cem.2020.353 sha: doc_id: 315358 cord_uid: 22srds0e a previously healthy 42-year-old male developed a fever and cough shortly after returning to canada from overseas. initially, he had mild upper respiratory tract infection symptoms and a cough. he was aware of the coronavirus disease-2019 (covid-19) and the advisory to self-isolate and did so; however, he developed increasing respiratory distress over several days and called 911. on arrival at the emergency department (ed), his heart rate was 130 beats/min, respiratory rate 32 per/min, and oxygenation saturation 82% on room air. as per emergency medical services (ems) protocol, they placed him on nasal prongs under a surgical mask at 5 l/min and his oxygen saturation improved to 86%. answer: while a majority of patients will have minor illnesses and never present to the ed, the progression of disease for those who may ultimately require intensive care unit level of care is relatively slow (9-10 days). 1 however, patients may deteriorate during self-isolation and therefore present relatively late, in acute distress. reports from areas with high incidence of covid-19 infection inform us that patients not uncommonly present with impressively low saturations on supplemental oxygen, and, while they are symptomatic with dyspnea, they are not necessarily "altered" 2,3 (personal communications, italy). careful escalation with oxygen therapy and other resuscitation measures should continue. 4 delays in making the decision to intubate must be balanced against the risk of later managing a crashing patient in an uncontrolled scenario. 3 covid-19 pneumonia patients in respiratory distress with persistent hypoxemia and who are showing signs of fatigue (altered mental status) despite escalation of oxygen therapy (i.e., non-rebreather face mask at 15 l/min) are at significant risk for requiring urgent intubation. answer: simply put, it's the same for the most part with a few important differences. we're performing a rapid sequence intubation (rsi) with the goal of a high first-pass success (fps) rate with your "team" that you are familiar with. the accompanying algorithm is very similar in approach to what most emergency medicine physicians do currently ( figure 1 ). it's different in that airway management of covid-19 patients requires a paradigm shift from a focus primarily on patient-oriented outcomes to one that focuses on provider safety. caregivers of covid-19 patients are at increased risk of contracting the virus primarily by contact/droplet spread. airway management additionally poses an increased risk to the provider for two major reasons: 1) these sick patients likely carry a greater viral load and 2) conventionally performed airway procedures will produce airborne particles (aerosol generating procedures [agps]). 5 another major reason why airway management in covid-19 patients is different relates to the details and sequencing related to provider safety. it's the small stuff, such as paying attention, having lean but complete equipment, knowing how to manage oxygen flow safely, and routinely using a checklist. lastly, covid-19 airway management is different because we are forced by circumstance to commit to processes and procedures using evidence that is at best, level c (low quality, consensus documents expert opinion). answer: there is considerable discussion and concern amongst healthcare providers around the availability and access of appropriate personal protective equipment (ppe) for high-risk agps such as intubation. lessons from previous experiences (severe acute respiratory syndrome [sars]) reveal that a significant proportion of infections is related to breaches in the donning and doffing process. 6 while every institution should have access to ppe for providers performing an agp, it is important to ask the question of whether these recommendations are what is best for a provider in a room (negative pressure or not) preparing to intubate the sickest of covid-19 patients. the question, therefore, beyond safe ppe is how does this ppe affect your ability to perform the stressful procedure? does it restrict your peripheral vision, and will your face protection fog from your own tachypneic state or cause glare? providers should liaise closely with their infection control experts regarding access to and training for donning and doffing ppe. patients entering the room should be either "buddy checked" or signed off by an assigned ppe "supervisor" to ensure adequate donning and then again on leaving the room for the higher risk doffing procedure. answer: preoxygenation in covid-19 patients will deviate from familiar ed practice. disclaimer: there is no concrete evidence to support specific no-risk preoxygenation techniques in this population. however, the overlying principle is to use the lowest flow necessary to achieve an acceptable saturation. pushing flows to achieve higher oxygen saturation increases risk without benefit. what exactly does that mean? aiming for an oxygen saturation of 90-92% may be reasonable, if achievable. it may initially mean having low flow (< 6 l/min) nasal prongs and then escalating to 15 l/min using a non-rebreather face mask), which is usually well tolerated. for most emergency physicians, preoxygenation will transition to using a bag-valve-mask (bvm) that can be purposely modified for covid-19 patients (figure 2 ; see also video: https://vimeo.com/406929923). the key difference from our standard equipment use is that from here on, anything applied to the face or trachea (mask or tube) needs a viral filter (figure 2 ). applying a tightfitting mask before you are ready may create an uncooperative patient. the following sequence will create an aerosolization risk, which is why we are in full ppe for an agp. having a dissociative dose of ketamine ready to give slowly (delayed sequence intubation 7 ) is critical. do not squeeze the bag! when ready, you can place it directly over the patient's mouth or over the nasal prongs. placing a mask over nasal prongs does create small risk of a leak that must be balanced against an uncooperative patient who will likely need the additional flow to generate positive end-expiratory pressure (peep). remember, these patients have underlying shunt physiology (pneumonia, evolving acute respiratory distress syndrome) and so they are apnea-intolerant, meaning that, following rsi drug administration, these patients will further desaturate very rapidly. answer: perform rsi and use a video laryngoscope (vl) as part of an old-fashioned "double setup." (be prepared to perform a cricothyrotomy.) pretty simple here, awake intubations are essentially contraindicated. period. ideally using a video laryngoscope that keeps your face safely away from the patient's face. however, rsi alone is not an approach. practice with and use checklists/visual aids which are accessible and ideally posted in the room (see figure 1 and supplemental material). as part of your pre-brief, communicate the plan including your primary and alternative approach to intubation, what to do between intubation attempts, and what your exit and emergency strategy is (plans abcd, figure 1 ). no airway carts should be in the room. organize pre-packs with appropriately sized equipment for that patient (see supplemental material). use a checklist that you and your team have practiced with and works for your environment (e.g., see supplemental material). draw up your labelled medications for your rsi, rescue push-dose pressors, and begin a norepinephrine infusion at a starting dose based on hemodynamics. have your bolus and infusion ready for post-intubation analgesia and sedation to take in the room. keep it simple for your rsi. use ketamine at 1.5 mg/kg and either high-dose succinylcholine or rocuronium at 1.5 mg/kg. lower your ketamine dose if the shock index is > 1 (it is difficult to calculate to decimal points when your heart rate is elevated!). the choice of paralytic cannot influence success. you can't get more paralyzed than paralyzed. give your drugs, wait (or risk cough and regurgitation), and go in on a "profoundly" paralyzed patient. driver et al. achieved an fps rate of 98% with routine use of a bougie in combination with a macintosh blade vl device. 8 an out-of-package bougie is straight with a coude tip and is meant for macintosh blade devices. recognize for some macintosh vl devices that a slight bend on the distal portion of the bougie may be necessary. the nuances of vl use are beyond the scope of this article; however, use of a hyper-angulated vl can be a primary approach for those trained and confident with the nuances of tube delivery and/or be considered if an "optimized" macintosh vl approach fails (see aimeairway.ca for procedure videos for laryngoscopy tips). answer: breathe. slow down. yes, slow down. place an oral airway, and apply oxygen via your bvm with two hands using a v-e grip jaw thrust with 10-15 cm of peep over nasal prongs at 5 l/min and your bvm at 15 l/min (apneic continuous positive airway pressure [apneic cpap]; see apneic cpap https://vimeo.com/400368564). don't look for the oxygen saturations to rise, but do ask for help if a second provider is available in ppe. you won't see an end-tidal co2 trace unless you gently provide pressure support. anytime you squeeze the bag, there is some risk to aerosolization; however, your patient has been rendered apneic. the risk of controlled ventilation (6-10 breaths over 1 minute) must be balanced against worsening hypoxemia that results in cardiac arrest (bad). a third option is your rescue supraglottic device (e.g., ems i-gel®). if you are able to maintain saturations, you have to consider whether a second attempt at vl will be of value by you or your help. alternatively, move to your exit strategy (see figure 1 ). if you can't maintain oxygenation by either apneic cpap, controlled ventilation, or a supraglottic device, employ your "emergency" double setup strategy and perform a cricothyrotomy. 9,10 • airway management of covid-19 patients requires a paradigm shift from a focus primarily on patientoriented outcomes to one that focuses on provider safety. • rsi using a familiar vl device is the default method to secure the airway. • slow down to ensure patient and provider safety. • train in donning and doffing ppe, best practice airway skills wearing ppe, and as a team executing your plans. george kovacs et al. care for critically ill patients with covid-19 precautions for intubating patients with covid-19 epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study airway management guidelines for patients with known or suspected covid-19 infection. nova scotia health authority practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-ncov) patients intubation of sars patients: infection and perspectives of healthcare workers delayed sequence intubation: a prospective observational study effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation consensus statement: safe airway society principles of airway management and tracheal intubation specific to the covid-19 adult patient group covid-19 airway management principles acknowledgements: to dr. adam law for sharing his expertise in airway management. to david hung for his video and technical support.competing interests: lead author is co-medical director of a caep-sponsored airway education program, airway interventions & management in emergencies (aime). key: cord-321443-89o13sox authors: umazume, takeshi; miyagi, etsuko; haruyama, yasuo; kobashi, gen; saito, shigeru; hayakawa, satoshi; kawana, kei; ikenoue, satoru; morioka, ichiro; yamada, hideto title: survey on the use of personal protective equipment and covid‐19 testing of pregnant women in japan date: 2020-08-10 journal: j obstet gynaecol res doi: 10.1111/jog.14382 sha: doc_id: 321443 cord_uid: 89o13sox aim: to clarify the status of personal protective equipment (ppe) and coronavirus disease 2019 (covid‐19) tests for pregnant women, we conducted an urgent survey. methods: the survey was conducted online from april 27 to may 1, 2020. questionnaires were sent to core facilities and affiliated hospitals of the obstetrics and gynecology training program and to hospitals of the national perinatal medical liaison council. results: a total of 296 institutions participated in our survey; however, 2 institutions were excluded. full ppe was used by doctors in 7.1% of facilities and by midwives in 6.8%. our study also determined that around 65.0% of facilities for doctors and 73.5% of facilities for midwives used ppe beyond the “standard gown or apron, surgical mask, goggles or face shield” during labor of asymptomatic women. n95 masks were running out of stock at 6.5% of the facilities and goggles and face shields at 2.7%. disposable n95 masks and goggles or face shields were re‐used after re‐sterilization in 12% and 14% of facilities, respectively. polymerase chain reaction (pcr) testing of asymptomatic patients was performed for 9% of vaginal deliveries, 14% of planned cesarean sections and 17% of emergency cesarean sections. the number of pcr tests for obstetrics and gynecology per a week ranged from zero to five in 92% of facilities. conclusion: the shortage of ppe in japan is alarming. sufficient stockpiling of ppe is necessary to prevent unnecessary disruptions in medical care. appropriate guidelines for ppe usage and covid‐19 testing of pregnant women at delivery are needed in japan. the novel coronavirus disease 2019 (covid-19), caused by a new strain of coronavirus identified as severe acute respiratory syndrome coronavirus 2 (sars-cov-2), has been detected in patients with pneumonia of unknown cause beginning in december 2019 in wuhan, china. since then, a covid-19 pandemic has become full-blown worldwide, which eventually resulted in the shortage of personal protective equipment (ppe). during childbirth, large amounts of aerosols are reportedly produced due to inevitable screaming, defecation and urination associated with labor and delivery. during this time, pregnant women and midwives are in close proximity, and ventilation in the delivery room is minimized for heat retention to keep the newborn warm. in order to prevent covid-19 transmission, medical workers should take precautions by wearing ppe. in new york, the location recently identified as the epicenter of the pandemic, universal screening using a polymerase chain reaction (pcr)-based test is a requirement before delivery for all pregnant women. this pcr screening has revealed that about 15% are infected with covid-19, of which about 90% (13.5% of total pregnant women) have asymptomatic infections. 1 in japan, only a small number of pcr tests have been used for diagnosis of covid-19. there are reports of sars-cov-2 infection transmitted from asymptomatic infected individuals. 2 therefore, the risk of infection is very high for medical workers attending to pregnant women with asymptomatic covid-19 during labor. a lack of available pcr tests for covid-19 has prompted the usage of ppe, which eventually resulted in its shortage. 3 in order to clarify the status of ppe usage during labor and delivery and covid-19 tests for pregnant women, we conducted an urgent survey in japan. the survey was conducted using online from april 27 to may 1, 2020. we carried out this online survey by two methods. the first method used snowball sampling techniques. the questionnaires were sent to the core facilities of obstetrics and gynecology training program, from which questionnaires were forwarded to the affiliated hospitals. the second method used mailing-list of hospitals of national perinatal medical liaison council in japan. in the survey, we gathered informed consent for the collection and publication of the results. we then incorporated the data from facilities that provided informed consent for analysis. the questionnaire included the following items: descriptive statistics were analyzed in the present survey. full ppe is defined as gown-type or one-piece prevention wear, and using n95 masks, goggles, double gloves, caps and shoe covers and other is defined as not full ppe. according to the state of emergency on april 7, special warning area included in tokyo, osaka, hokkaido, ibaraki, saitama, chiba, kanagawa, ishikawa, gifu, aichi, kyoto, hyogo and fukuoka. each category variable between full ppe and not full ppe was performed by chi-square test or fisher's exact test. all statistical analyses were performed using an assumed type i error rate of 0.05. statistical analyses were performed using ibm spss statistics 26 for windows (ibm japan). in this survey, we obtained questionnaire responses from 296 facilities including 117 (75%) of a total of 156 core facilities of obstetrics and gynecology training program, located in 46 prefectures throughout japan. also, 77 of the general and 100 regional perinatal maternal and child care center were included, representing 70% and 33% of the facilities nationwide, respectively. we excluded responses from two facilities that did not provide consent for publication; subsequently, we analyzed responses from the 294 facilities. the characteristics and locations of these facilities are shown in table 1 . the number of annual deliveries at the general perinatal maternal and child care center was determined to be higher than that of the regional perinatal maternal and child care center or other facilities (p < 0.01). we defined full ppe as gown-type or one-piece prevention wear, n95 masks, goggles, double gloves, caps and shoe covers. in vaginal deliveries of women without symptoms of covid-19, full ppe was used by doctors in 7.1% of facilities and by midwives in 6.8% of facilities. full ppe was most commonly adopted by facilities with 351-500 deliveries per year, of which 16.7% were reportedly used by doctors and 15.3% by midwives (table 2) . overall, approximately 90% of the facilities lacking full ppe use employed water-repelling gowns or aprons. goggles or face shields were used by doctors in 63% of facilities and by midwives in 73% of facilities. both doctors and midwives wore fewer shoe covers and caps (fig. 1 ). status of ppe use beyond "standard gown or apron, surgical mask, goggle or face shield" during labor of women without symptoms of covid-19 we defined the standard protection during vaginal delivery for asymptomatic women as a standard gown apron, surgical mask and goggles or face shield. protective equipment for covid-19 beyond this standard protection was used by doctors in 65.0% of facilities and by midwives in 73.5% of facilities, with higher rates of use in facilities with a large number of deliveries (doctors p < 0.01, midwives p < 0.01). doctors used this additional ppe at a higher rate of 70.6% in special warning areas compared to other areas (p < 0.01) ( table 3) . doctors in 42 facilities (14.3%) used goggles or face shields at outpatient clinics. regardless of the characteristics and locations of facilities, protective equipment of the trunka standard gown or apronwas sufficient in about 36.5% of facilities. n95 masks and goggles or face shields were also found sufficient only in 10.5% and 14.6% of facilities, respectively, and for the rest, ppe were re-used after re-sterilization in 12.2% and 14.3% of facilities, respectively. n95 masks and goggles or face shields were reported to be out of stock in 6.5% and 2.7% of facilities, respectively (fig. 2, table s1 ). figure 3 shows the percentage of facilities that provide covid-19 tests for asymptomatic women. pregnant women were tested for covid-19 not only in perinatal medical centers and university hospitals, but also other facilities, at a rate of 9-17% (table s2) . pcr testing of asymptomatic women was performed by 9% of facilities at vaginal delivery, 14% at planned cesarean section, 17% at emergency cesarean section and 15% at nonobstetric or nongynecological surgery. between april 27 and may 1, 2020, 18 facilities (6.1%) have reported that they were performing pcr tests on all asymptomatic pregnant women admitted for labor and nonobstetric or nongynecological surgery. we performed a secondary interview in early may to confirm these reports and found that all pregnant women (vaginal delivery, planned and emergency cesarean section) received the pcr test at eight facilities nationwide, and six of the eight additionally tested all surgical patients. approximately 61% of the participating facilities revealed that they performed pcr tests on less than 50 samples per week (fig. 4) . the number of pcr examinations available per week was higher in the general perinatal maternal and child care center (p < 0.001) and university hospitals (p < 0.001) than in other facilities; it was also higher in special warning areas (p < 0.05) (table s3 ). however, during the week prior to the survey, 92% of the facilities performed less than five pcr tests (fig. 5 ). this is the first report that showed the nationwide state of the ppe and covid-19 testing. this survey clarified the actual ppe usage in core facilities and affiliated hospitals of the obstetrics and gynecology training program as well as hospitals of the national perinatal medical liaison council, between april 27 and may 1, 2020. during this time, japan was in a in new york, 14 of the 43 (33%) asymptomatic pregnant women tested positive for covid-19, 10 (71%) of which developed symptoms after pcr tests. 4 furthermore, covid-19 screening among 215 pregnant women found that 32 (15%) tested positive, of which 29 (13.5% overall) were found asymptomatic. 1 asymptomatic patients are contagious and thus are at a high risk of nosocomial infection. 2 of those infected at a single institution, 41% were nosocomial and 29% were healthcare workers. 5 therefore, if universal screening is not performed, strict ppe usage for doctors and midwives is necessary at labor when large amounts of aerosols are produced. however, this situation may result in the depleting supply of ppe in facilities, and the burden of wearing full ppe on healthcare professionals will become heavier. in this survey, full ppe was used by doctors in 7.1% of facilities and by midwives in 6.8% of facilities (table 2) . however, n95 masks and goggles or face shields were out of stock in 6.5% and 2.7% of facilities, respectively. in addition, disposable n95 masks and goggles or face shields were re-used after re-sterilization in 12% and 14% of facilities, respectively (fig. 2) . the shortage of medical ppe in japan is very alarming. we determined that stockpiling was altered because facilities increased their normal stockpiling systems, rather than facilities increased their consumption due to the degree of covid-19 infection spread. this was apparent because locations of special warning areas were unrelated to stockpiling status. the number of pcr tests administered to obstetric and gynecologic patients in the week prior to this survey ranged from zero to five in 92% of facilities (fig. 5) . however, 61% of the facilities administered less than 50 pcr tests per week, indicating that the majority of facilities were limited in their capacity for pcr testing (fig. 4) . france ended their lockdown when 4.4% of the population had been infected, at which time population immunity was considered inadequate to avoid a second wave. 6 in japan, sufficient stockpiling of ppe is needed to prevent disruptions in medical care due to nosocomial infections until adequate mass immunity is slowly achieved. appropriate guidelines for ppe usage by medical providers and covid-19 testing for pregnant women before delivery are necessary in japan. none declared. additional supporting information may be found in the online version of this article at the publisher's web-site: universal screening for sars-cov-2 in women admitted for delivery transmission of 2019-ncov infection from an asymptomatic contact in germany personal protective equipment shortages during covid-19-supply chain-related causes and mitigation strategies covid-19 infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of new york city hospitals clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china estimating the burden of sars-cov-2 in france key: cord-314507-fgrvrlht authors: sule, harsh; kulkarni, miriam; sugalski, gregory; murano, tiffany title: maintenance of skill proficiency for emergency skills with and without adjuncts despite the use of level c personal protective equipment date: 2020-03-27 journal: cureus doi: 10.7759/cureus.7433 sha: doc_id: 314507 cord_uid: fgrvrlht objective to determine the impact of level c personal protective equipment (ppe) on the time to perform intravenous (iv) cannulation and endotracheal intubation, both with and without the use of adjuncts. methods this prospective, case-control study of emergency medicine resident physicians was designed to assess the time taken by each subject to perform endotracheal intubation using both direct laryngoscopy (dl) and video laryngoscopy (vl), as well as peripheral iv cannulation both with and without ultrasound guidance and with and without ppe. results while median times were higher using vl as compared to dl, there was no significant difference between intubation with either dl or vl in subjects with and without level c ppe. similarly, no significant difference in time was found for intravenous cannulation in the ppe and no-ppe groups, both with and without ultrasound guidance. conclusions existing skill proficiency was maintained despite wearing ppe and there was no advantage with the addition of adjuncts such as video-assisted laryngoscopy and ultrasound-guided intravenous cannulation. a safe and cost-effective strategy might be to conduct basic, just-in-time ppe training to enhance familiarity with donning, doffing, and mobility, and couple this with the use of personnel who have maximal proficiency in the relevant emergency skill, instead of more expensive, continuous, skills-focused ppe training. 2 3 1 the health crises related to ebola virus disease (evd) in 2014 and, currently, coronavirus disease 2019 (covid-19) highlighted a key challenge in caring for patients who have or may potentially have chemical-biological-radiological-nuclear (cbrn) exposures. although there are instances where healthcare is deferred until decontamination is complete or the risk of contamination eliminated, there are circumstances where aggressive airway management and hemodynamic stabilization is required with a significant risk of exposure to healthcare providers. given the high risk of contamination of front-line emergency medicine personnel, the use of appropriate personal protective equipment (ppe) is critical. there are generally two approaches to training exercises -focused training with periodic refresher courses or just-in-time training. the cost burden of preparing for high-risk, low-frequency events such as cbrn incidents is a significant challenge since it places a financial and personnel/time burden on hospitals [1] [2] [3] . moreover, training exercises tend to focus on donning and doffing ppe, and not procedural competence while in ppe. in recent years, the use of adjunct devices, such as video laryngoscopy (vl) and ultrasound, has become instrumental in the daily practice of emergency medicine. conflicting evidence exists in the literature as to whether the use of ppe impedes the ability to simply successfully intubate, and this is further complicated by the impact of vl when using ppe [4] [5] [6] [7] [8] [9] [10] [11] [12] . while there is also conflicting evidence regarding the impact of ultrasound on intravenous (iv) cannulation, there are no studies that address its use with ppe [13] [14] . our study is the first to examine these parameters while using both vl for intubation and ultrasound for intravenous cannulation. our primary objective was to determine the impact of level c ppe on the time to perform intravenous cannulation and endotracheal intubation, both with and without the use of adjuncts. we hypothesized that it would take longer to perform these key procedures while donned in ppe. the study was approved by the institutional review board of rutgers newark health sciences. this is a prospective, case-control study with self-matching that was performed in the extended treatment area (eta) of university hospital (newark, nj), which is part of the emergency department (ed) where all patients with suspected cbrn exposure are evaluated and treated. the subjects were emergency medicine (em) residents in our four-year residency program that had no previous training related to ppe used but were proficient in the technical skills being evaluated. each resident served as their own control. all study subjects were consented prior to participation. participants used ppe certified to provide the maximal level of protection to personnel responding to cbrn agents (level c). details of ppe, intravenous cannulation, and endotracheal intubation are shown in table 1 . four stations were set up and fully equipped to perform the necessary tasks: two for intubation and two for intravenous access. study subjects were randomized into one of two groups with regard to the sequence of performing procedures, thereby attempting to limit any bias related to the order of procedures. group 1 performed procedures first without ppe (standard hospital scrubs) and then with ppe, while group 2 performed procedures first with ppe and then without ppe, as shown in figure 1 . half of each em-year was assigned to each group. subjects donned and doffed ppe under the direction of experts in the appropriate protocols. each of the subjects was assigned to one of four procedure stations and rotated in sequence as described in table 2 . upon conclusion of the study, each subject had attempted each skill twice; once while wearing ppe and once while wearing standard clothing. a iv iv+us dl vl iv iv+us dl vl b iv+us iv dl vl iv+us iv dl vl c iv iv+us vl dl iv iv+us vl dl d iv+us iv vl dl iv+us iv a iv iv+us dl vl iv iv+us dl vl b iv+us iv dl vl iv+us iv dl vl c iv iv+us vl dl iv iv+us vl dl d iv+us iv vl dl iv+us iv vl dl e dl vl iv iv+us dl vl iv iv+us f dl vl iv+us iv dl vl iv+us iv g vl dl iv iv+us vl dl iv iv+us h vl dl iv+us iv vl dl iv+us iv time to successful intubation was recorded for each subject. the procedure start time was recorded when the subject first touched the equipment for preparation. preparation for intubation included inserting the stylet into the endotracheal tube (ett), testing ett balloon inflation, and placing the macintosh blade onto the laryngoscope handle or the glidescope tm (verathon; seattle, wa) cover onto the light source. the procedure stop time was recorded when the endotracheal tube (ett) had been correctly inserted in the trachea with initial inflation of the lungs. time to successful iv cannulation was recorded for each subject. the procedure start time was recorded when the subject touched the equipment for preparation. preparation for this procedure included unwrapping the iv catheter from the package, cleaning the surface of the mannequin, placing ultrasound gel, and turning on the ultrasound machine. the procedure end time was recorded upon the successful initiation of a saline flush of the iv line to confirm proper placement. all procedure times were recorded in seconds (sec) by volunteers who had experience and knowledge of the skills evaluated. each subject's times were recorded on standardized data collection forms. no identifying information was recorded on the forms except for em year. at the conclusion of the study, all forms were collected by the primary investigator. the subjects were then debriefed and given an opportunity to convey their impressions regarding their performance in the skill stations. the shapiro wilk test was utilized to determine if the data fit a normal distribution model. given the small sample size, a two-tailed mann-whitney u test was used to compare the time to perform each procedure with and without ppe. significance was defined as an associated p-value of < 0.05. sixteen of the total 25 eligible em resident physicians participated in the study. nine residents were excused because of either scheduling conflicts or work-hour restrictions. resident participants in the study included two first-year residents (em-1), 6 second-year residents (em-2), 3 third-year residents (em-3) and 5 fourth-year residents (em-4). one resident's data was excluded from the video laryngoscopy portion due to incomplete data collection. data for all four procedures were found to not fit the normal distribution model. therefore, median times with interquartile range (iqr) are reported below. when performance time was lower with ppe than without ppe, the time is reported as a negative value. the median time for each procedure with and without ppe is demonstrated in figure 2 . our study showed that there was not a significant difference related to level c ppe use for endotracheal intubation with and without the use of adjuncts. median times were higher using video laryngoscopy as opposed to direct laryngoscopy, but there was no significant difference in the no-ppe and ppe sub-groups. this is not consistent with several studies where there was an increase in intubation time with the use of ppe. consistent with our data, macdonald et al., in a study of 16 advanced and critical care paramedics, found no statistically significant difference in time to completion of intubation when comparing to a level c suit (69 sec vs. 79 sec) [7] . in addition, wang et al. studied 40 emergency physicians (residents) with and without level c ppe and found no difference in the mean time to successful endotracheal intubation (17.86 sec vs. 17.83 sec, p = 0.99) [8] . most recently, adler et al. studied 65 physicians and nurses with varying levels of ppe and found that there were no significant differences in tasks, including endotracheal intubation, except iv placement (median difference, 5.5 sec vs. 42 sec, p<0.01) [9] . we chose to start the time of intubation at the moment the subjects began to prepare equipment for the procedure. therefore, it is difficult to compare the intubation times in this study with other studies where the start time was post-preparation or insertion of the laryngoscope. however, we felt strongly that this should be included since preparing equipment requires manual dexterity that is influenced by ppe, and in an emergency situation, this preparation will likely be done while donned. unfortunately, there is limited and somewhat conflicting literature that addresses the question regarding the appropriate time needed to successfully complete airway tasks by otherwise procedurally competent personnel while wearing ppe [4] [5] [6] [7] [8] . in our study, the median times for successful intubation with dl and vl (including preparation for intubation), regardless of the use of ppe, were 67 seconds and 89 seconds, respectively. we feel that a time under one and half minutes for preparation and successful endotracheal intubation is an acceptable timeframe. similarly, our study showed no significant difference in time for iv cannulation in the no-ppe and the ppe groups, both with and without ultrasound guidance. although it was not a statistically significant finding, it was interesting that the median times for iv cannulation were faster with ppe than without ppe. castle et al. found an increase in the mean completion time of iv cannulation when wearing ppe level c (40.8 sec vs. 129.6 sec) [6] . macdonald et al. found a statistically significant increase in completion time for iv cannulation when wearing ppe (158 sec vs. 220 sec, p < 0.01) [7] . there has also been no previously established appropriate time for iv placement using ppe; however, the median time for iv cannulation with ultrasound using ppe was 98 seconds. we feel that successful iv cannulation under two minutes is an appropriate time frame. however, our study has a few limitations. first, the participant group was small thereby making statistical analysis challenging. as a result, we were unable to parse out subtle differences in proficiency that might occur across varying training levels. second, we did not track the time taken for each individual stage of the procedure; that is, specific time for preparation, time from the insertion of the laryngoscope to passing the ett and lung inflation. this would have been beneficial in making a direct comparison of our results to existing literature. finally, while our participant group of trainees completed the procedures in what we consider an appropriate time frame, future studies should include a group of experienced clinicians so that a "gold standard" can be introduced for comparison. in this study, we demonstrate that there is no significant difference in completion time for any of the studied procedures with and without level c ppe, with no advantage related to the use of adjuncts such as ultrasound and video laryngoscopy. maintenance of existing skill proficiency while wearing ppe is a key finding and perhaps obviates the need for continuous, skills-focused ppe training. a safe and cost-effective strategy might be to conduct basic, justin-time ppe training for personnel who have maximal proficiency in the relevant emergency skill. human subjects: consent was obtained by all participants in this study. rutgers newark health sciences irb issued approval pro20140000949. the study was approved by the institutional review board of rutgers newark health sciences. animal subjects: all authors have confirmed that this study did not involve animal subjects or tissue. in compliance with the icmje uniform disclosure form, all authors declare the following: payment/services info: all authors have declared that no financial support was received from any organization for the submitted work. financial relationships: all authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. other relationships: all authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work. world health organization: public health preparedness and response . public health response to biological and chemical weapons: who guidance occupational safety and health administration. personal protective equipment just-in-time training for high-risk lowvolume therapies: an approach to ensure patient safety antichemical protective gear prolongs time to successful airway management: a randomized, crossover study in humans practicality of performing medical procedures in chemical protective ensembles impact of chemical, biological, radiation, and nuclear personal protective equipment on the performance of low-and highdexterity airway and vascular access skills performance of resuscitation skills by paramedic personnel in chemical protective suits the effect of personal protective equipment on emergency airway management by emergency physicians: a mannequin study impact of personal protective equipment on the performance of emergency pediatric tasks comparison of the airtraq laryngoscope versus the conventional macintosh laryngoscope while wearing cbrn-ppe airtraq versus macintosh laryngoscope: a comparative study in tracheal intubation intubation efficiency and perceived ease of use of video laryngoscopy vs direct laryngoscopy while wearing hazmat ppe: a preliminary highfidelity mannequin study perceived difficulty and success rate of standard versus ultrasound-guided peripheral intravenous cannulation in a novice study group: a randomized crossover trial ultrasound-guided peripheral venous access: a systematic review of randomized-controlled trials the authors would like to acknowledge christine ramdin, phd, for her guidance with statistical analysis. key: cord-332815-1w1ikj7q authors: zhan, mingkun; anders, robert l.; lin, bihua; zhang, min; chen, xiaosong title: lesson learned from china regarding use of personal protective equipment date: 2020-08-11 journal: am j infect control doi: 10.1016/j.ajic.2020.08.007 sha: doc_id: 332815 cord_uid: 1w1ikj7q background: in wuhan, china, in december 2019, the novel coronavirus was detected. the virus causing covid-19 was related to a coronavirus named severe acute respiratory syndrome coronavirus (sars-cov). the virus caused an epidemic in china and was quickly contained in 2003. although coming from the same family of viruses and sharing certain transmissibility factors, the local health institutions in china had no experience with this new virus, subsequently named sars-cov-2. methods: based on their prior experience with the 2003 sars epidemic, health authorities in china recognized the need for personal protective equipment (ppe). existing ppe and protocols were limited and reflected early experience with sars; however, as additional ppe supplies became available, designated covid-19 hospitals in hubei province adopted the world health organization guidelines for ebola to create a protocol specific for treating patients with covid-19. results: this article describes the ppe and protocol for its safe and effective deployment and the implementation of designated hospital units for covid-19 patients. to date, only two nurses working in china who contracted sars-cov-2 have died from covid-19 in the early period of the epidemic (february 11 and 14, 2020). conclusion: the lessons learned by health care workers in china are shared in the hope of preventing future occupational exposure. in december 2019, a hospital in wuhan, hubei province, reported several cases of severe unexplained viral pneumonia. the outbreak appeared just before the spring festival, one of china's most significant holidays. millions of people traveled during the holiday. the government scrambled to determine the etiology of the disease. the first patients began seeking medical care with symptoms of respiratory distress, headaches, and fever. initially, the diagnosis was an upper respiratory infection and treated with standard therapy for influenza-like illness. as the number of infected patients continued to increase rapidly, and the treatments administered did not seem to improve patients' conditions, further investigations were necessary. there were approximately 110,000 health care workers (hcws) in wuhan, which could be called upon to provide care for this emerging epidemic. quickly the healthcare facilities became overwhelmed with patients. as a result of working long hours under very stressful conditions, there were reported deaths of hcws. throughout the epidemic, 42,600 travel nurses and physicians came into hubei province, primarily to wuhan from throughout china to provide relief to the wuhan hcws. 1 the paper focuses primarily on the use of ppe to help prevent transmission of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) to hcws. the aim is to provide more detail regarding level-3 protection protocols used at designated covid-19 hospitals in hubei province to prevent the spread of the virus to hcws. the methods to protect hcws, designated as level-3 protection in china, included a personal protection protocol for proper use of ppe with coveralls and procedures for changes to the flow of patients and personnel through the designated covid-19 hospitals. 3 during the ebola outbreak, the world health organization (who) had recommended extensive guidance on the protection of hcws. 4 biosafety level-3 protection is well known in laboratories that handle dangerous and potentially lethal microbes transmitted by droplets or aerosols. there are many similarities between the recommendations for the protection of laboratory workers and the who recommendations for ppe to protect bedside care providers from filovirus disease. after comparing the existing recommendations, all designated covid-19 hospitals adopted the recommendations endorsed by the who for filovirus disease (ebola). the recommendation ensures protection from head to toe using the coveralls (not the gown), thus minimizing any areas of skin exposure, in combination with the lockdown of designated covid hospitals. 4 hospital units treating covid-19 patients were locked, meaning only personnel wearing the proper protective equipment were allowed entry, and non-covid-19 patients were not admitted. most of these units did not have a negative pressure system. air disinfectant machines that operated 24-hours per day were used in the isolation units and in the transition unit (where removal of the ppe occurred). upon arrival at the hospital, nursing and physician staff entered the clean areas through a staff-dedicated hallway; patients arrived through another patient-dedicated entrance. additionally, there were separate elevators for staff and patients. the temperature of hcws was measured on entrance. hcws with a temperature of more than 37.2 ℃ (99 °f) were not allowed to enter the hallway. in the clean areas, staff would begin following a standardized procedure for donning ppe. the who ebola ppe protocol includes a first layer of a scrub suit, followed by rubber boots (which were too cumbersome for work in the isolation unit) or closed-toe shoes with shoe covers, two layers of gloves, coverall, face mask, face shield/goggles, a head and neck covering, a surgical bonnet covering the neck and sides of the head or a hood, and a disposable waterproof apron. 5 the adopted covid-19 protocol included a hospital-provided scrub suit, complete covering of dorsum of the foot and ankles with socks covered by plastic wrap and closed shoes with two layers of boot covers (substituted for the heavy rubber boots), three layers of gloves, a coverall, n95 face mask, surgical mask, face shield/goggles, hood with two layers of head covering, and a disposable waterproof surgical gown. the rubber boots were available for staff to wear from the transition unit to home or hotel. before starting the 4-hour shift (primarily for nurses) and a 6-hour shift (physicians), the staff arrived in the clean areas where a one-way hall led to the locked isolation unit. most of medical and nursing staff wore diapers instead of leaving the unit to use the bathroom. there are various approaches to donning and removing the ppe; posters developed by the who were available to staff for reference. 5 using 0.5% w/v isopropyl alcohol 75% v/v is the first step in performing hand hygiene. a total of 17 steps were involved in donning the ppe as described in the adopted protocol above. at the end of a four-or six-hours shift, staff moved to a transition unit, located outside of the locked isolation unit where the ppe removal and decontamination process began. the removal of ppe is a time with a high risk of contamination. the process started with washing the gloved hands with a solution of isopropyl alcohol; hand sanitizing is also recommended after the removal of each piece of ppe. when taking off the surgical gown and coveralls, ensure the front is folded inward to minimize the possibility of contamination. it is recommended the gloves be removed during this step and turned inward as well. all contaminated ppe must be disposed of properly. after removal of the n95 mask, it is recommended a surgical facemask be worn. after removal of the ppe, the staff then proceeds to the clean unit. the steps in table 1 are our recommendations for additional decontamination. the who protocol is silent on the steps to be taken after the ppe is removed. each agency needs to adapt the process to meet their goals for staff safety. table 1 illustrates only one method, which was the method used in covid-19 facilities in hubei province.  shower and change to clean clothes and rubber boots.  arrive at hotel/home, clean boots with disinfectant and remove them (leave them at the designated area in the lobby of the hotel), and change to slippers.  remove and leave the jacket provided by the hospital at the designated area of the hotel lobby and change to the coat (the coat was sprayed with chlorine disinfectant every 4 hours).  leave slippers outside of the individual room or home and change to house slippers.  perform hand hygiene with a solution of isopropyl alcohol, then remove the coat and leave in the area near the door to the room or home.  take a full-body bath with soap and move to a clean area of the room to change to a different pair of slippers.  clean the nasal cavity and ear canal with an alcohol swab.  use mouth wash before eating. in wuhan, the entire process of transiting from the hotel (for travel nurses and physicians), donning ppe, working their shift, removing the ppe, and returning home could take up to ten hours. thus, the staff had extensive time spent in preparing, providing care, or decontaminating before going home. isolation was encouraged to continue at the hotel or home to protect others from potential infection. as early as january 23, 2020, a total of 176 members of the hcws were clinically or laboratory diagnosed with covid-19. 6 since that time, with the implementation of the level-3 protection protocols and the implementation of covid-designated hospitals, the number of hcws diagnosed with covid-19 has decreased. 6 according to the chinese red cross foundation (crcf), as of june 2, 2020, a total of 3,623 hcws have been diagnosed with laboratory-confirmed or clinically confirmed covid-19 throughout mainland china. a total of 31 hcws had died from covid-19. 6 only two nurses were infected with sars-cov-2 while performing their duties and then died from covid-19. 7, 8 no other deaths from covid-19 of nurses who had worked in mainland china during the epidemic have been reported. in the usa as of april 9, 2020, there were 9,282 hcw with covid-19 and of these 73% were women. 9 investigators noted that the number of cases among hcws in the study were likely an underestimation as healthcare status was missing for 84% of patients reported nationwide. as of april 8, 2020, who had been recording 22,073 cases of covid-19 among hcws from 52 countries. nevertheless, there is currently no formal documentation of hcws covid-19 infections to the who. the true number of covid-19 hcws infections worldwide are potentially underrepresented. 10 liu and colleagues in a cross-sectional study of four hospitals in wuhan, china found that of 420 travel hcws caring for covid-19, none were infected with sars-cov-2. 11 the authors concluded the use of effective ppe is contributed to there being no infections among those hcws. their findings are consistent with the support recommendations in this study. the experience in designated covid-19 hospitals demonstrates the evolution of how hcws reacted to covid-19 in wuhan and hubei province. the lack of adequate ppe was a contributor to the number of hcws initially infected with sars-cov-2. many asymptomatic patients were seen for non-covid-related conditions unknowingly exposed to some hcws in the outpatient clinics, which also contributed to the infection rate. the ppe protocols implemented in designated covid-19 hospitals is thought to have approximately 90% of the 28,600 travel nurses were under age 40, and 25,300 travel nurses were women. 12 the nurses, for the most part, did not have underlying medical issues that might place them at risk. 10 younger age and gender has proven in some way to be protective. 13, 14 a cochrane systematic review of ppe supports the importance of putting on the ppe correctly, that it may be uncomfortable to wear, and there is a risk of contamination with removing it. 15, 16 before implementing the ppe protocols, nurses may have placed a greater emphasis on washing their hands, using gloves, and wearing a face mask and hair covering more frequently than other hcws (m. zhan, and b. lin, personal communication may 2, 2020). however, the rapid adoption of a level-3 protection and careful use of ppe including coveralls was most likely a significant factor in protecting the nurses and other hcws from infection. (see table 2 ) 6 most of the early infections occurred before the adoption of level-3 protection. the report provides useful insight for developing future strategies to deal with infectious disease pandemics. the need for continued preparedness is paramount. policymakers must assume that there will be another epidemic. it may be the sars-cov-2 reemerging in the fall of 2020 or perhaps another viral agent. public health officials working in collaboration with federal, state, and local health departments must plan for the next epidemic. there needs to be a federal (national) and provisional (state) stockpile of ppe including coveralls and other necessary supplies required to care for patients with infectious diseases. there needs to be a method of ensuring that supplies are kept secure, and as they become outdated are rotated with new ones. the need for planning and funding for such including the necessary equipment and supplies is critical. failure to plan may mean additional lives lost. other hospital units beyond the ones used in this pandemic also need to be identified. providing the current rate of infection has dramatically declined. the environmental controls limiting social contact and mobility have helped to create a safer environment. readily available testing for suspected individuals with covid-19 has helped to identify those who may be at risk quickly. as a result of the level-3 protection protocols combined with admitting patients to only covid-19 designated hospitals, the number of hcws infected declined significantly since mid-february 2020. our experience may help other health systems better cope with outbreaks of the highly contagious sars-cov-2. transcript of the press conference of the information office of the state council on response to social concerns on hot topics such as alleviating the current shortage of medical supplies in china (in chinese) national health commission of the people's republic of china. technical guidelines on prevention and control of novel coronavirus infection in medical institutions world health organization. personal protective equipment for use in a filovirus disease outbreak-rapid advice guideline world health organization. how to put on and how to remove personal protective equipment -posters public announcement (in chinese) public announcement (in chinese) public announcement (in chinese) characteristics of health care personnel with covid-19 -united states use of personal protective equipment against coronavirus disease 2019 by healthcare professionals in wuhan, china: cross sectional study sex-and gender-specific observations and implications for covid-19. the western journal of emergency personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff national health commission of the people's republic of china. transcript of the press conference of the information office of the state council on death from covid-19 of 23 health care workers in china apple and google build smartphone tool to track covid-19. npr new we want to acknowledge all state, local, and territorial health departments and personnel in china, working in and supporting the designated covid-19 hospitals in china. a special thanks to charon a. pierson, ph.d., gnp, faan, faanp, editor emeritus, journal of the american association of nurse practitioners for her medical editing support. key: cord-318348-7ns7r2g7 authors: bandaru, s v; augustine, a m; lepcha, a; sebastian, s; gowri, m; philip, a; mammen, m d title: the effects of n95 mask and face shield on speech perception among healthcare workers in the coronavirus disease 2019 pandemic scenario date: 2020-09-28 journal: the journal of laryngology and otology doi: 10.1017/s0022215120002108 sha: doc_id: 318348 cord_uid: 7ns7r2g7 objective: the current circumstances of the coronavirus disease 2019 pandemic necessitate the use of personal protective equipment in hospitals. n95 masks and face shields are being used as personal protective equipment to protect from aerosol-related spread of infection. personal protective equipment, however, hampers communication. this study aimed to assess the effect of using an n95 mask and face shield on speech perception among healthcare workers with normal hearing. methods: twenty healthcare workers were recruited for the study. pure tone audiometry was conducted to ensure normal hearing. speech reception threshold and speech discrimination score were obtained, first without using personal protective equipment and then repeated with the audiologist wearing an n95 mask and face shield. results: a statistically significant increase in speech reception threshold (mean of 12.4 db) and decrease in speech discrimination score (mean of 7 per cent) was found while using the personal protective equipment. conclusion: use of personal protective equipment significantly impairs speech perception. alternate communication strategies should be developed for effective communication. efficient communication is the key to effective healthcare. the current circumstances of the coronavirus disease 2019 (covid-19) pandemic have necessitated the routine use of personal protective equipment (ppe) in all areas of hospitals, from out-patient clinics to operating theatres. an n95 mask and face shield are being used as ppe to protect from aerosol-related spread of infection. with increased workload, effective communication between healthcare workers and between healthcare workers and patient is essential to ensure that healthcare is delivered effectively. the use of ppe, however, greatly hampers communication. the visual cues from lip reading are completely cut off and views of facial expressions are diminished greatly. patients may not completely understand the doctors' instructions. considering the ambient noise, communication between healthcare workers may require multiple repetition and increased strain on listening. further, communication errors are likely, with the potential for grave consequences. in the operating theatre or during procedures, assisting staff may not reliably follow the instructions of the operating surgeon. in our tertiary care ent out-patient set up, healthcare workers are now required to routinely wear an n95 mask and face shield in order to limit infection, and this level of ppe seems to be the minimum requirement in operation theatres as well. our aim was to quantitatively assess the effect of using an n95 mask and face shield on speech understanding among healthcare workers with normal hearing by determining its effect on speech reception thresholds and speech discrimination scores. this prospective observational study was conducted in the out-patient ent clinic of our tertiary care referral centre in south india, after institutional review board and ethical committee clearance. healthcare workers with normal hearing, in the age group of 20-60 years, working in the ent out-patient clinic, were recruited for the study. they underwent pure tone audiometry to ensure normal hearing, defined as a pure tone average of less than 25 db at 500, 1000 and 2000 hz. those with external or middle-ear pathology detected on otoscopy were excluded. healthcare workers aged over 60 years were excluded, to negate the effect of presbycusis. after obtaining informed consent and performing otoscopy, the participants underwent routine pure tone audiometry using a grason-stadler gsi-61 ™ clinical two-channel audiometer. pure tone air conduction and bone conduction thresholds were obtained for frequencies of 250-4000 hz. thresholds up to 25 db across the frequencies 250-2000 hz were considered normal. the pure tone average was calculated using thresholds at 500, 1000 and 2000 hz, and was also used to check the validity of the speech audiometry results. this was achieved by checking there was not more than 12 db discrepancy between the pure tone thresholds and the speech reception threshold. once a normal hearing threshold was ascertained, the volunteers were subjected to speech audiometry to determine speech reception threshold and speech discrimination score. speech audiometry was then repeated with the audiologist using an n95 mask (venus v-44 respirator n95 mask; venus safety & health, navi mumbai, india) and face shield (polycarbonate), as shown in figure 1 . the speech stimuli were presented through the audiometer to each ear separately using a headphone. the speech reception threshold was estimated using a validated list of 50 spondee words recommended by the american speech-language-hearing association. 1 these are two-syllable words that have equal stress on both syllables (e.g. 'tooth brush', 'play ball', 'birthday'). a volume unit meter was used to obtain equal syllabic stress. the words were initially presented 20 db above the pure tone audiometry threshold. if the response was correct, intensity was decreased by 10 db steps, until the subject stopped responding. if the subject responded incorrectly, intensity was increased in 5 db steps. the speech reception threshold was determined as the lowest hearing level (intensity) at which the subject could correctly recognise (perceive and repeat) the speech stimuli 50 per cent of the time. 2 an open set of monosyllabic phonetically balanced words was used to determine the speech discrimination score: the subject repeated the words, with no choice of options. standard word lists for determining the speech discrimination score included those issued by the psycho-acoustic laboratory and the central institute for the deaf w-22 word list for auditory testing. 3, 4 to suit the indian population, our study employed a validated list of phonetically balanced words, adapted from psycho-acoustic laboratory and central institute for the deaf w-22 lists. the words were presented at a level 40 db above the speech reception threshold. a list of 20 words was presented and the number of correct responses was expressed as a percentage. the speech reception threshold and speech discrimination score were then measured in the other ear in a similar manner, using a different set of spondee words and phonetically balanced words. speech audiometry (speech reception threshold and speech discrimination score measurement) was then repeated with the audiologist wearing an n95 mask and face shield. the new speech reception threshold was calculated while the audiologist was using the ppe. the speech discrimination score was calculated again, with the ppe, by presenting the stimuli 40 db above the initial speech reception threshold calculated without ppe. this was done to estimate the degree of hearing difficulty faced by the subject when the examiner spoke normally (and not in a louder tone) even while using ppe. hence, this simulates the healthcare ground situation where one tends to speak in a natural tone while wearing a mask, or more softly than normal, because of the positive feedback obtained with the occlusion effect of the mask. the speech reception threshold and speech discrimination score while using the ppe were compared to the initial measurements obtained when ppe was not used. a pilot study was conducted on five volunteers. the required sample size was calculated based on the results obtained. for a power of 90 per cent and 5 per cent error, the minimum sample size required was 11 subjects. in order to explore additional comparisons, 20 participants were recruited for the study. data were summarised using mean and standard deviation values for continuous variables, and frequency and percentage values for categorical variables. the pre-post changes were analysed using a paired t-test. independent t-tests were used to compare the pre-, postand change in speech reception threshold and speech discrimination score for the categorical demographic variables. for all comparisons, the level of significance was set at 5 per cent. analysis was performed using stata ® /ic16.0 statistical software. twenty healthcare workers (10 men and 10 women) at the ent out-patient clinic who volunteered for the study were recruited. both ears were tested separately for each volunteer and therefore a total of 40 ears were studied. our youngest subject was 23 years old, while the oldest was 54 years old (mean age of 40 years). there were 15 doctors, 3 nurses and 2 medical records officers in the study population. the speech reception threshold ranged from 5 db to 40 db before using the ppe. the thresholds increased while using the ppe, ranging from 15 db to 50 db, as shown in figure 2 . a mean increase of 12.4 db was observed. the speech discrimination score was 100 per cent for all the participants before using the ppe. it decreased while using the ppe, ranging from 90 per cent to 95 per cent, as shown in figure 3 . a mean decrease of 7 per cent was observed. table 1 summarises the mean values of the speech reception threshold and speech discrimination score obtained with and without using ppe, for the 40 ears. there was a statistically significant increase in speech reception threshold and a decrease in speech discrimination scores with the use of ppe; the p-values obtained for both parameters were less than 0.0001 on paired t-test. the changes in speech reception threshold and speech discrimination score measurements were further analysed with respect to age, gender and occupation. the results are summarised in table 2 . there were no statistically significant differences in the changes in speech reception threshold and speech discrimination score values obtained with and without using ppe when comparing between different age groups (20-40 years vs 41-60 years), sex (female and male) and occupation (doctors vs nurses and medical records officers). the importance of communication in all realms of human interaction is well understood. in the healthcare setup, effective communication among healthcare workers, and between healthcare workers and the patient or patient's caregivers, is key to the effective delivery of healthcare. most healthcare settings are usually overcrowded, especially those in developing countries which cater to large numbers of patients with limited infrastructure. aside from the resulting ambient noise, healthcare staff are likely to be working under significant work pressures. the covid-19 pandemic has put additional burden on these already strained healthcare systems and personnel. given the risk of aerosol-related spread of infection, all levels of healthcare workers are required to use additional ppe at work. in the ent out-patient setting at our tertiary care centre, the risk of aerosol generation has necessitated the use of an n95 mask and a face shield while interacting with patients. the operating theatres have also witnessed an increased use of ppe, because of the risk of aerosol generation during intubation and most ent procedures. with the required ppe on, it is a common experience to have to repeat oneself multiple times to convey information to others in the healthcare team or to the patient. it was also felt that there was frequent miscommunication between healthcare workers, which could lead to potential medical errors. this study attempted to quantitatively assess the effect of using ppe (n95 mask and face shield) on communication. speech audiometry tests comprise both the audibility component (loss of sensitivity) and the distortion component (loss of clarity), assessed through measurement of the speech reception threshold and speech discrimination score respectively. the results of our study clearly demonstrate a significant increase in the speech reception threshold (mean of 12.4 db) with the use of an n95 mask and a face shield. this result is comparable to a previous study on the degradation of speech reception associated with the use of medical masks, which recorded an attenuation of about 12 db with the n95 mask. 5 the speech discrimination score showed a worsening of about 7 per cent when the stimuli were presented at the same level with ppe versus without ppe. the presentation level was kept as 40 db above the speech reception threshold obtained when not using ppe, because one tends to speak at a natural tone despite using ppe. the occlusion effect of the face mask tends to produce a positive feedback effect of speech loudness, which may in fact cause one to speak with a softer tone than normal. this positive feedback effect was not however accounted for in our study, as the phonetically balanced word list was delivered through an audiometer at a set level of 40 db above the speech reception threshold obtained without using ppe. although a statistically significant difference is demonstrated in the speech discrimination score values without ppe versus with ppe, the difference may well be larger in the regular setting. our study was performed in a sound-treated audiology setting in order to standardise the environment for quantitative assessment. however, most conversations in the healthcare setting occur in the scenario of significant ambient noise. this may further impair speech perception and intelligibility. in a study by mendel et al. using surgical masks, there was a significant difference in the spectral analysis of speech stimuli with and without the mask. they did not find any difference in speech understanding between normal hearing and hearingimpaired individuals while using a surgical mask, but the presence of background noise (dental office noise) decreased speech understanding in both groups. 6 ideally, estimation should be conducted in the out-patient clinic setting; however, it is difficult to ensure a standard ambient noise and presentation level, to obtain reliable results. hence, testing was carried out in a sound-treated room in our study. the role of cues obtained from lip reading and facial expressions in the perception of speech cannot be ignored. these might have a negligible role in a normal hearing individual and in a quiet environment, but not for those with hearing impairment and in the presence of background noise. atcherson et al., in their study on speech perception in noise when using surgical masks and transparent masks, found that while normal hearing individuals did not require visual cues, hearing-impaired individuals did better when a transparent mask was used. 7 the stress and psychological effect of being in an unfamiliar environment, as for a patient in the hospital, can also impair speech understanding. 8 in our study, age, gender and occupation had no statistically significant correlations with changes in speech reception threshold and speech discrimination scores, suggesting that this impairment in communication while using ppe is applicable to all healthcare workers. the impairment in speech perception while using ppe was evident despite participants being tested in ideal conditions and with the possibility of familiarisation of words associated with repeated testing. • n95 masks and face shields are being used to protect from aerosol-related spread of infection • however, this personal protective equipment (ppe) hampers communication • this study found a significant increase in speech reception threshold (mean of 12.4 db) with ppe use • the speech discrimination score worsened by 7 per cent with ppe (vs without ppe) when stimuli were presented at the same level although a few previous studies have estimated the impairment in speech perception associated with face mask use, to our knowledge this is the first study to quantify the effect of using an n95 mask and face shield (as warranted by the current covid-19 pandemic), on speech perception. further studies on the compounded effect of various environmental variables on speech perception while using ppe will help to qualify these results substantially. the findings of this study justify working towards making the healthcare environment more conducive for effective communication, both among healthcare workers and between healthcare workers and the patients or their caregivers. the use of extra signage in the healthcare setting, adequate lighting, sign language for common instructions, and patient information hand-outs on disease conditions or hand-outs giving instructions may help overcome this communication barrier. while ppe has become an indispensable part of healthcare, its use significantly hampers communication, as evidenced by increased speech reception thresholds and decreasing speech intelligibility. it is important for healthcare workers to be conscious of this when communicating with each other and with the patient or their caregivers, to avoid errors and ensure effective delivery of healthcare. alternative communication strategies may also be explored where appropriate to ensure effective communication. srt = speech reception threshold; sd = standard deviation; sds = speech discrimination score guidelines for determining threshold level for speech handbook of clinical audiology development of materials for speech audiometry articulation testing methods how do medical masks degrade speech perception? speech understanding using surgical masks: a problem in health care? the effect of conventional and transparent surgical masks on speech understanding in individuals with and without hearing loss how social psychological factors may modulate auditory and cognitive functioning during listening acknowledgements. the authors are grateful to ms jemy thomas for performing the audiological tests on the volunteers. we are also grateful to all our colleagues who volunteered to participate in this study. this study was supported financially by the fluid research grant, christian medical college, vellore, india.competing interests. none declared key: cord-352902-isc3ek67 authors: powell, adam w.; mays, wayne a.; curran, tracy; knecht, sandra k.; rhodes, jonathan title: the adaptation of pediatric exercise testing programs to the coronavirus/covid-19 pandemic date: 2020-09-21 journal: world j pediatr congenit heart surg doi: 10.1177/2150135120954816 sha: doc_id: 352902 cord_uid: isc3ek67 objective: response to the coronavirus/covid-19 pandemic has resulted in several initiatives that directly impact hospital operations. there has been minimal information on how covid-19 has affected exercise testing in pediatric patients. design: a web-based survey was designed and sent to pediatric exercise testing laboratories in the united states and canada. questions were designed to understand the initial and ongoing adaptations made by pediatric exercise testing laboratories in response to covid-19. results were analyzed as frequency data. results: there were responses from 42% (35/85) of programs, with 68% (23/34) of laboratories discontinuing all exercise testing. of the 23 programs that discontinued testing, 15 (65%) are actively working on triage plans to reopen the exercise laboratory. personal protective equipment use include gloves (96%; 25/26), surgical masks (88%; 23/26), n-95 masks (54%; 14/26), face shields (69%; 18/26), and gowns (62%; 16/26). approximately 47% (15/32) of programs that typically acquire metabolic measurements reported either ceasing or modifying metabolic measurements during covid-19. additionally, 62% (16/26) of the programs that previously obtained pulmonary function testing reported either ceasing or modifying pulmonary function testing. almost 60% of respondents expressed a desire for additional guidance on exercise laboratory management during covid-19. conclusions: pediatric exercise testing laboratories largely closed during the early pandemic, with many of these programs either now open or working on a plan to open. despite this, there remains heterogeneity in how to minimize exposure risks to patients and staff. standardization of exercise testing guidelines during the covid-19 pandemic may help reduce some of these differences. in mid-december 2019, a novel strain of coronavirus (covid-19) began in the wuhan province and was noted to cause severe respiratory infections and began spreading rapidly around the world. 1 after introduction into the united states, response to the covid-19 pandemic resulted in several initiatives at the regional and national level to mitigate potential morbidity and mortality. 2 mirroring, and in many areas outpacing, the initiatives taken by governmental, societal, and business entities, the health care infrastructure has responded with a series of procedural, algorithmic, and material allocations designed to mitigate the morbidity and mortality associated with the covid-19 pandemic. this includes treatment of positive covid-19 patients, 3 allocation of personal protective equipment (ppe), 4 and triage based on urgency of medical and surgical procedures. 5, 6 additionally, procedures that are associated with particulate aerosol have been categorized, and the risk to patient/health care workers has been quantified. 7, 8 these responses directly impact operations and methodology associated with cardiopulmonary exercise testing (cpet)/ exercise testing. the exercise laboratory is in a unique position of risk as the aerosolization of particles from both symptomatic and asymptomatic patients could potentially infect patients, family, and staff. [9] [10] [11] while guidelines have recommended the annual clinical exercise testing and therapeutics symposiums cpet cardiopulmonary exercise testing pettnet pediatric exercise testing and therapy network ppe personal protective equipment reduction or elimination of elective surgeries and procedures, minimal guidance has been issued for exercise testing. this has resulted in a lack of consensus on proper testing protocols, staffing models, and ppe use in exercise laboratories. the primary aims of this study were to (1) better understand current practice patterns in pediatric exercise laboratories in the united states and canada, (2) assess local and institutional management during the covid-19 pandemic, and (3) investigate how centers are affected by the lifting of hospital restrictions for covid-19. a 21-question online survey (redcap) was designed and distributed to previous attendees of the annual clinical exercise testing and therapeutics symposiums (cetts) in cincinnati, ohio, and programs on the pediatric exercise testing and therapy network (pettnet). the survey was distributed on may 13, 2020, and the collection of responses ended on may 21, 2020. a reminder email asking to complete the survey was sent on may 18, 2020, for those programs that did not respond to the initial email. data were recorded regarding program location, changes to exercise laboratory staffing and operational protocols, current ppe use, changes to exercise testing protocols including deviations in measuring metabolic indicators of fitness, baseline pulmonary function testing, and noninvasive measures of cardiac output. more than one response per question was allowed, but only one completed survey was included per program. lastly, a text box was added for the program to describe additional observations. survey responses were tabulated as frequency data where applicable (categorical data). statistical analyses were performed using redcap. this study was exempt from review by the cincinnati children's hospital institutional review board. surveys were completed by 35 (41%) of 85 programs that received a questionnaire. of the 35 programs that completed the survey, 32 programs were located in the united states and 3 programs were located in canada. geographic regions where the responses originated are presented in figure 1 . of the responding programs, 80% (28/35) were either from a tertiary or major academic medical center, 12% (4/35) were from regional hospitals, and 8% (3/35) identified as either free-standing or other. survey responses are listed in table 1 . the survey responders all reported that covid-19 has led to major changes in the exercise laboratory, with the majority of programs stating that these changes occurred in mid-march (83%; 29/35). among the programs surveyed, 66% (23/35) reported discontinuing all exercise testing for a period of time during the covid-19 pandemic, 31% (11/35) continued testing but only for patients triaged by medical need, and 3% (1/35) did not alter testing protocols. of note, the program that did not alter its testing protocols did not routinely perform metabolic measurements during exercise testing. of the 23 programs that discontinued testing, 15 (65%) are actively working on triage plans to reopen the exercise laboratory, with the remaining 35% of exercise laboratories having no current plan to reopen. staffing changes occurring for programs included 20% of programs mandating furlough for staff, 43% of programs rotating staff over multiple days/weeks, and 40% of programs mandating staff work from home. only one program reported having an employee test positive or have symptoms of covid-19 and three programs (9%) reported having to quarantine staff secondary to covid-19 exposure. there was a wide variation in the ppe used for exercise testing. of the 26 programs that have either continued to conduct tests or have since restarted testing, ppe use included gloves (96%; 25/26), surgical masks (88%; 23/26), n-95 masks (54%; 14/26), face shields (69%; 18/26), and gowns (61%; 16/ 26), with 27% (7/26) reporting using other forms of ppe. one program reported not using ppe; however, they have remained closed and their answer likely reflects the fact that patients are currently not being tested at their center. disinfectants used are summarized in table 1 . there were 91% (32/35) of programs that reported typically acquiring metabolic measurements prior to the covid-19 pandemic, and 47% (15/32) of these programs reported either ceasing or modifying metabolic measurements during covid-19. modifications of acquiring metabolic measurements included minimizing parents in the room, ensuring social distance, and adding antiviral/antibacterial filters to the end of the mouthpiece. there were 74% (26/35) of programs that reported regularly obtaining pulmonary function testing prior to the covid-19 pandemic, with 62% (16/26) of programs reporting they have either ceased or modified pulmonary function testing. pulmonary function testing modifications included n-95 use during testing and using antiviral/antibacterial filters. the survey had an open text field for the exercise laboratories to make general comments with several noteworthy responses given. these responses include three programs discussing the concern with contamination of the tubing involved with metabolic testing and needing to discuss this concern with the metabolic cart manufacturer. additionally, five laboratories volunteered that they will require covid-19 testing prior to having tests performed. three laboratories volunteered that the infection control of their local hospital refused to supply or approve the use of n-95 masks for exercise testing. one program uses uv sterilization once a week in the laboratory. lastly, 57% (20/34) voiced concern over the lack of guidance on this issue and/or hope for consensus on how to perform exercise testing during the pandemic. the novel coronavirus/covid-19 pandemic has greatly affected many hospitals in the united states with over 1.5 million positive patients as of may 20. pediatric centers have not been immune to the impact of covid-19, which may even worsen with the emergence of pediatric multisystem inflammatory syndrome as a recently described pediatric sequela of covid-19. 12 while the impact of covid-19 on pediatric patients with congenital and acquired heart disease is largely unknown, cardiac centers have altered local protocols as many of their patients are known to be at high risk for acquiring acute infectious viral illnesses. 13 the cpet laboratory represents a troublesome combination of potentially high-risk patients in a testing environment that may lead to particle aerosolization. the responses from this survey reflect how each program is seeking to protect patients and staff from covid-19 complications through dramatically different protocols and plans. over 65% of exercise testing programs stopped testing all patients at some point during spring 2020 despite the fact that only 9% of programs had an employee who tested positive, showed symptoms, or was knowingly exposed to someone with symptoms. there are likely several reasons for this. given the lack of availability of ppe in many hospitals throughout the united states, many states mandated nonurgent testing to be postponed to a later date in order to preserve these potentially life-saving resources. pediatric exercise laboratories across the country have largely followed these appropriate requests. secondly, practice patterns likely shift in endemic areas with a high-virus prevalence, increasing the likelihood of transmission to the exercise testing staff, thus necessitating exercise laboratory closure. lastly, the lack of standardized guidelines in the management of pediatric patients with congenital and acquired heart disease and covid-19 likely plays a major role in the heterogeneity of the responses. the uncertainty related to the absence of guidelines was spontaneously disclosed by *60% of the respondents of the survey and is further demonstrated in the marked differences between programs in modifications to exercise testing protocols, reopening plans, and ppe utilization. personal protective equipment use has been a point of widespread concern in hospitals since the start of the current pandemic and will remain a major factor as exercise laboratories are reopened. this study has demonstrated a lack of consensus as to how programs are utilizing ppe to protect both staff and patients. while part of this may be secondary to geographic differences in covid-19 distribution or governmental mandates on the limiting of nonurgent medical testing, another factor may also be the lack of recognition of what constitutes a "high-risk" procedure for particle aerosolization in the nonintensive care settings. [8] [9] [10] [11] the center for disease control considers an aerosol-generating procedure to be a procedure that "creates uncontrolled respiratory secretions." 9 the european society of cardiology has recommended the avoidance of sputum-producing exercise in their guidance on providing cardiopulmonary rehabilitation during the covid-19 pandemic. 11 pulmonary function testing, which was used in conjunction with exercise testing in 74% of our programs, is also felt to have the potential to induce secretions which may increase the risk of transmission. 10 despite the not inconsequential risk of aerosolization, only *50% of programs reported n-95 mask use, although this is somewhat skewed by three programs that were not allowed n-95 use by their local hospital. there does appear to be a consensus among programs performing tests on the use of a facial mask and gloves during testing, and two-thirds of programs also include facial shields and gowns to their standard ppe approach. lastly, while the administration of covid-19 tests has been much discussed in the press, this will likely emerge as a major point of emphasis with the restarting of elective procedures and tests, including exercise testing. preprocedural covid-19 testing will also have additional importance as hospitals attempt to preserve ppe. unfortunately, this survey was created prior to the implementation of widespread testing in the united states, so programs were not specifically asked in the survey whether covid-19 testing is part of their reopening plan. of note, there were five laboratories that volunteered that they currently require or plan to require a covid-19 test prior to having an exercise test. this will take on particular importance as the country prepares for a second wave of infections. as the ability to test for covid-19 improves, it may be vitally important to test all pediatric patients prior to aerosol-generating procedures secondary to the high rate of asymptomatic disease transmission in pediatric patients. 14, 15 this was a study based on voluntary survey completion from a cross section of national pediatric exercise testing laboratories, which results in several limitations. first, there was an overall small number of pediatric exercise testing programs that responded to the survey. while this will limit the ability of the study to make broad conclusions, it is worth noting that this represents a sizable response rate as there are not a large number of exercise testing facilities in the united states specializing in pediatric patients. 16 secondly, the covid-19 pandemic has affected areas of the united states in different ways and at different times, resulting in a heterogeneity of responses to the outbreak based on geography. thus, some of the conclusions from this survey may not be applicable to all areas of the united states or other countries, especially as this survey had a greater response rate from the midwestern and southern united states. lastly, as this was a survey sent to selected programs based on affiliation with either the annual cetts in cincinnati, ohio, or pettnet programs, there is potential for sampling bias. in conclusion, pediatric exercise testing programs have not been immune to the effects of the covid-19 pandemic, with covid-19 epidemic: disease characteristics in children novel wuhan (2019-ncov) coronavirus interim u.s. guidance for risk assessment and public health management of healthcare personnel with strategies to optimize the supply of ppe and equipment ohio department of health. guidance on preparing workplaces for covid-19 infection control in the pulmonary function testing laboratory aerosol-generating procedures and risk of transmission of acute respiratory infections: a systematic review [internet]. ottawa: canadian agency for drugs and technologies in health healthcare infection prevention and control faq for covid-19 expert consensus on pulmonary function testing during the epidemic of coronavirus disease 2019. task force of pulmonary function testing and clinical respiratory physiology, chinese association of chest physicians; pulmonary function testing group recommendations on how to provide cardiac rehabilitation activities during the covid-19 pandemic. european society of cardiology acute heart failure in multisystem inflammatory syndrome in children (mis-c) in the context of global sars-cov-2 pandemic resource allocation and decision making for pediatric and congenital cardiac catheterization during the covid-19 pandemic sars-cov-2 infection in children supplement to sars-cov-2 infection in children clinical stress testing in the pediatric age group: a statement from the american heart association council on cardiovascular disease in the young the authors would like to thank all the first responders and health care workers who have cared for patients during the covid-19 pandemic. specifically, the authors would like to thank all the pediatric exercise laboratories that responded to this survey for completing this item and for all the effort and diligence they have placed in caring for their patients and staff during the pandemic. lastly, the authors would like to thank the cincinnati children's heart institute research core for their assistance with protocol creation and submission to the institutional review board. the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the author(s) received no financial support for the research, authorship, and/or publication of this article. adam w. powell, md https://orcid.org/0000-0002-5537-032x almost 66% of exercise testing facilities polled ceasing all testing at some point in time. there remains a great deal of heterogeneity between programs in the use of ppe and protocols for restarting routine exercise testing. with the wide differences in program responses to exercise testing protocols and ppe, standardized exercise testing protocols during covid-19 testing may be very useful for programs regularly performing testing in this population. a.p. contributed to the design, data analysis and interpretation, and drafting of the article. w.m. and t.c. contributed to the design, data analysis, and critical review of the article. j.r. contributed to the data analysis and critical revision of the article. key: cord-342666-7el8o6qq authors: mahmood, syed uzair; crimbly, faine; khan, sheharyar; choudry, erum; mehwish, syeda title: strategies for rational use of personal protective equipment (ppe) among healthcare providers during the covid-19 crisis date: 2020-05-23 journal: cureus doi: 10.7759/cureus.8248 sha: doc_id: 342666 cord_uid: 7el8o6qq as the coronavirus 2019 (covid-19) began spreading globally with no clear treatment in sight, prevention became a major part of controlling the disease and its effects. covid-19 spreads from the aerosols of an infected individual whether they are showing any symptoms or not. therefore, it becomes nearly impossible to point exactly where the patient is. this is where personal protective equipment (ppe) comes in. these are masks, respirators, gloves, and in hospitals where the contact with the infected and confirmed patient is direct, also gowns or body covers. the ppes play a major role in the prevention and control of the covid-19. the ppe is able to prevent any invasion of the virus particles into the system of an individual which is why it is an essential item to have for healthcare workers. due to the high demand for ppes all around the world, it is important to optimize the use of protective gear and ration the supplies so that the demand are met. however, there are guidelines recommended by the world health organization (who) and the centers for disease control and prevention (cdc) to maintain the supply in the wake of this increased demand of ppe, how the manufacturers should track their supplies, and how the recipients should manage them. various strategies can be used to increase the re-use of ppes during the covid-19 pandemic that has modified the donning and doffing procedure. personal protective equipment (ppe) is an article used to prevent the wearer from coming in contact with hazardous, infectious, chemical, radiological, electrical, and physical agents. it contains components illustrated in figure 1 [1] . the surge in demand and misuse of ppe has led to an acute shortage of protective gear, endangering the lives of healthcare workers [2] . more than 9,000 healthcare workers (hcw) in the united states (us) and more than 17,000 in italy have been infected with covid-19 [3] [4] . a total of 444 hcw in pakistan have been exposed to covid-19 as of april 29, 2020 [5] . many doctors are performing their duty without any ppe and are at high risk of becoming infected [6] . there have been peaceful protests all over the world by doctors, nurses, and other healthcare professionals demanding ppe. 1 2 3 4 5 in the wake of the covid-19 pandemic, ppe plays a significant role, with face masks and gloves being the most essential. doctors, nurses, and other frontline healthcare responders are using them to minimize the risk of contaminated contact or droplet exposure. some studies suggest that the psychological impact of ppe is such that individuals using them might feel more protected than they actually are in reality [7] . it should be ensured that the wearer practices hand hygiene before wearing and after removing the protective gear. also, an appropriate method for its disposal should be considered. the primary mode of transmission of coronavirus is known to be droplet or contact-based. infected individuals are prone to spread the virus while coughing, sneezing, or speaking. this micro virus, when ejected, can travel up to a distance of six feet. wearing a face mask, along with other precautionary measures like hand hygiene and self-isolation, limits the transmission of infectious agents [8] [9] . initially, the usage of masks among the general public was highly controversial. experts discouraged healthy people from wearing masks due to the scarce supply. this equipment was reserved for those in direct contact with infected patients [10] . however, the rapid rise in the degree of local transmission has caused many countries to allow their citizens to wear nonmedical/cloth masks, along with practicing social distancing [9, 11] . evidence-based studies reveal that the concomitant use of household (non-medical) face masks, as well as using a proper handwashing regimen, reduces the probability of local transmission, thereby decreasing the death toll [12] . it should be noted that according to the world health organization (who) guidelines, medical masks and respirators should only be reserved for healthcare workers [10] . factors that determine the efficiency of face masks are listed in table 1 [13]. the shape of the mask the main types of masks being used are respirators, medical masks, and non-medical/cloth masks. these are protective equipment which provides an almost accurate facial fit and effective filtration of airborne particles. they provide a proper seal around the mouth and nose, providing optimal protection. according to the recent who, cdc, and fda guidelines, such masks are only reserved for healthcare providers [10, [13] [14] . the fda has labeled these masks as single-use, disposable devices; however, in cases of shortage in supplies, these can be sterilized and reused [14] . while the respirator masks are highly efficient, they still do not provide complete protection. improper and misuse of these masks can lead to the spread of infection in the user [15] . these are thin, pleated, and disposable masks that protect the user from inhaling dust particles, contaminated liquid droplets, and bacteria. they are usually two layers thick and made from unwoven fabric. these masks only act as a physical barrier between the user's nose and mouth and the infected environment. they do not possess a proper seal and are less effective than respirators. these are loose masks, which allow comfortable breathing and reduce transmission probability [14] . according to recent studies, asymptomatic and pre-symptomatic carriers of the novel coronavirus have been detected and can transmit the virus. in the face of this discovery, cdc experts recommend that the general public uses non-medical/cloth coverings to shield their mouth and nose. these textile masks are made up of layers of cloth. some of them also possess a paper towel layer, which increases the filtration capability. they do not offer full protection but, along with other precautionary measures, are useful to slow down the spread of coronavirus [16] . as a general safety precaution, every frontline healthcare worker (hcw) should know which ppe needs to be used in different clinical settings [17] [18] . 1) under any clinical setting where there is a risk of getting infected, the individual should don (put on) a medical face mask, gloves, gown, and eye protection, 2) if the hcw is more than 2 meters away from the patient, he/she should use a fluid-resistant medical face mask with or without eye and face protection, depending on whether there is exposure to flashes or droplets. 3) in case of an ongoing aerosol-generating procedure (agp), all individuals present should wear a respirator, face and eye protection, gloves, and long-sleeved fluid-repellent gown. it is essential that every hcw should know the proper way to put on (donning) and remove (doffing) ppe. any mistake in doing so can render the individual exposed to infections agents. according to standard infection prevention and control (ipc) guidelines, ppe is a single-use, disposable item. however, due to the current shortage of ppe, health care providers are challenged to rationally use the limited supplies by decontaminating and reprocessing them. it should be noted that there is no proven effectiveness of these practices and priority is given to the rapid manufacture of protective items [21] . improper or inadequate decontamination of equipment before reuse is unsafe and can pose serious threats [22] . when disinfecting ppe, it is important to keep in mind the efficacy of the method used, check for any residual toxicity, and make sure that the functional integrity of the material is maintained. general strategies include following the manufacturer's guidelines to disinfect and reprocess the ppe. routine inspection of protective material should be carried out, along with the replacement of the equipment if the integrity is not maintained or it is damaged. 1) usually cleaning prior to disinfection is required. respirators and medical masks lose their protective property when they undergo cleaning. 2) considering the current conditions, these items can be worn by a single hcw for multiple shifts. factors, such as humidity and shelf-life, limit their use. 3) medical masks can be reprocessed using the environment protection agency (epa)registered disinfectants. filtering facepiece respirators can be decontaminated using vaporous hydrogen peroxide, moist heat, and bleach solution. gowns 1) submerge in hot water and detergent, then thoroughly scrub the gown. 2) afterward, soak in 0.05% chlorine solution for about 30 minutes. 3) rinse in clean water and ideally allow drying in the sun. 4 ) gowns having small holes and tears could be mended whereas worn out gowns should be discarded. 1) clean first the inside and then the outside surface of the visor using a detergent-soaked clean cloth. 2) clean the outside of the visor with a clean cloth saturated with disinfectant. 3) wipe the outside of the visor with clean water. 4) use towels or dry air to completely dry the visor. 1) immerse in warm water and neutral detergent solution. 2) rinse with clean water. 3) wipe with disinfectant and then again rinse with clean water. 4) dry completely using towels or dry air. potentially infectious medical waste (pimw), such as covid 19 testing kits and ppe, have a serious risk of coming in contact with infectious bodily fluids. these materials should be kept safely on site (hospitals, testing centers) in secure containers. they should then transferred to storage facilities, where they are disinfected and disposed of off to landfill sites [23] . individuals responsible for waste management should take caution and should wear appropriate gear. it is extremely critical to properly decontaminate and dispose of any waste material that could infect people who come in contact with it. the escalating demand for ppe has given rise to new state and local strategies to ensure the careful optimization of available resources. this policy helps reserve the reduced amount of ppe for the most critical conditions. as the situation improves and the ppe supply is sufficient again, the state can return to its conventional ppe guidelines. the following strategies should be observed to overcome the shortage of ppe [24] . there is a difference in the demand and supply of ppe, with severe shortages in supply on all fronts. it is crucial that all the equipment is used with care to prevent wastage, to ensure a continuous supply of protective equipment despite limited production [1, 22] . 1) the healthcare professionals who are working with patients of covid-19 and are in direct contact should have ppe consisting of gloves, gowns, masks, face shields, and goggles. 2) the same respirator can be used while examining multiple patients at a time. since the shortage of supply is a fact in most places, it is recommended to keep wearing a single one for multiple patients than to not have any respirator on. 3) hcw performing or assisting with invasive procedures should be wearing respirators, eye protection (like goggles), and a face shield aligned with the gown and gloves. if the gowns allow fluid to pass through, an additional layer of protective coverage like an apron should be worn. 4) people who are taking care of the sick at home should be provided with medical masks at home for their own protection and to limit the spread of the disease. 5) individuals who remain asymptomatic or do not show any signs of illness can use nonmedical masks and should not opt for medical masks. inappropriate use of medical masks may increase the demand and can also impede the supply to professionals who need them the most. the need for ppe can be minimized by the following interventions [25] : 1) limit patient contact and use alternate tools, such as telemedicine, for non-emergency cases. 2) make sure that no personnel who is not immediately needed for the patients' care should enter the premise of the covid-19 ward that should be a separated and isolated area. the visitors should either not be allowed at all or should have minimal contact with the patients. 3) all non-urgent procedures/appointments should be postponed. 5) ppe should be used beyond their shelf life making sure they are not worn out or damaged. 6) in the case of the absolute absence of ppe, alternate methods for barrier control (e.g., glass shields) should be employed. these practices do not guarantee the absolute safety of healthcare professionals, and their effectiveness is questionable. however, under the present circumstances, these crisis strategies given by the cdc should be duly addressed. the supply should be monitored and demand adjusted [21, 26] . this can be done using the following methods: 1) use of rational quantification-based forecasts regarding ppe. this helps in rationing available supplies to meet the demand. 2) the request for ppe from countries, as well as major responders, should be monitored and controlled. the distribution of ppe to healthcare institutions should be controlled and monitored. 3) to avoid stock duplication, a centralized request management system should be applied that takes notice of whether the stock management rules are being followed or not. this helps in controlling the wastage and overstock. 4) keep a check on the end-to-end distribution of ppe. due to the recent ease in lockdown measures and the commencement of the holy month of ramadan in the muslim world, an abrupt rise in public gatherings is feared. therefore, it is highly critical that ppe's should be used in all clinical and non-clinical settings. citizens should use a cloth barrier while stepping out of the house and public gatherings should be strictly avoided. the proper protocol should be followed when healthcare professionals consider reusing ppe. as pakistan is one of the major distributors of ppe throughout the world, it has set an exemplary approach during this pandemic. the pakistani government and national disaster management authority (ndma) have made tireless efforts to increase the manufacturing and distribution of ppe. moreover, many non-governmental organizations (ngos) and medical students have come forward to combat this deadly disaster and distribute ppe to those fighting on the frontline. disclosures risk at work -personal protective equipment (ppe) shortage of personal protective equipment endangering health workers worldwide health-care workers have been infected with the coronavirus 000 italian health workers infected with virus: study infections amongst healthcare workers increase by 75pc in a week uk doctors finding it harder to get ppe kit to treat covid-19 patients use of ppe in response of coronavirus (covid-19): a smart solution to global economic challenges rational use of face masks in the covid-19 pandemic keep your distance to slow the spread advice on the use of masks in the context of covid-19 recommends people wear cloth masks to block the spread of covid-19. surgical masks and n95 respirators should be reserved for health care workers face masks against covid-19: an evidence review 13. n95 respirators and surgical masks n95 respirators and surgical masks (face masks improper use of medical masks can cause infections use of cloth face coverings to help slow the spread of covid-19 accessed updated guidance on personal protective equipment (ppe) for clinicians personal protective equipment use in health care use personal protective equipment (ppe) when caring for patients with confirmed or suspected covid-19 operational considerations for personal protective equipment in the context of global supply shortages for coronavirus disease 2019 (covid-19) pandemic: non-us healthcare settings rational use of personal protective equipment ( ppe) for coronavirus disease ( covid-19) : interim guidance water, sanitation, hygiene and waste management for covid-19 strategies to optimize the supply of ppe and equipment sourcing personal protective equipment during the covid-19 pandemic critical preparedness, readiness and response actions for covid-19: interim guidance in compliance with the icmje uniform disclosure form, all authors declare the following: payment/services info: all authors have declared that no financial support was received from any organization for the submitted work. financial relationships: all authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. other relationships: all authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work. key: cord-345806-3ghtpji4 authors: boelig, rupsa c.; lambert, calvin; pena, juan a.; stone, joanne; bernstein, peter s.; berghella, vincenzo title: obstetric protocols in the setting of a pandemic date: 2020-07-24 journal: semin perinatol doi: 10.1016/j.semperi.2020.151295 sha: doc_id: 345806 cord_uid: 3ghtpji4 the purpose of this article is to review key areas that should be considered and modified in our obstetric protocols, specifically: 1) patient triage, 2) labor and delivery unit policies, 3) special considerations for personal protective equipment (ppe) needs in obstetrics, 4) intrapartum management, and 5) postpartum care. in the setting of a new pandemic certain changes need to be implemented in order to accommodate increased volume of patients seeking care, provide adequate staff protection against acquiring disease, provide adequate patient protection from acquiring disease, and limit disease related morbidity. recent epidemics that have challenged obstetric care include sars-cov-2 (covid19) , h1n1 influenza, zika virus, and ebola virus. the purpose of this article is to review key areas that should be considered and modified in our obstetric protocols, specifically: 1) patient triage, 2) labor and delivery unit policies, 3) special considerations for personal protective equipment (ppe) needs in obstetrics, 4) intrapartum management, and 5) postpartum care training of administrative staff on proper screening protocols is crucial. verified infectious screening tools should be utilized upon presentation to the labor floor. in addition, screening of support persons should also be performed. phone calls to labor and delivery (l&d) should be triaged according to figure 1 . patients calling with symptoms of illness or with direct contacts who have no urgent obstetrical issues and mild/moderate symptoms should be referred for testing outside of the hospital as per local protocols. women without urgent obstetrical issues awaiting results should stay home to selfisolate. those with urgent obstetrical issues (e.g. labor, rupture of membranes, vaginal bleeding, etc.) or severe symptoms should be evaluated in the hospital with appropriate plans for isolation and ppe. a system should be in place for continued remote follow up of patients who are selfisolating with test pending or positive test results (1). when women arrive to l&d, a designated staff member at the front of the unit should verbally screen each individual for symptoms of illness. all patients and support people should be given appropriate ppe to minimize transmission (ie mask or gloves) and evaluated by provider in an isolated area. patients who screen positive should be managed as in figure 2 based on acuity of symptoms and presenting complaint (1). one effective strategy to limit patient and healthcare worker exposure is universal screening and testing when available for case ascertainment (2) . this may be particularly useful for obstetrical patients who interact frequently with the health care system. moreover, advance knowledge of disease status may allow a labor unit to properly isolate a patient and provide appropriate ppe for healthcare workers. this screen can be simple, such as taking a basic clinical history, and exam, or complex including sophisticated serologic testing. early in a pandemic there may not be commercial testing available, so implementation of key screening questions is crucial. protocols for management of screen-positive patients should take into account the sensitivity and specificity of the method. early in a pandemic, centers should consider over-isolation, particularly when data on the disease is sparse. support persons should be screened and, if possible, tested. when possible, labor units should perform advanced screening and testing for scheduled deliveries. for any patient who screens positive, delaying delivery until diagnostic testing results are available should be considered, particularly if a rapid test is available for the pathogen. often a scheduled delivery cannot be safely delayed more than one week and if diagnostic testing cannot be resulted in that time frame, patient should be treated as infected with the appropriate precautions. during a pandemic, obstetrical units should have evidence-based policies on appropriate isolation of cases or persons under investigation (pui) (3) . if patients cannot be appropriately isolated on labor and delivery unit, there need to be contingency plans for isolation off of the unit while still providing maternal and fetal monitoring and care. the level of precaution will depend on the pathogen in question but fall into three levels (4): 1) contact precautions for patients known to have infections that represent an increased risk of contact transmission. 2) droplet precautions for patients infected with pathogens transmitted by a patient who is coughing or sneezing. 3) airborne precautions for patients infected with pathogens transmitted by the airborne route, including use of an airborne infection isolation room (aiir) (5) . case isolation includes not just physical isolation room but also ppe for patient to limit transmission, including gloves and/or mask. a center may elect to isolate a patient off labor and delivery to limit exposure to other pregnant patients, in which case they should consider remote fetal monitoring capabilities and having adequate equipment for emergency delivery near the patient. unit staffing may need to be modified in setting of a pandemic to limit risk of crossinfection and staffing shortfalls due to illness. one strategy is rotating dedicated teams to care for exposed or infected patients and developing a model of workplace segregation (6). a pandemic may strain hospital capacity and bed availability. this can be particularly problematic for busy labor units used to quick turnover. in anticipation of this challenge, centers should identify options for over-flow units, contingency plans for postpartum beds if they are not available, and alternative post-anesthesia recovery beds if this cannot occur on the labor unit. sites should also consider designating a section or floor for cohorting cases and puis. depending on the pathogen, sites may also have to alter their newborn and nicu rooming policies. labor unit leaders should work closely with hospital administration, nursing, anesthesia, neonatalogy/pediatrics, infectious disease, and critical care medicine to best address the unique needs and challenges of labor and delivery in the setting of particular pathogens. an interdisciplinary approach is necessary especially for pregnant women on "pandemic" floors or in icus where the potential for fetal monitoring, use of certain medications and potential need for delivery need to be addressed. centers should also develop plans for outpatient management of conditions that may traditionally have utilized inpatient care, this includes, for example, outpatient management of hyperemesis gravidarum, one of the more common reasons for antepartum admission, and early postpartum discharge with telehealth resources for lactation support/medical follow up. a pandemic may tap or make unavailable a hospital's typical critical care resources. consequently, sites should develop protocols that would allow obstetricians, nursing and anesthesiology to provide critical care on labor and delivery (8) . critical care resources that can be employed on labor and delivery include use of operating room/anesthesia machines as temporary ventilators, telemetry capabilities with remote cardiology monitoring, and acute nursing care. training and simulation in critical care obstetrics may be useful and enhance the confidence of members of the labor team (see critical care obstetrics: development of an obicu) (9) . additionally, a close relationship with the critical care team allows for consultation and assistance with initial stabilization, and once an icu bed becomes available, seamless transition. a pandemic can also lead to shortages of blood products, as such it is prudent to incorporate the blood bank into multidisciplinary planning (10). based on the characteristics of the pathogen, a patient's partners and family may also be a engaging stakeholders in the community when making these decisions can facilitate understanding of, compliance with and support for infection control policies. when developing protocols during an emerging pandemic, centers should focus on using available data to balance the risks of maternal disease with the risk of prematurity. if not already done so, labor units should ensure evidence-based guidelines for timing of induction of labor. this may reduce the burden of unindicated deliveries and may protect clinical volume in the case of a pandemic. if a pandemic causes extreme stress on a health system, centers should also develop protocols on how to prioritize deliveries and plan for maternal/fetal outpatient surveillance for those patients where delay of delivery is deemed necessary. as previously mentioned, obstetrical leaders are encouraged to communicate with hospital administration frequently, as the needs of a labor unit change. obstetric practice has unique clinical scenarios that need to be considered when determining the personal protective equipment (ppe) needs of healthcare workers in that setting. during active labor and delivery (second and third stage) there is significant close physical contact with a patient for prolonged periods of time with exposure to multiple body fluid typessweat, respiratory droplets/aerosols, amniotic fluid, blood, urine and feces. adequate ppe depending on transmission type is critical. the second stage of labor should be considered a risk for aerosol transmission based on heavy/labored breathing and close physical contact (11) (1). sars-cov-2, influenza, and other respiratory illnesses have high risk of droplet and aerosol spread during labor and delivery and thus in addition to gown/gloves/face shield, appropriate respiratory protection is necessary to consider as well (i.e. n-95 mask). another important example an illness that requires obstetric specific ppe is the ebola virus, which is transmitted easily through direct contact of bodily fluids, including amniotic fluid and cord blood, mucus membranes, or contaminated surfaces/objects (3). in preparation for such an epidemic, double gloves, eye/face shield, mask, impervious gowns, full coverage of shoes/pants are critical at time of delivery to prevent healthcare worker infection and further spread given the inevitable volume of bodily fluid exposure during labor and delivery (12) . in addition to considering the distinctive circumstances of active labor, patients on labor and delivery are also unique in that everyone is at risk for needing an emergent surgery necessitating rapid delivery under general anesthesia. this requires careful planning of the changes in ppe required when going from labor to cesarean birth under general anesthesia, including availability of all supplies and consideration of simulations (see obstetric simulation in this issue) to prepare for these contingencies. at the time of cesarean, considerations for ppe use include the potential for aerosol generating procedures including during intubation, suctioning, electrocautery, or the administration of aerosolized medications as well as the potential for exposure to body tissues/fluids. unless evidence demonstrate otherwise, standard obstetrical indications for delivery should continue to be used. however, delivery timing should also take into consideration the natural history of the disease as delivery may or may not improve disease course. for example, in the setting of respiratory illnesses (airborne versus droplet transmission) it is important to consider the extent to which pregnancy pulmonary physiology may complicate the patient's clinical presentation. with a reduction in residual volume and an increase in oxygen consumption, the burden of disease may increase the patient's oxygen requirements and ultimately lead to respiratory compromise. while delivery in the setting of concern for impending respiratory failure requiring intubation may not always improve respiratory status, theoretically it stands to improve pulmonary physiology (14) (15) . in arriving at this decision, care providers should weigh the risk of prematurity against the potential maternal benefit bearing in mind that significant maternal compromise also places the fetus at risk. in deciding on the timing and mode of delivery providers should consider the clinical status of the patient, the gestational age and the fetal status. no current data suggests absolute contraindications for vaginal delivery in most respiratory and blood borne illnesses. cesarean deliveries should be reserved for routine obstetrical indications, or concern for deterioration of the maternal condition over the course of labor such as acute organ failure or septic shock (16). this should be balanced against risks of cesarean delivery including bleeding, infection, and fluid shifts. regional anesthesia continues to be the preferred modality for obstetric analgesia. in fact, given the potential for either limited general anesthesia availability or increased transmission risks associated with intubation, early epidural may be encouraged to avoid the need for general anesthesia should an emergent cesarean delivery be indicated (17) . (see anesthesia considerations for the obstetric provider) the same absolute contraindications to regional anesthesia apply including patient refusal, infection at or near the site of needle insertion, and acute maternal hemorrhage/severe coagulopathy. in the setting of a blood borne pathogen pandemic, regional anesthesia may also be contraindicated. contingency plans should be in place in anticipation of the possible limited availability of anesthesia staff for the labor floor to address non-lifethreatening conditions. such plans might include: the use of intravenous narcotics, nitrous oxide, local anesthesia (pudendal block), a virtual companion for breathing techniques, laboring accessories that may assist in pain control, and other alternative means such as intradermal sterile water injections, or relaxation techniques. cervical ripening/labor augmentation: once patient has been admitted to labor and delivery, judicious use of resources to optimize timely vaginal delivery should be implemented including dual agent induction (e.g foley catheter and misoprostol) (18) and early amniotomy (19) . limiting the number of cervical exams to those that are most necessary can decrease the risk of exposure to medical personnel. depending on the etiology of a concerning fetal heart rate tracing, maternal repositioning, tocolysis, or amnioinfusion remain important tools in intrapartum fetal resuscitation. maternal oxygen via face mask or nasal cannula for fetal resuscitation is not recommended because although it may have a low risk of aerosol dispersion, but there is risk of surface transmission through handling equipment with nasal secretions and it has not been proven to have any fetal benefit (20). consideration should be given to the potential impact of commonly used medications in obstetrics and whether they can have a potential impact on the course of the given disease (table 1 ). obstetric services should have protocols in place to adjust the indications/dosing/usage of such medications. intravenous fluids are typically used quite liberally on labor and delivery. however, it is important to remember that labor and delivery is a significant strain on the maternal heart, lungs, and kidneys. in addition, the peripartum course involves significant fluid shifts, going from routine management of the second and third stages of labor still apply. steps to shorten these stages of labor will assist with reducing strain on limited resources including immediate versus delayed pushing (21) , use of operative delivery to shorten second stage especially in setting of maternal compromise, and use of perineal massage/warm compress to reduce risk of obstetric associated anal sphincter injury (22) . in the setting of a pandemic, it is reasonable to expect a strain on local blood banks due to a significant decline in donations, or inability to accept donations due to transmission risks. aggressive postpartum hemorrhage prevention is recommended. this starts as early as risk stratifying patients based on their history and intrapartum course as well as active management of the third stage of labor. early administration of the appropriate uterotonics or tranexamic acid (txa) to minimize these events is optimal (23). in the setting of a pandemic, considerations for breastfeeding include transmission through breastmilk, and proximity required for breastfeeding. in illnesses with no documented breast milk transmission, breastfeeding with attention to hygiene and/or pumping with limited neonatal contact to avoid person to person transmission is reasonable. for illnesses such as hiv and ebola with documented breast milk presence, breastfeeding is not advised; however limited resources or access to breastmilk may mitigate such recommendations. to alleviate both hospital capacity burdens and risk of nosocomial infection, discharge for all patients should be expedited as medically and socially appropriate, postpartum day 1 or 2 for vaginal deliveries and day 2 for cesarean deliveries. expedited discharge is facilitated by home blood pressure monitoring, telehealth visits, and placement of long acting reversible contraceptives during hospitalization to avoid need for additional in person visit. in summary, careful planning in preparation for managing obstetric patients during a pandemic can mitigate risks to patients, their newborns and families and staff. labor and delivery guidance for covid-19 universal screening for sars-cov-2 in women admitted for delivery emerging infectious diseases in pregnnacy. rh, beigi. 5, s.l. : obsterics and gynecology centers for disease. cdc infection control covid-19) pandemic and pregnancy ambulatory versus inpatient management of severe nausea and vomiting of pregnancy: a randomised control trial with patient preference arm framework for critical care in obstetrics. baird sm, martin s. 3, s.l the utility of bedside simulation for training in planning for pandemic influenza: effect of a pandemic on. zimrin ab, hess jr. 6, s.l. : transfusion influenza virus aerosols in human exhaled breath: particle size, culturability, and effect of surgical masks what obstetrician-gynecologists should know about ebola: a perspective from the centeres for disease control and prevention coronavirus (covid-19) infection in pregnancy: information for health care professionals management of acute respiratory failure in pregnnacy 2, s.l. : semin respir crit care med global interim guidance on coronavirus disease 2019 (covid-2019) during pregnancy and pueriperum from figo and allied partners: information for healthcare professionals combination foley catheter and prostaglandins or foley and oxytocin for cervical ripening: a network meta-analysis early amniotomy after cervical ripening for inductino of labor: a systematic review and meta-analysis of randomized controlled tirals delayed versus immediate pushing in the second stage of labor in women with neuraxial analgesia: a systematic review and meta-analysis of randomized controlled trials prevention and management of obstetrics lacerations at vaginal delivery practice bulletin no 165 american college of obstetricians and. 1, s.l uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis corticosteroid guidance for pregnancy during covid-19 pandemic key: cord-340887-k88hchau authors: khusid, johnathan a.; weinstein, corey s.; becerra, adan z.; kashani, mahyar; robins, dennis j.; fink, lauren e.; smith, matthew t.; weiss, jeffrey p. title: well‐being and education of urology residents during the covid‐19 pandemic: results of an american national survey date: 2020-05-27 journal: int j clin pract doi: 10.1111/ijcp.13559 sha: doc_id: 340887 cord_uid: k88hchau background: the rapid spread of covid‐19 has placed tremendous strain on the american healthcare system. few prior studies have evaluated the well‐being of or changes to training for american resident physicians during the covid‐19 pandemic. we aim to study predictors of trainee well‐being and changes to clinical practice using an anonymous survey of american urology residents. methods: an anonymous, voluntary, 47‐question survey was sent to all acgme‐accredited urology programs in the united states. we executed a cross‐sectional analysis evaluating risk factors of perception of anxiety and depression both at work and home and educational outcomes. multiple linear regressions models were used to estimate beta coefficients and 95% confidence intervals. results: among approximately 1,800 urology residents in the usa, 356 (20%) responded. among these respondents, 24 had missing data leaving a sample size of 332. important risk factors of mental health outcomes included perception of access to ppe, local covid‐19 severity, and perception of susceptible household members. risk factors for declination of redeployment included current redeployment, having children, and concerns regarding ability to reach case minimums. risk factors for concern of achieving operative autonomy included cancellation of elective cases and higher level of training. conclusions: several potential actions, which could be taken by urology residency program directors and hospital administration, may optimize urology resident well‐being, morale, and education. these include advocating for adequate access to ppe, providing support at both the residency program and institutional levels, instituting telehealth education programs, and fostering a sense of shared responsibility of covid‐19 patients. in december 2019, a highly contagious novel coronavirus (sars-cov-2) was identified in wuhan, china 1 , and on march 26 th , 2020 the usa became the world's most afflicted nation with 81,321 cases of coronavirus disease 2019 (covid-19) 2,3 . the rapid spread of covid-19 has placed tremendous strain on the american healthcare system and prompted drastic steps to divert healthcare resources for the treatment of patients with covid-19. for example, on march 14 th , 2020 the surgeon general advised all hospitals to halt elective surgery 4 . additionally, physicians have increasingly used telemedicine to facilitate social distancing 5 and in some instances, physician specialists, have been redeployed to "frontline" services such as the medical wards, intensive care unit, and emergency room 6 . in addition to clinical practice changes, numerous academic meetings have been cancelled, licensing exams are being rescheduled, and fellowship interviews are being conducted using teleconferencing software 7 . beyond the educational and structural changes experienced, covid-19 threatens the well-being of residents as nationwide personal protective equipment (ppe) shortages leave frontline workers at increased risk of viral exposure 8 . furthermore, a recent study conducted in wuhan during the covid-19 pandemic reported that frontline workers were at risk of unfavorable mental health outcomes 9 . despite these monumental changes and the unique challenges presented by the pandemic, the impact on resident well-being, clinical practice, and education are largely unknown. to address this gap, in the current study we aim to assess the well-being, clinical practice, and education of urology residents throughout the usa during the covid-19 pandemic through the use of an anonymous survey. given that routine urology practice encompasses elements of outpatient clinic, inpatient medicine, and surgery, and the low number of urology trainees nationally relative to other specialties, a national study of urology trainees may provide an important and timely initial assessment. to our knowledge, this is one of the first studies assessing trainees' well-being, clinical practice, and education during the covid-19 pandemic. the study obtained exempt status from the suny downstate health sciences university institutional review board. an anonymous, voluntary, 47-question survey was sent to all american council for graduate medical education (acgme)-accredited urology programs in the usa by contacting each program's coordinator and/or director and each american urologic association (aua) section secretary with the request to disseminate it to their residents. additionally, social/professional networks were used to disseminate the survey, which was available from april 7, 2020 until april 11, 2020. the study is cross-sectional and assessed resident perceptions of personal, institutional and residency program responses to the pandemic. the survey utilized questions that were single-answer, multiple-answer, and likert scales which were graded on a 1-5 scale with 1 representing "strongly disagree" and 5 representing "strongly agree." this article is protected by copyright. all rights reserved the study evaluated six likert scale outcomes related to resident mental health and training. perceived severity of anxiety was evaluated using the following statements "i have increased anxiety at work due to the covid-19 pandemic" and "i am more anxious outside of work due to the covid-19 pandemic." similar statements were used for perceived severity of depression: "i feel a sense of depression at work due to the covid-19 pandemic." and "i feel a sense of depression outside of work due to the covid-19 pandemic." declination of redeployment was measured with as follows: "i would decline redeployment to a covid-19 service if given the option." concern of operative autonomy was measured as follows: "i am concerned about my ability to operate independently as an attending urologist due to interruptions in training secondary to the covid-19 pandemic." the objective was to identify independent risk factors of outcomes among urology residents during the pandemic. potential risk factors included: resident age, gender identity, level of training, practice setting (urban/suburban/rural), aua geographical section, perception of local covid-19 severity (likert), marital status, children, perceived household susceptibility to disease (likert), history of covid-19 symptoms, months of intensive care unit training, redeployment status, perceptions of availability of ppe (likert) and covid-19 testing, cancellation of elective cases, number of weekly operations before the pandemic, perceived program and hospital support (likert), perception of shared responsibility with attendings (likert), and perceived difficulty meeting case minimums (likert). data analysis was executed using r. two-sided p-values with alpha=0.05 were used. distributions of characteristics were tabulated using percentages for categorical variables and means with standard deviations for continuous variables. six multivariable linear regressions were fit for the six outcomes using all risk factors as independent variables. models estimated beta coefficients (β) and 95% confidence intervals (ci) representing associations between risk factors and outcomes. linear regression assumptions were evaluated using plots and hypothesis tests. qqplots verified the assumption of normality. to test for heteroskedasticity, residual plots were generated along with a non-constant variance test. there was strong evidence of heteroskedasticity. to correct this, all outcomes employed a box-cox transformation. lack of multicollinearity was confirmed by estimating variance inflation factors. among approximately 1,800 urology residents, 356 (20%) responded. among these respondents, 24 had missing data leaving a final sample size of 332. table 1 reports the distributions of variables. the average age of the sample was 30.5. of the 332 respondents, 117 (35%) were female, 218 (66%) were married, 262 (79%) practiced in an urban setting, while 59 (18%) practiced in a suburban setting. the most represented aua regions were new york (32%), mid-atlantic (15%), and north-central (14%). a total of 72 (22%) had been redeployed to a different service and 18 (5%) reported a history of covid19 symptoms. figure 1 reports results of the risk factors associated with severity of anxiety outcomes. perception of ppe availability was associated with lower severity of anxiety at work (β=-0.14, 95% ci=-0.25, -0.02) and at home (β=-0.13, 95% ci=-0.25, -0.01) whereas perception of local covid-19 severity was associated with higher severity of anxiety at work (β=0.21, 95% ci=0.09, 0.33) and at home (β=0.16, 95% ci=0.03, -0.29). perception of susceptible household member was associated with higher severity of anxiety at work (β=0.14, 95% ci=0.05, 0.23) and at home (β=0.12, 95% ci=0.03, 0.22). urban practice setting (β=0.69, 95% ci=0.02, 1.36) and suburban practice setting (β=0.71, 95% ci=0.01, 1.42) was associated with higher anxiety severity at work compared to rural practice setting. personal history of infection with covid-19 was associated with higher severity of anxiety at work (β=0.14, 95% ci=0.04, 0.24). amount of prior intensive care unit training was associated with lower severity of anxiety at work (β=-0.08, 95% ci=-0.14, -0.02). current redeployment was associated with higher severity of anxiety at work (β=0.14, 95% ci=0.02, 0.26) while perception of program support (β=-0.11, 95% ci =-0.20, -0.03) was associated with lower severity of anxiety at work. availability of testing if symptomatic was associated with lower severity of anxiety at home (β=-0.39, 95% ci=-0.77, -0.02). males reported lower severity of anxiety at work (β=-0.37 95% ci=-0.63, -0.11) and at home (β=-0.35, 95% ci=-0.63, -0.08). figures 3 and 4 report the results for declination of redeployment and concern of operative autonomy, respectively. perception of support from hospital administration (β=-0.23, 95% ci=-0.40, -0.05) and shared responsibility between residents and attendings (β=-0.22, 95% ci=-0.39, -0.07) were associated with lower declination of redeployment whereas concern regarding ability to reach graduation case requirements was associated with higher declination of redeployment (β=0.16, 95% ci=0.00, 0.32). having children was associated with higher declination of redeployment (β=0.80, 95% ci=0.36, 1.24) whereas current redeployment was associated with lower declination of redeployment (β=-0.72, 95% ci=-1.18, -0.25). concern regarding ability to reach graduation case requirements was associated with higher concern of operative autonomy (β=0.60, 95% ci=0.49, 0.71). cancellation of elective cases was associated with higher concern of operative autonomy (β=0.74, 95% ci=0.20, 1.28) while being married was protective (β=-0.35, 95% ci=-0.62, -0.07). residents in pgy4 (β=0.53, 95% ci=0.31, 1.04) and pgy5 (β=0.80, 95% ci=0.31, 1.30) had higher concern of operative autonomy. the covid-19 pandemic has placed significant strain on the american healthcare system. in response, major efforts have been made to divert healthcare resources for the treatment of covid-meetings and conferences have been cancelled to comply with social distancing recommendations. we sought to characterize urology resident education, clinical practice, and well-being with a national survey, and identified several important trends. we identified several significant predictors of perceived anxiety and depression, both at work and home. perceived adequacy of access to ppe was inversely related to all four mental health outcomes. that is, urology residents who reported adequate access to ppe reported lower levels of anxiety and depression. similarly, a previous study of 1557 healthcare workers during the 2003 severe acute respiratory distress syndrome pandemic found that lower stress levels were associated with ppe availability 10 . the relationship between ppe availability and mental health during a pandemic may be related to fear of becoming ill and/or spreading the illness to loved ones. indeed, urology residents who reported the presence of a household member (including themselves) who was susceptible to covid-19 reported higher levels of anxiety at work, anxiety at home, and depression at work scores. this notion of self-protection is supported by a study of 169 healthcare workers during the avian flu epidemic in which 83% of respondents cited confidence in the hospital's ability to protect them as the most important factor influencing their willingness to report to work 11 . these findings suggest that ensuring adequacy of ppe availability is important for urology resident well-being during the covid-19 pandemic. another potentially modifiable predictor of urology resident anxiety and depression was perception of support by the residency program. residents who reported higher levels of program support had lower anxiety at work and depression at work scores. furthermore, previous literature has described the importance of perceived support and appreciation by faculty in mitigating burnout amongst general surgery residents under regular circumstances 12 . thus, it is important for program directors and faculty to regularly engage with residents and offer support and appreciation as this may improve well-being at work. performing surgery is a key component of routine urology practice. however, with the onset of the pandemic, there has been a precipitous decline in operative volume with 94% of urology residents reporting that non-oncologic cases have been cancelled and 37% reporting that oncologic cases have been cancelled. the sharp decline is further illustrated by the decrease in percentage of residents reporting participation in 6 or more operations per week since the onset of the pandemic (89% vs. 5%). this significant decrease in operative volume raises questions about disruption of surgical education. urology residents tend to be the most active in the operating room during their accepted article senior and chief years and accordingly pgy-4 and pgy-5 residents reported higher levels of concerns regarding comfort with operative autonomy at the conclusion of training. routine urology practice also encompasses outpatient clinic visits. there has been a radical increase in the reported use of telehealth by urology services since the onset of the pandemic (10% vs. 95%). however, 82% of urology residents report that they have not been trained on how to perform effective telehealth visits. given the reasonable possibility that increased telehealth usage will persist beyond the pandemic, urology residents would likely benefit from formal telehealth training. another major change to routine urology practice has been "redeployment" to a "frontline" covid-19 service. approximately one fifth of the urology residents surveyed have been redeployed, most commonly to the intensive care unit, medical wards, and emergency room. of the redeployed residents, 77% report that their redeployment was mandatory. for all respondents, we assessed perception of declination of voluntary redeployment. modifiable negative predictors of declination score were perception of institutional support and perception of shared responsibility for pandemic related activities with attendings. that is, urology residents who felt supported by their institution and that additional responsibilities were not being solely placed on the residents would be more likely to agree to voluntary redeployment. it may be helpful for hospital administrators to reach out to residents and inquire what resources they need to feel a greater sense of support (e.g. hazard pay, complementary lodging for self-quarantine, food subsidy). additionally, responsibility for the care of covid-19 patients should be shared between attendings and residents. implementing these changes may improve morale by making redeployment feel more voluntary than mandatory. our study had several notable limitations. our respondent rate was 20% and therefore not necessarily indicative of the entire population of urology residents. this may be an inherent limitation of using an optional survey in this population given that by comparison, the aua-sanctioned resident survey conducted over three years from 2016-2018 had a respondent rate of only 26% 13 . additionally, the survey was predominantly distributed through secondary means (i.e. residency program directors and aua section secretaries) rather than directly to respondents which may result in sampling error. furthermore, a simple 1-5 scale was used for assessing depression and anxiety rather than a validated questionnaire such as the patient health questionnaire 9. the use of a validated questionnaire may have provided more insight into the surveyed population. for example, in our study men reported lower depression and anxiety scores. previous research has found that men tend to underreport anxiety and depression 14,15 . without the use of a validated questionnaire, it accepted article is unclear if our findings are due to this known underreporting phenomenon or have another explanation. despite limitations, we have identified several important interventions which could potentially be undertaken by hospital administrators and urology programs to optimize urology resident wellbeing, education, and morale during the course of a pandemic. in summary these are: advocating for adequate access to ppe, providing support at both the residency program and institutional levels, instituting telehealth education programs, and fostering a sense of shared responsibility for covid-19 patients. interestingly, all of these findings are relatively general in nature and could potentially be applied to all specialties. thus, we believe it is imperative to perform a follow up study across all specialties to assess the generalizability and validity of our findings. furthermore, our study provides a unique and timely prospective, as it was conducted during a critical period of the pandemic in the us, capturing the days leading up to and including april 11 th , 2020 (the date that the usa became the nation with the most total covid-19 mortalities). the covid-19 pandemic has placed unprecedented strain on the healthcare system and prompted dramatic resource reallocation to minimize patient morbidity and mortality. these resource shifts have resulted in major changes to previous routines of urology residents. our study has identified several potential actions that could be taken by residency programs and hospital administration which may optimize urology resident well-being, morale, and education. these include advocating for access to ppe, providing support at both the residency program and institutional levels, instituting telehealth education programs, and fostering a sense of shared responsibility for covid-19 patients. our study was limited in scope to urology residents. however, to our knowledge, ours was one of the first national study characterizing covid-19 pandemic responses among american trainees. importantly, these findings, if appropriately validated, could be applied to nonurology trainees. thus, we recommend further research with a large national study of trainees from all specialties to assess the validity and generalizability of our findings. a novel coronavirus from patients with pneumonia in china accepted article this article is protected by copyright. all rights reserved 2 now leads the world in confirmed coronavirus cases. the new york times hospitals push off surgeries to make room for coronavirus patients to-minimize-contact-with-virus-patients-11583337283.) 6. 'today, we are all covid-19 doctors'. the new york times role of the urologist during a pandemic: early experience in practicing on the front lines in critical supply shortages -the need for ventilators and personal protective equipment during the covid-19 pandemic factors associated with mental health outcomes among health care workers exposed to coronavirus disease factors associated with the psychological impact of severe acute respiratory syndrome on nurses and other hospital workers in toronto survey of hospital healthcare personnel response during a potential avian influenza pandemic: will they come to work? accepted article this article is protected by copyright. all rights reserved 12 surgical resident burnout and job satisfaction: the role of workplace climate and perceived support the state of the urology workforce and practice in the united states gender and depression in men toward the reconstruction of masculinity key: cord-317323-wp3vh4c1 authors: kandhari, rajat; kohli, malavika; trasi, shrilata; vedamurthy, maya; chhabra, chiranjiv; shetty, kamlakar; dhawan, sachin; rajan, renita title: the changing paradigm of an aesthetic practice during the covid‐19 pandemic: an expert consensus date: 2020-10-28 journal: dermatol ther doi: 10.1111/dth.14382 sha: doc_id: 317323 cord_uid: wp3vh4c1 until vaccination for the sars‐cov‐2 becomes a reality, it appears that the infection is here to stay. with many countries lifting lockdown restrictions, aesthetic clinics have started reopening with strict standard operating procedures in place. it is pertinent that the physician today understands the infection, disinfection measures, and personal protective equipment to reduce chances of viral transmission and provide safe clinical settings for oneself, the staff and the patients. an online meeting of eight experts in the field of aesthetic dermatology was convened, which particularly focussed on ppe in detail, risk categorization of aesthetic procedures, preprocedure recommendations, and generalized and specialized sop's for aesthetic procedures. these recommendations were aimed to bridge the gap between published guidelines and clinical practice and are by no means fully conclusive, but signify learnings over the past few months in an active clinical aesthetic practice. the sars-cov-2 pandemic has changed the homeostasis of the medical world, affecting millions worldwide. amidst the global crisis, other than the health implications, there are major consequences on the world economy. 1 in light of this massive economic slowdown, many nations have ended their lockdowns, albeit on shaky ground. with reopening of services in many countries, dermatology and aesthetic clinics, which were staring at a bleak future, have started opening up with strict standard operating procedures (sop's) in place. in any pandemic, the need to feel good is inherent to a healthy mental-well-being, and wishing away the need for an aesthetic practice as "nonessential" may appear weak to some. while certain guidelines and expert consensus have recently been published [2] [3] [4] providing an overview of "safe" working protocols, it appears that we are evolving every day in our practices with respect to "what works" and "what does not." our article aims to bridge the gap between guidelines and in-clinic experiences to provide a set of best practices to follow for aesthetic procedures after reopening our practices. an invitation to participate in the consensus group meeting along with a formulated questionnaire was sent by email by one of the moderators (rk) to seven experts in the field of dermatology and aesthetics, having experience in the working and administration of single or multiple clinics, from different parts of india, in order to avoid a regional bias. the questionnaire focused on scope of the guidelines, the preparation before resuming practice, triaging/categorization patients, ppe and general sop's and specialized sop's for aesthetic procedures. (table s1 ) while analyzing the questionnaire, the response to general sop's (cleaning, sanitization etc.) and triaging achieved over a 75% concordance in response the final meeting focussed on ppe and specialized sop's for aesthetic procedures. an online meeting of the group members was held on 31 may 2020, using zoom online app. the virtual meeting was led by the moderators, via a prepared slide deck. further, the meeting was recorded for final analysis and simultaneous notes were taken. to encourage equal participation the moderators used an open questioning style, however, few of the questions were closed ended (yes/no) to arrive at a consensus. analysis of the detailed discussion was divided into the following sections to provide recommendations for optimal and safe "in clinic" functioning for the physician. seven out of the eight experts had reopened their clinics after overcoming initial apprehensions. all the participants agreed that they were functioning at limited capacity in terms of number of staff visiting the clinic, number of days and/or hours at work. those with more than one center started reopening with a single/flagship center and slowly imposed similar guidelines after 2 weeks of work in other centers. all participants agreed that a "dry run" prior to reopening is crucial for staff training and creating awareness and educating oneself and the staff, as the margin for error learning on the job would be minimal. moreover, constant updating of oneself and the staff resulted in smoother functioning and execution of new sop's. the experts agreed upon the fact that the patients have been understanding and appreciative of clinic efforts and responsive in terms of cooperating with protocols. all experts agreed to doing and encouraging tele consultation. while certain modes of viral transmission have been suggested, 5 in a statement issued by the who precautions have been laid out for droplet transmission, contact, and airborne precautions for aerosol generating procedures. 6 an aerosol is defined as a suspension of fine solid particles or liquid droplets in air or another gas, which maybe produced by either natural or anthropogenic phenomena. 7 the coronavirus has the potential to become "aerosolized" by certain procedures leading to a possible airborne transmission. the exact definition of "aerosol generating procedures" (agp's) in the theme of aesthetic procedures seems unclear with no clear evidence regarding the same. although, it is clear that an aerosol generating procedure increases the risk of viral transmission in healthcare workers (hcw) and should only be undertaken when necessary, this is primarily suggested for respiratory and surgical procedures generating aerosols. the different types of aerosol comprise: 1. respiratory aerosol: respiratory or upper airway secretions, containing a higher viral content and a greater risk of viral transmission. 2. surgical or nonrespiratory aerosol: aerosolisation of blood and tissue fluids leading to relatively lower risk of viral transmission. the who defines "droplets" as >5 μm in diameter and "airborne particles" as <5 μm in diameter. 8 droplet transmission is the result of larger particles, which have the tendency to settle on the ground and on nearby surfaces. this type of transmission occurs due to proximity of the hcw with the patient. in contrast, the occurrence of airborne transmission is due to smaller particles, which maybe suspended in the air for long periods and can infect people distant from the source (eg, agp's)ppe consists of protective apparel and/or equipment designed for providing protection against infectious agents to hcw's and their patients. the appropriate use of ppe is crucial, and the decision regarding the ppe to be used is based on the setting between the hcw and the patient, the procedure being carried out, the secretions produced. the panel recommendations for ppe are discussed below. globally, recommendations for protection of hcw's against covid-19 for nonaerosol-generating procedures (nonagp's) are conflicting. [9] [10] [11] [12] with the barrage of masks available, choosing the right one becomes crucial. the expert panels recommendation and the differing types of masks have been elaborated ( table 1 ). the panel felt that while the role of the staff and the type of procedure would be key factors defining the type of mask used, the space in the clinic would also be a defining factor, as certain clinics would be smaller wherein maintaining an "ideal social distance" (6 ft apart/2 arm's length) maybe a challenge. 13 in such scenarios, an n95 respirator maybe used by the support staff as well ( figure 1 ). use of n95 facial facepiece respirator (ffr) 1. all the experts unanimously agreed upon the use of n95 respirators for themselves, particularly when involved in non-agp's close contact procedures or agp's. 3. beard hair:it is recommended for one to be clean shaven, however, beard styles such as soul patch, side whiskers, pencil, toothbrush, lampshade, zorro, zappa, walrus, painter's brush, chevron, and handlebar maybe considered. 17 the recommendations are to make sure that the n95 ffris well fitted on face. 4. use of n95 ffr in sikhs: the religious beliefs in the sikh population, leads to an inability to trim or cut the beard hair leading to difficulty in achieving a tight fit of the respirator. in such cases, either a powered air-purifying respirators (papr) maybe used, which provides facial coverage despite the facial hair or any facial irregularity. 18 paprs are more expensive than n95 ffr's. else, the individual in question can make use of a "cotton cloth" or "thatha" around the beard and tie a knot on the top of the turban. this allows for coverage and a smooth surface over the facial hair for the respirator to sit on and achieve a tight fit. • use of paper bags: while only considered single use masks, all panel members agreed to reuse of their masks. a 5-mask set maybe used by each individual, along with four brown paper, breathable bags, which are marked 1 to 5. after use of first mask, it should be placed in the paper bag and allowed to dry for 4 days. it should be reused on day 6. the masks maybe used sequentially in such a manner and once all masks have been used five times, they should be discarded. use of a disposable, surgical three ply mask/face shield on top of the respirator will further prevent it's contamination. 19 this was being followed by three of the panelists and has been suggested as an additional safe practice. the physiological burden (heart rate, oxygen saturation, tidal volume, respiratory rate, etc.) of using a surgical mask over an n95 respirator has been a matter of concern and while using it for short durations appears to have no significant physiological burden, studies with usage over longer periods are suggested in order to consider this as a routine practice or recommendation in daily practice. 20 • uvc (254 nm) at the appropriate dosing 21 or vaporous hydrogen peroxide 22 if available can be used for decontamination of the n95 mask. • negative seal check: on inspiration face piece should collapse. • fogging: while minimal fogging of glasses is inevitable, due to water vapor released via the edge of the mask, it may suggest that the ffr may not be air tight. it is recommended to squeeze the metal frame on the upper edge of the mask in such cases and re-assess the fit of the mask. following strict hand hygiene along with use of nonpowdered, latex gloves are adequate for examination of patients and/or consultation room. the recommendations for hand hygiene include use of an alcohol-based hand sanitizer (60% ethanol or 70% isopropanol) or hand wash for at least 20s with soap and water. 25 • nitrile gloves are preferable over, latex gloves in the procedure rooms, as they are resistant to damage by chemicals or disinfectants, and are hypoallergenic. • housekeeping staff may use nitrile or rubber gloves which cover above the wrists. • while donning of gloves one must make sure the gloves extend to cover above the wrist of the isolation gown. a. face shield and goggles: • the panel agreed upon the use of a face shield as a routine measure in current circumstances, during all consultations and procedures as it not only provides protection to the mucosal surfaces but also prevents inadvertent touch to the face, eyes, nose or mouth with a contaminated hand. • face shield and/or goggles are a must in agp's. • use of face shield/goggles may result in fogging at times due to expired air escaping from the mask, in such circumstances one may reassess the fit of the mask or seek the use of well fitted antifogging goggles ( figure 5 ). 26 b. coverall or gowns • disposable, below knee, spunbondmeltblownspunbond (sms) material, breathable gowns are adequate for consulting and examination. an autoclavable, below knee, surgical cloth gown for routine consultations was suggested by three of the experts, however, the panel did not arrive at a consensus for this. practice. if a coverall is used, one coverall should be used per patient and these maybe reserved for agp's. one may use a 60-70 gsm, coverall, as extrapolated from data during the ebola outbreak. • a plastic apron maybe used over the gown, in procedures involving body fluid splatter or splash. • the panel agreed upon the use of head caps during "close contact" procedures and these should be worn by the patient and the doctor/therapist. if wearing a coverall, that itself would provide head coverage, else a surgical head cap should be used. • experts felt that that if regular cleaning and sanitation of the premises is being carried out, the use of shoe covers is not mandatory. • if shoe covers are used they should be made ideally be impermeable, for example, plastic • one of the experts on the panel suggested the use of washable rubber slippers for patients and staff in place of shoe covers. • the common principles regarding use of ppe, including hand hygiene prior donning and during doffing of ppe, protocols of donning/doffing and correct disposal should be repeatedly discussed with the clinic staff. • a room with a mirror is ideal for donning and doffing of ppe.developing a "buddy system" may help, that is, a team member who may observe the donning and doffing process. 28 and/or use of zinc ointment before donning and after doffing the ppe. 31 4. make sure the ffr is "well fit" and not "overtight". the lips touching the front of the mask is suggestive of a tight fit and can become uncomfortable for the user. a mix of "natural" and "mechanical ventilation" is ideal for a clinical premises, which allows the air to flow from areas where there is a suspected source, towards the areas free of susceptible individuals. the use of laser and ebd's, requiring contact of the skin with the laser tip, particularly need to be handled with caution. the cases for laser procedures maybe divided into low, medium or high risk (table 4 ). further, certain points regarding the procedures maybe taken into consideration. certain laser systems, (ablative co2, erbium yag) lead to "plume" the panel categorized the risk involved with injectable procedures in the following manner: (table 5) a. low risk: the mask of the patient can remain on. b. medium risk: the mask of the patient is off. c. high risk: the mask of the patient is off and the procedure involves the oral or nasal mucosa. certain procedures for example, periorbital enhancement even though carried out on the upper face, are often done with cannulas and ideally require the mask be off, so that the injector can carry out the procedure comfortably and look out for vascular events. further, a tight fitting mask during and postprocedure may lead to external compression and/or make evaluation of a unexpected vascular event challenging. the risk categorization for chemical peels is below: • low risk: body peels, spot peels on face with mask, peels for nails and periorbital area. • low risk: prp therapy for scalp and body areas, mesotherapy for scalp and body (stretch marks) • moderate risk: prp and mesotherapy for face numerous other procedures carried out in an aesthetic clinic have been categorized below (table 6 ). the above recommendations do not necessarily signify a "cook book" approach but are learnings over the past few months in an active clinical aesthetic practice during the ongoing pandemic. while one must adapt fast to the "new norms", the real challenge would lie in the strength of the practitioner to balance one's own and our staffs mental health, to attain equilibrium of financial setbacks with concerns over self, staff, and patient safety, and to conduct practices in a just manner. the well-known adage to "lead as an example" is the best reinforcer of safe practices and general wellbeing. the authors declare no conflict of interest. covid-19 and economy covid-19 pandemic: consensus guidelines for preferred practices in an aesthetic clinic safety guidelines for non-surgical facial procedures during covid-19 outbreak lasers use in dermatology practice in the evolving covid-19 scenario: recommendations by sig lasers (iadvl academy) coronavirus disease (covid-19): an updated review based on current knowledge and existing literature for dermatologists world health organization. modes of transmission of virus causing covid-19: implications for ipc precaution recommendations: scientific brief nosocomial transmission of emerging viruses via aerosol-generating medical procedures infection prevention and control of epidemic-and pandemic-prone acute respiratory diseases in health care infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings european centre for disease prevention and control. guidance for wearing and removing personal protective equipment in healthcare settings for the care of patients with suspected or confirmed covid-19 rational use of personal protective equipment for coronavirus disease 2019 (covid-19) coronavirus disease (covid-19): for health professionals aerosol filtration efficiency of common fabrics used in respiratory cloth masks hair care during covid-19: practical tips for health care workers to papr or not to papr? can effect of surgical masks worn concurrently over n95 filtering facepiece respirators: extended service life versus increased user burden surgical mask placement over n95 filtering facepiece respirators: physiological effects on healthcare workers decontaminating n95 masks with ultraviolet germicidal irradiation (uvgi) does not impair mask efficacy and safety: a systematic review extended use or reuse of n95 respirators during covid-19 pandemic: an overview of national regulatory authority recommendations respiratory performance offered by n95 respirators and surgical masks: human subject evaluation with nacl aerosol representing bacterial and viral particle size range hand hygiene recommendations. guidance for healthcare providers about hand hygiene and covid-19 personal protective equipment (ppe) and its use in covid-19: important facts aerodynamic characteristics and rna concentration of sars-cov-2 aerosol in wuhan hospitals during covid-19 outbreak skin damage among health care workers managing coronavirus disease-2019 reply to: skin damage among healthcare workers managing coronavirus disease-2019 wearing the n95 mask with a plastic handle reduces pressure injury natural ventilation for infection control in health-care settings. geneva: world health organization possible aerosol transmission of covid-19 and special precautions in dentistry health technical memorandum 03-01: specialised ventilation for healthcare premises. part a -design and installation. estates and facilities division. london: the stationery office covid-19: infection prevention and control guidance personal protective equipment during the coronavirus disease (covid) 2019 pandemic: a narrative review the use of povidone iodine nasal spray and mouthwash during the current covid-19 pandemic may reduce cross infection and protect healthcare workers microbiologic activity in laser resurfacing plume and debris human immunodeficiency virus-1 (hiv-1) in the vapors of surgical power instruments risk of acquiring human papillomavirus from the plume produced by the carbon dioxide laser in the treatment of warts safe management of surgical smoke in the age of covid-19 aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 coronavirus disease 2019: coronaviruses and blood safety covid-19: new insights on a rapidly changing epidemic the changing paradigm of an aesthetic practice during the covid-19 pandemic: an expert consensus key: cord-335477-po201szv authors: o'leary, fenton; pobre, karl; mariano, maricel; tan, ker fern; jani, shefali title: personal protective equipment in the paediatric emergency department during the covid‐19 pandemic. estimating requirements based on staff numbers and patient presentations. date: 2020-09-21 journal: emerg med australas doi: 10.1111/1742-6723.13653 sha: doc_id: 335477 cord_uid: po201szv objectives: to estimate the personal protective equipment (ppe) required in a paediatric emergency department during the covid‐19 pandemic comparing the use per patient to use per patient zone, based on the nsw clinical excellence commission (cec) guidelines in place at the time of the study. methods: a retrospective case note review of all patients and staff present in the emergency department of the children's hospital at westmead, sydney, australia in the 24hour period of sunday 5(th) april 2020. the primary outcome of ppe estimates was generated from identifying the number of patient contacts and aerosol generating procedures (agps) performed per patient as well as the number of staff on shift. results: one hundred patients attended the ed (50% of usual) and all were included in the study. for a low risk community environment allocating ppe per patient contact required 48 face shields, 382 surgical masks, 48 n95 masks and 430 gowns for the day, increasing to 430 face shields, 331 surgical masks, 430 n95 masks and 761 gowns in a high‐risk community environment. allocating ppe using zoning reduces the requirement to 48 face shields, 192 surgical masks, 48 n95 masks and 204 gowns, increasing to 196 face shields, 96 surgical masks, 196 n95 masks and 292 gowns per day in a high‐risk community environment. conclusion: this study has demonstrated the considerable requirement for ppe in a paediatric ed, which varies according to presentation type and the background prevalence of covid‐19 in the community. this article is protected by copyright. all rights reserved. personal protective equipment (ppe) is essential for health care workers (hcws) and ancillary staff working in australian emergency departments (eds) during the covid-19 pandemic. ppe is required to protect staff from potentially infected patients or carers, from asymptomatic contagious colleagues and to prevent staff from infecting patients. whilst the first reason is well established, the other two are more controversial but becoming more evident as clusters of infection occur in hospitals and nursing homes from asymptomatic transmission by staff (1) (2) (3) (4) . the problem was exemplified by the outbreak in nw tasmania where, as of 21 st april 2020, 114 people had acquired covid-19 comprising 73 staff members, 22 patients, and 19 others including household contacts, from two index cases admitted to a medical ward and resulting in 12 deaths. this led to the temporary closure of two hospitals and forced 1200 staff into quarantine (5) . in victoria, as of 20th august 2020, 2563 healthcare workers have been infected, with over 763 current active cases with health care workers representing > 30% new cases on some days. as of 13 th may 2020 in the anglicare newmarch house nursing home there have been 71 cases, with 37 residents and 34 staff infected and 16 deaths (6) . international guidance suggests covid -19 is spread by direct droplet infection. airborne transmission occurs during aerosol generating procedures (agps) and ppe guidance follow these principles (7) . however, some reports suggest that the droplet/airborne theory is oversimplified, with aerosol generation occurring from laryngeal activity such as talking and coughing. there is some evidence to suggest that sneezes and coughs are able to form a turbulent multiphase gas cloud which may travel up to eight metres (8) . the centre for disease control (cdc) review of the choir practice in skagit county, washington concluded that one index patient infected 52 people in a 2.5 hour period, an attack of rate of 87%, resulting in three hospitalisations and two deaths. the emission of aerosols from the loudness of vocalisation might have been a significant factor (9) . with small numbers of potential patients, staff can wear individual items of ppe for each patient contact and then discard. however, as the number of patient contacts or potentially infected patients increase, the need for ppe increases. a switch from individual patient contact ppe to staff focused, patient zoning ppe may then more effectively balance the availability of ppe against its need. however, the disadvantage of this includes increased staff discomfort, ppe breaches with long term wear, cross contamination of clean areas (such as store rooms) and cross contamination of colleagues and other patients. in new south wales, the clinical excellence commission (cec) produced a document outlining the use of ppe in eds that encompasses the risk of transmission, based on local disease prevalence, the procedure being undertaken and the risk of an individual patient having the disease (epidemiological or clinical risk factors)(10), figure 1 . the role of children in the spread of covid-19 is unclear. studies suggest that the secondary attack rate for children is 4%-7.3%, compared to the adult rate of 6.2%-21.9%, meaning that exposed this article is protected by copyright. all rights reserved. children are less likely to become infected than adults (11) (12) (13) . this is supported by literature from population testing in italy, south korea and iceland where children (especially < 10 years) had a much lower incidence of positive testing compared to adults (14) (15) (16) . there is no current literature on the risk to adults from infected children, but there is limited evidence from a nsw study in schools suggesting that the risk of spread from children to children and teachers in schools is low(17). until recently it was thought that children have very mild illnesses, however the identification of paediatric inflammatory multisystem syndrome temporally associated with covid-19 (pims-ts) has renewed interest in the impact of covid-19 on children (18) . the aim of this study was to identify the number of staff contacts and agps with patients in the paediatric ed over a 24 hour period and attribute ppe required according to the nsw cec guideline and compare this to the ppe required based on staff zone allocations. a retrospective chart review was performed on all children who presented to the ed of the children's hospital at westmead (chw) on sunday 5 th april 2020. chw is a major referral paediatric hospital in sydney, australia with an annual ed attendance of approximately 60,000 patients. in order to estimate potential ppe use per patient, an initial search was obtained from the electronic medical records [cerner firstnet, kansas city, mo, usa] to identify the patients. data was then extracted manually by study investigators using a standardised instrument. data was entered into a database [access: microsoft, redmond, wa, usa] for processing. data entry was double checked by a second investigator for 25% of cases. the number of contacts was estimated from documented observations, clinical reviews and procedures. throat examination was included if documented in the examination notes. if multiple procedures were performed at the one time then this was included as one contact. radiology staff were captured by the request for a mobile x-ray and clerical staff by their standard practice of initial clerking and admission clerking primary outcomes were the location of the patient in the ed, the number of patient contacts by hcws and the number of agps performed. secondary outcomes were patient demographics, diagnoses and the type of procedures performed. agps (encompassing high risk procedures) were classified as per australasian college for emergency medicine and safe airway society and the throat exam was included as per royal college of paediatrics and child health uk (19) (20) (21) . anzics guideline includes 'procedures on screaming children' as an agp however this wouldn't be recorded and therefore wasn't assessed as part of this study (22) . 'coughing /sneezing / expectorating' as defined by sas were also not retrieved from the emr for the same reason. at the time of the study the ed at chw had been divided into three zones: cold -no infective symptoms; warm -fever with infective symptoms such as diarrhoea or vomiting and hot -fever with no source and /or respiratory symptoms or high-risk epidemiological criteria for covid-19. for the purpose of the study, warm and hot patients were combined and labelled non-cold. gastrointestinal symptoms have been well described in children with covid-19 and staff caring for these patients should wear the same ppe as they would for hot zone patients (23) accepted article this article is protected by copyright. all rights reserved. to estimate potential ppe use per staff member, the medical and nursing staff rosters for sunday 5 th april were accessed and the number of staff present and their allocated locations recorded. staff were all assumed to have three meal/rest breaks per shift that would require a change of mask and gown if worn. the amount of ppe (goggles / face shields, surgical masks, n95 masks and gowns) required was then estimated based on the nsw cec recommendations (24 april 2020_v3), calculations being made for each community risk level (low, medium and high) (10), figure 1 . for eye wear the number of goggles was calculated per staff member working, as these could be wiped down in between patients and meal /rest breaks. the number of face shields was estimated against the number of agps, as generally staff would use the better droplet protection of the face shields when performing agps and some of the n95 masks were not fluid resistant. as ed activity had reduced by almost 50% during the covid-19 pandemic, estimates were then calculated for 50% and 100% increase in attendances by multiplying results assuming the same percentage of non-cold vs cold presentations. data was analysed using spss version 22.0 [ibm, armonk, ny, usa] to obtain simple frequencies and descriptives. one hundred patients attended the ed on sunday 5 th april and all were included in the study (representing approximately 50% of usual presentations). table 1 describes the primary and secondary numerical outcomes, divided by cold and non-cold status. overall, in the cold zone there were 198 contacts with hcws, 37 general procedures and five agps. in the non-cold zone there were 219 contacts with hcws, 46 procedures and 43 agps. table 2 -supplementary file, describes the presenting complaints, divided by zone. documented agps were covid-19 swab (n=14), throat swab / npa (n=1), removal of nasal foreign body (n=2), throat exam (n=19), acute airway management/ ventilation (n=6) and nebulisation (n=6). the most common nursing agp was a covid-19 swab and the most common medical agp was throat exam. agps on cold zone patients were removal of nasal foreign body, covid-19 swab and throat exam. fourteen patients met the covid-19 testing criteria and had negative swabs. ed staffing on that day showed 39 nurses and 22 doctors and nurse practitioners (np). the day shift had 16 nursing including the nurse unit manager (num) and clinical nurse educator (cne) and eight doctors, the evening had 10 nurses and 11 doctors /np and the night 13 nurses and four doctors. as this was a weekend, senior medical staff was reduced compared to a week day. estimated ppe requirements for each of the three levels of risk of infection and transmission based on staff roles and zone allocations are described in table 3 -supplementary file and based on patient contacts and procedures in table 4 -supplementary file. table 5 summarises these results and then provides an extrapolation of 50% and 100% increase in ed attendances fifteen patients presented with a primary respiratory problem, with 10 of those being category 3 or above, indicating they would meet the cec criteria for 'interaction with a patient with respiratory accepted article this article is protected by copyright. all rights reserved. distress or significant cough' and hence require contact, droplet and airborne precautions. for this group there were three clinical initiative nurse (cin) contacts, 17 clerk contacts, 38 ed nursing contacts, 16 nursing procedures, 19 agps, 29 doctor/np contacts and two doctor/np procedures. in low and moderate risk environments this would increase the number of face shields, gowns and n95 masks required by 88, as every contact becomes equivalent to an agp. only one of these patients met testing criteria for covid-19. this study has demonstrated that in the paediatric ed, even in a region with a low level of infection, a considerable amount of ppe is required in a 24 hour period and that as presentations increase or community prevalence increases the need for ppe will increase considerably. with a small number of ed presentations and a low regional risk level, single use ppe for individual patients makes practical and economic sense. however, in the paediatric ed, fever or respiratory symptoms are common presenting symptoms, resulting in almost 50% of patients need isolating in the non-cold zone and require ppe when being assessed and managed. as presentations increase zone based ppe becomes increasingly necessary for conservation of ppe. there is still however considerable daily ppe requirements despite zone based ppe. as the pandemic progresses, ppe utilisation in the ed will require more thought and research. reducing the need for ppe might occur from being able to reclassify patients as cold on presentation or the use of reliable rapid testing to reclassify patients as cold. unfortunately, covid-19 is difficult to exclude clinically at presentation in children, rapid tests are not yet readily available and conventional pcr only has 70% sensitivity in identifying disease (24) . other savings may be made by reducing patient contact in the ed, through telehealth solutions in or before ed to reduce attendances and by reducing total ed length of stay. grouping patient contacts episodes and having flexible roles is another solution. for example, with the same set of ppe, the doctor can take a history, perform an examination, do a set of observation, perform a covid-19 swab and collect a urine specimen by in out catheter. unfortunately, procedures on children often involve at least two hcws, increasing ppe consumption . information on the cost of public hospital ppe is not freely available. newmarch nursing home was spending $21,000 daily on personal protective equipment, which included 2,000 gowns, 12,000 gloves, 50 sets of goggles, 400 shoe covers, and 30 face shields. in total anglicare sydney had spent $650,000 on ppe in the 31 days to 16 th may 2020 (25) . this study hasn't considered the possibility of parents and carers in the ed having asymptomatic covid-19. to protect staff and other carers would result in an extra 100 surgical masks/day. this study also did not consider the possible benefit of all hcws wearing a surgical mask to prevent asymptomatic transmission to or from the wearer, approximately 50 surgical masks a day. during the study chw ed clerks were not required to wear ppe, so another 36 surgical masks/day would be required to protect them. it was not possible to quantify the cleaners' use of ppe in this study but this adds considerably to requirements as rooms need specific cleaning after patients leave. curtains don't require cleaning, so keeping patients zoned in open wards rather than single rooms saves ppe by reducing cleaning this article is protected by copyright. all rights reserved. requirements, although the downside is the increased risk of spreading the virus to staff, other patients and their families. this study is limited by its retrospective nature, and relying on documentation in the emr to identify all patient contacts and agps. it's likely that these have been underestimated, from inaccurate documentation, however this may be offset by grouping patient contact episodes. we were unable to identify the number of cleaning contacts from the emr and some staff groups were not required in the timeframe but need to be included in estimation e.g. child and family health nurses and the mental health teams. mental health teams may be at particular unrecognised risk as they often spend prolonged time with patients and families with an inability to physical distance to maintain rapport with them. the study was not preformed prospectively as the aim was to record anticipated ppe usage, rather than actual ppe utilised. there was no guarantee that staff would follow the ppe guidelines in place at the time. in australia, health administrators now have to balance the costs of purchasing and using ppe against the potential benefit to staff and patients, particularly as the disease prevalence is currently low in some states. however, when outbreaks do occur, the devastating impact of covid-19 on staff, patients and the community make this an emotive issue. novel solutions may be required to conserve ppe which could include covid-19 facilities in the major cities, rather than each facility having its own zoning approach. from an ed perspective we need to ensure there is a whole of hospital approach to the care of potential covid-19 patients. this might include ensuring rapid testing, early risk reclassification and ensuring adequate inpatient beds so there is no covid-19 access block. administrators also need to consider the benefits for all staff (and possibly patients and visitors) in healthcare facilities to wear surgical masks in low risk regions to try and mitigate the risk of asymptomatic transmission. this study demonstrates the considerable requirement for ppe in a paediatric ed, which varies according to presentation type and the background prevalence of covid-19 in the community. ethics approval was obtained for the study (schn hrec qie-2020-05-02) asymptomatic transmission, the achilles' heel of current strategies to control covid-19 covid-19 staff infections waitakere hospital deaths in healthcare workers due to covid-19: the need for robust data and analysis universal masking in hospitals in the covid-19 era covid-19 north west regional hospital outbreak interim report coronavirus) statistics 2020 world health organisation . modes of transmission of virus causing covid-19: implications for ipc precaution recommendations. scientific brief airborne transmission of severe acute respiratory syndrome coronavirus-2 to healthcare workers: a narrative review high sars-cov-2 attack rate following exposure at a choir practice -skagit county new south wales clinical excellence commission. quick guide to ppe for the emergency department age specificity of cases and attack rate of novel coronavirus disease (covid-19) household secondary attack rate of covid-19 and associated determinants the characteristics of household transmission of covid-19 coronavirus disease-19: the first 7,755 cases in the republic of korea spread of sars-cov-2 in the icelandic population national centre for immunisation research and surveillance. covid-19 in schools -the experience in nsw kawasaki-like disease: emerging complication during the covid-19 pandemic. the lancet clinical guidelines for the management of covid-19 in australasian emergency departments v3.0. melbourne consensus statement: safe airway society principles of airway management and tracheal intubation specific to the covid-19 adult patient group covid-19 -guidance for paediatric services london: rcpch australasian and new zealand intensive care society. anzics covid-19 guidelines review article: gastrointestinal features in covid-19 and the possibility of faecal transmission detection of sars-cov-2 in different types of clinical specimens newmarch house dogged by staffing and equipment crises. sydney morning herald this article is protected by copyright. all rights reserved. this article is protected by copyright. all rights reserved.clinical excellence commission, nsw. ppe use at different risk levels 441x302mm (300 x 300 dpi) this article is protected by copyright. all rights reserved. accepted article this article is protected by copyright. all rights reserved. key: cord-335638-p84nmtfp authors: swaminathan, ashwin; martin, rhea; gamon, sandi; aboltins, craig; athan, eugene; braitberg, george; catton, michael g.; cooley, louise; dwyer, dominic e.; edmonds, deidre; eisen, damon p.; hosking, kelly; hughes, andrew j.; johnson, paul d.; maclean, andrew v; o’reilly, mary; peters, s. erica; stuart, rhonda l.; moran, rodney; grayson, m. lindsay title: personal protective equipment and antiviral drug use during hospitalization for suspected avian or pandemic influenza(1) date: 2007-10-17 journal: emerg infect dis doi: 10.3201/eid1310.070033 sha: doc_id: 335638 cord_uid: p84nmtfp for pandemic influenza planning, realistic estimates of personal protective equipment (ppe) and antiviral medication required for hospital healthcare workers (hcws) are vital. in this simulation study, a patient with suspected avian or pandemic influenza (api) sought treatment at 9 australian hospital emergency departments where patient–staff interactions during the first 6 hours of hospitalization were observed. based on world health organization definitions and guidelines, the mean number of “close contacts” of the api patient was 12.3 (range 6–17; 85% hcws); mean “exposures” were 19.3 (range 15–26). overall, 20–25 ppe sets were required per patient, with variable hcw compliance for wearing these items (93% n95 masks, 77% gowns, 83% gloves, and 73% eye protection). up to 41% of hcw close contacts would have qualified for postexposure antiviral prophylaxis. these data indicate that many current national stockpiles of ppe and antiviral medication are likely inadequate for a pandemic. of current stockpiles. this study aimed to estimate the resource needs that a hospital might face in the fi rst few hours of management of a single patient who sought treatment with possible avian or pandemic infl uenza (api) or similar highly virulent respiratory infection. in a prospective, multicenter, simulation exercise, we assessed the initial 6 hours of management of a patient (actor) who appeared for treatment at a hospital emergency department with a history consistent with api. tertiary-level university teaching hospitals across eastern australia were invited to participate. the inclusion criteria were willingness to join the simulation and possession of a formal local infection control protocol for the management of api that followed australian (3) or who guidelines (7) . the study was approved as a quality assurance project by the ethics committee at each participating site. for each of the participating hospitals, the 6-hour simulation was conducted midweek, beginning between 8:30 and 9:30 am, to avoid the busiest emergency department periods and to minimize the possibility that the care of actual patients might be compromised. the simulated patient was an actor unknown to the hospital staff, who appeared at the triage area of the emergency department and followed a prerehearsed script designed to trigger the hospital protocol for api. the standardized history included a 72-hour period of high fever, cough, shortness of breath, and severe malaise after a recent return from a southeast asian country. the patient reported handling unwell live poultry in a rural setting where human cases of avian infl uenza were known to have occurred. this standarized clinical scenario was chosen because guidelines for managing human cases of avian infl uenza (h5n1) form the current template for pandemic infl uenza case management (4, 5, 7) . to heighten staff awareness of the appropriate management of an api case, each hospital organized education sessions on ppe use, infection control practices, and protocol familiarization in the 1-2 weeks before the simulation. staff members were informed that the simulation would occur at some time during the allocated week (but not the exact day) and were instructed that hospital protocol should be followed as if it were an actual api case. each site had at least 3 trained infection control observers available who were familiar with using a modifi ed version of a validated hand hygiene assessment data input tool (8) to accurately record potential api exposures in a standard manner. the observers were provided by the coordinating center or by the participating hospital. a principal investigator (a.s.) was present at each simulation to ensure standardization. the following 3 procedures were observed and assessed (figure) : 1) patient management through triage, emergency, radiology, and inpatient ward (including transfer between areas); 2) respiratory specimen collection, transport, and processing; and 3) cleaning of clinical areas after the suspected api patient had left the area or the simulation had been completed. detailed observations were collated on infection control practice, clinical resources used, sequence of donning and removing ppe, time spent by the patient in each clinical area, and close contacts and exposures generated. the observation period could be stopped at any time if an actual patient's care was judged to be compromised by continuation of the simulation. at the time of collecting blood, respiratory specimens, or chest radiographs, surrogate specimens (venipuncture tube containing water, water-moistened swabs, and archival chest x-ray, respectively) were substituted by the accompanying study observer. surrogate blood and respiratory specimens were followed to the laboratory, where infection control practices were observed until specimens were sent to the reference laboratory for molecular testing. a hcw was defi ned as any person working within the healthcare facility. we used the who defi nition of a "close contact" as any person (including non-hcws) coming within 1 m of an api patient within or outside of an isolation room or area (7) . close contacts were counted only once. an "exposure" was counted each time a close contact came within 1 m of the api patient. a "ppe item" included a disposable gown, pair of gloves, pair of protective eyewear, or n95 mask (or equivalent particulate respirator). a "ppe set" was defi ned as the appropriate combination of ppe items recommended for hcw use in a particular clinical setting (7) ( table 1) . "opportunity for ppe item use" was defi ned as any instance of actual use of a ppe item during the study as well as any instance where the wearing of a ppe item was recommended by who guidelines (7) , as objectively noted by accompanying study observers (table 1 ). these items included ppe worn by hcws involved in direct patient care (hcw close contacts) and ancillary hcws who performed indirect clinical tasks associated with the api case-patient such as cleaning, ward support, and specimen transportation and processing. environmental decontamination of clinical areas after use was considered adequate if cleaning and disinfection procedures were undertaken in a manner consistent with who recommendations (7) . the time spent in each clinical area was recorded from when the api patient fi rst entered an area to the time when the patient entered the next area. for the purpose of identifying hcw close contacts who would be offered postexposure antiviral prophylaxis, hcw close contacts were stratifi ed into either moderate-or lowrisk groups derived from who criteria (9) . high-risk close contacts, defi ned as "household or close family contacts of a strongly suspected or confi rmed avian infl uenza (h5n1) patient" were not relevant to our study. the moderate-risk group included hcw close contacts wearing an insuffi cient or inappropriate ppe set during any of their exposures. the low-risk group included hcw close contacts wearing an appropriate ppe set for all exposures (9) . the study outcome measures were the following: 1) number of close contacts associated with the api patient during the initial 6 hours of patient management, including how many of these were hcw close contacts; 2) the total number of exposures experienced by close contacts; 3) overall quantity and type of ppe items (gowns, gloves, n95 masks, eyewear) actually used during the simulation by hcw close contacts and ancillary hcws; 4) overall "opportunities for ppe item use" for hcw close contacts and ancillary hcws (i.e., actual use plus missed opportunities for appropriate ppe use); and 5) stratifi cation of hcw close contacts into medium-or low-risk groups for the purpose of recommending antiviral postexposure prophylaxis. nine tertiary-level university teaching hospitals in 3 states of eastern australia participated in the study ( table 2 ). the simulations occurred in the winter season, from may through august 2006. all sites conducted targeted staff education sessions 1-2 weeks before their exercise. seven of the 9 simulations proceeded for the planned 6 hours of observation, and 2 were curtailed because of a critical need for the emergency department bed. had these latter 2 sites continued, the patient would almost certainly have spent the entire study period isolated in the emergency department, as suitable ward beds were not available. the time spent in each clinical area for each site is summarized in table 2 . all sites performed radiography within the emergency department. the number of close contacts and total exposures to the potential api patient are summarized in table 3 . the highest number occurred in the fi rst hour of hospital care (triage and emergency department), which correlated with the initial intensive clinical and radiologic assessment and gloves, either gown or apron patient transport within healthcare facilities gown, gloves specimen transport and processing not defined except to use "safe handling practices"; interpreted as use of gloves (minimum) and gown if opening specimen bag. *who, world health organization; hcw, healthcare worker; ppe, personal protective equipment; api, avian or pandemic influenza. †derived from (7). [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] . hcw close contacts constituted 85% of all close contacts; the remainder were patients or visitors who were generally exposed in the triage area. all 9 sites processed the respiratory specimen, with an average of 2.9 hcws (median 3, range 2-6) handling or transporting the specimen, predominantly in the pathology department. two sites used a vacuum transport system to deliver specimens from the emergency department to the laboratory, contrary to who recommendations (7) . environmental decontamination of clinical areas after departure of the suspected api patient was performed haphazardly at all sites. the triage area was appropriately cleaned in none of the 9 sites, whereas the emergency department and ward areas at sites that completed the full simulation were cleaned appropriately in 6 of 7, and 4 of 7 instances, respectively; 1-2 cleaners were required per clinical area to appropriately perform this task. large quantities of n95 masks, disposable gowns, gloves, and eye protection were used and indicated during the study period (table 4 ). adherence to appropriate use by hcws (hcw close contacts and ancillary hcws) was variable and depended on the particular ppe item, clinical area, and participating institution. appropriate use of n95 masks by hcws occurred in 93% of exposures (actual use/ total opportunities for ppe use, 18/19.4), although the corresponding fi gures for disposable gowns, gloves, and eye protection were lower (77%, 83%, and 73%, respectively). hcw close contacts were stratifi ed into either moderate-or low-risk groups, depending on whether an appropriate ppe set was worn during every exposure. the proportions of hcw close contacts who appropriately wore a ppe set, rather than an n95 mask alone, for every exposure were 59% and 92%, respectively. thus, depending on how rigorously who antiviral medication guidelines (9) were followed, from 8% to 41% of all hcw close contacts would be classifi ed as having experienced a medium-risk exposure and therefore would potentially require postexposure antiviral prophylaxis. this amounts to an average of 0.8 to 4.3 courses of antiviral medication per suspected api patient during the initial 6 hours of management. to our knowledge, this is the fi rst multicenter study to estimate the quantity of ppe and antiviral therapy that may be required to manage patients with suspected api admitted to hospitals. during the initial 6 hours of hospital assessment, the number of close contacts of a single suspected api patient was high (mean 12.3), with a mean number of exposures of 19.3. not surprisingly, most (85%) close contacts were hcws, and ppe use was at its most intense (11) 3 (9) 7 (10) 6 (9) 7 (10) 6 (9) 3 (4) † 3 (5) † 5.9 (9.9) ‡ ward 4 (7) 4 (5) 2 (5) 2 (8) 3 (3) 4 (9) 2 (5) --3.0 (6.0) by study period, h 0-1 10 (12) 8 (8) 3 (4) 6 (8) 7 (7) 8 (8) 5 (5) 9 (10) 5 (6) 6.8 (7.6) (9) . if appropriate ppe, especially n95 masks, were not available, the number of hcws who would experience moderate-risk api exposure requiring postexposure antiviral prophylaxis would increase substantially. notably, a substantial minority of close contacts (15%; ≈2 per api patient) were non-hcws (e.g., hospital patients or visitors), generated primarily in the triage area. although the duration of unprotected exposure was often short (<5 minutes) for these persons, they represent a potential risk for subsequent community and hospital spread of api. this highlights the importance, in triage and reception areas particularly, of using appropriate infection control measures and signage to assist in cohorting of potential api patients and minimizing exposure of unprotected bystanders. the critical importance of effective ppe in hospital infection control was demonstrated during the outbreak of sars in 2003 (10) (11) (12) (13) (14) . nosocomial transmission of sars was a prominent feature of the epidemic (15) and played a large role in the initiation and maintenance of outbreaks. as reported in a case-control study by seto et al. (13) , staff who used masks (in particular), gowns, and performed hand hygiene were less likely to become sars infected than those who did not. similarly, lau et al. (14) noted that inconsistent use of ppe by hcws working on wards with sars patients in hong kong was associated with a signifi cantly higher risk for nosocomial disease transmission. provision of adequate ppe stock is therefore likely to be important in controlling the spread of api. many countries are compiling extensive stockpiles of ppe and antiviral medications for use if a new pandemic occurs. planning for suffi cient numbers of resource items is complex and dependent on estimations of pandemicrelated additional emergency presentations, hospitalizations, general practice, and outpatient visits. in australia, offi cial estimates of additional hospitalizations range from 57,900 to 148,000 (4). our data suggest that management of this number of hospitalizations without regard for suspected infl uenza patients who are assessed but who are not suffi ciently ill to require admission, would require from 1,123,260 to 3,714,800 ppe sets (depending on whether they were n95 masks, gowns, or gloves, or all 3 items). although ascertaining (from these data) the number of courses of postexposure antiviral prophylaxis required is diffi cult, if stocks of readily available ppe were inadequate, the number of courses of antiviral medication required would likely increase dramatically, up to 12-13 courses per suspected api case during the initial 6-hour assessment. thus, adequate stocks of ppe provide a means of protecting valuable antiviral drug stockpiles for use in ill or heavily exposed persons. an important consideration when extrapolating our data to other healthcare systems is that recommendations regarding the optimal form of respiratory protection vary between countries. the who interim guidelines for management of human cases of avian infl uenza (ai) state, "hcws working with ai-infected patients should select the highest level of respiratory protection available, preferably a particulate respirator… designed to protect the wearer from respiratory aerosols expelled by others" (7) . this recommendation is refl ected in the australian pandemic infl uenza guidelines (3) and explains the high use of n95 masks in our study. however, pandemic infl uenza plans in the united kingdom (5), united states (6), and canada (16) currently recommend the use of surgical masks for close patient care, unless the hcw is engaged in procedures in which aerosolization occurs. thus the proportion of n95 masks to surgical masks required will vary between countries with different guidelines, which affects assessment of stockpile adequacy. our study did not assess the relative effi cacy of n95 masks compared with surgical masks for protection against api transmission. this study has several limitations. first, the duration of the study was short (6 hours), much shorter than the likely in-hospital stay of days for a patient with severe infl uenza. thus, total ppe and antiviral agent usage per admission is likely to be substantially higher. second, the study was conducted at a less busy time of day for emergency departments and therefore may not refl ect the greater number of persons who would likely be exposed in the triage and emergency department areas during busier periods. third, the patient was not clinically unwell or hypoxic; thus, relatively few hcws were required to assess, manage, or review the api patient's condition. fourth, we observed the management of the index api case-patient alone, although we acknowledge that actual patients are likely to come to the hospital with other household members (high-risk close contacts). however, extending observation to include management of asymptomatic but potentially infectious accompanying persons in a standardized manner would have substantially increased the complexity of the exercise. our fi ndings, therefore, likely underestimate the true resources required and contacts exposed for the management of a genuine api patient. finally, the presence of observers and the preceding education sessions may have artifi cially increased compliance with ppe use, although in the event of a true pandemic one might assume that hcw compliance rates would be high as they aim to minimize their personal risk. also, this study was designed to quantify the use of ppe in an environment with raised awareness of infection control practice, mimicking that which might occur during a pandemic, and thus provide relevant data for health resource planners. this study suggests that managing a single api patient is resource intensive and exposes a high number of persons to a potentially severe infection. these data represent the likely minimum clinical resources required during an api patient's initial hospital assessment using current whoderived infection control guidelines. given our fi ndings, if a global infl uenza pandemic occurs with attack rates even on the lower end of projected estimates, demand for ppe and antiviral medication in healthcare facilities will likely outstrip current supply in industrialized countries, let alone the supply in resource-poor settings. further studies are needed to assess resource usage in other healthcare settings such as intensive care units, fever clinics, general practice, and the community. the economic impact of pandemic infl uenza in the united states: priorities for intervention world health organization writing group. nonpharmaceutical interventions for pandemic infl uenza, national and community measures national infl uenza pandemic action committee. interim infection control guidelines for pandemic infl uenza in healthcare and community settings. annex to australian health management plan for pandemic infl uenza department of health and ageing. australian health management plan for pandemic infl uenza guidance for pandemic infl uenza: infection control in hospitals and primary care settings united states department of health and human services. hhs pandemic infl uenza plan supplement 4, infection control avian infl uenza, including infl uenza a (h5n1) in humans: who interim infection control guidelines for health care facilities hand hygiene: a standardized tool for assessing compliance who rapid advice guidelines on pharmacological management of humans infected with avian infl uenza a (h5n1) virus the severe acute respiratory syndrome severe acute respiratory syndrome (sars) and healthcare workers sars outbreak: global challenges and innovative infection control measures effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (sars) sars transmission among hospital workers in hong kong public health agency of canada. infection control and occupational health guidelines during pandemic infl uenza in traditional and nontraditional health care settings (annex f) email: lindsay.grayson@austin.org.au emerging infectious diseases • www.cdc.gov/eid • we thank the infection control, emergency, pathology, and radiology departments, ward staff and "patient" volunteers of the following hospitals for their kind assistance in this study: austin health, box hill hospital, barwon health, monash medical centre, royal melbourne hospital, st. vincent's hospital, western hospital, royal hobart hospital, and westmead hospital.the study was funded in part by a grant from the department of human services, victoria, australia, which played no role in the data analysis of this study.dr swaminathan is infectious diseases registrar at austin health, melbourne, australia. among his main clinical interests are tropical infectious diseases and public health policy development. all material published in emerging infectious diseases is in the public domain and may be used and reprinted without special permission; proper citation, however, is required. key: cord-346176-w6uaet7l authors: nayeri, shadi; walshe, margaret; lee, sun-ho; filice, melissa; rho, stella; jeyakumar, ajani; stempak, joanne; smith, michelle i; silverberg, mark s title: conducting translational gastrointestinal research in the era of covid-19 date: 2020-08-26 journal: j crohns colitis doi: 10.1093/ecco-jcc/jjaa171 sha: doc_id: 346176 cord_uid: w6uaet7l abstract spread of the novel coronavirus sars-cov-2 has resulted in a global pandemic that is affecting the health and economy of all world health organization [who] regions. clinical and translational research activities have been affected drastically by this global catastrophe. in this document we provide a suggested roadmap for resuming gastrointestinal translational research activities, emphasising physical distancing and use of personal protective equipment. we discuss modes of virus transmission in enclosed environments [including clinical workplaces and laboratories] and potential risks of exposure in the endoscopy environment for research staff. the proposed guidelines should be considered in conjunction with local institutional and government guidelines so that translational research can be resumed as safely as possible. the novel coronavirus sars-cov-2 [which causes covid-19] remains a major public health threat. this virulent organism has caused the deadliest pandemic since the 'spanish' influenza pandemic of 1918. 1 the virus is transmitted mainly through respiratory droplets. 2 however, the virus is also detectable in the gastrointestinal [gi] tract. 3 a recent study reported the isolation of viral nucleocapsid protein and expression of angiotensinconverting enzyme 2 [ace2] protein [a receptor which facilitates entry of sars-cov-2 to cells] in the gastric, duodenal, and rectal epithelial cells of patients infected by sars-cov-2. 4, 6 additionally, stool samples from approximately 50% of covid-19 patients remain positive for viral rna up to 5 weeks after their respiratory samples test negative. 3, 5 currently, the viability and infectivity of the virus in faeces is poorly understood. 6, 7 droplet [>5-10 мm] transmission occurs primarily during close contact [usually within 1-2 m] with an infected person who has respiratory symptoms [eg, coughing, sneezing]. 8 however, asymptomatic infected individuals also play a major role in transmission of sars-cov-2. 9 exposure to high concentrations of bio-aerosols in relatively closed environments has also been suggested as a route of virus transmission. 3 sars-cov-2 can also be transmitted through fomites in the immediate environment of an infected person. 3 one study reported detection of the virus from sink and toilet bowl samples taken from the isolation room of a covid-19 patient. 3 in addition, viable virus particles can be detected on surfaces [such as plastic and stainless steel] for up to 72 h. 10, 11 globally, government and public health bodies have implemented policies in an attempt to mitigate the spread of sars-cov-2. efforts focus primarily on physical distancing, use of phase personal protective equipment [ppe] , and addressing capacity needs of health care systems to deal with the outbreak. this has led to significant curtailment of translational research activities for multiple reasons. first, physical distancing measures have restricted the ability of researchers to work 'on site' and handle samples at the same capacity as before the pandemic. second, the pandemic has resulted in limitation of resources such as access to shared laboratory equipment, ppe, and endoscopy. third, availability and willingness of patients to engage in research has been negatively affected, in part due to drastic reduction in non-urgent clinical activity. we suggest that a phased approach be taken to re-expand non-essential research activities. in this guidance document, we address the roadmap to re-engaging in gi translational research in the era of the covid-19 pandemic, while keeping researchers and research participants safe. these guidelines were formulated with collaboration across our translational research group, with incorporation of international as well as local institutional recommendations. given the rapidly evolving landscape of the pandemic worldwide, these guidelines should be considered in conjunction with local institutional and government regulations. considering the risk of viral transmission associated with conducting office/laboratory-based research, re-opening of research environments should be performed in stages. potential risks relate to sharing of work space and handling of biospecimens. the following suggestions should be considered in the context of local factors including capacity, ppe availability, and feasibility of monitoring procedures to ensure new safety measures are being followed. all workplaces should be prepared to re-introduce restrictions on research activities in the event of sars-cov-2 resurgence. we propose that re-expansion of research activities take place across four phases [as outlined in figure 1 ]: phase 1, preparation; phase 2, re-start research activities with total staff numbers not to exceed 20% of on-site capacity; phase 3, continue to increase staff numbers to maximum 40-60% of on-site capacity; and phase 4, continue to increase staff numbers to approximately 60-100% of on-site capacity, while maintaining significant sars-cov-2 restrictions for the foreseeable future. this phased approach will enable researchers to ramp up projects in order of priority. we propose suggested time frames for implementation of each phase, but the decision to progress through phases must factor in local risk assessment based on prevalence of infection in the community. the time frames described should allow for monitoring of adherence to safety measures and detection of outbreaks resulting from increased traffic in the workplace, both of which must be prospectively and actively monitored within each phase. decision makers for advancing through the phases should be designated based on institutional policies. phase 1 should be completed within an estimated 2-week time frame. the main scope of this stage consists of: 1] increasing the number of staff on site while introducing new safety routines to maintain physical distancing; 2] provision for increased levels of hygiene [hand, surfaces, and equipment]; 3] increasing access to critical supplies when supply lines may already be stretched. we suggest the following phase 1 measures. • access to all research areas should be restricted to research personnel only. all visitors from outside research institutes, including other researchers, service personnel, delivery personnel, and vendor representatives must follow local sars-cov-2 restrictions for booking appointments. additionally, they must follow screening procedures and wear appropriate ppe. • programme leaders should develop specific plans for resuming work in their laboratories, allowing identification of staff who will work on site. this should take laboratory space, layout, and ventilation into account to allow for physical distancing in all shared areas such as laboratory bays, equipment rooms, tissue culture rooms, offices, and break areas. for common areas we suggest an online calendar for booking equipment and rooms. • re-organisation of workplace layout may be considered to facilitate shared use of space and equipment while maintaining physical distancing. • presence of staff in the workplace should be prospectively recorded to ensure that future contract tracing [if required] is feasible, and to monitor occupancy on site. we suggest web-based sign-in to facilitate this process. • in-person meetings should be limited to maintain the 2 m rule for physical distancing. in addition, face masks should be required for face-to-face meetings in enclosed spaces. • meetings [including in-laboratory meetings and meetings with external groups and collaborators] should take place online wherever possible. • all staff who can work from home should continue to do so; this includes staff coming into the workplace to carry out specific activities but who do not need to remain for the entire day. re-assignment of 'on-site' tasks should also be implemented where feasible, in order to minimise staff numbers in the workplace. • staggered work hours to avoid crowding of work spaces should be considered. • in order to maximise opportunity for staff to work from home, access to relevant resources should be addressed. this may include laptops, analysis software, and remote access to datasets. subsidies for work-related costs incurred to staff as a result of working from home [eg, internet access costs] may be considered. • an updated cleaning schedule for common areas should be executed by housekeeping. cleaning schedules should include wiping down door handles and other highly used surfaces with approved disinfectants. 12 • on-site laboratory staff should regularly wipe down common surfaces/equipment using approved disinfectants or 70% ethanol. these areas include but are not limited to: • equipment: incubators, fridge and freezer doors, bench tops, biological safety cabinets [bsc], fume hoods, keyboards, microscopes, centrifuges, etc. • office and break areas: tables, chairs, desks, microwaves, coffee pots, etc. • as research programmes restart, staff in different supply centres, research receiving, stabilisation, and glass washing should re-schedule staffing to match research activity. • laboratory managers should ensure availability of supplies for at least 2-3 months following re-initiation of research activities. this includes availability of ppe, molecular kits, plasticware, chemicals, and reagents. • research units must take responsibility for acquiring ppe, and remain cognisant of any impact on the availability of ppe for clinical care workers. co-ordination of ppe procurement with allied hospital services may help to mitigate costs through 'bulk buying'. the estimated time frame considered for this phase is 3-6 weeks. during phase 2, we suggest that areas be restricted to a maximum of 20% occupancy at any one time, though this can be customised based on the overall size of the research group. • as staffing numbers increase at this stage, cleaning logs should be implemented for all laboratory areas. • staff will be responsible for self-monitoring for symptoms of covid-19 [eg, cough, sore throat, dyspnoea, rhinorrhoea, fever, anosmia]. symptoms and/or close contact with infected individuals should be reported immediately to occupational health and laboratory management. self-isolation should be adopted while awaiting further direction from occupational health. the suggested time frame for this phase is 1-2 months. phase 3 is subject to a maximum 40-60% staff occupancy at any given time. • the plan for this stage is to return to research activity based on approvals of local research group work committees. • some dry laboratories can move directly to phase 4, where physical distancing [2 m] can be practised or working remotely is possible. • physical distancing of 2 m should continue to be practised. during this time, the occupancy of areas is suggested to be maintained at 60-100% at any one time depending on how space constraints limit capacity for physical distancing. this phase will persist as long as sars-cov-2 remains a community health risk. • the research environment will essentially run at full capacity but on-site occupancy may need to remain reduced by up to 40%. • staff should be encouraged to continue to work from home where possible. translational research relies on in-person involvement of research staff and patients in most circumstances. researchers must remain cognisant at all times of any potential risk posed to research participants and research staff. whereas all persons should consider themselves at risk of covid-19, research patients may represent a particularly vulnerable population due to underlying disease processes and/or medical intervention. 14 as always, the option to withdraw from research studies must remain open to participants, whose willingness may be significantly affected by the pandemic. local and institutional guidance is required to resume translational research activities, including patient interactions. these guidelines are intended to assist safe resumption of such activities. • wherever possible, research study participants should be engaged remotely. • study protocols should be adapted in order to minimise in-person patient visits. suitability of phone/video or electronic interaction should be considered. all such adaptations must be subjected to reb approval before implementation with stringent protection of patient privacy and confidentiality. • visits to hospitals and research facilities should be minimised and confined to clinical research areas. • for research relating specifically to sars-cov-2 infection, in-person contact with patients known to be infected may be necessary. for all such contact, full ppe including n95 masks or equivalent, long-sleeve gowns, gloves, and goggles or face shields must be worn. fit testing of n95 masks must be performed before use. • invitation of persons currently infected with sars-cov-2 from the community into the research environment would cause unnecessary and inappropriate risk of viral transmission. as such, research involving patients with current sars-cov-2 infection should be limited to inpatients. as outlined above, sars-cov-2 has been isolated from gi biopsies and stool samples. 5, 15 it is unclear at this time whether transmission of sars-cov-2 can occur via handling of biospecimens. 6 no cases have been reported to date, but precautions are required. in keeping with standard laboratory protocols, all specimens should be regarded as potentially infected. additionally, particular consideration is necessary when obtaining biospecimens in the endoscopy environment. the nature of endoscopic procedures poses potential for viral transmission via aerosolisation of viral particles. 11, 16 the risk of viral transmission to staff from patients during gi endoscopy has not been quantified, but many consider gi endoscopy 'high-risk'. 17, 18 here, we provide guidance on laboratory biosafety in relation to sample collection, handling, processing, transportation, and storage. • for outpatient blood sample collections, patients should be sent to commercial medical laboratory services or hospital outpatient laboratories if possible. • if in-person blood sampling by research staff is needed, it should be performed in areas where there are minimal additional exposed individuals [ie, dedicated examination rooms], and with adequate ppe. for research staff, gloves and masks should be mandatory. we recommend also using eye protection and gowns. patients should also be wearing masks. • stool and urine sample kits can be couriered to subjects to obtain samples at home. the samples should be couriered back to research staff, if possible. • where patients must return biospecimen samples in person, sample drop-off by the patient and pick-up by the research staff should be sequenced with minimal contact. designated drop-off locations will facilitate these practices. • samples need to be wiped down with disinfectant before placing them in the storage container and transfer bag. • a drop-off bay should be designated. • all surfaces touched by the research staff or specimen containers during drop-off and pick-up must be sanitised. all transfer bags and container bags should be sanitised between uses. • dedicated standard operating procedures should be in place for transfer of samples which may contain live virus to research areas. • standard universal precautions should be followed when handling clinical specimens which potentially contain infectious materials: hand hygiene, use of ppe, ie, laboratory coats or gowns, gloves, and eye protection. • all laboratory processing of samples should be performed based on risk assessment and only by certified technicians following local or institutional guidelines. • processing of all specimens should be performed in certified class 2 bsc [with the exception of virus propagation, for which class 3 bsc is required]. viral inactivation through addition of 1% detergent or heat treatment is highly recommended and significantly reduces concerns for laboratory handling. 20-22 • a sample manifest or tracking log should be maintained. • routine laboratory practices including procedures for decontamination of work surfaces and disposal of laboratory waste should be followed using local safety protocols. • there should be a clear framework of communication between management and research staff such that relevant parties are notified in a timely manner should inadvertent potential exposure to sars-cov-2 occur. • a contingency plan with a specific protocol must be developed in case of a biosafety incident, ie, exposure to a potentially infected biospecimen. • such incidents should be reported immediately to the appropriate personnel. • spill kits and first aid kits including medical supplies should be prepared at all times. • research staff exposed to a potentially infected biospecimen or infected patient should be self-isolated and be tested for sars-cov-2 as soon as possible. this should be performed in collaboration with occupational health services. we have proposed guidelines for gradual re-expansion of gi research activities during the sars-cov-2 pandemic. stage-wise resumption of research activities should be implemented with consideration for ongoing risk assessment, availability of resources such as appropriate ppe, and proper physical distancing measures. considering the risk of exposure in enclosed environments, we propose re-engagement in research activities in four phases: phase 1, preparation, phase 2, start-up, phase 3, ramp-up of research activities; and phase 4, maintaining and monitoring the safety situation at the new normal. these guidelines address safety precautions in relevant workspaces [including laboratory and endoscopy environments] as well as in specific research activities such as sample collection, handling, and transportation. as the pandemic continues to evolve, vigilance and flexibility must be applied, particularly as risk of future waves of infection fluctuates. accordingly, the guidelines should be interpreted in conjunction with local institutional and government policies. influenza: the mother of all pandemics the epidemiology and pathogenesis of coronavirus disease [covid-19] outbreak air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 [sars-cov-2] from a symptomatic patient evidence for gastrointestinal infection of sars-cov-2 gastrointestinal manifestations of sars-cov-2 infection and virus load in fecal samples from the hong kong cohort and systematic review and meta-analysis prolonged presence of sars-cov-2 viral rna in faecal samples rigidity of the outer shell predicted by a protein intrinsic disorder model sheds light on the covid-19 world health organization. modes of transmission of virus causing covid-19 : implications for ipc precaution recommendations asymptomatic transmission, the achilles' heel of current strategies to control covid-19 environmental contamination and viral shedding in mers patients during mers-cov outbreak in south korea aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 to world health organization. laboratory biosafety guidance related to coronavirus disease clinical trials for inflammatory bowel disease: a global guidance during covid-19 pandemic. j crohn's colitis 2020 endoscopy in inflammatory bowel diseases during the covid-19 pandemic and post-pandemic period the time sequences of oral and fecal viral shedding of coronavirus disease covid-19 pandemic: which ibd patients need to be scoped-who gets scoped now, who can wait, and how to resume to normal practice of endoscopy during covid-19 pandemic: position statements of the asian pacific society for digestive endoscopy peyrin-biroulet l. the day after covid-19 in ibd: how to go back to 'normal aga institute rapid recommendations for gastrointestinal procedures during the covid-19 pandemic evaluation of heating and chemical protocols for inactivating sars-cov-2 sodium lauryl sulfate, a microbicide effective against enveloped and nonenveloped viruses inactivation of the coronavirus that induces severe acute respiratory syndrome, sars-cov we wish to acknowledge the zane cohen center for digestive diseases, lunenfeld-tanenbaum research institute and toronto academic health science network for providing the principles for the guidelines. specifically we would like to thank jim woodgett for his detailed comments and review of the paper. the authors have no financial disclosures or conflicts of interest. key: cord-330666-puhijixa authors: carrico, ruth m.; coty, mary b.; goss, linda k.; lajoie, andrew s. title: changing health care worker behavior in relation to respiratory disease transmission with a novel training approach that uses biosimulation date: 2007-02-02 journal: am j infect control doi: 10.1016/j.ajic.2005.12.013 sha: doc_id: 330666 cord_uid: puhijixa background: this pilot study was conducted to determine whether supplementing standard classroom training methods regarding respiratory disease transmission with a visual demonstration could improve the use of personal protective equipment among emergency department nurses. methods: participants included 20 emergency department registered nurses randomized into 2 groups: control and intervention. the intervention group received supplemental training using the visual demonstration of respiratory particle dispersion. both groups were then observed throughout their work shifts as they provided care during january-march 2005. results: participants who received supplemental visual training correctly utilized personal protective equipment statistically more often than did participants who received only the standard classroom training. conclusion: supplementing the standard training methods with a visual demonstration can improve the use of personal protective equipment during care of patients exhibiting respiratory symptoms. health care personnel are at risk for exposure to a variety of infections during the routine performance of their job responsibilities. despite these risks, compliance with protective equipment has remained suboptimal. 1 the safety of emergency department (ed) personnel, often the first to encounter an ill patient, is an important area to target for improvement. the risk factors for those individuals include the emergent nature of the care provided and the unknown circumstances that initially led to the patient's utilization of health care. 2 despite the emphasis on standard precautions training for health care workers (hcws), the consistent use of personal protective equipment (ppe) remains poor. 3, 4 various descriptions and analyses of the 2002-2003 severe acute respiratory syndrome (sars) outbreak reported lack of basic preemptive infection prevention and control strategies. as the outbreak grew, attention was paid to use of protective equipment, including respiratory protection, as symptomatic patients were identified. the experiences of hcws confronted with suspected or confirmed sars cases revealed an often inadequate and incorrect use of ppe. 5, 6 a fundamental flaw in the preventive process seemed to involve failure to recognize quickly the key signs, symptoms, or risks that might have led to the early implementation of protective equipment. although there is little research concerning changing hcw behavior when providing care for patients with respiratory illness, there was some evidence from the sars outbreak that pointed toward the benefits of training programs and availability of adequate ppe. 7 the workplace practices identified as problematic during the sars epidemic mirror those identified by jagger et al at the international healthcare worker safety center of the university of virginia. jagger et al's work has focused on injuries and exposures involving blood and body fluid exposures among hcws. in 2001, as part of the epinet surveillance program, 8 a total of 463 blood-body-fluid exposures were reported from 49 participating health care facilities. of these exposures, over 13% occurred in the ed. less than 10% of the exposed hcws reported wearing appropriate eye protection, and fewer than 20% reported wearing some sort of mask or other facial barrier. 9 clearly, the need still exists for effective training techniques to promote the use of ppe as a way to minimize such workplace exposures. traditional infection prevention and control training for hcws has involved a review of the occupational safety and health administration (osha) bloodborne pathogens training, 10 as outlined in the current centers for disease control and prevention (cdc) isolation guidelines, 11 with emphasis on transmission-based precautions. when we conducted an informal telephone interview with infection control professionals (icps) from 10 us hospitals chosen at random, results indicated that this type of training involved a classroom setting (80%) and/or written handouts (20%). a pretest and posttest process typically assessed competency. none of the interviewed hospitals reported the consistent inclusion of an observational component in their training or subsequent assessments. much of the existing research and education involves exposures to bloodborne pathogens; very little involves respiratory pathogens. the research does, however, enforce the concepts of disease transmission and identifies the lack of consistent protective activities used by health care personnel. [1] [2] [3] [4] the risks involved in respiratory pathogen transmission have been included in the concept of ''cough etiquette'' outlined in the draft version of the impending cdc draft guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings, 2004. 12 it is important to identify innovative methods that will impact practice and result in procedural changes that will better protect the care provider. developing new methods that can change the behavior and increase the appropriate use of ppe is a challenge. this pilot study evaluated a novel training approach for hcws to use ppe when encountering patients who have known or suspected respiratory illnesses. the training approach involved the use of a human patient biosimulator to visually demonstrate respiratory disease transmission. the effectiveness of the visual demonstration was assessed by comparing the ppe-specific knowledge, attitudes, and skills of ed registered nurses (rns) who received the demonstration to those who only received the standard disease transmission training. the study hypotheses were as follows: (1) the standard disease transmission training will result in an increase in knowledge among rns, and (2) the additional use of a visual demonstration would result in significant improvement in appropriate ppe use among hcw beyond the improvement produced by the standard training methods. this pilot project involved the use of the patient biosimulator (medical education technologies, inc. [meti], sarasota, fl) to demonstrate particle dispersal during a cough. when the biosimulator ''coughed,'' fluorescent powder was dispersed into the air, allowing the study subject to visualize the impact to themselves and the environment. the study subjects were able to see the particles move directly from the patient to the air and contaminate the environment as well as the subject's physical person (fig 1) . the effectiveness of ppe was demonstrated using a black light that showed areas of fluorescent powder contamination and areas in which ppe provided a barrier, thereby preventing contamination. we used pre-/posttest knowledge assessments and observations of hcw-patient interactions to evaluate the impact of the visual demonstration of respiratory disease transmission on ppe use by hcws. the study was conducted during the peak of the 2005 influenza season (january to march) to ensure that the hcws could be observed interacting with the greatest number of patients with respiratory symptoms. the study was conducted at a university medical center in a large metropolitan city. training sessions and observations took place in the ed. initially, 22 rns were recruited into the study; 2 subjects withdrew from the study following job transfers. an effort was made to recruit an equal number of day shift (7 am to 7 pm) and night shift (7 pm to 7 am) nurses into the study. the university hospital institutional review board approved the study. eligible rns were identified by the ed nurse manager and were informed of the study during scheduled staff meetings and by posted flyers. eligible rns were those nurses who were employed by the hospital; therefore, mobile or per diem nurses were excluded. during the staff meetings, the investigators provided a brief overview of the study, answered questions, and determined staff members' willingness and eligibility to participate in the study. the rns who agreed to participate were provided with a consent form to sign. after the consent form was signed, all subjects were scheduled to attend classroom training. this training focused on mechanisms of disease transmission, standard precautions, and appropriate use of ppe. the 20 subjects were randomly assigned to either the intervention group or the control group. the intervention group received classroom training plus biosimulated visual training, and the control group received classroom training only. after group assignments were made, a colored sticker was placed on the subjects' identification badges to indicate participation in the study. observers with experience in the education and training of health care personnel were trained to recognize and evaluate the use of ppe by study participants during real patient interaction. the observers were blinded to the subjects' group assignment. a work schedule was provided to the observers to allow equal opportunity for evaluation on both shifts throughout the observation period. the study was designed to continue until a minimum of 10 patient-subject interactions were observed for each study participant or until the ed activity indicated that the presentation of symptomatic patients had declined to a point that observation opportunities were minimal. personal handheld computers were used for data entry by the observers. the investigators developed software, and training was provided to the observers. use of the handheld data collection device allowed the observers to collect and record information in an unobtrusive manner and minimize data entry errors. written scenarios and monitoring of real-time nursepatient interactions were observed in an effort to promote interrater reliability between the 2 observers. the 2 observers participated in specific education and evaluation sessions held prior to the study, during the study, and after completion of the study. sessions were held with both observers together as well as separately. scenarios were presented to determine the ability of each observer to identify the care setting (eg, triage, assessment) specific types of ppe (eg, mask vs n95 respirator), and symptoms exhibited by the patient (eg, temperature readings, cough, rhinitis). during all reviews, both observers consistently demonstrated 100% accuracy. data were collected at 3 points in time: (1) participants completed a knowledge assessment prior to the classroom training. the pretest phase included an assessment of subject's knowledge of respiratory pathogen transmission as well as standard precautions; (2) once classroom training was completed, the subjects retook the knowledge assessment; and (3) observations began after the posttest had occurred. observations of the subjects' use of ppe were made in the weeks immediately following the completion of training. a patient-subject interaction was considered appropriate for study inclusion if the observers noted that the patient exhibited respiratory symptoms (ie, cough and/or fever). if the patient-subject interaction was appropriate, the observers evaluated the subject's behavior with regard to ppe use. the observers also recorded the patient's symptoms, the time and location of the care, and the care that was being provided. type of care provided was coded as triage, physical assessment, invasive procedure, noninvasive procedure, and resuscitation event. knowledge related to respiratory pathogen transmission and standard precautions guidelines were measured by a questionnaire developed for this study. evaluations of the patient-subject interaction by the 2 trained observers included the date/time of observation, presenting diagnosis, procedure(s) performed during the observation episode, presence of respiratory symptoms, patient cooperation as related to each procedure, and a list of all ppe items used or worn by the observed hcw. the opportunity for the observer to make special comments that may impact the use of ppe (eg, if the patient is masked during the observation episode) was included in the data collection form. table 1 . the 2 groups were found to be similar on most demographic variables. the age range was 23 to 56 years with a mean age of 38 years. the 2 groups were primarily female (95%), with slightly less than half (48%) having a college or graduate degree (bachelor's degree or master's degree in nursing). both the intervention group and the control group completed standard classroom training designed to provide text-based information about disease transmission. the preclassroom training knowledge assessment indicated no difference between the intervention and control groups (t(19) = 1.11, p = .28). the average pretest score was .67 (sd = .12) for the control group and .62 (sd = .09) for the intervention group. the 2 groups also did not differ significantly on the postclassroom training assessment (t(19) = 1.22, p = .24). the average posttest score for the control group was .81 (sd = .17) and .72 (sd = .18) for the intervention group. combining the scores of both groups yielded a pretest score of .64 (sd = .11) and a posttest score of .76 (sd = .17). overall, both groups showed a a total of 114 observations were recorded: 56 for the control group and 58 for the intervention group. of these, 35 involved more than 1 observation on a single patient. in an effort to ensure independent observations, 1 observation was randomly selected from each patient to be included in the final data set. this was done to prevent multiple observations of a single patient for whom ppe was used or not used during each patient interaction. in the final dataset, there were 84 observations, with 42 in each group. cough, fever, rhinitis, and/or sneezing were considered conditions in which ppe was required. the intervention group did not differ significantly from the control group on the proportion of patients with symptoms requiring ppe use (86% vs 93%, respectively, [fisher exact test, p = .16]). table 2 shows the breakdown of protective equipment used by study participants stratified by group. interestingly, rns in both groups routinely elected to place masks on the patients instead of on themselves. a mask, used on the rn and/or the patient, was considered to be appropriate ppe when the patient condition included fever, cough, sneeze, and/or rhinitis. self-use of a mask did not differ between the control and intervention groups (fisher exact test, p = .60). although use of a mask on the patient occurred more frequently in the intervention group, it was not significant (fisher exact test, p = .08). upon analysis of data, the practice of nurses masking patients was an unexpected finding. it was then decided to aggregate self and patient mask use into a single dichotomous variable: ppe mask use. when use of ppe (self-use of mask and placement of mask on patient) was dichotomized into ''yes'' or ''no'' and was cross-tabulated with group assignment, analysis comparing use of ppe between control and intervention groups indicated that subjects who received the visual training demonstrated use of ppe more often (74% vs 53%, respectively). given the exploratory nature of the study and the unidirectional hypothesis that the visual demonstration would improve ppe use, statistical significance for this hypothesis was evaluated as a 1-tailed distribution test (a = .05). a fisher exact test was performed to determine whether the visual demonstration increased appropriate ppe use relative to the standard training alone. results are shown in table 3 and indicate that the standard training plus biosimulation significantly increased the use of ppe for patients with respiratory symptoms (p = .04). the literature that addresses ppe use among hcws continues to stress the need for education as a means of improving safety practices. [1] [2] [3] [4] [5] [6] [7] this study showed, however, that traditional education is not necessarily the sole or even key factor in improving ppe use. two basic components were addressed in this pilot project. the first involved the increase in knowledge regarding disease transmission using a traditional didactic training process. the second component investigated whether a biosimulated, visual demonstration of particulate transmission would result in increased ppe use. traditional classroom training did, indeed, make a significant difference in pre-and posttraining knowledge. the addition of a visual component to training emphasized the personal risk of the individual hcw. direct observations showed that the subjects trained using this visual approach appropriately used ppe more often than those subjects whose training did not include this visual component: 74% versus 53%, respectively. therefore, these results suggest that use of the biosimulator and visual training is an important new approach for learning in the health care setting. this type of learning allowed the hcw to see the impact of disease transmission as opposed to simply hearing about it through traditional didactic education. in addition, the components of this visual demonstration built on the principles of adult learning. teaching occurred within the context of work experience, thereby making the learning relevant to the individual. feedback from the subjects in the intervention group reinforced the value of the visual component of training. several staff commented that they recognized environmental or personal contamination when they could see the blood or other fluids they encounter during emergency procedures but admitted that their use of protective strategies, including ppe, was less than ideal. every subject trained in the intervention group remarked on the impact they felt the visual demonstration had on their individual practice. the major limitation of this pilot study was the small size of the sample. although many results demonstrated significance, the question remains whether or not the results are generalizable. repeating this study on a larger scale could help answer that question. the logistics involved in unobtrusively observing practice and working around nurses who were not involved in the study made planning and implementation a difficult task. another issue of concern was our inability to ascertain the influence of the organization on the use of safety practices, including use and selection of ppe. if this study were repeated and involved multiple sites, the culture of safety and its impact could be assessed. with the availability of inexpensive computer technology in recent years, simulation technology has blossomed, especially in the field of medicine, in which applications range from scientific modeling to clinical performance appraisal in the setting of crisis management. much of the initial work with human patient biosimulators, or use of a simulation ''dummy,'' has been done by anesthesiologists as part of their road toward medical error reduction. biosimulators are now used in university medical centers across the country to assist and improve the learning of residents, medical students, nursing students, and employed hcws. the benefits of simulation technology in medical training include improvements in cardiovascular examination skills, increased precision in surgical technical skills, and acquisition and retention of knowledge compared with traditional modes of teaching (eg, lectures). [13] [14] [15] [16] [17] [18] although there has been significant knowledge and experience gained through simulation in the area of medical education, there has been a lack of research concerning the use of simulation as a method of enhancing performance involving respiratory disease transmission. developing an improved model for training hcws that demonstrates a significant improvement in behavior regarding ppe use has the potential to protect the millions of hcws that currently practice in health care settings. reducing the respiratory exposures because of influenza and preventing the repeated scenarios identified during the sars 2003 global epidemic may also prevent the unnecessary illness/deaths of hcw because of inadequate or inappropriate use of respiratory ppe. successful demonstration of improvements could change the way hcw education is conducted throughout a variety of environments, not simply the ed. furthermore, this type of education could be used in other professional disciplines, including physician, therapist, and administrative training. epidemiology and prevention of blood and body fluid exposures among emergency department staff compliance with universal precautions among emergency department personnel: implications for prevention programs risks for exposure to and infection with hiv among health care providers in the emergency department variables influencing worker compliance with universal precautions in the emergency department lack of sars transmission among healthcare workers, united states investigation of a nosocomial outbreak of severe acute respiratory syndrome (sars) in toronto, canada the bc interdisciplinary respiratory protection study group. protecting health care workers from sars and other respiratory pathogens: organizational and individual factors that affect adherence to infection control guidelines occupational safety and health administration. occupational exposure to bloodborne pathogens: final rule. 29 cfr part 1910.1030 guideline for isolation precautions in hospitals. the hospital infection control practices advisory committee cdc cdc draft guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings patient safety and simulation-based medical education simulation technology for health care professional skills training assessment educating health professionals to respond to bioterrorism practical health care simulations recognizing biothreat diseases: realistic training using standardized patients and patient simulators the authors thank the observers, david walsh, bs, and jonathan carrico, bs, for their commitment to the project and attention to excellence and the hospital emergency department staff for their support and participation. the authors have made available to the readers a visual component to this article. readers may visit the following web site to see a brief video clip (there is no sound with this clip): http://www.louisville. edu/television/cough.asx key: cord-342810-41dghl0c authors: nguyen, thanh n.; jadhav, ashutosh p.; dasenbrock, hormuzdiyar h.; nogueira, raul g.; abdalkader, mohamad; ma, alice; cervantes-arslanian, anna m.; greer, david m.; daneshmand, ali; yavagal, dileep r.; jovin, tudor g.; zaidat, osama o.; chou, sherry hsiang-yi title: subarachnoid hemorrhage guidance in the era of the covid-19 pandemic -an opinion to mitigate exposure and conserve personal protective equipment date: 2020-06-05 journal: j stroke cerebrovasc dis doi: 10.1016/j.jstrokecerebrovasdis.2020.105010 sha: doc_id: 342810 cord_uid: 41dghl0c aneurysmal subarachnoid hemorrhage (sah) patients require frequent neurological examinations, neuroradiographic diagnostic testing and lengthy intensive care unit stay. previously established sah treatment protocols are impractical to impossible to adhere to in the current covid-19 crisis due to the need for infection containment and shortage of critical care resources, including personal protective equipment (ppe). centers need to adopt modified protocols to optimize sah care and outcomes during this crisis. in this opinion piece, we assembled a multidisciplinary, multicenter team to develop and propose a modified guidance algorithm that optimizes sah care and workflow in the era of the covid-19 pandemic. this guidance is to be adapted to the available resources of a local institution and does not replace clinical judgment when faced with an individual patient. aneurysmal subarachnoid hemorrhage (sah) patients require frequent neurological examinations, neuroradiographic diagnostic testing and lengthy intensive care unit stay. previously established sah treatment protocols are impractical to impossible to adhere to in the current coronavirus-disease-2019 (covid-19) crisis due to the need for infection containment and shortage of critical care resources, including personal protective equipment (ppe) and health care providers. as with acute stroke protocols, centers need to adopt modified protocols to optimize sah care and outcomes during this crisis [1] [2] [3] [4] . in this opinion piece, we assembled a multidisciplinary, multicenter team to develop and propose a modified guidance algorithm ( table 1 ) that optimizes sah care and workflow in the era of the covid-19 pandemic. this guidance is to be adapted to the available resources of a local institution and does not replace clinical judgment when faced with an individual patient. every suspected sah patient (evaluated in the field, direct presenting to the emergency department (ed) or in transfer) should be screened for possible covid-19 symptoms and risk factors per local institutional guidelines. symptoms and risk factors may include, but are not limited to: cough, fever, shortness of breath, new loss of taste or smell, nausea, vomiting, diarrhea, myalgia, and potential exposure to a covid-19 positive person. any patient identified as meeting covid-19 investigation criteria should be immediately placed under droplet plus contact precautions and into a negative pressure room if available. a surgical mask should be placed on the patient 5 unless the patient is intubated. utilize telecommunication tools (phone +/-video) for neurological assessments if available. follow local institutional guidelines for persons under investigation (pui) for covid-19, including nasopharyngeal swab testing or the recently available rapid severe acute respiratory syndrome coronavirus 2 (sarsif there is positive pulmonary symptomatology, consider non-contrast chest ct at the same time as head and neck ct/ cta. ct chest can facilitate diagnosis of covid-19 6 but may be nonspecific. note, if a patient is clinically unstable, received in transfer from another hospital, or has already returned from radiology, chest ct should not be performed prior to aneurysm securing. urgent stabilization and resuscitation including treatment of acute life-threatening hydrocephalus should follow established societal guidelines 7, 8 . long intravenous tubing can be utilized through the patient's course to help maintain drips for patients in need of hemodynamic support or blood pressure lowering. the medication pump can be titrated outside the patient's room to protect nursing staff from exposure and to limit ppe use. however, these long intravenous tubings should be used judiciously. with increased use, shortages of these tubing have now been reported. 9 long intravenous tubing is typically used with central lines, midlines or peripherally inserted central catheters. peripheral intravenous (iv) lines may not work as well with long tubing due to flow rate challenges with longer tubing and smaller diameter of the peripheral iv. 9 bar code scanning with the patient's medication and identification may not be possible when the pumps are located outside the patient's room, and hence extra caution should be utilized to avoid medication error. pumps in the hallway should not be used when there are two patients in one room. tripping over long extension lines could expose patients and health care workers to fall risk. decisions for definitive securing of the aneurysm via embolization or microsurgical clipping should be discussed in a multi-disciplinary approach based on the clinical and imaging findings. if the patient is felt to be a good endovascular candidate, cerebral angiography and/or aneurysm embolization should be planned with general anesthesia. in patients in whom aneurysm securing is delayed for unavoidable reasons, empiric use of prothrombotic agents such as aminocaproic acid or tranexamic acid should be avoided due to the presumptive increased risk of disseminated intravascular coagulation or pro-thrombotic conditions in covid-19 patients. [10] [11] [12] [13] patients with good-grade sah should be treated as per standard guidelines. 7, 8, 14 in the setting of the covid-19 pandemic with severe shortages of ventilators and critical care beds, 15 thresholds for treating patients with high-grade sah with diffuse cerebral edema or other comorbidities need to take into consideration the patient's likelihood of benefit and in accordance to proposed ethical frameworks for resource allocation during a pandemic. 16 this needs to be balanced by the fact that many high-grade patients can recover well even if presenting with high-grade sah. 17, 18 early aneurysm repair should be pursued as per local protocols to prevent aneurysmal re-rupture. in centers where there is a rapid turnaround time for sars-cov-2 testing (i.e. within few hours), it may be reasonable to wait for this test result as preparations are made to secure the aneurysm. a negative test may decrease ppe usage among all staff members. however, precautions should still be utilized in high-suspicion patients in the event of a false negative test. if the patient is not able to participate in the informed consent process, the legally authorized representative (lar) should consent for the patient. two physician emergency consent should be obtained if the lar is not available in a timely manner. if the patient is able to participate in the informed consent process, perform verbal procedural consent with a witness and avoid contact with inanimate objects such as pens and tablets which can be potential vehicles of viral transmission. 19 alternatively, if a physical signature is preferred or required, pens should be disinfected before and after contact with the patient. to minimize patient contact and preserve ppes, a single informed consent session should include all necessary consents such as consent for general anesthesia, aneurysm securing, external ventricular drain (evd) placement, central line and/or arterial line if appropriate. in addition, the patient should designate a health care proxy with a staff witness in the event that patient loses the ability to provide informed consent later in their hospital course. 19 when a patient with suspected or confirmed covid-19 is at risk for impending respiratory failure (i.e. orthopnea or respiratory distress lying flat, high oxygen requirement, rapid neurological decline), consider early and controlled intubation in a negative pressure room in the er/icu/or with staff wearing full ppe including n95 mask, gown, double gloves, face shield or per local institutional covid-19 intubation policy. an aerosol box can be utilized to protect the intubating proceduralist from droplet and aerosol spread. 20, 21 most angiography suites are positive pressure rooms; hence, this would not be the room of choice for any non-emergent aerosolizing procedure. following intubation and while the clinical team is still in full ppe, consider completing all other potentially necessary procedures such as placement of an oro-or naso-gastric tube in high-grade patients thought likely to need enteral access, and/or central venous line and/or arterial line access for close hemodynamic monitoring and control. cerebrospinal fluid diversion should proceed according to otherwise established guidelines and institutional practices. 7, 8 any neurosurgical procedure that requires a burr hole including an evd placement should consider the logistics of minimizing the risk of virus aerosolization during drilling. prior research has shown in animal models that bony microspicules can serve as a vector of virus transmission, including through the cornea, although the applicability to sars-cov-2 is unknown. 22 although it is expected that aerosolization through a twist-drill is reduced compared with a high-speed drill, the procedure should be performed using full ppe in covid-19 confirmed or suspected patients including the use of a face-shield and an n95 respirator. additionally, depending on the clinical urgency and the hospital logistics, consider performing this procedure in a negative-pressure room. due to these considerations, as well as the hypercoagulable state associated with covid-19 which may require early venous thromboembolism prophylaxis, lumbar csf drainage may be an option in patients with communicating hydrocephalus who do not have contraindications such as an intraparenchymal hemorrhage or low-lying cerebellar tonsils. similar to thrombectomy room preparations, 19 when treating a covid-19 confirmed or suspected patient, all unnecessary objects or items in the angiography suite / operating room (i.e. lead aprons that won't be utilized) should be removed to minimize need for cleaning postprocedure. countertop items should be covered with plastic or removed. medications and the procedural table should be prepared in the room before patient arrival (i.e. for an angiography suite, cover detector, pedals with plastic, bags etc.) to minimize the time of the patient in the room and to protect room equipment. the cabinets and supply closet should be covered before the patient arrives. 19 gloves, a face shield that covers the eyes, n-95 mask or powered, air-purifying respirator (papr) and protective gear should be utilized in covid-19 pui or positive patients. in an angiography suite, hanging lead shields and standing lead shields should be used as another layer of protection. proceduralists' pager and phone should be placed inside plastic bags at a pre-planned area in the control room and communication maintained in the event the proceduralist is called. devices should be placed in plastic bags that can be cleaned from the outside. staff should be kept to a minimum during the procedure (i.e. 1 nurse, 1 technologist/scrub rn, 1 physician, 1 anesthesiologist) to minimize exposure, conserve ppe and to allow 6 feet of distancing. all persons in the control room should wear a surgical mask particularly if there is an opening between the procedure room and the control room. place a sign on the room or tape the doors to avert room entry without protective gear. maintain euvolemia during the aneurysm procedure but take care to avoid hypervolemia / overresuscitation given the risk of pulmonary complications in covid-19 patients may be worsened by excessive fluid intake. intraprocedural blood loss and need for transfusion should be minimized due to the current national shortage of blood products. discuss with the primary team regarding additional blood tests the proceduralist can draw off the arterial sheath for covid-19 and sah workup (i.e. abg, cbc, comprehensive metabolic profile, lfts, bnp, ck in young patients, troponin, ferritin, crp, sedimentation rate, ddimer, fibrinogen, cardiac biomarkers, and additional coagulation studies). 23 if available, performing cone-beam ct in the angiography suite or hybrid room at the end of the procedure may help avoid another trip to ct post-procedure to evaluate for developing hydrocephalus or interval hemorrhage. when microsurgical clipping is determined to be the best modality for aneurysm treatment, there are many considerations among patients who are sars-cov-2 confirmed, suspected, or unknown. due to the risk of virus aerosolization during bony work, as described above, operating rooms should be set up to minimize the risk of contamination of equipment and staff members. as high-speed drills have a risk of aerosolization, surgeons and staff members may want to consider the use of a papr during the actual craniotomy to minimize the risk of both inhalational and transconjunctival exposure. if papr is not available, then an n95 mask and full face-shield or protective goggles may be used. 24 given the logistical limitations to wearing full ppe while utilizing the operating microscope, as well as the fact that arachnoid dissection and aneurysm clipping may be a lower risk portion of the procedure, it would be reasonable for surgeons to continue to use the n95 mask and may consider forgoing eyewear. the eye piece of the operatoing microscope should be disinfected and fully covered prior to the surgeon coming into contact with equipment without eyewear. given the high-viral load that is associated in the upper airway and sinuses, a clinoidectomy may be a high-risk portion of the procedure, particularly if the clinoid is pneumatized. to minimize aersolization, consider preferentially using nonpowered tools such as curettes. 25 post-procedure neurological exams and access site checks should be performed by one identified provider and minimized to conserve ppe. when available, telecommunication/video should be utilized to evaluate the patient remotely. otherwise, consider another neurological exam, vital sign and/or access site check 30 minutes after hand-off, and then every hour for two consecutive hours. thereafter, these combined checks can be performed every 4 hours. the frequency of combined neurological, vital sign, and/or access site checks should be adjusted depending on the patient's clinical status (less if they are intubated and sedated), the patient's hemodynamic stability, and concern for access site bleeding. telephone or video communication with the family to update them post-procedure is important, as visitation rights may be restricted. in high-grade sah patients thought likely to have a poor prognosis, consider early goals of care discussions with the family. during rounding, stable sah patients on contact and/or droplet precautions should be seen at the end of rounds to avoid unintentional viral spread to patients not on precautions. a non-intubated, good-grade sah patient may be treated on a step-down unit with appropriate nursing expertise in the event of a severe shortage of critical care beds. in stable, good-grade sah patients, nursing and neurological exam checks may be reduced to every two or every four hours. in patients who are at high risk for neurological deterioration and requiring frequent (hourly or more frequent) neurological examinations, it may be feasible for the nurse in full ppe to stay inside the room with scheduled breaks to minimize ppe use and repeated ppe donning and doffing. repatriation of sah patients to centers with neurosurgical or neurocritical care expertise can also be considered in systems of care with shortages in critical care beds. this model has been demonstrated to work well in maintaining access for thrombectomy patients. 26 to minimize patient/staff exposure and preserve ppes, consider deferring and minimizing tests that are unlikely to change clinical management. for example, daily transcranial doppler in an asymptomatic patient is unlikely to change management 27 and there is little evidence that routine tcd in sah patients leads to better outcomes. 28 alternatively, a modified transcranial doppler protocol with a focus on an artery of concern could be considered for a related clinical concern. diagnostic testing for sars-cov-2 status should be obtained as soon as possible in all symptomatic or high-risk patients. in the event a patient develops classical symptoms of covid-19 following initial negative screen for sars-cov-2 virus, repeat sars-cov-2 testing should be considered as initial testing may be falsely negative and interval nosocomial transmission is possible. sah patients should maintain intravascular euvolemia per national treatment recommendations and guidelines. in covid-19 suspected and/or confirmed patients with symptomatic pneumonia, avoid intravascular hypervolemia given the risk of respiratory deterioration and hypoxia with fluid resuscitation in ards. 29 as per icu best practices, repeated icu-phlebotomy should be minimized to reduce risk for anemia of chronic investigation and need for blood transfusion. in stable, good-grade sah patients, consider reducing daily phlebotomy practice to every-other day or less. frequently recommendations include adequate pre-oxygenation (100% oxygen for 5 minutes), complete paralysis to ensure there is no coughing or movement, ventilation only with cuff inflation, stopping ventilation prior to entering the airway, avoiding suctioning, and minimizing cautery. 32 thromboprophylaxis should be initiated as soon as the aneurysm is secured and there is no evidence of a bleeding diathesis or requirement for an urgent evd ( table 2 ). the rates of thromboembolic complications may be high in severe covid-19 patients, with dvt reported in 25% 33 and pe in 21%, 34 despite already being on thromboprophylaxis. case series to date suggest that coagulopathy and elevated serum d-dimer levels are associated with higher risk for multi-organ failure and mortality in covid-19, 13 and low molecular heparin use may reduce mortality. 12 patients with d-dimer elevation to greater than 6 times normal value or elevated sepsis induced coagulopathy (sic) scores > 4 may derive a mortality benefit from thromboprophylaxis. 13 additionally, patients who weigh greater than 100kg may benefit from higher doses of thromboprophylaxis. 35 at this time, there is limited evidence to support routine use of full dose anticoagulation in patients with severe covid-19. for patients with creatinine clearance less than 30 ml/min, subcutaneous heparin should be used for thromboprophylaxis instead of low-molecular weight heparin. prior to starting an anticoagulant in a patient with evd or post craniotomy either for venous thromboembolism chemoprophylaxis or systemic anticoagulation, it is important to ensure there is consensus among treating neurointensivist, neurosurgeon, and/or neurointerventionist and adherence to local institutional protocol. in covid-19 confirmed or suspected patients with hypoxia and/or respiratory failure, early discussion and pre-planning of potential treatment approaches for possible cerebral vasospasm is recommended. sah patients with concomitant symptomatic hypoxia and/or respiratory failure due to covid-19 may not tolerate medical therapy for dci such as intravascular volume resuscitation or induced hypertension therapy. use of vasopressor agents alone for blood pressure augmentation without volume resuscitation may be warranted. patients with cardiac involvement of covid-19 may need ionotropic support and yet may not tolerate the proarrhythmogenic effects of ionotropes. vasospasm treatment strategies may need to be individualized based on each patient's clinical condition. in a patient who develops new focal neurological deficit attributable to cerebral vasospasm whose symptoms are refractory to or unable to tolerate medical therapy, consider early intra-arterial therapy under controlled conditions and with adequate ppe. given the reported increased risk for acute kidney injury (aki) in 5-25% of covid-19 patients, 36, 37 routine use of surveillance cta/ctp for vasospasm screening should be minimized as the contrast load may increase risk for aki and cta is not a therapeutic procedure. an evaluation of a patient's mental health is essential to alleviate the psychosocial impact of the covid-19 pandemic for a patient in isolation with a new diagnosis of sah. 38 this can be done via telemedicine with a social worker, psychologist, or psychiatrist. health care workers on the frontline of care for covid-19 patients are also vulnerable to the psychological burden of this pandemic and should be attended to. 39 a periodic multi-disciplinary team debrief to learn from each patient and perform quality improvement is important. in patients who will be transitioning to a post-acute care facility, consider routine sars-cov-2 screening prior to transfer to minimize risk for asymptomatic viral transmission to the receiving facility. 40 coordination with case management, the post-acute care facility and the primary team is important. the covid-19 pandemic has wreaked havoc on healthcare systems worldwide. clinical protocols for sah care must be adjusted incorporate infection containment, adequate provider staffing, ppe and critical care resources conservation while optimizing patient safety and care. we provide potential recommendations for sah clinical protocol adjustments in this new covid-19 era. recommendations are subject to change with new data and scientific advances. preserving stroke care during the covid-19 pandemic. potential issues and solutions optimization of resources and modifications in acute stroke care in response to the global covid-19 pandemic rapid dissemination of protocols for managing neurology inpatients with covid-19 letter: perioperative and critical care management of a patient with severe acute respiratory syndrome corona virus 2 infection and aneurysmal subarachnoid hemorrhage respiratory virus shedding in exhaled breath and efficacy of face masks sensitivity of chest ct for covid-19: comparison to rt-pcr guidelines for the management of aneurysmal subarachnoid hemorrhage critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the neurocritical care society's multidisciplinary consensus conference venous and arterial thromboembolic complications in covid-19 patients admitted to an academic hospital in hematological findings and complications of covid-19 isth interim guidance on recognition and management of coagulopathy in covid-19 anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy indications for the performance of intracranial endovascular neurointerventional procedures: a scientific statement from the a framework for rationing ventilators and critical care beds during the covid-19 pandemic preoperative and postoperative predictors of long-term outcome after endovascular treatment of poor-grade aneurysmal subarachnoid hemorrhage high-grade aneurysmal subarachnoid hemorrhage: predictors of functional outcome predictors of outcome in world federation of neurologic surgeons grade v aneurysmal subarachnoid hemorrhage patients mechanical thrombectomy in the era of covid-19 pandemic. emergency preparedness for neuroscience teams barrier enclosure during endotracheal intubation taiwanese doctor invents device to protect us doctors against coronavirus mastoidectomy and trans-corneal viral transmission diagnostic utility of clinical laboratory data determinations for patients with severe covid-19 a commentary on safety precautions for otologic surgery during the covid-19 pandemic letter: rongeurs, neurosurgeons, and covid-19: how do we protect health care personnel during neurosurgical operations in the midst of aerosol-generation from high-speed drills? early repatriation post-thrombectomy: a model of care which maximises the capacity of a stroke network to treat patients with large vessel ischaemic stroke transcranial doppler monitoring and clinical decision-making after subarachnoid hemorrhage the rise and fall of transcranial doppler ultrasonography for the diagnosis of vasospasm in aneurysmal subarachnoid hemorrhage surviving sepsis campaign. guidelines on the management of critically ill adults with coronavirus disease 2019 (covid-19) a first case of meningitis/encephalitis associated with sars-coronavirus-2 safe tracheostomy for patients with severe acute respiratory syndrome. the laryngoscope covid-19 and the otolaryngologist: preliminary evidence-based review prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia pulmonary embolism in covid-19 patients: awareness of increased prevalence incidence of thrombotic complications in critically ill icu patients with covid-19 kidney disease is associated with in-hospital death of patients with covid-19 clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study psychological interventions for people affected by the covid-19 epidemic factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019 postacute care preparedness for covid-19 table 1: subarachnoid hemorrhage traditional protocol vs covid-19 pandemic guidance cta review and aneurysm treatment planning with neurointerventionist, neurosurgeon, neurointensivist or per local protocol. designated angio suite or operating room for covid-19 if multiple rooms available. covid-19 room preparation including clearing all unnecessary equipment, preparing medications and necessary equipment in advance, cover supply closets before patient entrance, utilization and covering of lead shields for radiation and covid-19 protection.in patients where there is unavoidable delay of aneurysm securing procedure, avoid empiric use of pro-thrombotic agents such as aminocaproic acid or tranexamic acid given presumptive increased dic/ thrombotic risk in covid19 key: cord-334124-w9jww3hk authors: murphy, david l; barnard, leslie m; drucker, christopher j; yang, betty y; emert, jamie m; schwarcz, leilani; counts, catherine r; jacinto, tracie y; mccoy, andrew m; morgan, tyler a; whitney, jim e; bodenman, joel v; duchin, jeffrey s; sayre, michael r; rea, thomas d title: occupational exposures and programmatic response to covid-19 pandemic: an emergency medical services experience date: 2020-09-21 journal: emerg med j doi: 10.1136/emermed-2020-210095 sha: doc_id: 334124 cord_uid: w9jww3hk rigorous assessment of occupational covid-19 risk and personal protective equipment (ppe) use is not well-described. we evaluated 9-1-1 emergency medical services (ems) encounters for patients with covid-19 to assess occupational exposure, programmatic strategies to reduce exposure and ppe use. we conducted a retrospective cohort investigation of laboratory-confirmed patients with covid-19 in king county, washington, usa, who received 9-1-1 ems responses from 14 february 2020 to 26 march 2020. we reviewed dispatch, ems and public health surveillance records to evaluate the temporal relationship between exposure and programmatic changes to ems operations designed to identify high-risk patients, protect the workforce and conserve ppe. there were 274 ems encounters for 220 unique covid-19 patients involving 700 unique ems providers with 988 ems person-encounters. use of ‘full’ ppe including mask (surgical or n95), eye protection, gown and gloves (megg) was 67%. there were 151 person-exposures among 129 individuals, who required 981 quarantine days. of the 700 ems providers, 3 (0.4%) tested positive within 14 days of encounter, though these positive tests were not attributed to occupational exposure from inadequate ppe. programmatic changes were associated with a temporal reduction in exposures. when stratified at the study encounters midpoint, 94% (142/151) of exposures occurred during the first 137 ems encounters compared with 6% (9/151) during the second 137 ems encounters (p<0.01). by the investigation’s final week, ems deployed megg ppe in 34% (3579/10 468) of all ems person-encounters. less than 0.5% of ems providers experienced covid-19 illness within 14 days of occupational encounter. programmatic strategies were associated with a reduction in exposures, while achieving a measured use of ppe. the first case of covid-19 in king county, washington, usa, was reported on 28 february 2020. incidence rose exponentially in subsequent weeks. 1 emergency medical services (ems) are the front line of the healthcare system, responding with incomplete information to provide care in heterogeneous, often uncontrolled, circumstances. the covid-19 pandemic challenges healthcare worker (hcw) safety in part because of limited supplies of personal protective equipment (ppe). ideally, ems strategies would incorporate covid-19 risk assessment and target use of the limited ppe resource in order to achieve ems provider safety, extend the supply of ppe and support high-quality patient care. the us centers for disease control and prevention (cdc) established criteria for covid-19 testing and case management based on history and recent travel to a highrisk area, contact with known or suspected covid-19 cases and presence of fever and signs/symptoms of lower respiratory illness. 2 based on national guidelines, our regional ems system initially adopted a screening framework based on travel, exposure to known cases and specific symptoms. during the initial days and weeks of the outbreak, we identified longterm care facilities (ltcfs) as high-risk locales and observed the atypical presentations involving covid-19 illness. [3] [4] [5] as a consequence, we implemented a series of iterative protocol changes with regard to covid-19 risk assessment and ppe use based on the patient's clinical profile and response location. we evaluated all 9-1-1 ems responses to patients with covid-19 to (1) determine occupational exposure, related workforce quarantine and potential transmission, and (2) understand how programmatic changes influenced occupational exposure, workforce quarantine and ppe use amidst the covid-19 outbreak in seattle and king county. the study is a retrospective cohort investigation of ems providers responding to 9-1-1 calls for laboratory-confirmed covid-19-positive patients in king county, washington, usa between 14 february 2020 and 26 march 2020. the first us case was documented in neighbouring snohomish county on 20 january, with unrecognised transmission of covid-19 until clinical diagnosis within king county in late february 2020. 6 7 ems providers who cared for patients with covid-19 were monitored through 9 april 2020 to complete a 14-day surveillance after the final patient encounter date. during this time, covid-19 disease was defined by the state of washington as positive reverse transcriptase-pcr (rt-pcr) testing for sars-cov-2. king county is a metropolitan region, covering 2132 square miles, with 2.2 million persons who reside in urban, suburban and rural areas. the primary 9-1-1 medical response in king county is two-tiered. the first tier is provided by firefighter emergency medical technicians. paramedics comprise the second tier and are dispatched in cases of more severe illness. there are 28 first-tier fire departments and five overarching secondtier paramedic agencies that collectively provide primary emergency response to all 9-1-1 medical calls. in general, stable patients are transported via fire department or private ambulance basic life support units, and more acute patients are transported by advanced life support paramedic units. all ems, fire and private report from the front ambulance agencies in king county participated in this study. collectively, there are approximately 4000 ems providers in king county. the study population consisted of ems providers who cared for patients with confirmed covid-19 by rt-pcr tests. ems is administered by public health-seattle and king county, enabling direct engagement between ems and public health to undertake covid-19 surveillance. to identify ems encounters with patients with covid-19, we linked local and state covid-19 surveillance systems with ems electronic records using the patient's name and date of birth. patient encounters were included if they occurred within a transmission window of 3 days prior to symptom onset (if known) or 14 days prior to or after the diagnosis date. the median interval from ems encounter to diagnosis date was 4 days (iqr 2-6). each match was independently verified by an epidemiologist and physician. a physician reviewed each matched encounter for potential ems exposure in the electronic health record. if the documented ppe was not a complete ensemble of appropriate mask, eye protection, gown and gloves (megg), the case was further investigated by the ems agency's appointed health officer (figure 1). health officers contacted individuals with possible exposure to understand the specific circumstances of patient involvement and clarify ppe use. the health officer in consultation with physician leadership then made the final determination of exposure and whether quarantine or isolation was indicated according to the cdc risk assessment matrix. 8 an encounter was defined as a 9-1-1 ems response to a patient confirmed to have covid-19. an occupational exposure to covid-19 was defined as a providerlevel encounter with inadequate ppe for the patient contact. 8 in addition to eye protection and gloves, a surgical mask was judged to be sufficient for routine patient encounters. however, an n95 mask was required ppe for aerosol-generating procedures. for any physical contact with the patient, a gown was required. by the second week of march, most ems agencies had implemented regular employee symptom screening on arrival at work and during the shift. anyone who felt unwell for any reason returned home until they were asymptomatic and fit for duty per their agency return to work guidelines. ems providers who became ill regardless of exposure status were deemed symptomatic, placed on isolation and prioritised for covid-19 rt-pcr testing through dedicated first responder testing sites. these rt-pcr tests were performed by the university of washington virology laboratory using an assay shown to have a low false negative rate. 9 each ems agency assessed quarantined providers daily. the current investigation used information from both the health officer monitoring programme and the public health surveillance to ascertain any covid-19 tests performed among the ems provider cohort. prior to the first laboratory-confirmed case of covid-19 in king county on 28 february 2020, ems medical direction issued directives for covid-19 screening and patient care on 6 february and 27 february 2020. beginning 4 march, ems providers were advised to don full megg ppe if covid-19 screening included (1) a person with febrile respiratory illness and travel from an endemic area (initially wuhan, then broadened to china, south korea, iran or italy) or (2) febrile respiratory illness and known contact with a patient with confirmed covid-19. after 28 february, ems updated the highrisk criteria to include the first ltcf where initial cases were identified, with dispatch to alert 'ppe advised' for any response to the address. after additional cases were identified at a second ltcf and a dialysis centre, these sites were added as high-risk locations for dispatch. a growing list of ltcfs and congregate living centres soon followed. beginning 7 march, ems began to treat all ltcfs (skilled nursing facilities, assisted living figure 1 flow diagram. ems, emergency medical services; ppe, personal protective equipment. facilities and adult family homes) as highrisk requiring full megg ppe, regardless of clinical illness profile. with evidence of community transmission, the requirements for travel history or covid-19 contact were eliminated as criteria to don megg ppe during the first week of march. medical record review determined that ems covid-19 patients did not consistently demonstrate a febrile respiratory illness; criteria were expanded to include any respiratory or fever symptoms beginning 11 march. 5 case review indicated that initial symptom classification-often derived from dispatch reporting-did not adequately characterise illness and the potential for covid-19 illness. in response, ems was using large quantities of ppe to address this uncertainty, though the prevalence of confirmed covid-19 ems encounters was estimated to be less than 5%. 1 hence, ems leadership implemented a 'scout programme' beginning 14 march in which one or two ems providers donned full megg ppe and entered the 'hot zone' to perform the initial in-person evaluation while additional crew remained in the 'cold zone', maintaining sight or voice contact, with scout responder(s). the scout evaluation informed the need for remaining ems crew to don ppe to assist. conversely, risk assessment was often not feasible in high-acuity, time-sensitive cases. all cardiac arrest cases and cases requiring aerosol-generating therapies required full megg ppe with n95 masks. we used a uniform methodology to review the narrative and formatted data fields from dispatch and ems records. dispatch records were abstracted to characterise 9-1-1 patient concern and prearrival notifications. ems records were abstracted to describe patient characteristics, location, initial vital signs, disposition, clinician impression and ppe use. ppe use was assessed through review of the ems report narrative and discrete data fields. following the first recognised case of covid-19 in king county, the ems leadership directed reporting of full ppe use in the electronic record by responding ems personnel. beginning 20 march, mandatory, item-specific ppe reporting became available through the electronic health record (eso solutions, austin, texas, usa) for all ems responses. ems provider quarantine dates and results from covid-19 testing were recorded. we evaluated the number of patient with covid-19 encounters, ppe use, consequent exposures due to inadequate ppe, resulting quarantine and positive covid-19 tests among ems providers. descriptive analyses were performed at the ems encounter and ems provider levels. ems encounters were stratified by level of transport, while providerlevel assessments were stratified at the chronologic midpoint of ems encounters. due to a subset of providers with multiple patient encounters, we report provider-level assessments as both total ems provider encounters and unique ems providers. we used χ 2 test for trend to evaluate whether adequate ppe use and ems provider exposure changed over time, where calendar time was the independent variable and ems provider exposure (or adequate ppe use) was the dependent variable. we used a χ 2 test to compare the proportion of encounters with occupational exposures in the first and second half of ems encounters. to estimate the potential conservation of ppe relative to an indiscriminate megg ppe deployment strategy (megg for all ems personnel for all calls), we determined the actual ppe use during the week of 20-26 march among the total number of ems providers involved on 9-1-1 responses. sas (v.9.4; sas institute) was used to conduct analyses. there were 220 unique patients with confirmed covid-19 in seattle and king county with 9-1-1 ems encounters in the 14 days prior to, and first 28 days after, the sentinel laboratory-confirmed case in king county. of these 220 individuals, 54 had two ems encounters for a total of 274 distinct ems encounters. half were female (53%), and the mean age was 74 years. the dispatch complaints were heterogeneous; difficulty breathing was the most common complaint, accounting for about 25% (table 1). the median initial pulse oximetry reading was 93%. the most common ems impressions included suspected covid-19 illness (26%), flulike symptoms (17%), respiratory distress (17%) and weakness (14%). among the 274 ems encounters with patients with covid-19, there were 429 responding units, involving 700 unique ems providers with a total of 988 ems provider encounters (table 2) . based on initial ems record review, use of ppe during patient contact was full megg (66.9%), basic gloves and eye protection (29.3%), delayed application or partial megg (3.1%), or unknown (0.7%), resulting in 327 possible ems provider exposures. after health officer investigation and physician consultation, 151 ems provider encounters were determined to have an exposure. as a result, there were 129 unique ems providers placed on quarantine: 107 after a single exposure and 22 with two exposures. of the 700 unique ems providers caring for patients with confirmed covid-19, 3 (0.4%) tested positive during the 14 days following an encounter (table 3 ), yet none of these three had a documented occupational exposure. the series of practice changes involving dispatch advisement, patient covid-19 risk criteria and initial ems scene deployment were associated with a temporal increase in adequate ppe use and conversely a decrease in ems provider exposures (figure 2, p<0.01). when stratified at the encounters midpoint, 94% (142/151) of exposures occurred during the first 137 ems encounters compared with 6% (9/151) during the second 137 ems encounters (table 2, p<0.01). the number of ems providers quarantined each day increased to a peak of 69 on 13 march and then declined ( figure 3) . during the final week of the study (20-26 march), there were a total of 3704 ems incidents involving 10 468 ems providers. of the 10 468 opportunities for ppe deployment, megg ppe was used in 3579 (34%) ems provider encounters. in this population-based observational investigation of 274 ems encounters for patients with covid-19 involving nearly 1000 ems provider encounters, three ems providers subsequently tested positive for covid-19 during the 14 days following the patient encounter. iterative dispatch and operational ems responses to covid-19 risk identification and ppe use were associated with both a temporal decrease in ems provider covid-19 exposure and conservation of ppe. based on these programmatic efforts, full megg ppe was deployed in about one-third of all report from the front potential ems provider uses by the end of the study period. although hcws seem to be at higher risk to contract covid-19, rigorous assessment of exposure and transmission is largely lacking. epidemiological reports from china and italy highlight the substantial burden of illness in hcws. [10] [11] [12] locally, in washington state, a large portion of ltcf staff tested positive for covid-19. 3 a preliminary report from cdc regarding the burden of covid-19 infection among us healthcare personnel suggest hcws account for 11%-19% of national case burden, but did not discern specific type of employment or evaluate the potential source of exposure. 13 other reports involving high-risk circumstances to include aerosolising procedures however have not observed substantial rates of transmission to hcws. 14 similar to our findings, a taiwanese study reported a transmission rate of 0.9% among the subset of covid-19 exposures occurring in the healthcare setting. 15 none of these experiences have reported risk to ems providers, though ems care appears to be integral for sicker covid-19 patients. in the 2009 sars outbreak, the overall incidence of infection was 1.3% in the taiwanese ems workforce, which was >100-fold higher than the general public. 16 in the current investigation, ems had substantial involvement with covid-19 illness. the 220 patients represented 14% of all covid-19 diagnoses in king county, washington, through 26 march. ems was typically involved in care for older adults who often presented with heterogeneous symptoms and a range of clinical presentations. covid-19 in king county was first detected in a clinical population not considered high-risk according to national guidelines at that time, which accounted in part for the fact that 18% of ems providers in the study had an exposure. indeed, 85.4% of patients had not been diagnosed with covid-19 at the time of their ems encounter. the high rate of quarantine early on motivated the ems system to move quickly to adapt to the evolving clinical features and local epidemiology of the covid-19 outbreak. ems leadership engaged dispatch and operations to expand covid-19 risk criteria and to stage patient assessment. the set of measures was associated with a marked reduction in the risk of exposure over the course of investigation. certainly, there was a learning curve that may have also contributed to reduction in exposure. the collective effect appears to be a temporal reduction in ems worker quarantine, even though the number of provider encounters with covid-19 increased over time (figure 2). we observed that 3 of the 700 ems providers (0.4%) with covid-19 encounters subsequently tested positive for covid-19. one case occurred at the outset of the outbreak with onset of provider illness occurring on the same date of covid-19 encounter. the cdc investigated this case and determined that the 9-1-1 incident that qualified the provider for study inclusion was not responsible overall, the cumulative laboratoryconfirmed prevalence in this ems cohort of 700 unique providers (0.4%) is comparable with the community prevalence (0.2%) during this time frame. 1 taken together, these findings suggest that occupational risk can be relatively low and that protective measures can potentially limit disease transmission. the anecdotal experiences in other regions reporting high rates of covid-19 among ems providers may be related to the higher prevalence of disease paired with limited availability and use of ppe. there is an inherent tension between proactive measures to don adequate ppe and conservation efforts due to limited supplies. if ppe were limitless, then indiscriminate use by all providers for every call would help assure ems provider protection. however, our system had limited supply that was coupled with uncertainty about the severity and duration of the pandemic. thus, the ems system strived to target the use of ppe to risk-positive patients. the scout strategy for stable patients enabled more deliberate decisions regarding ppe. in contrast, time-critical events such as cardiac arrest required comprehensive ems ppe, given the need for care prior to evaluating covid-19 risk. the current targeted strategies for megg utilisation appear to be a viable means to protect ems providers and conserve ppe. the retrospective methodology used to assess ppe is imperfect, relying on documentation and case-specific investigation; the two-stage process however enabled detailed provider interviews to assess potential exposure. the initial stage of screening mandated investigation anytime there was no clear documentation of full ppe in a patient with covid-19. in the second stage health officer review, ems providers sometimes clarified that full ppe was in fact in place though not adequately documented in the report. in other instances, individual ems providers without megg ppe were not in proximity of the patient (ie, the scout method that deployed only a subset of the crew for direct patient contact). we acknowledge that provider documentation may introduce bias, although providers were motivated to accurately document ppe. providers received training and education on best practices of donning and doffing of ppe, but there was not a dedicated observer to document the quality of the process. the study could not report on the temporal use of ppe across the system, but rather the status after implementation of various interventions designed to better assess covid-19 risk and responsibly use ppe. ideally, the study would have tracked ppe use across the system from the outset of the covid-19 pandemic to better understand how programmatic changes influenced ppe deployment. documentation of quarantine evolved during the study period to use a central monitoring database. thus, quarantine decisions early in the outbreak may be an underestimate of quarantine. we relied on the statewide washington disease reporting system database to identify covid-19 positive patients. there likely were patients ill with covid-19 who interfaced with ems but were not tested. alternatively, ems encounters with covid-19 positive patients may exist that were not captured due to failed linking of identifiers between ems and surveillance databases. the study relied on ems agency health officers and the washington disease reporting system database to identify ems providers tested for covid-19. although unlikely, this dual approach may have missed a laboratory-confirmed infection in an ems provider. ems providers may also have chosen not to get tested or had asymptomatic infection, though symptomatic providers were motivated to be tested and had prioritised access to testing. we cannot confirm the source of the infectious exposure-patient-specific, other occupational or community transmission-among the few providers with positive tests. in conclusion, less than 0.5% of ems providers experienced covid-19 illness within 14 days of caring for a patient with laboratory-confirmed covid-19. programmatic risk mitigation strategies were associated with a reduction in occupational exposures to covid-19 among ems providers, while achieving a measured use of ppe. public health-seattle & king county. covid-19 data dashboard centers for disease control and prevention. update and interim guidance on outbreak of coronavirus disease 2019 (covid-19) clinical characteristics of coronavirus disease 2019 in china epidemiology of covid-19 in a long-term care facility in king county, washington clinical characteristics of patients with coronavirus disease 2019 (covid-19) receiving emergency medical services in king county cryptic transmission of sars-cov-2 in washington state first death due to novel coronavirus (covid-19) in a resident of king county guidance for risk assessment and public health management of healthcare personnel with potential exposure in a healthcare setting to patients with coronavirus disease (covid-19) occurrence and timing of subsequent sars-cov-2 rt-pcr positivity among initially negative patients clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention case-fatality rate and characteristics of patients dying in relation to covid-19 in italy characteristics of health care personnel with covid-19 -united states covid-19 and the risk to health care workers: a case report contact tracing assessment of covid-19 transmission dynamics in taiwan and risk at different exposure periods before and after symptom onset emergency medical services utilization during an outbreak of severe acute respiratory syndrome (sars) and the incidence of sars-associated coronavirus infection among emergency medical technicians acknowledgements we wish to acknowledge public health-seattle and king county, the washington state department of health, the centers for disease control and the telecommunicators and ems professionals of seattle and greater king county. contributors dlm, byy, mrs and tdr conceived the study and designed the investigation. lmb, cjd, crc, jme, ls, tyj, amm and tam supervised data collection. lmb, cjd, crc and jme managed the data, including quality control. lmb, jme and tdr provided statistical advice on study design and analysed the data. dlm drafted the manuscript, and all authors contributed substantially to its revision. dlm takes responsibility for the paper as a whole.funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.competing interests none declared. patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. ethics approval the study was approved by the university of washington institutional review board.provenance and peer review not commissioned; externally peer reviewed. non commercial (cc by-nc 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. key: cord-319567-4t5t8bcx authors: şentürk, mert; tahan, mohamed r. el; szegedi, laszlo l.; marczin, nandor; karzai, waheedullah; shelley, ben; piccioni, federico; gil, manuel granell; rex, steffen; bence, johan; cohen, edmond; gregorio, guido di; drnvsek-globoikar, mojca; jimenez, maria-josé; licker, marc-josephjo; mourisse, jo; mukherjee, chirojit; navarro-ripolli, ricard; neskovic, vojislava; paloczi, balazs; paternoster, gianluca; pelosi, paolo; salaheldeen, ahmed; stoica, radu; unzueta, carmen; vanpeteghem, caroline; vegh, tamas; wouters, patrick; yapici, davud; guarracino, fabio title: thoracic anesthesia of patients with suspected or confirmed 2019 novel coronavirus infection: preliminary recommendations for airway management by the eacta thoracic subspecialty committee date: 2020-04-11 journal: j cardiothorac vasc anesth doi: 10.1053/j.jvca.2020.03.059 sha: doc_id: 319567 cord_uid: 4t5t8bcx abstract the novel coronavirus has caused a pandemic around the world. management of patients with suspected or confirmed coronavirus infection who have to undergo thoracic surgery will be a challenge for the anesthesiologists. infection who have to undergo thoracic surgery will be a challenge for the anesthesiologists. the thoracic subspecialty committee of european association of cardiothoracic anaesthesiology (eacta) has conducted a survey of opinion in order to create recommendations for the anesthetic approach to these challenging patients. it should be emphasized that both the management of the infected patient with covid-19 and the self-protection of the anesthesia team constitute a complicated challenge. the text focuses therefore on both important topics. -thoracic anesthesiologists might be involved in the perioperative care of patients suspected to have or diagnosed covid-19 who might undergo thoracic surgery during the acute or convalescence phases of the disease. -caution should be exercised when securing the airway and performing lung separation (if required), through vigilant donning/doffing of personal protection equipment (ppe), planning ahead, team briefing, proper preparations, systematic approach, and debriefing. -lung separation / isolation should be individualized using either bronchial blockers or double lumen tubes according to the patient"s status and postoperative care plan. -optimum ppe donning should be maintained during surgery and anesthesia. one lung ventilation could be challenging in this group of patients. -the anesthesiologists should discuss the feasibility of extubating the patient following thoracic surgery, and procedures for postoperative care andtransferring the patient to the isolation wards or intensive care unit. the novel coronavirus has caused a pandemic around the world. management of patients with suspected or confirmed coronavirus infection who have to undergo thoracic surgery will be a challenge for the anesthesiologists. infection who have to undergo thoracic surgery will be a challenge for the anesthesiologists. the thoracic subspecialty committee of european association of cardiothoracic anaesthesiology (eacta) has conducted a survey of opinion in order to create recommendations for the anesthetic approach to these challenging patients. it should be emphasized that both the management of the infected patient with covid-19 and the self-protection of the anesthesia team constitute a complicated challenge. the text focuses therefore on both important topics. in december 2019, a novel, ongoing outbreak of pneumonia was reported in wuhan city, hubei province, china. a novel coronavirus (cov) was found to be responsible for the outbreak in patients from wuhan, now named severe acute respiratory syndrome coronavirus 2 (sars-cov-2). though primarily a zoonotic infection, sars-cov-2 is now known to spread from person-to-person, in which asymptomatic as well as symptomatic carriers play a role. in a very short time, sars-cov-2 has become an international outbreak and who has declared it as of 2 rd of march 2020 a "pandemic". the most common symptoms are dry cough, fever, and shortness of breath leading in about 5% of cases to respiratory failure. age and co-morbidities are risk factors; older patients and patients with diseases such as hypertension, diabetes mellitus, immunocompromised, cancer, etc, have a higher mortality. viral particles entering the lungs via droplets propagated through sneezing, coughing and even talking to the infected are responsible for the spread of the disease. in patients undergoing procedures such as intubation, extubation, airway suctioning or even with using some types of non-invasive ventilation, aerosols (containing droplets having a diameter of < 5µm ø) may be propagated which more easily reach small airways. other routes of spread such as direct contact with the infected are also possible. as of march 25, 2020, there are 428405 confirmed cases and 19273 deaths in 195 countries around the world. these patients present with a spectrum of respiratory distress ranging from dyspnoea and hypoxia to acute respiratory distress syndrome (ards) and may require respiratory support in different locations such as the emergency room, isolation ward and intensive care units. a significant portion of these patients require early mechanical ventilation involving urgent or emergency tracheal intubation. in addition, with the pandemic nature of the current outbreak, patients with mild or asymptomatic disease may still present for urgent or emergency general or specialised surgery. recognizing the unique risks of intubation and mechanical ventilation in these high-risk groups and the high potential of infection risk to healthcare workers, several useful reports, algorithms and society endorsed recommendations have emerged in the recent literature regarding the general airway and anesthesia management of these patients. these societies include siarrti (società italiana di anestesia analgesia rianimazione e terapia intensiva) anesthesiologists. [1] [2] [3] [4] [5] [6] [7] [8] [9] most of these recommendations are in the context of intensive care management or the surgical setting including emergency surgical cases and those presenting for specific disciplines like cesarean delivery (in 17 cases). 10 the novel coronavirus pandemic has radically changed the landscape of normal surgical practice with most elective surgeries being postponed. lifesaving cancer surgery however remains a clinical priority and there is an increasing need to fully define the optimal oncological management of patients with varying stages of lung cancer, allowing prioritization of which urgent and emergency thoracic procedures should be performed in the current era. management of general anesthesia, particularly airway management, ventilation and perioperative care of these patients constitutes a further and important challenge for the anesthetist. anaesthesia subspecialty group has considered these challenges and developed a preliminary set of expert recommendations regarding the airway management and ventilation of covid-19 thoracic patients. our consensus builds on the previous society recommendations on general airway management principles but expands those recommendations by specifically focusing on unique aspects of thoracic anesthesia. the principal methodologies underpinning our recommendations include expert opinions the survey was sent to 28 members of the eacta thoracic network via what"s app and facebook. twenty-one responses (75%) were received after sending two reminders. the responses have been evaluated in light of recent publications of different societies and groups (referred to above). the group has considered a broad spectrum of issues regarding thoracic anesthesia in covid-19 patients and decided to focus on overall approaches to general and specific aspects of airway management, preparation for anaesthesia, lung isolation/separation and ventilation. to arrive at consensus recommendations, we combined the principles outlined in the reviewed publications and our expert opinions. the recommendations take into consideration the balance between benefit and harm, safety concerns, and feasibility in specific environments. as our goal was to make this preliminary consensus rapidly available to all thoracic teams, we acknowledge limitations of the adopted methodology. our document should be the basis of future task forces to develop a more comprehensive and perhaps multi-society consensus taking into appropriate consideration new evidence uncovered during the covid-19 epidemic. general considerations and principles: table 1 summarizes our recommendations regarding general aspects of airway management. they provide a comprehensive framework with major emphasis towards efficient team efforts to achieve successful airway control and establishing controlled ventilation without compromising the high-risk patient whilst providing maximal protection to the health care team. it appears that most of these recommendations are fairly consistent among these societies considering vigilant infection control and the required organizational tasks and technical conduct of intubation. we recognize that many of these are relevant to thoracic patients and generally endorse those conclusions with some modifications as follows.  tracheal intubation in covid-19 patients for thoracic surgery is a high-risk procedure for the anesthesia team because of the risks of aerosol transmission of the infection during placement of the airway device and check bronchoscopy. it is also a risk for the patients with severe covid-19 who would not tolerate long periods of apnea or inadequate oxygenation in case of delayed or failed tracheal intubation.  the procedure should be "s"afe (for staff and patient), "a"ccurate (avoiding unreliable, unfamiliar or repeated techniques) and "s"wift (timely, without rush and delay). (mnemonic: sas). 4  as asymptomatic patients may also have the viral infection during the pandemic, and false negative tests cannot be excluded with certainty, it is prudent that the team takes a cautious approach and considers every patient undergoing surgery as potentially positive for infection. these considerations require specific protective measures, sophisticated organization and team practices.  an elective procedure should be preferred if possible, as emergency intubation may compromise protective procedures and could also increase the patient"s risk.  ideally, the location of intubation should be an "isolated" negative pressure room with >12 air changes/minute. there are hoewever few operating rooms (or) with negative pressure facilities which are more commonly available in intensive care units. if a negative pressure or is not available: -the level of personal protection equipment (ppe) should be increased (e.g. mask/respirator type and face shield or helmet. -alternatively, intubation can be performed in a negative pressure room followed by transfer to the or, such as in isolated ward or intensive care unit (icu). the benefits of such an approach however need to be judged against its disadvantages and possible complications.  medical staff involved in tracheal intubation should be limited to those with essential roles. due to the high risk of infection, we suggest that members of the intubating team should not include practitioners with significant vulnerability such as older age (> 60yrs), immunosuppressed, pregnant or having serious chronic co-morbidities. -inside the room, there must be two attendants in the "red zone": intubation should be performed by the most experienced physician to minimize delay or related complications; a second doctor should help to administer drugs and monitor the patient be available in case of unanticipated difficulty. the authors want to note that many other societies suggest three attendants (with full donning) in the red zone; however, in this period of the pandemic, this criterion is probably not possible to achieve. -there must a "runner" physician available directly outside the room in "yellow zone" with full donned personal protection equipment (ppe), in case of need for help. -outside the dedicated or "white zone", there must be also be an observer to monitor the "donning/doffing" process of the ppe. -the surgical, anesthesia, nursing and paramedical staff who are not involved with airway management should not enter the operating theatre until after the airway has been secured.  several levels of personal protection equipment (ppe) have been defined for different procedures by different societies. intubation and bronchoscopy are among the "aerosolgenerating" procedures and are associated with increased infection risk. during intubation in thoracic anesthesia, it is suggested to work with so-called "air borne level" precautions, which include the following components of appropriate ppe: • hair covers/hoods. • fitted filtering facepiece (ffp)3 / n95 / ffp2 masks. • goggles or face shield. • long sleeve fluid-resistant gown. • double gloves. • overshoes.  maintaining the sequence for donning and doffing ppe ( table 2) is very important to avoid any contagion. this process can be challenging especially for attendants with less experience, and therefore requires thorough training, practice and constant monitoring during the actual procedures by an external observer. -trolley: it is recommended to prepare a dedicated trolley for tracheal intubation of this special group of patients (table 3 shows the possible content). disposable devices (e.g. single-use blades, laryngoscopes, video laryngoscopes with remote screens, and flexible bronchoscopes) should be preferred. a closed system for suction should be kept ready. antifogging material is required. specific equipment for thoracic surgery (appropriate sizes of double-lumen tubes, bronchial blocker, and fiberoptic bronchoscope) should also be ready and prepared. -before intubation, a complete evaluation and optimization of patient"s position (45degree head up, sniffing position), oxygenation and hemodynamic status should be performed using a developed checklist. -standard routine monitoring, including continuous waveform capnography should be available before, during and after tracheal intubation. -the breathing circuit should be checked as normal. the authors suggest that antiviral filters should be attached to the expiratory limb of the circuit. -appropriate preoxygenation is crucial as it can prevent / decrease the need for mask ventilation before securing the airway. -face mask ventilation should be avoided unless needed. if necessary, a 2-person, low flow, low pressure technique should be used; a 2-person, 2-handed mask ventilation with a ve-grip should be performed to improve seal. -a "rapid sequence induction" should be applied in all patients. -ketamine 1.5-2 mh/kg or appropriate doses of propofol and an opioid is recommended for hypnosis and analgesia; rocuronium 1.2 mg/kg or suxamethonium 1.5 mg/kg for neuromuscular blockade. -intubation should be performed using videolaryngoscopy, preferably via a laryngoscope with a and single-use blade if applicable and separate remote screen. the latter would extend the distance between the airway of the patient and the anesthetist to minimize or avoid "airborne spread". o if the 1 st attempt fails, a re-oxygenation period can be needed, which needs to be performed with a low tidal volume/pressure to avoid leakage of contaminated air. o if a 3 rd attempt is necessary, an early switch to a second generation-intubatable supraglottic airway device should be considered. intubation through this device should be performed with a flexible (preferably disposable) endoscope, again with a separate remote screen. -the ett cuff or the cuff of the tracheal lumen of the dlt should be inflated to seal the airway before starting ventilation and the depth should be noted and recorded. the cuff pressure should be kept at least 5-10 cmh 2 o above the maximum airway pressure using an inflatable manometer. this is to ensure adequacy of cuff seal and minimize the risks for aerosol spread double-lumen tube (dlt) or bronchial blocker (bb) (figure 1b) -the attending anesthetist should be aware of the indications and the difference between lung separation and isolation. this definition has replaced the historical classification of absolute and relative indications of one-lung ventilation (table 4 ). -in general, 95.2% of the respondents to the survey have reported that they would use a bronchial blocker (bb), and 47.6 % a double-lumen tube (dlt) in patient with, or suspected to have covid-19, the sum is > 100% as some members advocated the possible use of both devices for different indications (figure 2 ). -the use of bb for all patients is advocated by 52.4%; 33.3% would use bb in already intubated patients, and 9.5% in patients with difficult airway. conversely, 28.6% would use dlt in all cases, and 19% only in non-intubated cases ( figure 3 ). -lung separation with endotracheal tube (ett) and bb can be preferred particularly:  in already intubated patients (this approach would avoid the risk of aerosolization during tube exchange);  in patients with difficult airway (a "difficult" airway for ett can be even more difficult for dlt);  in short procedures;  in patients in whom the mechanical ventilation will be continued in the postoperative period (to avoid the need for tube exchange at the end of the operation, which can be more difficult because of the edema of the airways and be an additional mechanism of contagion). -it is suggested to use an et-tube swivel-connector with a valve. before opening the valve of the swivel and introducing the bronchoscope, the anesthesia ventilator should be paused. if saturation is critical, preoxygenation can be performed in advance. during bronchoscopy, ventilation may be resumed, but it is important to ensure that the valve of the swivel fits snuggly enough such that there is no leakage. otherwise bronchoscopy should be performed during apnea. the same procedure should be carried out when the bronchoscope is withdrawn from the tube. other openings of the airway, e.g. suctioning, should also be performed under apnea. -if a bb is to be used, the trachea of the patient is intubated with a standard ett: a 7.5-8.0 mm id (females) or 8.0-9.0 mm id (males) ett with a subglottic suction port should be chosen. it is a general rule to choose the largest possible ett for intubation in order to allow enough room for the insertion of both the bronchial blocker and the fiberoptic bronchoscope. these ett"s diameters are convenient for this approach. as the confirmation of the position of the tube may be difficult while wearing ppe, the cuff should be passed 1-2 cm below the cords to avoid bronchial placement. -tracheal intubation should be confirmed with continuous waveform capnography. -ideally, disposable bronchoscopes are the best option to avoids the need for decontamination after the procedure. if disposable devices are not available, reusable bronchoscopes can also be used with strict adherence to cleaning regulations. in any case, using a bronchoscope (either disposable, or reusable) should not be o an ez-blocker can be used. -awake intubation should be avoided where possible and should be limited to strict indications in patients with an anticipated difficult airway. in these cases, no aerosol or vaporization should be used for airway topicalization. titrated sedation with an infusion pump and sedation depth monitoring has to be performed. 1, 4 for intubation, a flexible (preferably disposable) endoscope with a separate remote screen should be used. a rescue intubation through a third generation supraglottic airway devices or early cricothyrotomy/front of neck access (fnac) can be necessary and equipment should therfore be ready before the intubation attempt. -if necessary, a nasogastric tube can be placed, immediately after the intubation. -if the diagnosis of covid-19 is not already confirmed, a deep tracheal aspirate for virology should be taken using closed suction. -the patient should remain connected to the breathing circuit as much as possible. a closed system with infra-glottic catheter tip should be used for suction. 4, 6, 11 if a disconnection from the breathing circuit is inevitably necessary, the ventilator should be switched to stand-by, and the endotracheal tube should be clamped. -after tracheal intubation, disposable equipment should be discarded appropriatelt and reusable equipment should be immediately placed inside sheaths and decontaminated according to the manufacturer"s recommendations,  doffing should be performed according to the prescribed sequence (table 2) and be monitored by the doffing observer meticulously.  if the intubation room is separate to the or, this room should be cleaned 20 minutes after intubation (and after all similar aerosol generating procedures).  ppe should be worn until the end of the operation, after immediately changing the outer gloves. 6, 11 otherwise, hand hygiene must be performed before and after all patient contact. for tracheal extubation, caution should be exercised in view of the risks of aerosol transmission with coughing or need for reintubation .6, 11 . the whole donning and doffing procedure should be repeated as described. although some guidelines for other clinical conditions advocate regional anesthesia for nonintubated surgery as an option in non-intubated, less-unwell patients to avoid the need for airway management, we do not suggest approach during thoracic surgery. regional anesthesia would leave the airway open to the room for the duration of the procedure with risks of contagion. there is no supporting evidence or previous reports describing the non-intubated technique in patients with highly contagious diseases. even in the "healthy" (non population, non-intubated thoracic surgery is a novel, less well described approach, which contrary to some beliefs, is more challenging for the anesthetist. under the new condition with the sars-cov2, there may be some exceptional cases that would benefit from this approach, but overall, it should be considered as too heroic, and cannot be recommended. it should be kept in mind that all techniques (but helmet) of non-invasive ventilation (niv) are associated with an increased risk of aerosol spread., it is therefore suggested that to avoid niv and hfno in patients undergoing thoracic surgery.  another antiviral filter should be applied to the end of the lumen corresponding to the non-dependent lung, which is disconnected during one-lung ventilation. this would avoid (or decrease) the risk of aerosolization through the disconnected lumen ( figure 4) .  as the oxygenation of sars-cov2 patients is already compromised, one-lung ventilation could be more challenging, and a higher incidence of hypoxemia during onelung ventilation can be expected.  generic recommendation for the conduct of one-lung ventilation (olv) can also be considered to be also valid in these patients: o it is an advantage that lung compliance is usually good in sars-cov2 patients (as reported by the italian group). o patients may get benefit from the application of an alveolar recruitment maneuver, and a trial is recommended. it should be kept in mind however that the recruitment strategy can impair the hemodynamic stability in a more extended way than the "healthy" patients.  clearly in some patients with active lung disease, maintenance of olv may be impossible due to oxygenation problems. in such cases it should be kept in mind that in cases without obligatory indications for a lung "isolation" (e.g. airway leakage, unilateral bleeding), the price to continue the olv must never be to compromise oxygenation. this general rule must be even more strictly adhered to in challenging cases like sars-cov2 patients.  in open thoracotomies, application of cpap to the non-dependent lung can be very useful to prevent hypoxemia. the authors suggest that the benefits to achieve sufficient oxygenation would overcome the (unproven) possibility of aerosolization from the open cpap system.  in some cases, application of extracorporeal assist systems (for oxygenation and/or carbon dioxide removal) can be indicated. but these cases are beyond the scope of this review. extubation ( figure 5 )  the authors assume that in almost all sars-cov2 patients undergoing thoracic surgery, mechanical ventilation may need to be continued after the operation.  if a bb was used, it can simply be removed at the end of the operation.  if a dlt was used, it should be changed to a normal ett using an appropriate tube exchanger (caveat: specific tube exchangers for dlt"s should be used), in such cases, regulations for ppe (donning and doffing) should be repeated step by step.  if dlt was used, and an exchange to ett may not be warranted in some circumstances (e.g. the anticipated need for a brief duration of mechanical ventilation); a classical method in such cases is -after deflating both cuffs-to pull back the dlt above the carina. now, only the bronchial cuff can be inflated; and ventilation can be continued only via the bronchial lumen.  it has been reported that the patients with sars-cov2 usually have excessive retained secretions, especially during the weaning phase. it therefore makes sense to postpone this phase to a later time frame than the immediate postoperative period.  in patients who are to be extubated: o prior to extubation, aspiration via a closed system, followed by a recruitment maneuver is suggested. o any maneuver which risks precipitating coughing should be avoided: oral suctioning (if any) should be very gentle, patients should not be asked to cough. in difficult airway cases, using an extubation catheter (e.g. with a soft thin tip) can be possible, but in these cases, keeping the patient intubated is more rational. o use of medication known to effectively lower the incidence of coughing (e.g. o placing a n95 or surgical face mask on the patient after extubation, with an oxygen mask immediately above could be feasible not only to prevent postoperative hypoxemia, but also to minimize aerosolization. o transferring extubated patients should follow local regulations. the covid-19 "pandemic" has undoubtedly become the most important challenge for the human race in recent memory health personnel will in all likelihood will have to deal with a wide range of covid-19 cases undergoing different operations. observing the changes that the "covid crisis" has already caused, we can foresee that the "routine life" of daily practice in our hospitals will be radically different, with all materials used for anaesthesia potentially subject to shortage in time. this "opinion survey" has been prepared with expert opinions, and therefore cannot claim to be "evidence based" or "comprehensive". still, we hope that it can be helpful to our colleagues, not only for thoracic anesthesia but also to organize a general management of this challenging patient group. for the procedure "s"afe (for staff an patient), "a"ccurate (avoiding unreliable, unfamiliar or repeated techniques) and "s"wift (timely, without rush and delay). airway management in patients suffering from covid-19. siaarti covid19 airway management protocol information, guidance and resources supporting the understanding and management of coronavirus outbreak of a new coronavirus: what anaesthetists should know consensus statement: safe airway society principles of airway management and tracheal intubation specific to the covid-19 adult patient group propositions pour la prise en charge anesthésique d"un patient suspect ou infecté à coronavirus covid-19. montravers p practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-ncov) patients perioperative management of patients infected with the novel coronavirus: recommendation from the joint task force of the chinese society of anesthesiology and the chinese association of anesthesiologists chinese society of anesthesiology and the chinese association of anesthesiologists covid-19) and pregnancy: what obstetricians need to know aana issue joint statement on the use of ppe by anesthesia professionals during the covid-19 pandemic all disposable equipment should be discarded after the operation, even if not used  breathing circuit should be changed.  airway breathing system (abs) and soda lime canisters should be decontaminated. all disposable material should be discarded; reusable material should be sent for decontamination. a waiting period of 20 minutes is necessary to disinfect with 3% -5% chlorine solution. key: cord-320640-5m6sqwq8 authors: kumar, harender; azad, amaanuddin; gupta, ankit; sharma, jitendra; bherwani, hemant; labhsetwar, nitin kumar; kumar, rakesh title: covid-19 creating another problem? sustainable solution for ppe disposal through lca approach date: 2020-10-09 journal: environ dev sustain doi: 10.1007/s10668-020-01033-0 sha: doc_id: 320640 cord_uid: 5m6sqwq8 amid covid-19, there have been rampant increase in the use of personal protective equipment (ppe) kits by frontline health and sanitation communities, to reduce the likelihoods of infections. the used ppe kits, potentially being infectious, pose a threat to human health, terrestrial, and marine ecosystems, if not scientifically handled and disposed. however, with stressed resources on treatment facilities and lack of training to the health and sanitation workers, it becomes vital to vet different options for ppe kits disposal, to promote environmentally sound management of waste. given the various technology options available for treatment and disposal of covid-19 patients waste, life cycle assessment, i.e., cradle to grave analysis of ppe provides essential guidance in identifying the environmentally sound alternatives. in the present work, life cycle assessment of ppe kits has been performed using gabi version 8.7 under two disposal scenarios, namely landfill and incineration (both centralized and decentralized) for six environmental impact categories covering overall impacts on both terrestrial and marine ecosystems, which includes global warming potential (gwp), human toxicity potential (htp), eutrophication potential (ep), acidification potential (ap), freshwater aquatic ecotoxicity potential (faetp) and photochemical ozone depletion potential (pocp). considering the inventories of ppe kits, disposal of ppe bodysuit has the maximum impact, followed by gloves and goggles, in terms of gwp. the use of metal strips in face-mask has shown the most significant htp impact. the incineration process (centralized−3816 kg co2 eq. and decentralized−3813 kg co2 eq.) showed high gwp but significantly reduced impact w.r.t. ap, ep, faetp, pocp and htp, when compared to disposal in a landfill, resulting in the high overall impact of landfill disposal compared to incineration. the decentralized incineration has emerged as environmentally sound management option compared to centralized incinerator among all the impact categories, also the environmental impact by transportation is significant (2.76 kg co2 eq.) and cannot be neglected for long-distance transportation. present findings can help the regulatory authority to delineate action steps for safe disposal of ppe kits. in december 2019, a pneumonia type outbreak was reported in wuhan, china (new york times 2020) which was traced to a novel strain of coronavirus (who 2020a). during january 2020 who declared coronavirus disease (covid-19) as a pandemic disease (who 2020b), which spread very rapidly from human to human by personal contact, contact with air-water droplets during sneezing, and coughing of coronavirus affected person (bherwani et al. 2020a; nair et al. 2020; wathore et al. 2020; gupta et al. 2020) . as of 14 june 2020, there have been at least 4, 30,139 confirmed deaths, and more than 77, 87,271 (covid-19 dashboard csse) confirmed cases under covid-19 pandemic. since to date, there is no vaccine identified yet (who 2020a, b, c, d, e; healthline 2020) for the effective prevention of covid-19 disease, thus other measures recommended by who to mitigate the spread of covid-19 (who 2020c) become very vital for peoples among this pandemic (kaur et. al. 2020) . the adverse impacts of covid-19 on human and planetary health will arise from different sources during the response (unep 2020). as per a who estimate, 89 million medical mask, 76 million examination gloves and 1.6 million goggles are required for the covid-19 response each month (who 2020e) for which the manufacturing capacity should ramp by 40%, to meet the rising global demand (park et al. 2020) . with reported cases of covid-19 infected health and sanitation workers (satheesh 2020 ; hindustan times 2020; new india express 2020), waste management of used infectious safety gears has become a critical component to restrict the spread of novel coronavirus (bherwani et al. 2020b; vanapalli et al. 2020) . according to wwf report (italy wwf 2020) , "if only 1% of the masks were disposed of incorrectly and perhaps dispersed in nature, would result in 100 million masks per month in the environment". across the globe, an unprecedented rise in the covid-19 cases, the amount of waste of infectious waste generated, far exceeds the available capacity for treatment. worldwide waste management systems have already been unable to deal with existing waste satisfactorily, the imminent surge in the volume of waste from covid-19 pandemic threatens to overwhelm existing waste management systems as do healthcare capacity. the directives from who, which mandate incineration of ppes and other infectious wastes, especially made from plastic, has increased the load on the incineration facilities (who 2017a, b) . in china, with 370% rise in hubei province and with 600% rise in wuhan, i.e., from a normal level to 40 t/day to about a peak 240 t/day, exceeding the maximum incineration capacity available with the country (jiri et al. 2020; ivy s. 2020; klemeš et al. 2020) . similar, the waste agency of catalonia (arc), spain, has noticed a 350% increase in medical waste with added 925 tons/month more than usual (acr 2020). in the usa, a multi-fold increase in from ppes has been reported (justine 2020). in india, gurugram city has seen two times increase in the quantity of covid-19 related bmw with a prediction of over a ton of covid-19 related bmw every day (prayag 2020) . the north delhi municipal corporation (ndmc), india, has also observed an additional 11.4 tons of hazardous waste from households (abhimanyu c. 2020) , and ahmedabad's apollo hospital gave reported a 1.5 fold increase in bmw in comparison to normal of 100-120 kg per day (yahoo 2020) . the effective management of coronavirus infectious waste, including ppes, has been identified by as a key area of concern by regulatory agencies in india, with the release of waste handling-treatment-disposal guidelines generated during treatment-diagnosis-quarantine of covid-19 patients (cpcb revision 2020; aggarwal 2020). unlike india, other countries like eu member countries have made changes in waste management in the context of the coronavirus crisis (virjinijus s. 2020). some european municipalities have suspended the plastic recycling industry with the fear that workers getting infected as the virus remains on the surface of waste bags and materials when they are collected (zero waste 2020a; zero waste 2020b) the use of personal protective equipment (ppe) has emerged as the most reliable and visible preventive control safety gear to keep the covid-19 transmission at bay (herron et al. 2020) . typical ppes, also referred as ppe kits, are made of over 50% plastics (which takes up to 500 years to degrade) like pp, pc, and pvc, etc., includes surgical face mask with metal strip, gloves, goggles, full-body suits containing pant, gown with head cover and shoe cover (park et al. 2020 ). national disaster management & safety protocols have advised the use of ppes, by attending physicians and all the healthcare-nursing staff, funeral workers including visiting families etc., who are directly or indirectly in contact of any covid-19 (confirmed or suspected) patients (selvakumar et al. 2020; who 2020d; nmpa 2020) . in the wake of necessary preventive control measures, it is evident that the used ppes waste is likely to increase multiple folds and will stress the current waste management systems, and now pose a grave threat to the environment, if not tackled properly (ict 2008) . in developing countries, with lack of complete connectivity and waste handling capacities in existing centralized bio-medical waste treatment facilities (cbmwtf), the covid-19 infectious waste handling has become a grave concern (henam and shrivastav 2019; who 2017a, b; cpcb 2017). in india, practical implementation of effective covid-19 waste management guidelines, with multiple cares at each step, including containers/bins/ trolleys be disinfected daily, use of double-layered bags (using 2 bags) of collection, regular sanitization of workers, and vehicle sanitization etc. (cpcb 2020; aggarwal 2020) becomes looming and challenging. in populous countries like india of 138 crore people (worldometer 2020) and having fifth-highest number of confirmed cases in the world (the guardian 2020), with overcrowded hospitals, large cities only connected to cbmwtf and lack of training of health workers (who 2017a, b) and having institutional and residential quarantine centre's staff, adds to the challenges. there have been reports of dumping of masks and medical waste, leading to unknowing containmination of workers with coronavirus from various cities of india (abhimanyu c. 2020; the new york times 2020). hence, in consideration with the above, it becomes essentially important to explore and encourage decentralized disposal techniques, with treatment and disposal at source, of effective waste management, considering handling, storage and transportation-related risks. from table 1 , it can be inferred that majority of the previous research works focused on the alternatives to use and reuse ppes and to minimize its requirement as well as waste generation through methods like disinfection by ultraviolet rays or treating used ppes with hydrogen peroxide. but these studies lacked in considering other vital environmental impact parameters, during manufacturing and disposal of ppes waste to the environment. the current research focused on the cradle to grave analysis of ppes for environmentally sound and sustainable management of these wastes, which has not been reported till date. thus, our present study on life cycle assessment of ppes for disposal of infectious ppe waste becomes very vital for environmentally sound management of ppe waste. the present work has tried to evaluate different disposal options for ppe kits, i.e., landfill, centralized incinerator and decentralized incinerator, with a view to promote environmentally sound management of waste. the study entails an assessment of all the life cycle stages including raw material extraction, material processing, production, use, disposal of ppe kits, using life cycle assessment (lca) tools, with an idea to transform the country's waste management sector into a secondary resource recovery sector, coupled with its integration with the manufacturing sector, to implement and promote a circular economy and ecosystem services conservation approach through a life cycle approach (bherwani et al. 2020c; draft nerp 2019) . lca is defined as "a tool to assess the potential environmental impacts and resources used throughout a product's life cycle, i.e., from raw material acquisition, via production and use stages, to waste management" (iso 2006) . lca enables the estimation of the cumulative and realistic environmental impacts resulting from all the stages of a product life cycle, while also including impacts which are sometimes not included in the conventional analysis. in the current research, lca is conducted according to the iso 14,040 and iso 14,044 standards. the main goal of this study is to evaluate the relative human health and environmental impacts caused by raw material extraction, production, use, and disposal of ppe kit. amid the analysis is done in the form of three case studies namely case-i, case-ii, and case-iii as shown in fig. 1 , based on disposal options. • case-i: centralized incineration waste management system refers to the system in which the common facility of waste treatment is considered. the waste is collected from the source of waste generation and is transported to the waste disposal site with the help of compacted trucks. the distance from nagpur city to bhandewadi yard, site for waste disposal is 10 km, and therefore, this distance has been taken for centralized system analysis (arcadis 2017). • case-ii: a decentralized incineration waste management system is about each community managing and processing their waste in their locality and not sending it to a centralized large processing facility or often landfill (agrawal and jadon 2018. • case-iii: comprising of landfill disposal technique for ppe. the three case studies are so designed to estimate, compare, and evaluate the environmental and health impacts caused by the transportation activity as well as by landfill and incineration process. the functional unit refers to a quantified description of the primary function of the system under study. the functional unit adopted for this study is the 1 ton of ppe kit (babu et al. 2014 ). the ppe kit comprised of the goggles, gloves, shoe cover, mask, and overall suit, comprising of gown and pant. all the above-mentioned components of the ppe kit were precisely measured and weighed with the help of a weighing balance. all the items of the disposable ppe kit were one-time use only except goggles, which can be reused for 6 days (mohfw). the reusability of goggles has been taken in this study as well (mohfw 2020) after following proper precaution and disinfection guidelines as stated by the world health organization (who guidelines 2020). figure 2 gives details about the ppe kits configuration and composition. the material that comprises of these products were identified primarily based on manufacturer specification and through peer-reviewed literature (marcin 2013; seemal et al. 2020 ; halyard; paho 2020; the conversation 2020). the system boundary is the set of criteria specifying which activities are part of the studied system and which resource use and emissions associated with them are included in the study. the system boundary of the lca study includes all direct and indirect resources use and emissions, like manufacturing, suppliers, along with the use and endof-life phase. in this study, materials like polypropylene (pp), nitrile butadiene rubber (nbr), polycarbonate (pc), and metal strip used in the manufacturing of ppe kit were included in the system boundary. also, the use of ppe by frontline workers, vehicles used in transportation, and ppe disposal are also incorporated under the system boundary as shown in fig. 3 environmental impacts are calculated in terms of gwp (kg co 2 equivalent), ap (kg so 2 equivalent), ep (kg po 4 equivalent), http (kg dcb equivalent), faetp (kg dcb equivalent) and pocp (kg ethane equivalent). the life cycle inventory (lci) model aims to link all unit processes that are required to deliver the product studies in an lca. in the current study, all flows of the materials, energy, and all the waste streams related to the functional unit were identified and quantified. the study focused on the total impact caused by the ppe kit from their process of "cradle to grave". the impact categories are selected in a way that laid more emphasis on the environment and human health. since there were only a few inventories contributing to other impacts, they are not considered in this study. the six impact categories chosen for this study are mainly global warming potential (gwp), human toxicity potential (htp), acidification potential (ap) eutrophication potential (ep), freshwater aquatic ecotoxicity potential (faetp), and photochemical ozone creation potential (pocp) (rejane et al. 2019) . the emission from the incineration process may give negative values due to application of heat recovery systems (jeswani et al. 2016; parkes et al. 2015) . while conducting lca, material wise. after running lca in gabi, the inventory results were analyzed for the ppe kit. the inventory analysis for this study was based on centrum voor milieuwetenschappen (cml 2001-jan. 2016) methods. the cml method is one of the strongly preferred methods followed by edip and ecoindicator99 (hand book of life cycle assessment 2018). it focuses on a series of environmental impact categories expressed in terms of emissions to the environment or resource use. the cml method groups the result into midpoint categories (klemeš et al. 2020) , the cml impact category used in this study were: gwp, htp, ep, a.p, faetp, and pocp. the impact assessment of the case-i revealed that the highest gwp impact was caused by ppe suit among all the inventories, with a total of 3,816.06 kg co 2 eq. emission. the ppe suit is made of pp fabric resulting in emission during the manufacturing with a total of 1850 kg co 2 eq, and additional emissions of co 2 eq were observed through masks. the details of the impact profiles are shown in fig. 4 . 1487.37 kg co 2 eq. emission occurred during the incineration process of ppes which contributed as the second-highest gwp related emissions. the gwp impact was from gloves with a total of 169.29 kg co 2 eq. emission. the details reveal that manufacturing of gloves resulted in more gwp, due to a large amount fig. 3 an illustration of the lca of ppe kit of energy being consumed during its steam cracking process (design life cycle 2018). the transportation by trucks for a payload of 1 ton ppe waste and 10 km travel to a disposal site, resulted in total gwp impact of 2.76 kg co 2 eq, which is inclusive of diesel mix at the refinery. the htp, faetp, and ap values are also reported to be very high for ppe suit and mask, while negative values for incineration were observed probably due to heat recovery. case ii results are similar to case i result, except for transportation. while most of the values are same, it is to be noted that impact categories values have reduced due to reduced transportation. the benefit may seem to be minuscule for the considered case; however, the large-scale operations lead to evident differences and reduced environmental and health footprint. the results are showcased in fig. 5 . the reduced transportation is also better due to multiple reasons other than reduced lca-related impacts. the number of direct and indirect people handling also reduces significantly, which reduces fatalities and morbidities. case iii is analyzed with respect to cradle to grave boundaries, with grave being the landfilling of the ppe. it can be seen from fig. 6 , the impact categories have shown a drastic increase except for gwp, which is lower due to the reduced amount of heat input in the disposal process. in case iii, transportation is also included till the landfill site. the values of ep, faetp, htp and pocp are higher than cases i and ii, while ap values seem to remain constant across all the cases. it is worthwhile to note that there is no negative value for landfill cases except for transportation pocp, which is negligible. at present, the whole worlds are fighting a war against covid-19 with countries implementing various measures to ensure reduced fatalities and morbidity from this novel coronavirus sars-cov-2. while this battle is being fought against a micro-sized with these changing habits, the use of ppes have increased drastically, especially by medical practitioners, in order to safeguard themselves and humanity from this novel coronavirus. while the use is absolutely essential and justified, it is to be noted that disposal of these ppes might become a problem in the near future, for which we should finding solutions today. in the current analysis, we have explored various options of disposing of these ppes through lca approach. three cases with different disposal options are considered. two of them include centralized and decentralized incineration, and one is landfill. the complete environmental footprint is considered through the cradle to grave in order to understand the detailed impact magnitude from each of the steps during the life cycle of ppes. the results are collated and presented in table 2 . from table 2 , it is evident that decentralized incineration seems to be a viable option for disposal of ppes both in terms of environment and health. the least viable option is landfill based disposal with all impact categories on a higher side except for gwp. the decentralized incinerator has a lower footprint in terms of ep, htp, pocp, and gwp when compared to centralized incinerators. at the same time, it produces almost similar impact in terms of ap and faetp. decentralized incinerator is a viable option because of additional reasons as well which are not considered in the scope of these impacts. the centralized incinerator adds number of people handling the ppes which might be infected by sars-cov-2. right from local disposal to centralized collection facility, there are additional number of people handling the waste and hence have higher chances of contracting the disease which can be avoided if decentralized systems are put in place. considering the above, it is important to note that lca impact categories have produced high footprint values for decentralized system as well, hence there is always a need to improve the systems at hand to reduce the overall impacts. given the above results, it is important to create strategies of handling such type of wastes in advance given that times are changing fast and policy decisions are to be taken with speed and scientific accuracy to reduce the impact on human lives. the lca approach in the present work has demonstrated that it can be used as an important tool in such decision making and that environmentally sound and sustainable strategies can be devised using it. furthermore, in addition to preparing for the future with respect to increase in generation of biomedical waste, there is a need to educate people who are handling it. the pandemic has altered the waste generation dynamics, creating distress among workers involved in sanitation and policymakers. covid-19 times have shown that microbes can be very deadly if proper hygiene is not followed, and one of the important components of hygiene is the proper handling of waste. while efforts are being made to make people understand the severity of this virus, there is a need to educate and inform these front line workers who are handling this waste as well. the results from the research can be used for decision making to plan future strategies for environmentally sound management of covid-19 infected ppe waste. fighting from the bottom, india's sanitation workers are also frontline workers battling covid municipal waste management and covid-19 pollution watchdog releases guidelines to handle covid-19 biomedical waste decentralized waste management: analysis for residential localities of gwalior city solid waste management for nagpur, feasibility study-united nations life cycle analysis of municipal solid waste (msw) land disposal options in bangalore city exploring dependence of covid-19 on environmental factors and spread prediction in india valuation of air pollution externalities: comparative assessment of economic damage and emission reduction under covid-19 lockdown. air quality, atmosphere and health valuation of ecosystem services and environmental damages: an imperative tool for decision making and sustainability covid-19 pandemic and personal protective equipment shortage: protective efficacy comparing masks and scientific methods for respirator reuse covid-19 dashboard by the center for systems science and engineering (csse) at johns hopkins university (jhu), arcgis. johns hopkins university annual progress report: cpcb envis centre on control of pollution (water, air, & noise) /envis _annua l_repor t/annua l%2520p rogre ss%2520r eport guidelines for handling, treatment and disposal of waste generated during treatment/diagnosis/ quarantine of covid-19 patients-revision 2 guidelines for handling, treatment and disposal of waste generated during treatment/diagnosis/ quarantine of covid-19 patients covid-19 and personal protective equipment: treatment and prevention of skin conditions related to the occupational use of personal protective equipment nitrile gloves: a life cycle assessment air pollution aggravating covid-19 lethality? exploration in asian cities using statistical models. environment, development and sustainability here's exactly where we are with vaccines and treatments for covid-19 biomedical waste management in india: still a looming concern personal protective equipment and covid 19-a risk to healthcare staff? 548 doctors, nurses, paramedics infected with covid-19 across india covid-19 personal protective equipment (ppe) for the emergency physician us pandemic could severely strain face mask, other ppe supply pipeline in the disposal of masks and gloves, responsibility is required wwf international how the plastic industry is exploiting anxiety about covid-19 electrostatic properties of selected personal protective equipment regarding explosion hazard assessing the environmental sustainability of energy recovery from municipal solid waste in the uk disinfecting personal protective equipment with pulsed xenon ultraviolet as a risk mitigation strategy for health care workers minimizing the present and future plastic waste, energy and environmental footprints related to covid-19 the covid-19 pandemic is generating tons of medical waste understanding covid-19 transmission, health impacts and mitigation: timely social distancing is the key minimising the present and future plastic waste, energy and environmental footprints related to covid-19 electrostatic properties of selected personal protective equipment regarding explosion hazard advisory on reprocessing and re-use of eye protection-goggles assessment of contribution of agricultural residue burning on air quality of delhi using remote sensing and modelling tools sanitation workers, attendants most vulnerable to covid-19 among hospital staff: aiims study is the world ready for the coronavirus? distrust in science and institutions could be a major problem if the outbreak worsens state council issues guideline on regular covid-19 prevention requirements and technical specifications of personal protective equipment (ppe) for the novel coronavirus (2019-ncov) in healthcare settings global shortage of personal protective equipment amid covid-19: supply chains, bottlenecks, and policy implications life cycle assessment of integrated waste management systems for alternative legacy scenarios of the london olympic park as covid-19 cases in district surge, so does the quantity of biomedical waste rationing ppes during a pandemic: the covid-19 scenario suggestion of life cycle impact assessment methodology: selection criteria for environmental impact categories protection of anesthesia providers from silent carriers of covid-19 while minimizing disposable ppe utilization challenges and solutions for addressing critical shortage of supply chain for personal and protective equipment (ppe) arising from coronavirus disease (covid19) pandemic-case study from the republic of ireland coronavirus: mumbai waste collectors work with their bare hands. retrieved june30 covid-19 and personal protective equipment: treatment and prevention of skin conditions related to the occupational use of personal protective equipment hospital preparedness for emergency in india (hope-i) to combat covid-19 outbreaks personal protective equipment and intensive care unit healthcare worker safety in the covid-19 era (ppe-safe): an international survey your used mask needs to make it to the trash can working with the environment to protect people unep's covid-19 response challenges and strategies for effective plastic waste management during and post covid-19 pandemic report on health-care waste management status in countries of the south-east asia region understanding air and water borne transmission and survival of coronavirus: insights and way forward for sars-cov-2 safe management of wastes from health-care activities: a summary coronavirus disease (covid-19) advice for the public: mythbusters statement regarding cluster of pneumonia cases in wuhan report: laboratory testing of human suspected cases of novel coronavirus (ncov) infection covid-19) advice for the public rational use of personal protective equipment for coronavirus disease (covid-19) and considerations during severe shortages ahmedabad hospitals shell out rs 45/kg for disposal of covid-19 bio-waste zero waste europe statement on waste management in the context of covid-19 the authors greatly acknowledge the support of council of scientific and industrial research (csir) and director, csir-neeri under the major laboratory project number mlp-162. the manuscript is checked for plagiarism using licensed version of ithenticate software with assigned manuscript reference number as csir-neeri/krc/2020/july/csum-drc-ermd-dir/1 dated 04 july 2020. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. harender kumar 1 · amaanuddin azad 1 · ankit gupta 1,2 · jitendra sharma 3 · hemant bherwani 1,2 · nitin kumar labhsetwar 1,2 · rakesh kumar 1,2 1 csir-national environmental engineering research institute, csir-neeri, nagpur, maharashtra 440 020, india 2 academy of scientific and innovative research [acsir], ghaziabad, uttar pradesh 201 002, india key: cord-355577-w1yhtbz8 authors: kowalski, luiz paulo; imamura, rui; castro junior, gilberto de; marta, gustavo nader; chaves, aline lauda freitas; matos, leandro luongo; bento, ricardo ferreira title: effect of the covid-19 pandemic on the activity of physicians working in the areas of head and neck surgery and otorhinolaryngology date: 2020-05-22 journal: int arch otorhinolaryngol doi: 10.1055/s-0040-1712169 sha: doc_id: 355577 cord_uid: w1yhtbz8 introduction coronavirus disease 2019 (covid-19) is an acute infection caused by the new coronavirus (sars-cov-2) and it is highly transmissible, especially through respiratory droplets. to prepare the health system for the care of these patients also led to a restriction in the activity of several medical specialties. physicians who work with patients affected by diseases of the head and neck region constitute one of the populations most vulnerable to covid-19 and also most affected by the interruption of their professional activities. objective the aim of the present study was to assess the impact of the covid-19 pandemic on the practice of head and neck surgeons and otorhinolaryngologists in brazil. methods an anonymous online survey of voluntary participation was applied, containing 30 questions regarding demographic aspects, availability of personal protective equipment (ppe), and impact on the routine of head and neck surgeons and otorhinolaryngologists, as well as clinical oncologists and radiation oncologists who work with head and neck diseases. results seven hundred and twenty-nine answers were received in a period of 4 days, ∼ 40 days after the 1 (st) confirmed case in brazil. with professionals working in public and private services, there was a high level of concerns with the disease and its consequences, limited availability of ppe and a significant decrease in the volume of specialized medical care. conclusion the study demonstrated a direct impact of the covid-19 pandemic on the clinical practice of specialties related to the treatment of patients with diseases of the head and neck region already in the beginning of the illness management in brazil. infection by the new coronavirus (sars-cov-2) started in late 2019 in wuhan, in the province of hubei, in china. the virus spread very fast across asia and quickly became a pandemic. it is a highly contagious disease, with many oligosymptomatic or even asymptomatic patients, with high mortality rates for vulnerable patients (those with chronic disease, immunocompromised and/or elderly). 1 another striking feature of the disease is the prolonged hospitalization of severe cases, which makes physicians and other health professionals very exposed to the virus. the main route of contamination by the disease is by droplets and aerosol dispersion, which makes professionals who deal with diseases of the upper airways tract particularly more susceptible to contamination. 2, 3 in this context, the correct use and availability of personal protective equipment (ppe) is essential to protect the healthcare providers (hcps). [4] [5] [6] [7] to prepare the healthcare system to receive these patients has led to a major change in the routine of most healthcare services. many institutions have restricted their activities only to the management of patients affected by the coronavirus 2019 (covid19) , practically interrupting other treatments, especially the elective ones. this fact directly affected the care of patients with other health problems and also the professional activity of several medical specialties. thus, the aim of the present study was to assess the impact of the covid-19 pandemic on the practice of physicians working in the areas of otolaryngology and head and neck oncology in brazil. a web-based survey was created using the surveymonkey audience platform. information on how data are collected, stored and exported may be obtained in: www.surveymonkey.com/mp/audience. demographic, professional, and clinical practice data were collected through 30 questions of different formats: multiple choice, dropdown lists, and text boxes, with the possibility to add commentaries as open text in some questions. specifically, we collected data regarding the impact of de covid-19 pandemic on: 1) the amount and type of outpatient appointments, surgeries and exams with the risk of generating aerosols; 2) availability of adequate ppe in different settings and practices; 3) the preparedness of the responder's health institution in orienting their hcps and developing strategies to manage covid-19 suspected and confirmed patients. pilot testing of the survey was performed with members of the research team, and questions were modified to improve readability and adequacy. the target population consisted of specialists who worked in the field of the head and neck, particularly otorhinolaryngologists, head and neck surgeons, oncologists, and radiation oncologists. the survey platform generated a link to access the survey that was distributed electronically, through email and social media, to members and participants of the involved medical organizations (grupo brasileiro de cabeça e participation in the survey was voluntary, and all data that could identify the responder was kept anonymous in all phases of the study. the survey collected responses from april 13 th to 17 th 2020, when the pandemic was ongoing for 7 weeks in brazil, after the first diagnosed case. a short period of data collection was planned beforehand to capture a specific moment of the covid-19 pandemic, as many responses could change during the progression of the disease. each physician could participate only once in the survey. the data was imported to an excel spreadsheet and then submitted to procedures to ensure data consistency and, finally, it was imported to spss version 26.0 (ibm corp., armonk, ny, usa) for statistical analyses. categorical data was compared with chi-square tests. non-parametric spearman was used to test the correlation between ordinal variables. the study was considered as exploratory, and neither sample size calculation nor correction for multiple comparisons were performed. the survey was answered by 729 physicians; 228 head and neck surgeons, 293 otorhinolaryngologists, 111 clinical oncologists, and 97 radiation oncologists. the demographic and professional characteristics of the physicians are shown in ►table 1. there were differences in some of these characteristics in relation to the specialties. head and neck surgeons and otorhinolaryngologists had more practice time than clinical specialists, and the proportion of head and neck surgeons in both sectors of care (private and public) was greater than that of physicians in other specialties. we asked how physicians self-perceived their risk of developing severe forms of covid-19, according to their age and the presence of comorbidities. there were no differences between specialties: 57.3% considered themselves without risk of developing severe forms, 27% at low risk, and only 15.6% considered themselves at high risk (p ¼ 0.43). there was a remarkable reduction in the volume of medical care, both in the private and public scenarios. the reduction was more evident in the private sector than in the public services (p < 0.001), with $ 50% of the physicians who assist in the private sector referring to a reduction of 75% or more in the volume of care (►table 2). the reduction in the volume of medical care was not uniform among the responders. the impact was greater in surgical specialties (head and neck surgery and otolaryngology), than in oncology clinics (clinical international archives of otorhinolaryngology vol. 24 no. 3/2020 oncology and radiation oncology), both in the private sector (p < 0.001) and in the public services (p < 0.001) (►table 3). another impacting factor in determining the volume of care reduction was the self-perceived risk of developing serious forms of covid-19. in the private sector, the reduction of 75% or more in the volume of assistance was 66.4%, 51.1%, and 44.5% for the high, low, and risk-free groups, respectively (p < 0.001). in the public services, these proportions were 52.1%, 36.2%, and 28.9%, respectively (p ¼ 0.001) faced with the reduction in the volume of medical appointments, physicians have been looking for another way to serve their patients. however, the face-to-face appointment still corresponds to more than 70% of the attendance for 49.6% of the physicians. telemedicine is not yet a reality in our country: 77.2% of the physicians use it in less than 10% of their visits. for ⅔ of physicians (66.9%), contact with patients by phone or social media corresponded to less than 30% of the appointments. physicians reported a decrease in the performance of potentially aerosol-generating exams. a decrease of 50% or more in oroscopy, nasofibroscopy, and laryngoscopy was reported by 53.1%, 81.9%, and 81.3% of the respondents, respectively. if we consider who reported almost complete interruption of the exams (reduction of 90-100%), these values were 23.1%, 64.3% and 62.4%, respectively. the impact of covid-19 was particularly significant on the reduction of operating volume of surgeons who responded to the survey. an almost complete (90-100%) decrease in thyroidectomies, elective surgeries in the pediatric range, and nasosinusal surgeries was reported, respectively, by 60.7%, 91.1%, and 90.3% of the surgeons who normally perform them. even in those surgeries that were supposed to continue during the pandemic, a drastic reduction in comparison to prepandemic period was mentioned. tracheostomies and surgeries for resection of head and neck cancer had a reduction of 50% or more reported by 65.4% and 49.3% of physicians, respectively. if we consider who reported near interruption of the surgeries (reduction of 90-100%), these values were 44.8% and 24.8%, respectively. most surgeons reported difficulties in scheduling elective surgeries both in the private sector (78.7%) and in the public services (75.5%), chiefly due to guidance from the hospital itself in not allowing such appointments. the performance of surgical interventions in confirmed covid-19 patients was small in the studied group (22 cases, 4.6%). these cases were operated mainly because they were urgencies, oncological cases, or tracheostomies. of the 22 operated patients, 19 had no complications or had complications as expected for the procedure, and 3 patients had serious complications or died. most of the interviewed physicians (74.8%) reported knowing a professional colleague with confirmed covid-19 infection. the median of professionals (physicians or other hcps) infected was 2 (p25%: 2; p75%: 6; minimum: 0; maximum: 94). thirty-two (4.4%) of the physicians interviewed reported having become infected with the disease. of these, 11 were head and neck surgeons, 9 were radiation oncologists, 7 were oncologists, and 5 were otorhinolaryngologists. the limitation in the availability of complete ppe for exams that potentially generate aerosol is shown in ►fig. 1. to facilitate understanding, only the extremes of availability (0-10% and 90-100%) were represented. complete ppe available in only 0 to 10% of examinations was reported by $ 20% of physicians working in the private sector, and by 25% of those working in the public services. at the other end of the analysis, complete equipment available in 90 to 100% of examinations was reported by $ 55% and 45% of physicians in the private and public sectors, respectively. the lack of ppe was greater in the public sector in relation to oroscopies (p ¼ 0.01) and laryngoscopies (p ¼ 0.024). for nasofibroscopies, no difference was observed (p ¼ 0.068). we assessed whether the lack of ppe for the exams could have influenced the decrease in the volume of each exam (oroscopy, nasofibroscopy, and laryngoscopy). in both the private and public sectors, we did not find significant correlations for any of the tests mentioned (data not shown-spearman test). ►fig. 2 shows the availability of masks for patient care in the private and public sectors. although surgical masks are available in both services (p ¼ 0.157), the type n95 mask had more restricted and lower availability in public services, when compared with private ones (p < 0.001). again, only the availability extremes (0-10% and 90-100%) were represented. the opinion of 48.0% of respondents in the private and 69.1% in the public sector was that ppe would end during the pandemic (p < 0.001), in a time interval ranging from 1 to more than 10 weeks, with a median of 4 weeks, both in the public and private sectors. when asked whether, in the absence of suitable ppe, the colleague would postpone or refuse care for a suspected or confirmed covid-19 patient, 20.3% replied that they would still attend. the main consideration for care in these circumstances was urgencies or medical emergencies. we observed that this attitude was greater in clinical specialties (oncologists and radiation therapists) than in surgical specialties (p ¼ 0.004) and was not related to time of clinical practice or risk of developing serious disease due to covid-19 (►table 4). although the pandemic is already in its 7 th week in brazil, since the identification of the 1 st case, 45.3% and 48.8% of physicians in the private and public sectors, respectively, reported that they had not received face-to-face or distance training in the management of confirmed or suspected patients with covid-19. on the other hand, health services in both the private and public sectors seem to have been prepared to manage the covid-19 crisis. according to the physicians interviewed, 71.1% and 76.8% of the private and public services, respectively, created a crisis management committee and institutional protocols for the management of these patients. the commitment to the management of suspected or confirmed patients with covid-19 was considered to be good or excellent by 79.5% and 65.2% of physicians in private and public services, respectively (p < 0.001). presence of pretreatment screening areas were equivalent in the private (53.5%) and public (55.2%) sectors. the presence of an isolated hospitalization area for patients with suspected or confirmed covid-19 was reported by 83.7% of physicians in the public sector and by only 67.3% of those in the private services (p < 0.001). patients with covid-19 usually present with symptoms seen by these specialists, such as cough, sore throat, headache, increased sputum production and anosmia. half of these patients do not present fever at the onset, lowering the index of suspicion of the disease. 8, 12 furthermore, physical examination in these specialties require exposure to the nasal and oral cavities and oropharynx. these regions present high concentrations of sars-cov-2, even in the asymptomatic patients, who may also spread the disease. 8, 9, 13 this survey aimed to quantify the impact of the covid-19 pandemic in the daily practice of otorhinolaryngologists, head and neck surgeons, clinical oncologists, and radiation oncologists. it revealed a drastic reduction in outpatient visits, and in the number of exams and surgical procedures. some degree of reduction in the volume of outpatients was expected, as many institutions and medical societies have suggested postponing non-urgent appointments, in response to the elevated occupational hazard of these specialists. 5, 8, 9, 12, 14, 15 furthermore, on march 20th 2020, due to the progression of the pandemic, the brazilian federal council of medicine recommended cancelling appointments and elective procedures for all physicians in brazil. 16 finally, patients may be reluctant to seek medical care, due to the fear that the physician or the health care unit may be a source of covid-19 contagion. 14 this fear seems to play a major role on the side of the physician as well. the amount of reduction in outpatient visits was associated with the physician's selfperceived risk of developing severe forms of covid-19, both in the private and the public sectors. the decrease in the volume of outpatient appointments was higher among surgical specialties and in the private sector. in this group, the majority of responders referred a decrease of more than 75% of visits. this reduction, without previous planning, will impact not only the financial income of physicians, but will probably impair the expedited diagnosis and treatment of progressive diseases, such as cancer, thus influencing their morbidity and mortality rates. one alternative to keep the flow of outpatients would be an increased use of telemedicine, which has been recently regulated by the ministry of health (ordinance n. 467 of 20/3/2020), to mitigate the problem of providing adequate healthcare during the covid-19 pandemic. 12, 17 however, probably due to the recent regulation and lack of familiarity by both physicians and patients, it is still not commonly used among us. our study demonstrated that when telemedicine was adopted as an alternative to face to face appointments, it was usually employed in less than 10% of cases. to organize the flow of outpatients, it would be productive to categorize them in tiers: those who would need to be seen face to face (urgent cases, in which physical exam is essential), those appropriate for telemedicine or telephone visit, and those who could be simply rescheduled. 18 our study also revealed a marked reduction of exams considered aerosol generating procedures (agps), especially nasofibroscopies and laryngoscopies. in these exams droplets and aerosols may be generated, especially in the event the patient sneezes or coughs during the procedure, 13 leading to an increased risk of transmission. surgical masks are not protective against aerosols, and aerosolized particles of sars-cov-2 have been shown to remain viable in the air for at least 3 hours. 19 therefore, most experts recommend that agps should be performed with adequate ppe, including: long sleeve gown, gloves, face shield and n95 mask. 5, 9, 12, 18, 20 nonetheless, the role of aerosols in the transmission of covid-19, both in the community and to hcps, is not known. in sars patients, a meta-analysis showed a consistent association between tracheal intubation and transmission of sars-cov to hcps. lower-quality studies have demonstrated increased risk of sars infection with tracheostomy, non-invasive ventilation and mask ventilation before intubation. twenty other agps were assessed, and none demonstrated an increased risk of sars transmission. 21 so far, sars-cov-2 is considered, at most, an opportunistic airborne pathogen, 13 and, according to the world health organization (who), covid-19 is primarily transmitted through respiratory droplets and contact routes. 22 the availability of complete ppe for agps, as suggested, was investigated in our study. of concern was the finding that 20 to 25% of responders referred that complete ppe were available in less than 10% of the procedures. the shortage of ppe was more pronounced in the public sector. there was no association between the availability of ppe and the amount of reduction of agps, suggesting that the shortage of ppe was not the main reason to explain the reduction of exams. probably, the decrease in the volume of outpatients impacted the amount on exams performed. the availability of surgical masks for outpatient appointments was adequate in both public and private sectors. the same was not observed for n95 masks. they were available in less than 10% of appointments in 26% of public facilities and 16% of private ones, with the difference being statistically significant. there are conflicting recommendations regarding mask use under low risk situations, as in routine clinical care. the who recommends surgical masks, while the centers for disease control and prevention (cdc) recommends n95 masks. 13 given the possibility of transmission of covid-19 from asymptomatic patients, at least surgical masks should be used by hcps in all outpatient visits. 12 there is, actually, little evidence to support the superiority of n95 masks over standard surgical masks in the scenario of routine clinical care. a recent meta-analysis failed to demonstrate the superiority of n95 masks over surgical masks in preventing influenzae infection in hcps. the lack of compliance with proper fit and adequate use, due to the discomfort associated to its use may have influenced the results. 23 furthermore, not only compliance to the adequate use of mask during exposure but appropriate doffing of ppe is vital to prevent contagion, even in agps. 9, 20 moreover, in a case report regarding 41 hcps who took care of a patient with covid-19 and pneumonia and were exposed during various agps (tracheal intubation, extubation, and noninvasive ventilation), none of them got infected, despite 85% having used only surgical masks during the procedures. proper hand hygiene and standard procedures were adopted by all hcps. the authors emphasize the limitations of a case report study, but suggest that the superiority of n95 masks for agps should be questioned and that further studies are necessary to determine how best to protect hcps from covid-19. 24 our study also confirmed a marked disruption in surgical practice, including elective sinonasal procedures, surgeries in children, and thyroidectomies. surgery will probably be a component of our practice that will take longer to resume. medical organizations and societies still recommend limiting all non-essential surgeries, to preserve needed resources and the safety of patients and hcps. 11 due to the high viral titers in the nasal mucosa, even in asymptomatic patients, 13 sinonasal procedures have a high risk of aerosolization and contagion 5 and should be avoided. also in children, surgery should be postponed, if considered non-urgent. 18 when infected, children tend to be asymptomatic or to present milder symptoms and may be still contagious. 20 on the other hand, surgeries without mucosal exposure, such as thyroidectomies, are considered of lower risk of covid-19 transmission, as compared with surgeries on the nasal cavities or pharynx. the caveat is the use of energy devices that may theoretically result in aerosolization of the virus from the bloodstream. 9 even so, thyroidectomies have also been reduced, according to our study. as a matter of fact, most surgeons referred to difficulties in scheduling elective procedures, mainly due to restrictions imposed by the surgical center, both in the private and the public sectors. even procedures that should continue during the pandemic, such as cancer resections and tracheostomies, were reduced, albeit, to a lesser degree. this finding suggests that currently, the waiting list of patients requiring surgery is gradually increasing, as cancer and diseases that lead to airway obstruction, such as recurrent respiratory papillomatosis will continue to progress. as the pandemic evolves, there will be an increasing need to resume surgeries in patients without a definite covid-19 diagnosis. the urgency of the procedure will need to be weighed against the risk of getting a nosocomial covid-19 infection on a case-by-case basis. that is a real concern for cancer patients, as they have been associated with poorer outcomes if they become infected with sars-cov-2. 25 therefore, for initial (t1/t2) laryngeal carcinoma, radiation therapy may be an appropriate alternative to the high-risk microlaryngeal surgery with co2 laser during the pandemic. 26 on the other hand, trying to keep a covid-free environment is a real concern for some hospitals. screening for sars-cov-2 in the 48 h prior to the procedure, although with questionable sensitivity in asymptomatic patients, may help to identify unsuspected positive patients, whose procedure could be postponed. 9 an unexpected finding in our study was the low amount of surgeries (22 cases) performed in covid-19 patients, given the presence of more than 500 surgeons among responders, most of them with more than 10 years of experience in the field. at least, a larger amount of tracheostomies was expected, as it was the most performed surgery in sars patients. 27 elective tracheostomies in covid-19 patients have a narrower range of indication, due to the increased risk of aerosolization and contagion. 9 even so, these numbers should increase as the pandemic evolves. according to the opinion of responders in our study, most institutions, in both the private and public sectors, are concerned with their preparedness to combat the covid-19 pandemic. it is interesting to notice that public services were better than private ones, in regard to the presence of isolated covid-19 inpatient areas. however, communication and orientation of hcps seem to be limited, at best. close to 50% of responders, in both sectors, said they did not receive any kind of training about the management of covid-19 patients. this is a deeply worrying finding, given the high occupational risk of contagion in our field and that the pandemic is close to completing 2 months in brazil. studies based on surveys are particularly prone to sampling bias, especially if they rely on open, digital recruitment, as performed in this study. however, our aim was to capture the momentary effect of an evolving pandemic on the medical practice. other recruitment strategies would not be as efficient in providing the same yield in such a short time. the study sample revealed a predominance of physicians from the southeast region of brazil and from metropolitan areas. also, surgical specialists (head and neck surgeons and ents) were older than oncologists and radiation therapists. these characteristics are in accordance with the medical demographics in our country. 28 another limitation of the study refers to the representativity of the medical specialties in the sample. considering the number of registered specialists in brazil, 28 our study sampled 21.2% of head and neck surgeons; 13.2% of radiation oncologists; 4.6% of ents; and 3.1% of clinical oncologists. although sampling bias is not prevented by higher sampling yields, ear, nose & throat (ent) specialists and oncologists were indeed poorly represented in our sample. however, when different responses according to specialties were observed in our analyses, they tended to group among surgeons and clinicians. therefore, we speculate that the low representativeness of ents and clinical oncologists might have been compensated by the higher proportion of head and neck surgeons and radiation oncologists, respectively. surveys such as the present one may help to quantify the impact of covid-19 on the daily practice of physicians, their current concerns and limitations, and to suggest alternative ways to mitigate these limitations. specifically, medical societies could broaden programs aiming to train their members about how to: 1) deal with covid-19 suspected or infected patients in different situations, 2) proper use of telemedicine, 3) manage their waiting list for surgeries and 4) providing distance learning courses on patient management and protection during exams and surgeries. many aspects investigated in the present survey will probably evolve during the course of the pandemic, and follow-up studies are planned to capture these changes. coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine practical aspects of otolaryngologic clinical services during the 2019 novel coronavirus epidemic: an experience in hong kong occupational risks for covid-19 infection integrated infection control strategy to minimize nosocomial infection of coronavirus disease 2019 among ent healthcare workers precautions for endoscopic transnasal skull base surgery during the covid-19 pandemic covid-19: what's the current advice for uk doctors? protecting health care workers during the covid-19 coronavirus outbreak -lessons from taiwan's sars response otolaryngology providers must be alert for patients with mild and asymptomatic covid-19 safety recommendations for evaluation and surgery of the head and neck during the covid-19 pandemic otorhinolaryngologists and coronavirus disease 2019 (covid-19) an update on covid-19 for the otorhinolaryngologist -a brazilian association of otolaryngology and cervicofacial surgery (aborl-ccf) position statement endonasal instrumentation and aerosolization risk in the era of covid-19: simulation, literature review, and proposed mitigation strategies covid-19 pandemic: effects and evidence-based recommendations for otolaryngology and head and neck surgery practice guidance for ent during the covid-19 pandemic 2020 combate à covid-19 -orientação geral ao trabalho dos médicos dispõe, em caráter excepcional e temporário, sobre as ações de telemedicina, com o objetivo de regulamentar e operacionalizar as medidas de enfrentamento da emergência de saúde pública de importância internacional previstas no art. 3°da lei n°13.979, de 6 de fevereiro de 2020, decorrente da epidemia de collaborative multidisciplinary incident command at seattle children's hospital for rapid preparatory pediatric surgery countermeasures to the covid-19 pandemic aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 covid-19 and the otolaryngologist -preliminary evidence-based review aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review modes of transmission of virus causing covid-19:implications for ipc precaution recommendations. 26/3/2020 [this version updates the 27 march publication by providing definitions of droplets by particle size and adding three relevant publications effectiveness of n95 respirators versus surgical masks against influenza: a systematic review and metaanalysis covid-19 and the risk to health care workers: a case report cancer patients in sars-cov-2 infection: a nationwide analysis in china impact of coronavirus (covid-19) on otolaryngologic surgery: brief commentary surgical considerations for tracheostomy during the covid-19 pandemic: lessons learned from the severe acute respiratory syndrome outbreak demografia médica no brasil the present survey revealed that covid-19 impacted brazilian specialists that work in the head and neck field, with marked reduction in outpatient visits, exams and surgical procedures. we could also identify limitations in regard to: 1) adequate training of specialists in dealing with covid-19 patients, 2) the availability of adequate ppe for agps, 3) the use of telemedicine as an alternative to face-to-face appointments. the authors declare no potential conflict of interests. key: cord-335704-qejpc4x8 authors: kuhar, hannah n.; heilingoetter, ashley; bergman, maxwell; worobetz, noah; chiang, tendy; matrka, laura title: otolaryngology in the time of corona: assessing operative impact and risk during the covid-19 crisis date: 2020-06-02 journal: otolaryngol head neck surg doi: 10.1177/0194599820930214 sha: doc_id: 335704 cord_uid: qejpc4x8 objective: limited research exists on the coronavirus disease 2019 (covid-19) pandemic pertaining to otolaryngology–head and neck surgery (ohns). the present study seeks to understand the response of ohns workflows in the context of policy changes and to contribute to developing preparatory guidelines for perioperative management in ohns. study design: retrospective cohort study. setting: pediatric and general adult academic medical centers and a comprehensive cancer center (ccc). subjects and methods: ohns cases from march 18 to april 8, 2020—the 3 weeks immediately following the ohio state-mandated suspension of all elective surgery on march 18, 2020—were compared with a 2019 control data set. results: during this time, ohns at the general adult and pediatric medical centers and ccc experienced 87.8%, 77.1%, and 32% decreases in surgical procedures as compared with 2019, respectively. aerosol-generating procedures accounted for 86.8% of general adult cases, 92.4% of pediatric cases, and 62.0% of ccc cases. preoperative covid-19 testing occurred in 7.1% of general adult, 9% of pediatric, and 6.9% of ccc cases. the majority of procedures were tiers 3a and 3b per the centers for medicare & medicaid services. aerosol-protective personal protective equipment (ppe) was worn in 28.6% of general adult, 90% of pediatric, and 15.5% of ccc cases. conclusion: for ohns, the majority of essential surgical cases remained high-risk aerosol-generating procedures. preoperative covid-19 testing and intraoperative ppe usage were initially inconsistent; systemwide guidelines were developed rapidly but lagged behind recommendations of the ohns department and its academy. ohns best practice standards are needed for preoperative covid-19 status screening and ppe usage as we begin national reopening. c oronavirus disease 2019 (covid19) is an acute infectious respiratory disease caused by the novel b-coronavirus sars-cov-2, or 2019 novel coronavirus (2019-ncov). covid-19 was recognized by the world health organization as a global pandemic on march 11, 2020. 1 covid-19 spreads primarily via respiratory tract droplets, secretions, and direct contact. 2 increasing evidence has demonstrated that procedures and examinations involving the upper aerodigestive tract pose a high risk for transmission. 3 particularly, the nose and nasopharynx are understood to be reservoirs for high concentrations of the sars-cov-2 virus. 4 for this reason, the risk of transmission is high during maneuvers that involve the aerodigestive tract of patients with covid-19. in these cases, the virus can spread via inhalation or mucosal contact with infected respiratory secretions. 5 otolaryngologists have been identified as a particularly vulnerable population among health care workers, as the majority of otolaryngologic procedures involve instrumentation of the upper aerodigestive tract. 6 in the early stages of the pandemic, many health care workers, specifically nonprimary care or consulting service providers such as otolaryngologists, were getting infected at higher rates as compared with other specialties. 7, 8 as nearly half the patients with covid-19 present as afebrile and asymptomatic or with generalizable symptoms of nasal congestion, sore throat, and hyposmia, screening for clinical signs of covid-19 infection is not effective to guide perioperative precautions. 7, 9, 10 the possibility for occult positivity among children and adults who raise low clinical suspicion puts health care workers at risk of infection. for these reasons, otolaryngology examinations and aerosol-generating procedures (agps) are considered high risk for exposure from aerosol and droplet contamination by asymptomatic carriers of disease. 11 any procedure involving the mucosa of the aerodigestive tract is considered an agp. 11, 12 researchers posit that following manipulation of any of these areas, viral particles may be airborne for 3 hours. 13 recent safety guidelines on the recommended management of otolaryngologic cases suggest that examinations and procedures be limited to patients with clear indication and need, performed by the most experienced personnel available, and deferred if nonessential (ie, for a routine or lowerpriority reason). 11 a high-risk procedure is defined as surgery involving the nasal mucosa or contact with oral, pharyngeal, and pulmonary secretions. 11 researchers assert that the risk of transmission is highest during intubation, tracheostomy, and open airway procedures, which most often involve positive-pressure ventilation. 5 regarding surgical management of otolaryngologic cases, it is recommended that patient covid-19 status be determined ahead of surgery, that high-risk operations be performed in negativepressure operating rooms with appropriate personal protective equipment (ppe) worn by all staff, and that only essential staff be in the operating room for intubation and extubation. 11 the american academy of otolaryngology-head and neck surgery (aao-hns) released covid-19related resources, including patient screening algorithms and postexposure risk classifications. 5 on march 18, 2020, the centers for medicare & medicaid services (cms) released recommendations to delay all adult elective surgery and nonessential medical, surgical, and dental procedures during the covid-19 response. 14 cms organized procedures into a series of tiers (1a-3b) meant to provide a framework for hospitals and clinicians to implement immediately during the covid-19 response. the tier system takes into account patient risk factors; the availability of beds, staff, and ppe; and the urgency of the procedure. 14 while guidelines on the perioperative management of otolaryngology-head and neck surgery (ohns) cases are developing, there are several challenges to the implementation of such recommendations. one obstacle confronting otolaryngologists is the nationwide shortage of ppe necessary to perform surgical procedures. 15, 16 additionally, the availability of timely covid-19 testing has been limited due to regulatory processes and the time required to validate clinical tests, the initial lack of certified laboratories with polymerase chain reaction capabilities, and the shortage of chemicals and supplies. [17] [18] [19] these limitations have restricted feasibility of consistent covid-19 testing in the preoperative setting. moreover, false-negative rates for these tests have been reported up to 21.4%. [20] [21] [22] as national and local policies affecting the health care workforce change rapidly without consistent perioperative guidelines and adequate supplies, otolaryngologists are increasingly left to develop their own policies and practices to ensure surgeon and patient safety. limited research exists on the covid-19 pandemic as it pertains to ohns experiences, and urgent studies are required to characterize specialty response to the disease and streamline perioperative management. the purpose of the present study is to understand the impact of covid-19 on perioperative workflows for ohns at 2 tertiary academic medical centers in the context of national and state policy changes. the study focuses on the period since the ohio state-mandated suspension of all elective surgery on march 18, 2020. this date was selected to capture the earliest phase of covid-19 preparation in our state, prior to a peak in covid-19 cases. this study examines institutional recommendations, department recommendations, society recommendations, and surgeon practices during this time. we seek to contribute to anticipatory efforts and preparatory guidelines for surgical planning and perioperative management in ohns moving forward. the objectives of the present study are 2-fold. first, we seek to examine the change in ohns case volume and nature during the covid-19 pandemic in the context of policy changes. we compare covid-19 pandemic case numbers and types (march 18-april 8, 2020) directly with 2019 control data from the same date range, to understand the impact of the ohns department response to policy changes. second, we explore the spectrum of essential care that otolaryngologists are providing during covid-19 in the adult and pediatric settings. we hypothesize that the majority of essential ohns procedures performed remain highrisk (ie, agps) despite efforts to minimize surgical volume. we also examine the prevalence of perioperative covid-19 testing and aerosol-protective ppe selection among otolaryngologists in response to the pandemic and national policy changes. this was a retrospective cohort study of all ohns cases performed from march 18 through april 8, 2020, at a pediatric academic medical center and an adult academic medical center, inclusive of a comprehensive cancer center (ccc). the study was approved by the institutional review board of the ohio state university wexner medical center. data were extracted from the electronic medical record through chart review. the following data points were extracted from electronic medical record chart review: covid-19 history and symptoms, comorbid conditions (including immunosuppression, age .59 or \1 year, coronary artery disease or other heart disease, pulmonary disease), whether covid-19 testing was performed, surgical procedure details (including inpatient/ outpatient, cms tier, primary international classification of disease, tenth revision code, and current procedural terminology code), case airway management (intubation, laryngeal mask airway, bag mask, spontaneous or jet ventilation, ventilation through tracheostomy), and ppe utilized. a case was determined to be mucosal or an agp if it involved the mucosa of the head and neck, specifically within the nose, sinuses, nasopharynx, oral cavity, oropharynx, larynx, trachea, mastoid or middle ear, and esophagus. 11 rationale for including the esophagus is that instrumentation of the upper airway is required to access. additional data points collected included case volumes and types from march 18 through april 8, 2019, as a reference point for direct comparison with data for march 18 through april 8, 2020. additionally, all scheduled ohns cases were captured that were deemed elective and subsequently canceled from march 18 and april 8, 2020. a timeline of events from march through april 2020 was designed to capture policy changes related to the covid-19 response at national, state, local institutional, and departmental levels. data on use of aerosol-protective ppe were collected from surgeons directly when not noted in the electronic medical record. on april 2, 2020, a standardized template was instituted to capture data regarding airway management and covid-19 testing and status, as well as ppe usage by surgeons, staff, and anesthesia. this template was included by attending and resident surgeons at the end of brief operative notes. ppe information was collected from these templates when available. descriptive statistical analyses were performed. categorical variables were described as frequency rates and percentages. all statistical analyses were performed with microsoft excel. analyses included cases from a pediatric academic medical center and an adult academic medical center, inclusive of a ccc. data were collected for march 18 to april 8, 2020, which includes the 3 weeks immediately following the statemandated suspension of all nonelective procedures in ohio. data were also collected for march 18 to april 8, 2019, to compare case volume and procedure type between 2019 and 2020 for the same date range. comprehensive data were collected on each surgical case, including types of procedures performed, as many cases comprised 2 procedures. from march 18 to april 8, 2020, there were 14 general adult cases (38 procedures), 142 pediatric cases (225 procedures), and 58 ccc adult cases (221 procedures). canceled cases during this time frame included 258 general adult, 418 pediatric, and 46 ccc adult. of the general adult procedures, 86.8% were agps; of pediatric procedures, 92.4%; of ccc adult procedures, 62.0% ( table 1) . anatomic locations of agps performed across all 3 sites included 26.9% for the nose, sinus, and nasopharynx; 26.1% for the middle ear and mastoid; 20.5% for the oral cavity and oropharynx; 11.2% for the trachea; 9.9% for the larynx and supraglottic airway; and 5.3% for the esophagus (figure 1) . preoperative covid-19 testing was performed in 7.1% of general adult cases, 9% of pediatric cases, and 6.9% of ccc cases. no tested patients were covid-19 positive at any of the 3 sites. general adult procedures included 71.4% cms tier 3a, 7.1% cms tier 3b, 7.1% cms tier 2, and 14.3% cms tier 1. pediatric procedures included 71.1% cms tier 3a, 28.2% cms tier 3b, 0.7% cms tier 2, and no cms tier 1. procedures performed at the ccc included 81% cms tier 3a, 15.5% cms tier 3b, 1.7% cms tier 2, and 1.7% cms tier 1. all data are summarized in table 1 . of the general adult patients, 35.7% were female, and their mean age was 46.4 years. of general adult patients included in this study, 50% had no comorbidities; 42.9% had heart disease; 35.7% were 59 years old; 28.6% were immunocompromised secondary to malignancy; 14.3% had pulmonary disease; and 7.1% had other comorbidities. among pediatric patients, 52.5% were female, and their mean age was 3.4 years. of the pediatric patients included in this study, 69.6% had no comorbidities; 34.1% were \1 year old; 8.9% had pulmonary disease; 5.9% had other comorbidities; 4.4% had heart disease; and 0.7% were immunocompromised. at the ccc, the patient population was 50% female and averaged 59.4 years of age. of ccc patients included in this study, 87.0% were immunocompromised secondary to malignancy; 57.4% were 59 years old; 40.7% had heart disease; 20.3% had pulmonary disease; 13.0% had other comorbidities; and 13.0% had no comorbidities. all data are summarized in table 1 . of the general adult patients, 92.9% were intubated for procedures; 7.1% underwent jet ventilation; and no patients underwent ventilation via tracheostomy or bag mask ventilation as the sole form of perioperative ventilation. of the pediatric patients, 47.2% were intubated for procedures; procedure volume and type were collected for march 18 to april 8, 2019, across all 3 sites. during this period, 313 general adult procedures were performed, of which 307 were agps (98.1%). a total of 983 pediatric procedures were performed, of which 925 were agps (94.1%), and 325 ccc adult procedures were completed, of which 236 were agps (72.6%). comparison of 2019 and 2020 surgical volume by week across all 3 sites is summarized in figure 2 . general adult, pediatric, and ccc medical centers experienced 87.8%, 77.1%, and 32% decreases in surgical volume as proper preparation and health system response in the setting of a pandemic involve the implementation of social precautions, medical resource conservation and reallocation, and development of standardized best practices responsive to the situation at hand. also of importance is the protection of all members of the perioperative ecosystem from potential infection. as a result, many states have mandated the suspension of elective procedures for staff safety as well as resource preservation. despite dramatic de-escalation of overall surgical volume, we identified that otolaryngologists remain at high risk when providing essential care during the covid-19 pandemic due to the overwhelming proportion of agps forming their case load. the goal of the present study is to describe the responses of a health care system and ohns departments to inform future preparedness efforts. during the covid-19 pandemic, ohns departments proactively responded to institutional, national, and state mandates by adjusting operative case volumes and types. in the 3 weeks immediately following the ohio state-mandated suspension of all nonelective surgery on march 18, 2020, general adult, pediatric, and ccc medical centers experienced 87.8%, 77.1%, and 32% decreases in surgical volume as compared with 2019, respectively. as seen in figure 3 , surgical case volume decreased significantly across all medical centers following the march 18 mandate. the decreasing number of ohns surgical procedures performed across all medical centers was associated with major state-and hospital-level recommendations (figure 4) . over 700 cases were canceled in a 3-week period ( table 1 ). the greatest impact on case volume occurred at the general adult medical center, where the majority of cases are elective and outpatient procedures. guidelines evolved most rapidly during the third week of the study, during which a brief hiatus in surgery occurred at the general adult medical center while policies were more firmly characterized. case volume at the ccc decreased, though not as significantly as that at the pediatric and adult medical centers, likely due to the comparatively more urgent nature of the oncologic cases at the ccc during this time. of patients who underwent surgery at the ccc during the covid-19 response, 87.0% had an established cancer diagnosis. the nationally mandated cms tier criteria also affected the types of surgical cases that took place across all 3 centers during this time. the majority of procedures performed were cms tier 3a: 71.4% of general adult cases, 71.1% of pediatric cases, and 81% of ccc cases. all cms tier 2 and 1 cases (n = 5) at the ccc and general adult medical center during this period occurred between march 18 and 19, 2020 ( table 1) . state and national mandates affected the volume and nature of cases encountered across all 3 sites. cases performed from march 18 to april 8, 2020, were fewer in number but greater in urgency. agps have been established in the limited existing covid-19 literature to be higher risk for viral transmission due to the potential for viral particles to become aerosolized during mucosal procedures that involve the upper aerodigestive tract. 3, 4 in this study, we defined agp as any procedure involving mucosal surfaces of the nose, sinuses, nasopharynx, oral cavity, oropharynx, larynx, trachea, esophagus, and middle ear/mastoid. during march 18 to april 8, 2019, agps made up 98.1% of all general adult procedures, 94.1% of all pediatric procedures, and 72.6% of all ccc procedures. although the number of overall ohns procedures decreased during this time, the proportion of agps did not change significantly across these 3 medical centers. of the general adult, pediatric, and ccc procedures performed during the covid-19 pandemic and response, 86.8%, 92.4%, and 62.0% were agps, respectively ( table 1) . despite widespread recognition that agps are particularly high-risk procedures for covid-19 transmission, the present study demonstrates that agps remained essential and often unavoidable in the field of ohns during this time. for 3 medical centers in the immediate covid-19 response period, agps represented a substantial proportion of otolaryngologic surgical cases. while agps continued, changes in perioperative management occurred in the immediate covid-19 response period of march 18 to april 8, 2020. preoperative covid-19 testing took place in 7.1% (n = 1) of general adult cases, 9% (n = 13) of pediatric cases, and 6.9% (n = 4) of ccc cases ( table 1 ). the limited amount of covid-19 testing performed during this time reflects the known nationwide shortage of timely and readily available testing. [15] [16] [17] [18] [19] such limitations restricted the ability to efficiently integrate consistent covid-19 testing into the preoperative setting of 3 academic medical centers in the first 3 weeks of the pandemic response. this encouraged the necessary development of a perioperative risk management infrastructure. while ohns society recommendations call for determination of patient covid-19 status prior to surgery, the reality of operationalizing such a requirement is extremely difficult in the face of limited testing and lengthy test turn-around times. 5, 11 additionally, it has been established that patients with covid-19 may be asymptomatic for some time, creating the potential for patients to escape established screening processes and testing. 2 these issues present challenges for ohns departments attempting to standardize risk mitigation strategies during the pandemic response. as testing with faster turn-around times becomes more readily available, there is opportunity for the development of preoperative screening and testing policies for ohns procedures. for example, following the present study period of data collection (march 18-april 8, 2020), with the increasing availability of efficient covid-19 tests, all 3 medical centers developed systemwide standardized protocols for universal preoperative covid-19 testing of all scheduled essential cases. aerosol-protective ppe use during this time also reflects developing perioperative risk mitigation strategies during the immediate covid-19 response period. we defined ppe as eye protection and an n95 mask. on march 23, 2020, the aao-hns recommended that otolaryngologists limit their practice to only urgent or emergent care, treat any patient with unknown covid-19 status as covid-19 positive, and have necessary ppe for all procedures. 23 the aao-hns stated that, based on the experiences of ohns departments during the sars-1 pandemic in 2003, n95 masks are necessary for patients who are undergoing airway surgery and have suspected or confirmed covid-19 positivity. 24 while ohns societal recommendations call for appropriate ppe for all staff during any potential agp, independent of patient covid-19 status, 11 the operationalization of this recommendation was hindered in the earliest stages of the covid-19 response period by a shortage of available supplies. among cases for which ppe data were available at our institutions, aerosol-protective ppe was worn by surgeons in 28.6% of general adult cases, 90% of pediatric cases, and 15.5% of ccc cases. the low aerosol-protective ppe utilization numbers reflect significant nationwide concerns during the immediate covid-19 response period regarding ppe availability resulting from the national shortage. 15, 16 additionally, the establishment of recommendations regarding the use of aerosol-protective ppe selection is a multifactorial process. differences among institutional n95 utilization reflect many contributing variables, including availability of aerosol-protective ppe, procedure type, hospital policy, and surgeon preference. the present study findings reaffirm the need for standardization of perioperative risk management protocols, including aerosol-protective ppe usage, among ohns providers during the pandemic response period. immediately following the present study period of data collection (march 18-april 8, 2020), with the increasing availability of ppe, ohns departments across all 3 centers developed standardized protocols for universal use of aerosol-protective ppe for all agps, regardless of the patient's covid-19 status. data from this phase of the covid-19 response are currently being analyzed and will be reported in a separate publication. definitive airway management data during this time demonstrate a delay in the development of aerosolization risk-minimization strategies in the immediate covid-19 response period. across all 3 sites, intubation was performed in the majority of cases. one general adult case (7.1%) involved jet ventilation, and 23 pediatric cases (16.2%) involved spontaneous ventilation ( table 1) . existing literature on covid-19 transmission has described intubation as a procedure with one of the highest risks of viral transmission. 11 jet ventilation airway management also poses a high risk of viral transmission, as the patients' airways are unobstructed without an endotracheal tube and aerosolized particles have fewer barriers to their spread in a positive pressureventilated open airway. in the present study, 50 pediatric cases (35.2%) involved bag mask ventilation. this form of airway management also exposes surgeon and staff to aerosolized particles through the intermittent covering and uncovering of patient's upper aerodigestive tract throughout a procedure. guidelines for preferred airway management for ohns recommend closing circuits, minimizing bag mask ventilation, and avoiding awake intubation. 5 additionally, researchers discourage thrive, jet ventilation, or positivepressure ventilation without a cuffed tracheal tube. 5 such guidelines on best practices for airway management must be made abundantly clear to ohns and anesthesia departments early on during pandemic response efforts. several barriers exist to the operationalization of standardized protocols for aerosol-protective ppe and covid-19 testing in the setting of ohns. from the experience of ohns departments at pediatric and adult academic medical centers, we identified availability of rapid covid-19 testing and adequate aerosol-protective ppe to be significant limitations to operationalizing society recommendations. large tertiary academic medical centers specifically face a host of challenges to the rapid integration of standardized testing and equipment requirements. the larger the care center, the more that levels of leadership and policy changes are necessary for the operationalization of new initiatives. the integration of preoperative covid-19 testing into perioperative workflows is therefore a complex issue with multiple contributing limiting factors. standardized protocols recommended by ohns societies should reflect the various stages of pandemic response. for example, as fast covid-19 testing and ppe become more readily available through enhanced production and sterilization processes, preoperative covid-19 testing and aerosol-protective ppe for all otolaryngologic procedures should become standards of practice. the present academic medical centers adopted these practices starting april 9, 2020, when testing and ppe were more readily available. preoperative covid-19 testing became a universal requirement for all ohns cases, and recycling policies with check-in/check-out rules for n95 masks were instituted. the present study represents an opportunity for international ohns leadership to better define barriers to operationalization of pandemic response measures and to improve the design of emergency preparedness and response planning. there are several limitations to the present study. ppe information that was not readily available in the electronic medical record was collected retrospectively by asking attending surgeons to recall their ppe usage for each case. additionally, detailed intubation information across all 3 sites was not available to researchers (rapid sequence intubation, preoxygenation status, etc). the academic centers studied herein also present unique geographic considerations. the centers are located directly across from the batelle n95 sterilization processes. we are aware that ready access to these resources has afforded our institutions opportunities. the present study represents an analysis of ohns experiences during the covid-19 pandemic across pediatric and adult academic medical centers. in the present study, we examine perioperative management in the covid-19 pandemic response immediately following the national mandate to suspend all elective cases. the pandemic response led to decreased case volume and a shift in the nature of surgery performed, from elective to nonelective/urgent cases. in the field of ohns, the majority of essential surgical cases remained high-risk agps. during this initial response period, preoperative covid-19 testing was performed and ppe worn by surgeons for a limited number of cases. these practices reflect a misalignment between ohns society recommendations and the reality of hospital operations during a time of international covid-19 testing and ppe shortages. ohns departments responded by creating standardized protocols for universal covid-19 testing and ppe usage. the findings of the present study highlight the need to create gold standards of preoperative screening for covid-19 status, perioperative ppe usage, and airway management for ohns procedures during pandemic response periods. additionally, further definition is needed for essential versus nonessential cases as well as staffing requirements in the field of ohns as the country transitions toward national reopening. hannah n. kuhar, study concept and design, acquisition of data, analysis and interpretation of data, drafting of the manuscript; ashley heilingoetter, analysis and interpretation of data, critical revision of the manuscript for important intellectual content; maxwell bergman, study concept and design, acquisition of data, administrative, technical, and material support; noah worobetz, acquisition of data, administrative, technical, and material support; tendy chiang, study concept and design, acquisition of data, analysis and interpretation of data, critical revision of the manuscript for important intellectual content, administrative, technical, and material support; laura matrka, study concept and design, acquisition of data, analysis and interpretation of data, critical revision of the manuscript for important intellectual content, administrative, technical, and material support. n-cov): situation report-51 early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia integrated infection control strategy to minimize nosocomial infection of coronavirus disease 2019 among ent healthcare workers sars-cov-2 viral load in upper respiratory specimens of infected patients covid-19 pandemic: what every otolaryngologist-head and neck surgeon needs to know for safe airway management. otolaryngol head neck surg pediatric otolaryngology divisional and institutional preparatory response at seattle children's hospital after covid-19 regional exposure. otolaryngol head neck surg clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72314 cases from the chinese center for disease control and prevention epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study clinical characteristics of coronavirus disease 2019 in china safety recommendations for evaluation and surgery of the head and neck during the covid-19 pandemic interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease (covid-19) in healthcare settings aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 non-emergent, elective medical services, and treatment recommendations covid-19: the crisis of personal protective equipment in the us personal protective equipment during the covid-19 pandemic-a narrative review the laboratory diagnosis of covid-19 infection: current issues and challenges testing individuals for coronavirus disease 2019 (covid-19) detection of sars-cov-2 in different types of clinical specimens false-negative of rt-pcr and prolonged nucleic acid conversion in covid-19: rather than recurrence use of chest ct in combination with negative rt-pcr assay for the 2019 novel coronavirus but high clinical suspicion chest ct for typical 2019-ncov pneumonia: relationship to negative rt-pcr testing otolaryngologists and the covid-19 pandemic tracheotomy recommendations during the covid-19 pandemic competing interests: none. funding source: none. key: cord-356041-tc2cumv2 authors: cotrin, paula; moura, wilana; gambardela-tkacz, caroline martins; pelloso, fernando castilho; dos santos, lander; carvalho, maria dalva de barros; pelloso, sandra marisa; freitas, karina maria salvatore title: healthcare workers in brazil during the covid-19 pandemic: a cross-sectional online survey date: 2020-10-09 journal: inquiry doi: 10.1177/0046958020963711 sha: doc_id: 356041 cord_uid: tc2cumv2 brazil is in a critical situation due to the covid-19 pandemic. healthcare workers that are in the front line face challenges with a shortage of personal protective equipment, high risk of contamination, low adherence to the social distancing measures by the population, low coronavirus testing with underestimation of cases, and also financial concerns due to the economic crisis in a developing country. this study compared the impact of covid-19 pandemic among three categories of healthcare workers in brazil: physicians, nurses, and dentists, about workload, income, protection, training, feelings, behavior, and level of concern and anxiety. the sample was randomly selected and a google forms questionnaire was sent by whatsapp messenger. the survey comprised questions about jobs, income, workload, ppe, training for covid-19 patient care, behavior and feelings during the pandemic. the number of jobs reduced for all healthcare workers in brazil during the pandemic, but significantly more for dentists. the workload and income reduced to all healthcare workers. most healthcare workers did not receive proper training for treating covid-19 infected patients. physicians and nurses were feeling more tired than usual. most of the healthcare workers in all groups reported difficulties in sleeping during the pandemic. the healthcare workers reported a significant impact of covid-19 pandemic in their income, workload and anxiety, with differences among physicians, nurses and dentists. coronavirus disease 2019 (covid19) is an infectious disease caused by the novel coronavirus (sars-cov2). the world health organization (who) characterized covid-19 as a pandemic due to the rapid increase in the number of cases. to date, on july 24, 2020, there are more than 15 million confirmed cases of covid-19 worldwide, including 619,150 deaths. brazil has a current critical situation with the second-highest number of cases and deaths in the world. 1 963711i nqxxx10.1177/0046958020963711inquiry: the journal of health care organization, provision, and financingcotrin et al. inquiry unfortunately, an effective vaccine or medicine is not available to treat covid-19, and the most efficient strategies for controlling the covid-19 pandemic are preventive measures and social distancing. however, these interventions make this pandemic a problem more significant than a health crisis with an impact meaningful in societies, politics, and economies as a whole. 2, 3 in this context, the covid-19 pandemic causes concerns to the entire population, especially the health care professionals that are essential and continued to work and maintained patient care, despite the social distance and lockdown adopted in many countries. many of the healthcare workers are in the front line, in close contact with covid-19 infected patients, at high risk of infection and of transmitting the disease to their families and coworkers. 4 in brazil, there is lack of a homogeneous, transparent, and comprehensive surveillance system for covid-19 cases among brazilian health care workers during the covid-19 pandemic. 5 the coronavirus pandemic represents one of the greatest health challenges worldwide in this century, and this has a more devastating effect in third world countries, like brazil. an increase in the workload of healthcare workers during the covid-19 pandemic was reported in other countries, 6, 7 but the financial impact to these professionals were not yet fully reported, especially in brazil, that is facing an economic crisis that appears to be only in its beginning. to prevent infection and transmission of covid-19 by healthcare workers, the who and other national and international public health authorities recommended the use of appropriate personal protective equipment (ppe). however, a shortage of ppe is being observed as a result of the high demand considering the increasing number of cases. 3 in brazil, since the beginning of the pandemic, there is a great concern with the lack of ppe, low adherence to the social distancing measures suggested, and low coronavirus testing, indicating an underestimation of the number of cases in the country. 5, 8 another critical aspect regarding the protection of healthcare workers is the training to deal with covid-19 disease. a study performed with healthcare workers working in the national health service (nhs) across the united kingdom showed that approximately 50% of them did not receive proper training. 4 in addition to the risk of contamination, healthcare workers have suffered high-stress rates. many studies observed high rates of anxiety, stress symptoms, mental disorders, and post-traumatic stress among the healthcare workers during the pandemic. [9] [10] [11] [12] [13] [14] [15] primary care services are slightly superior as compared to traditional health care. in the brazilian health system, the first contact of patients occurs with professionals of the primary care service such as physicians, nurses and dentists. 16 however, with the covid-19 pandemic, there were changes in workload, jobs and general life of these professionals. this way, this study aimed to compare the impact of covid-19 pandemic in the healthcare workers: physicians, nurses, and dentists, regarding workload, income, ppe, training, behavior, feelings, and level of anxiety. this study was approved by the ethics research committee of ingá university center uningá, under number 31054320.6.0000.5220 and all participants agreed to participate in the survey. sample size calculation was performed with a confidence interval of 95% and margin of error of 5%, considering the application of a survey/questionnaire, with the number of physicians (496 422), 17 nurses (2 321 509), 18 and dentists (338 790), 19 in brazil, resulted in the need for at least 385 answers. the sample was randomly selected among the three categories of healthcare workers in brazil. a google forms (google inc, mountain view, ca, usa) questionnaire was elaborated and sent by e-mail and whatsapp messenger (whatsapp inc, mountain view, ca, usa) to 700 healthcare workers. inclusion criteria were: healthcare workers (physicians, nurses or dentists), above 22 years of age, working in the front line of the pandemic in private and public hospitals, healthcare units and private clinics, but not necessarily with direct contact with covid-19 infected patients. healthcare students were excluded from the sample. in the introduction of the questionnaire, the informed consent approved by the human research ethics committee was described, and the subjects were informed about the objectives. the participant's anonymity was ensured. the survey comprised questions about personal information, jobs, income, workload before, and during the pandemic. personal protective equipment (ppe) and training for covid-19 patient care and behavior during the pandemic were also assessed in the questionnaire. a structured questionnaire was developed and tested on a pilot population before its administration in this study. the pilot study was undertaken with 30 healthcare workers previously and randomly selected to clarity the questions and the language used. some words were rewritten with synonyms so that all participants were more likely to understand. the pilot study participants were not included in the main study. the levels of concern, anxiety, anger, and impact of the pandemic were evaluated with a numerical rating scale from 0 to 10. 20 to evaluate the intrarater agreement, one of the questions with yes/no responses was duplicated in the questionnaire. the answers to this duplicate question were compared using kappa statistics. the result showed a coefficient of 0.96, indicating an excellent agreement. 21 the percentage of distribution among the groups about sex, age, years of experience, income and workload information, knowledge about personal protective equipment (ppe), training to treat covid-19 suspected or infected patients, and behavior during the pandemic were assessed with chi-square tests. the one-way anova and tukey tests were used for the intergroup comparison of the levels of anxiety and confidence about work, anger, concerns with family, and the influence of pandemic in the relationship with patients and the work team. statistical analyzes were performed by statistica software (statistica for windows, version 10.0, statsoft, tulsa, okla, usa), and the results were considered significant at p < .05. the response rate was 76.6% since a total of 536 healthcare workers answered the survey: 179 physicians (117 female; 62 males), 170 nurses (151 female; 19 male), and 187 dentists (125 female; 62 male). most healthcare workers were between 31 and 40 years old, and physicians were younger than dentists and nurses. females were the majority in all groups, but more significant in the nurses' group. physicians' respondents had fewer years of experience in the profession than nurses and dentists (figure 1 ; demographics). physicians and dentists had more jobs than nurses before the pandemic. with the pandemic, the number of jobs reduced in all groups, but significantly more in the dentists' group. workload before the pandemic was higher for physicians, followed by dentists, and then the nurses, that presented a significantly lesser workload. the majority of physicians and dentists reported a reduction in workload during the pandemic. the monthly income was higher for physicians, followed by dentists and lesser for nurses. the majority of physicians and dentists reported a change in the monthly income with the pandemic. the income was reduced significantly in all professional groups and maintained the same pattern of difference between the groups ( figure 2 ). almost all healthcare workers knew the who recommendations about the use of ppe. more nurses reported to have only partially the ppe, and more dentists have ppe in their work environment. more physicians and dentists reported that their work has ppe following the who recommendations than nurses, and approximately one-third of the healthcare workers reported that available ppe followed who recommendations. about half of the physicians and nurses were working directly with covid-19 infected patients, but the minority of dentists were. most healthcare workers did not receive training for treating patients suspected and infected from coronavirus ( figure 3 ). nurses were respecting the quarantine more than physicians and dentists. most of the healthcare workers believed that their positioning and behavior influence people around them, but physicians and nurses believed more than dentists. more dentists and nurses thought about giving up their jobs or professions after the beginning of the pandemic than physicians. in all groups, approximately 90% of the respondents reported being afraid of being infected by coronavirus in the clinical or hospital environment, and more than 95% of them changed habits fearing to contaminate their family members. the minority were pressured by family members to quit their jobs. more physicians and nurses were feeling more tired than usual than dentists. most of the healthcare workers in all groups reported difficulties in sleeping during the pandemic (figure 4) . dentists felt less prepared and confident to care for covid-19 patients than physicians, and nurses and dentists were more anxious and stressed with the pandemic. nurses believed that the pandemic will have a more positive impact on their profession and that the experience during the pandemic will have a more significant influence in their professional future than physicians and dentists. the level of concern about infecting family members was high (above 8 of 10) and similar between the three groups. physicians, nurses, and dentists were feeling comfortable similarly in providing patient care during the pandemic. nurses were feeling angrier than physicians and dentists. dentists reported being more anxious when providing patient care during the covid-19 pandemic than physicians. dentists answered that the relationship with the patient was more influenced by the pandemic than physicians and nurses, and the relationship of dentists with their work team was more influenced by the pandemic than physicians (table 1 ). this survey gives a broad outlook of the brazilian healthcare workers' views about the covid-19 pandemic. at first, it is necessary to bring the brazilian context in facing of the pandemic, mainly because the projections about the behavior of the pandemic and people related to it depend not only on scientific knowledge but mainly on quality and reliable data regarding the new disease, 5,22 and currently it is not possible in brazil. there is no clear leadership. 23, 24 since may 15, 2020, brazil does not have a health minister, and the governors and the president of the republic do not follow the same guidelines regarding the implementation of quarantine and medications. effective quarantines and lockdown measures were not even implemented in brazil. while the world scientific community says that only strict social isolation measures can slow the spread of the virus 25, 26 and that there is still no effective pharmacological treatment for covid-19, 27 the brazilian denialist actual president 24, 28 insists on reopening of business offices, schools and churches, he also is against the use of face masks. he makes open advertisements about a medicine whose studies have already been canceled by who because the medicine is not effective against coronavirus. 27 so, in brazil, there have been no federal guidelines for primary health care services in response to covid-19. 28 amid this situation, the healthcare workers do not know whether to follow the who recommendations or the president's denialist recommendations. the national response is, in practice, being guided by developments at the local level, without any semblance of central coordination. 28 healthcare in brazil is the responsibility of the municipalities, using the health unic system (called sus in brazil), including pandemic preparedness. it means that matters such as the provision of ppe, rules on social distancing, and testing arrangements vary. 24 starting from this specific information, it is then possible to begin to affirm that the covid-19 pandemic has burdened unprecedented psychological stress on people around the world, especially the medical workforce. 29 emotional and behavioral reactions that healthcare workers may experience during this crisis (e.g., difficulty sleeping, anger) are also being shared by the entire community. 30 healthcare providers are vital resources for every country, mainly in disruptive periods like this that we are facing. the intensive work drained healthcare providers physically and emotionally, 6 and the entire population trusts in the work of these professionals and hopes that they can carry out their tasks safely and correctly. therefore, it is essential to know the impact that the pandemic has had on health professions to promote strategies to counteract stressors and challenges during this outbreak. studies like this are necessary because mobilization now will allow public health to apply the learnings gained to any future periods of increased infection and lockdown, which will be particularly crucial for healthcare workers and vulnerable groups, and to future pandemics. 31 reporting information like this is essential to plan future prevention strategies. 10 the questionnaire was created using google forms and was sent via a link in a messaging app, e-mail and social media, and is in accordance with iqbal et al. 4 consolo et al 32 also used google forms to create their survey, but they sent it via an anonymous e-mail. in this study, a messaging app was chosen because they are practical and can be accessed quickly by cell phone, which facilitates the healthcare workers' response. most health care workers were in the 31 to 40 years age range (figure 1 ). lai et al 33 found similar results; however, the respondents of chew et al 9 were younger (age range: 25-35 years). this age difference, although not significant, may have been due to the methodology that the surveys were conducted. chew et al 9 survey was conducted directly at the healthcare workers' workplace, while this present study sends on-line questionnaires via messaging app. the greatest part of the respondents were females, and also the females were the majority in all health profession groups, but even so, greater in the nurses' group ( figure 1 ) other authors found similar results. 9,33 also, cross-sectional studies show minimal male participants in this type of study. 32, 34 besides that, women are more willing to participate in researches, 35 and the majority of nursing professionals in brazil are females. 36 the workload was reduced for physicians and dentists during the pandemic (figure 2 ). this reduction was observed because quarantines were recommended in several cities in brazil, and private practices, both for physicians and dentists, were closed for elective procedures. this result also justifies why the dentists and physicians had more jobs than nurses before the pandemic. most respondent nurses work in public health, with a predetermined workload, which has not been changed due to the pandemic. besides that, the income was significantly reduced in all professional groups (figure 2 ). it is known that a pandemic often brings economic recession, and this is what happened during the first quarter of 2020. 37, 38 this result is in agreement with a study about dental practitioners, 32 conducted in italy in the early stages of the pandemic, where all respondents reported practice closure or substantial activity reduction with serious concerns regarding their professional future and economic crisis. previous crises have shown how an economic crash has direct consequences for public 39 and this is no different for healthcare workers. with the increasing cases in brazil, it was expected that job opportunities would also increase, but this was not observed in this study, no new hires were made, which leads to the conclusion that the concern about the future financial impact is great among health professionals. however, this survey was conducted in an earlier stage of the pandemic, and now, in the peak, this scenario may have changed. it can be speculated that physicians and dentists have more ppe following who recommendations than nurses because as most of them work in their private practice, they bought the necessary ppe themselves, while the majority of the nurses work in public health, where ppe is sometimes not adequate (figure 3 ). ppe has gained even more importance in recent times because with the increased demand for use, ppe has become more expensive and scarcer. healthcare workers reported that there was limited access to essential ppe and support from healthcare authorities during the covid-19 pandemic from latin america to europe. 3, 4 some physicians related reusing face masks that are meant to be disposable because their hospitals may run out in the next few weeks. 30 consolo et al 32 related that 77% of the dentists in their study increased the use of ppe during the covid-19 pandemic. in addition to the professionals' inherent concern with ppe, in brazil there is also a concern about the shortage of supplies needed to treat the more severe patients, scarce availability of diagnostic tests and constant tension regarding the collapse of the icu beds available is also observed. 5 to date and exemplify, as of july 22, drugs used to keep icu patients sedated will end in four days on paraná state, in the south region of brazil. 40 about half of the physicians and nurses were working directly with covid-19 infected patients, but the minority of dentists were (figure 3) . a survey conducted in the united kingdom in the first two weeks of april showed similar results, where 95.26% of the healthcare workers had direct patient contact in daily activity. 4 dentists had less contact with infected patients because as already seen, their elective appointments were suspended due to the quarantine. 41, 42 in this scenario, it would be expected that healthcare workers have adequate training to care for patients infected with covid-19, but most healthcare workers did not receive this training. in a study conducted in the uk, half of the healthcare workers also reported that they did not have adequate training. as already stated here, this is an unprecedented event, so many countries, even the richest, are having difficulties in establishing training protocols for healthcare workers. besides that, dentists reported being more anxious when providing patient care during the covid-19 pandemic than physicians ( figure 3 and table 1 ). it is reasonable that dentists feel more anxious to assist patients during the pandemic, as it is known that the contamination rate of this disease is very high in aerosols and droplets, 43, 44 which makes the dental community a relatively high-risk population. however, it is essential to highlight that in the early stages of the pandemic, the brazilian ministry of health launched a national program called "brazil counts on me". 45 this program focused on training and registering healthcare workers to face the coronavirus pandemic. it seems that many professionals did not do this training offered by the government. moreover, a recent survey 29 showed that as compared to the non-clinical staff, front line medical staff with close contact with infected patients showed higher scores of fear, anxiety and depression. this implies that effective strategies toward to improving mental health should be provided to these individuals. 29 healthcare workers often feel fully responsible for the well-being of their patients. they usually face the challenges of work as their duty. 6 this has become more evident in recent times and could reflect in the way that they influence people around them, like respecting the quarantine, as an example. in this study, the majority of the healthcare workers believed that their positioning and behavior influence people around them, and physicians and nurses believed more than dentists (figure 4 ). one can say that physicians and nurses believed they have a more considerable influence on society than dentists due to the nature of their work. people, in general, tend to view physicians and nurses as essential professionals, and they tend to observe them as an example, even outside the work environment. so, it is natural for them to believe that their behavior can influence (in a positive way) the people around them. in all groups, approximately 90% of the respondents reported being afraid of contamination by the coronavirus in the clinical or hospital environment (figure 4) , agreeing with previous reports. 4, 32 this was probably the cause of more dentists and nurses thought about giving up their jobs or professions during the pandemic, although the minority of healthcare workers reported pressure from family members to quit their jobs ( figure 4 ). as already discussed above, several factors must be related to the insufficient training to care for infected patients, lack of adequate ppe, and decreased income. another point that must be taken into account is the amount of healthcare workers deaths by the coronavirus, which is alarmingly high in brazil. in may 2020, which was the early stage of the pandemic in brazil, brazil already surpassed the usa in deaths of nursing professionals by covid-19 and had more deaths than italy and spain combined. 18 most of the healthcare workers in all groups reported difficulties in sleeping during the pandemic (figure 4) . previous pandemic experiences showed that these reactions reflect a sense of fearful waiting, or even terror, about what the future may hold for all humankind while an unfamiliar and uncomfortable quiet fills the halls. 46 this is expected because the own nature of the pandemic and the unique characteristics and unpredictable evolution of the covid-19 disease, like a uniquely high risk of asymptomatic transmission and significant knowledge gaps about the viral pathophysiology 47, 48 can also lead to loss of sleep. recent studies showed that a significant part of the healthcare workers presented symptoms of insomnia. 9,33,34 all these features generate many uncertainties in healthcare workers, but, for the brazilian ones, the challenge is even greater, and the scenario is even scarier. additionally to the already established insufficient scientific knowledge about the new virus and its high speed of dissemination, 49, 50 little is known about the transmission characteristics of the covid-19 in a context of great social and demographic inequality. here in brazil, people are living in precarious housing and sanitary conditions, without constant access to water, in an agglomeration and with a high prevalence of chronic diseases. 22 nurses and dentists were more anxious and stressed with the pandemic, and nurses were feeling angrier than the other healthcare workers evaluated in this survey (table 1) . a recent systematic review showed that anxiety was the most prevalent mental health symptom during the pandemic. 12 studies on the mental health of the healthcare workers during the covid-19 pandemic showed that there are occupational differences regarding affective symptoms among healthcare workers, and nurses showed the highest levels. 34 besides that, nurses may face a higher risk of exposure to covid-19 patients as they spend more time in the front line, providing direct care of patients. 6 dentists, physicians, and nurses had a similar level of concern about infecting family members (table 1 ). it was observed that more physicians and nurses were feeling more tired than usual than dentists. this was expected, because, in addition to all the concerns inherent to the actual moment, these two categories of healthcare workers are dealing directly with infected patients, and there are also other contributing factors related to this: excessive workload and work hours, work-life imbalance, inadequate support, insufficient rewards, interpersonal communication, and sleep privation). 13 although many of the health care workers accept the increased risk of infection as part of their chosen profession, some may have concerns about family transmission or feel pressure to comply because of fear of losing their job, desire to be part of the team, and altruistic goals of caring for patients in need. 30 disruptive periods like this generate uncertainty and fear of the unknown, especially in the professional field. when asked how the covid-19 pandemic could influence the future of their professions, nurses were more optimistic than physicians and dentists. they believed that the pandemic would have a more positive impact on their profession. consolo et al 32 showed that ¾ of the respondent dentists reported that there had been an extremely negative impact on their practice. dentists believed that the relationship with the patient and their staff were more influenced by the pandemic than physicians and nurses (table 1) . this is understandable, as dentists usually have a very close relationship with their patients and staff. since the dental team is considered to be at high risk for covid-19 infection, dental offices had to prepare for providing care, improving communication with their patients, changing the routine of their dental offices, and improving the ppe of their employees and patients. in the long term, patients will notice these changes and will value professionals who care about them. on the other hand, according to consolo et al 32 there is a concern regarding the inability to prevent the end of the pandemic, followed by the impaired economy that might affect future patient turnover and the capability to pay for the dental practice expenses, which include buying further devices and to adequate to new clinical protocols to counteract the spreading of sars-cov-2. the number of jobs reduced to all healthcare workers during the pandemic, but this reduction was more significant for dentists. also, the workload and income reduced to all healthcare workers. almost all healthcare workers were aware of the who recommendations about the use of ppe. nurses related that their work has ppe partially following the who recommendations. most healthcare workers did not receive training for treating patients suspected and infected from coronavirus. physicians and nurses were feeling more tired than usual than dentists. most of the healthcare workers in all groups reported difficulties in sleeping during the pandemic. dentists reported being more anxious when providing patient care during the covid-19 pandemic than physicians. the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the author(s) received no financial support for the research, authorship, and/or publication of this article. karina maria salvatore freitas https://orcid.org/0000-0001 -9145-6334 world health organization. coronavirus disease 2019 (covid-19) epidemiology of covid-19 in brazil: using a mathematical model to estimate the outbreak peak and temporal evolution personal safety during the covid-19 pandemic: realities and perspectives of healthcare workers in latin america covid-19: results of a national survey of united kingdom healthcare workers' perceptions of current management strategy -a cross-sectional questionnaire study covid-19 among health workers in brazil: the silent wave the prevalence and influencing factors in anxiety in medical workers fighting covid-19 in china: a cross-sectional survey impact of covid-19 outbreak on healthcare workers in italy: results from a national e-survey paho director calls for "extreme caution" when transitioning to more flexible social distancing measures a multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid-19 outbreak pandemic fear" and covid-19: mental health burden and strategies covid-19 and mental health: a review of the existing literature how essential is to focus on physician's health and burnout in coronavirus (covid-19) pandemic? cureus mental health and psychosocial problems of medical health workers during the covid-19 epidemic in china prevalence and influencing factors of anxiety and depression symptoms in the first-line medical staff fighting against covid-19 in gansu sus: supply, access to and use of health services over the last 30 years federal council of dentistry. general number of specialist dental surgeons visual analog scale versus numeric pain scale: what is the difference? the measurement of observer agreement for categorical data what is urgent and necessary to inform policies to deal with the covid-19 pandemic in brazil? covid-19 and orthodontics in brazil: what should we do? covid-19 in latin america impacts and effectiveness of quarantine in the outbreak of covid-19: a comparison among pandemics report 9: impact of non-pharmaceutical interventions (npis) to reduce covid19 mortality and healthcare demand a systematic review on the efficacy and safety of chloroquine for the treatment of covid-19 community health workers reveal covid-19 disaster in brazil psychological status of medical workforce during the covid-19 pandemic: a cross-sectional study healing the healer: protecting emergency health care workers' mental health during covid-19 multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science epidemiological aspects and psychological reactions to covid-19 of dental practitioners in the northern italy districts of modena and reggio emilia factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019 prevalence of depression, anxiety, and insomnia among healthcare workers during the covid-19 pandemic: a systematic review and meta-analysis a nationwide survey of psychological distress among chinese people in the covid-19 epidemic: implications and policy recommendations general characteristics of nursing: the socio-demographic profile covid-19: implications for business covid-19 outbreak and its monetary implications for dental practices, hospitals and healthcare workers if the world fails to protect the economy, covid-19 will damage health not just now but also in the future coronavirus: drugs used to keep icu patients sedated end in four days in paraná, says secretary impact of coronavirus pandemic in appointments and anxiety/concerns of patients regarding orthodontic treatment how does the quarantine resulting from covid-19 impact dental appointments and patient anxiety levels? aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 transmission of 2019-ncov infection from an asymptomatic contact in germany provides for the strategic action "brazil counts with me-health professionals", aimed at training and registering health professionals acute stress disorder, depression, and tobacco use in disaster workers following 9/11 presumed asymptomatic carrier transmission of covid-19 evaluation and treatment coronavirus (covid-19) covid-19 -navigating the uncharted how will country-based mitigation measures influence the course of the covid-19 epidemic? key: cord-337785-fwo0r4bb authors: mercer, scott thomas; agarwal, rishi; dayananda, kathryn sian satya; yasin, tariq; trickett, ryan w title: a comparative study looking at trauma and orthopaedic operating efficiency in the covid-19 era date: 2020-10-21 journal: perioper care oper room manag doi: 10.1016/j.pcorm.2020.100142 sha: doc_id: 337785 cord_uid: fwo0r4bb backgroud: covid-19 has led to a reduction in operating efficiency. we aim to identify these inefficiencies and possible solutions as we begin to pursue a move to planned surgical care. methods: all trauma and orthopaedic emergency surgery were analysed for may 2019 and may 2020. timing data was collated to look at the following: anaesthetic preparation time, anaesthetic time, surgical preparation time, surgical time, transfer to recovery time and turnaround time. data for 2019 was collected retrospectively and data for 2020 was collected prospectively. results: a total of 222 patients underwent emergency orthopaedic surgery in may 2019 and 161 in may 2020. a statistically significant increase in all timings was demonstrated in 2020 apart from anaesthetic time which demonstrated a significant decrease. a subgroup analysis for hip fractures demonstrated a similar result. no increase in surgical time was observed in hand and wrist surgery or for debridement and washouts. although the decrease in anaesthetic time is difficult to explain, this could be attributed to a reduction in combined anaesthetic techniques and possibly the effect of fear. the other increases in time demonstrated can largely be attributed to the ppe required for aerosol generating procedures and other measures taken to reduce spread of the virus. these procedures currently form a large amount of the orthopaedic case load. conclusion: covid-19 has led to significant reductions in operating room efficiency. this will have significant impact on waiting times. increasing frequency of regional anaesthesia concurrently with non-aerosol generating surgeries may improve efficiency. the covid-19 pandemic has caused disruption to health care services across the world. the nhs has had to adapt in terms of departmental restructuring, redeployment of staff, service prioritisation and acclimatisation to ever changing ppe guidance 1 . as operating departments across the uk adapt to new ways of working this will undoubtedly have an effect on operation room (or) efficiency. at the time of writing this paper, full ppe was recommended for all procedure involving a high speed device. the patients were anesthetised in the or and not in the anesthetic room. all patients were anesthetised by consultants as trainees and other junior doctors were redeployed to intensive care units and ward-based care of covid patients. to minimise contamination with settling aerosolised particles, all packed implants and instruments are kept in a clean room outside the or. after completion of surgery, the patients were extubated and recovered in the or and not the recovery room. a careful exploration of or efficiency will help understand the new time pressures secondary to covid-19. this is imperative in both planning a response to a possible second surge of covid-19 cases, or a return to planned surgical care, hopefully in the near future. we hypothesise that due to the stringent restrictions imposed by covid-19, or efficiency has reduced. we aim to identify where inefficiencies lie, any contributing factors, and consider how these may be addressed as we scale up operating during a return to planned surgical care. we analysed all trauma and clinically urgent orthopaedic surgeries performed in cardiff and vale university health board during may 2019 and may 2020. institutional review board approval was not required because as per our local trust guidelines, approval is not required for service evaluations and we consider this project to be a service evaluation. informed consent was not applicable as no patient data has been collected for this project. only or timings have been collected. strobe guidelines for observational studies were followed. before the pandemic, we had an 8am to 8pm trauma list everyday (3 sessions), dedicated hand trauma lists twice per week (total 5 sessions), dedicated spine trauma list once a week (2 sessions) and 2 additional trauma lists per week (3-4 sessions). during the pandemic due to redeployment of staff members and overall reduced trauma/ urgent orthopaedic cases, we had 2 all day lists from 8am to 8pm. all trauma / urgent cases including hands and spines were done on this list. data was collected from the electronic or data management systems 2,3 . utilising two or management systems for data collection allowed cross referencing, ensuring maximal data collection. specific timings are routinely added as part of standard procedure by the or team. data for 2020 was collected prospectively and data from may 2019 collected retrospectively. specific times collected were: anaesthetic room entry; commencement of anaesthesia; or entry; operation start (knife to skin); operation end (dressings on); and or exit. from these timings the following could be calculated: data was analysed using spss (ibm, version 25). continuous data was tested for normality using shapiro-wilk's test. all timing data differed significantly from a normal distribution and thus non-parametric analyses were performed using the mann-whitney u test. a total of 222 patients underwent orthopaedic trauma or urgent surgery during may 2019 and 161 during may 2020. all timing data was non-normally distributed and thus medians and interquartile ranges are described throughout. overall, more cases were performed in may 2019 compared to may 2020 (table 1 ). there was a higher proportion of local anaesthetic cases done in 2020 however this was not statistically significant (table 2 ). there was a statistically significant increase in all timings recorded in 2020 except anaesthetic time which showed a significant reduction (table 3) . we performed a sub-group analysis for surgery for neck of femur fractures which also showed similar results (table 4) . a further sub-group analysis of hand and wrist surgery showed that there was no significant increase in surgical time in 2020 (table 5) . a sub-group analysis of debridement and washouts showed the same result (table 6 ). covid-19 has placed an unprecedented pressure on all aspects of the nhs 4 . although the total number of surgical cases has decreased, there has been a constant demand on operating theatres across all surgical specialities 5 . significant changes in or pathways, personal protective equipment (ppe), and altered thresholds for both surgery and general anaesthesia, have led to a relatively unfamiliar or environment. we have confirmed an increase in total or time for our urgent orthopaedic and trauma cases compared with a similar cohort in 2019. the changes introduced for covid-19 operating relate to our observations. all patients are currently anesthetised in the or, with the anaesthetic room left empty. apt reflects a short period of time between entering or and commencing anaesthesia. in 2020, the majority of cases had an apt of 0 minutes. this may reflect a better readiness of the anaesthetic team, often already wearing appropriate ppe, when the patient enters the or. the observed decrease in anaesthetic time is difficult to explain. the shorter anaesthetic time may reflect a reduced incidence of combined general and regional anaesthetic techniques, information that is not routinely recorded on the or systems. addition of regional anaesthesia to general anaesthesia is good for post-operative pain relief but this adds to the time that is spent by the patient in close proximity to the anaesthetist. this may be one of the reasons why a combined anaesthetic was avoided. fear can be a potent motivator and it is also possible that the fear of aerosol generation during intubation may decrease the time taken to perform the procedure 6 . all anaesthetics in 2020 have been performed solely by a consultant anaesthetist as registrars and other junior doctors were redeployed to covid zones. this was not true in 2019, when trauma lists were routinely staffed either by a senior registrar grade, or a more junior registrar with consultant supervision. thus, the reduced anaesthetic time observed overall may reflect a reduction in anaesthetics performed as part of training. we hypothesise that an overall reduction in anaesthetic time appears to be due to a combination of the above factors. the increase in spt likely represents the time necessary to don full ppe. we have improved efficiency in this regard with the surgical team donning during anaesthesia. as soon as anaesthesia is complete the scrub staff commence opening instrument trays. prior to covid-19 these stages were routinely performed during anaesthesia. spt could be reduced by opening instrument trays prior to the commencement of anaesthesia. the trays would need to be covered with a sterile drape during this time and the scrub team would be required to vacate or. however, this would increase cost by using extra drapes, surgical gowns and gloves. st increased for most surgeries. during the study time frame, any orthopaedic procedure utilising a high-speed device, either a drill, burr or saw, was considered an aerosol generating procedure (agp). agps require all staff in or to wear full ppe, including a water-resistant gown, gloves, an ffp3 mask and eye protection (visor or goggles). healthcare workers find ppe very uncomfortable and this can lead to decreased efficiency 7 . fear of aerosolising the contagion whilst using a high-speed device may also contribute to an increase in operating timing. furthermore, the ffp3 masks hinder communication between the surgeon and all other members of the team. for most orthopaedic cases, individually packed sterile implants and screws are used. to minimise contamination with settling aerosolised particles, all implants and instruments are kept in a clean room outside the or. thus, any request for implants or additional instruments is relayed through a number of staff, all impaired by ppe to the "clean" runner outside the or. the implant is then delivered through the same pathway in reverse. subgroup analysis showed that the st did not increase significantly for hand and wrist procedures and washouts. implants for most hand and wrist operations are sterilised on the instrument trays, negating the need for the "ppe relay". similar logic applies to washouts where no implants are required. guidance around standard procedures change regularly as the covid-19 pandemic continues to develop. initially, following any agp, the patient was not moved from the or for 20 minutes 8 , leading to an increase in trt. the or is then cleaned using a chlorinebased solution that is left to work for 20 minutes. a subsequent clean is then completed before the or is ready to use. these measures that were introduced to minimise viral spread significantly add to the tt. procedures performed under local anaesthesia or those that did not generate aerosol did not require additional cleaning steps. there was no significant increase in trt and tt for procedures such as washouts or non-agp procedures performed under local anaesthesia. new guidance for planned surgery, including agps, allow patients to immediately vacate the or once surgery is complete 9 . this will likely reduce the trt and tt. the observed reduction in or efficiency will have major implications when planned surgery is reintroduced. it would be commonplace for a normal all-day elective list in 2019 to include four primary major joint arthroplasties. given the current changes in pathways and observed timings, a realistic projection would be the completion of 2-3 major joint arthroplasties. this would equate to a 25-50 % drop in throughput. it is essential that this is considered in planning future surgical lists. this will be an added burden on the overall waiting lists for planned surgery, an already significant worry for many patients 10 . the nhs and uk government may need to consider providing additional operating capacity to cope with the increase in waiting lists. this will have a significant impact on nhs expenditure. continuing changes to national guidance suggests that only the use of high-speed devices on the respiratory tract are considered agp 1 . this is contradictory to other evidence that exists in the literature regarding aerosol production and the use of high-speed devices 11, 12, 13 . currently, we have chosen to continue using full ppe for orthopaedic procedures involving use of high-speed devices, accepting the reduced efficiency in order to maintain patient and staff safety. we acknowledge the limitations of our study. data for 2019 was collected retrospectively. there are inconsistencies and missing data for both years, but there is no reason to think that these inconsistencies changed between 2019 and 2020. also, the 2 cohorts are not directly comparable as the surgeries were performed in physically different operating rooms in 2019 and 2020 with different surgical staff. the mindset of surgeons, anaesthetists and other members of staff throughout the hospital were also different in 2020 compared to 2019. changes implemented during covid-19 have led to a significant reduction in the efficiency of ors. this will have significant effect on increased waiting times for elective surgery. increasing frequency of regional anaesthesia concurrently with safe non-aerosol generating surgeries may improve operating room efficiency however, further research is needed to prove this. tibial shaft/plafond fracture fixation 7 5 guidance covid-19 personal protective equipment (ppe) [internet]. public health england -coronavirus (covid-19) guidance and support bluespier -clinical software -theatre management systems theatreman -theatre management system emergency surgery during the covid-19 pandemic: what you need to know for practice frequency and severity of general surgical emergencies during the covid-19 pandemic: single-centre experience from a large metropolitan teaching hospital role of anaesthesiologists during the covid-19 outbreak in china barriers and facilitators to healthcare workers' adherence with infection prevention and control (ipc) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis managing theatre processes for planned surgery between covid-19 surges covid-19: infection prevention and control guidance the wider impacts of the coronavirus pandemic on the nhs*. fisc stud infection prevention measures for orthopaedic departments during the covid-2019 pandemic: a review of current evidence covid-19 blood-containing aerosols generated by surgical techniques a possible infectious hazard key: cord-352324-tle14vtm authors: martini, chiara; nicolò, marco; tombolesi, alessandro; negri, jacopo; brazzo, oscar; di feo, daniele; devetti, angie; rigott, irene gertrud; risoli, camilla; antonucci, giuseppe walter; durante, stefano; migliorini, matteo title: phase 3 of covid-19: treat your patients and care for your radiographers. a designed projection for an aware and innovative radiology department. date: 2020-10-23 journal: j med imaging radiat sci doi: 10.1016/j.jmir.2020.08.019 sha: doc_id: 352324 cord_uid: tle14vtm since the spread of covid-19 outbreak, healthcare workers (hcws) have faced an unprecedented and unpredictable situation on the frontlines. the aim of this document is therefore to provide useful and operative recommendations to radiographers who perform imaging services, such as chest x-ray (xr) and computer tomography (ct) scans to three types of patients: negative, suspected or suffering from severe acute respiratory syndrome by coronavirus (sars-cov-2). it is paramount to design two different paths’ layouts for patients entering the radiology department. one path should care for the confirmed and suspected sars-cov-2 patients, whereas the other path should be for negative patients. a setting envisaging two radiographers is highly recommended when managing covid-19 patients. one radiographer fully-equipped with proper personal protective equipment (ppe) should deal with the patient in the scanning or x-ray room. the second one should stay in the console room wearing essential ppe. disinfection plays a crucial role in reducing the risk of disease transmission. moreover, having clear protocols is key to ensure personal safety and avoid cross-infections. taking care of patients and hcws, such as radiographers, is crucial to minimize the risk of disease transmission. within a radiology department, different designed pathways should be taken into consideration both for everyday and epidemic/pandemic healthcare situations. though covid-19 pandemic has been a harsh experience in terms of world health and care systems for patients and health professionals being radiographers among the most involved we must not miss this chance to learn from what happened. there is the need to address wider causes through learning and in order to prevent failures. the distinction between passive learning (where lessons are identified but not put into practice) and active learning (where those lessons are embedded into an organization’s culture and practices) is crucial in understanding why truly effective learning so often fails to take place. suffering from severe acute respiratory syndrome by coronavirus (sars-cov-2). it is paramount to design two different pathways for the patients entering the radiology department: one should include the confirmed and suspected sars-cov-2 patients, whereas another should be used for negative patients. a two-radiographer scenario is highly recommended in managing covid-19 patients. finally, disinfection plays a crucial role in reducing the risk of disease transmission and having clear protocols is paramount to ensure personal safety and avoid cross-infections. taking care of patients and healthcare workers, such as radiographers, is paramount to minimize the risk of disease transmission. within radiology department, different designed pathways should be taken into consideration for common and epidemic/pandemic healthcare situation. though covid-19 pandemic has been a tremendous experience both for world health and care systems even for patients and health professionals, we must not miss the chance to learn from this experience that has involved everyone firsthand. activity to learn from and prevent failures therefore needs to address their wider causes. the distinction between passive learning and active learning is crucial in understanding why truly effective learning so often fails to take place. j o u r n a l p r e -p r o o f phase 3 of covid-19: treat your patients and care for your radiographers. a designed projection for an aware and innovative radiology department. since the spread of covid-19 outbreak, healthcare workers (hcws) have faced an unprecedented and unpredictable situation on the frontlines. the aim of this document is therefore to provide useful and operative recommendations to radiographers who perform imaging services, such as chest x-ray (xr) and computer tomography (ct) scans to three types of patients: negative, suspected or suffering from severe acute respiratory syndrome by coronavirus (sars-cov-2). it is paramount to design two different paths' layouts for patients entering the radiology department. one path should care for the confirmed and suspected sars-cov-2 patients, whereas the other path should be for negative patients. a setting envisaging two radiographers is highly recommended when managing covid-19 patients. one radiographer fully-equipped with proper personal protective equipment (ppe) should deal with the patient in the scanning or x-ray room. the second one should stay in the console room wearing essential ppe. disinfection plays a crucial role in reducing the risk of disease transmission. moreover, having clear protocols is key to ensure personal safety and avoid cross-infections. taking care of patients and hcws, such as radiographers, is crucial to minimize the risk of disease transmission. within a radiology department, different designed pathways should be taken into consideration both for everyday and epidemic/pandemic healthcare situations. though covid-19 pandemic has been a harsh experience in terms of world health and care systems for patients and health professionals -being radiographers among the most involved since the covid-19 outbreak, healthcare workers (hcws) have faced an unprecedented and unpredictable situation on the frontlines. clear and solid instructions are crucial to manage covid-19 patients and protecting hcws. operating in safe conditions is extremely important to minimize the risk of contracting the disease. the aim of this document is therefore to provide useful operative recommendations to radiographers who perform imaging services, such as chest x-ray (xr) and computer tomography (ct) scans, aimed at three kinds of patients: negative, suspected or suffering from severe acute respiratory syndrome by coronavirus (sars-cov-2). the following information may undergo modifications and therefore can be adjusted according to individual department guidelines as covid-19 situation evolves. considering recent evidence, it is necessary to design two different paths for patients who enter a radiology department [2, 3, 9] : one should be followed by confirmed and suspected sars-cov-2 patients, whereas the other should be used by negative patients [15] . this measure aims to keep covid-19 patients as much distant as possible from the non-covid-19 patients. every hospital or department dealing with this situation should arrange its layout accordingly. if the radiology department only has one single entrance, scheduling or postponing the confirmed or suspected covid-19 patients at the end of day might be a suitable solution to perform the examinations safely [7, 13] . besides, it is encouraged to designate and have a clean area, a buffer room and a contaminated area before entering the imaging room [6] . finally, the implementation of proper signs to easily differentiate the two paths is strongly recommended [2] . several hospitals have chosen to avoid the term "covid" on their signs in order not to scare patients. this might be a valuable option to obtain patient's compliance. wordings such as "respiratory" or "fever path" may be used instead [3] . hcws who daily face covid-19 management should work in pairs [8, 13] when it comes to imaging in order to minimize the risk of contamination and the usage of ppe. a tworadiographers scenario is highly suggested when possible [13, 14] . the rationale is to have one radiographer fully equipped (three-level protection standard) with all the ppe dealing with the patient in the scanning or x-ray room, while the other one working on the console wears only essential ppe in a clean zone. although this operation might be time-consuming, wearing the proper ppe is mandatory [19, 20] . if the two-radiographers scenario is not feasible due to staff shortage, a couple of other options might be considered, such as having a team of one radiographer and one hcw, or having one radiographer only. this last one might be the worst-case scenario with a higher risk of contamination. overall, dedicated ct scanners, standing and mobile radiographic units are strongly recommended to avoid disease spreading among patients [2, 3] . a period of at least thirty minutes for each patient should be considered for the exam administration. the fully-ppe-equipped radiographer would be called "radiographer 1" and the essential ppeequipped radiographer would be called "radiographer 2". in the radiology room: • at the end of the procedure, radiographer 1 disinfects the mobile radiographic unit. as mentioned above, the fully-ppe-equipped radiographer would be called "radiographer 1" and the essential ppe-equipped radiographer would be called "radiographer 2". • radiographer 1 takes care of the patient and wears three pairs of gloves, • radiographer 2 remains in the control room and wears two pairs of gloves (in case the colleague needs help) • radiographer 1 places the patient on the ct couch, removes a pair of gloves and performs hand hygiene with alcohol-based gel, • radiographer 1 proceeds to patient centering and moves to an isolated protected area, • radiographer 2 performs the examination, • radiographer 1 wears a third pair of gloves, takes care of the patient on his way out, removes a pair of gloves and proceeds with disinfection of the ct scan unit. a low-dose high resolution protocol is strongly advised for detecting covid-19 [16, 18, 21] due to patient radiation protection concerns [17] , mostly when it comes to patient screening [16] . surface wiping disinfection, floor disinfection and air exchange must be performed daily. every time a radiological exam is carried out, the equipment must be disinfected by wiping the surface j o u r n a l p r e -p r o o f with alcohol 75%. floor disinfection is performed with 1000 mg/l of chlorine-containing disinfectant every four hours at least, or when needed. disinfection sprays must be used carefully because they might infiltrate into the equipment circuits. to facilitate disinfection, it may be useful to cover any electronic part (keyboards, pushbutton panels, touchscreen monitors) with plastic. using negative air pressure in the imaging room could be a suitable option to minimize the risk of disease spreading. otherwise, the recommendation is to keep air temperature in a range between 19 and 21 degrees. furthermore, to gather information about proper disinfectant products, the suggestion is to contact the application specialist in advance. a hospital readiness checklist developed by who-europe is supporting hospital managers and emergency planners in order to ensure a rapid and effective response to the covid-19 outbreak [10] . the step-by-step list is designed to help hospitals to review systems, resources and protocols, and outline specific actions to strengthen responsiveness to covid-19 spread [11] . some of the elements in the checklist include: • surge capacity -the ability of a hospital to expand beyond its normal capacity and to meet an increased demand for clinical care; • adapted human resource management to guarantee adequate healthcare staff capacity; j o u r n a l p r e -p r o o f • accurate and timely communication to ensure informed decision-making, effective collaboration, public awareness and trust; • an operational infection prevention and a control programme to minimize the risk of transmission of healthcare-associated infections to patients, hospital staff and visitors; • an efficient and accurate triage system and a management strategy to ensure adequate treatment of covid-19 patients; • the ability of hcws to recognize and immediately report suspected cases as the cornerstone of hospital-based covid-19 surveillance. a rapidly evolving outbreak requires all hospitals to be able to adapt to a swift increase in demand while continuing to ensure safe environments for hcws. all hospitals need to take precautions against potential interruptions of critical support services and in case of shortage of equipment, supplies and healthcare personnel. in radiology departments, radiographers performing ct scans and x-ray examinations are at a high risk of direct or indirect exposure to pathogens from infected patients [18] . hence it is critical to ensure personal safety and avoid cross-infection. overall, when working under pressure, clear messages are strongly needed and need to be put into practice in order to guarantee and maintain patient safety [12] : non-technical skills (nts) as effective communication, good teamwork and clear leadership will give hcws and patients a better chance of safety. taking care of patients and hcws, such as radiographers, is fundamental to minimize the risk of disease transmission. within a radiology department, different paths' layouts should be designed to separate ordinary from epidemic/pandemic healthcare situations. a two-radiographers scenario is highly suggested to deal with suspected or confirmed patients, alongside proper disinfection to prevent cross-infections. the first radiographer should be fullyequipped with proper ppe and deal with the patient in the scanning or x-ray room. the second one wears essential ppe and remains in the console room. therefore, having solid and clear protocols is key to reducing the risk of disease spreading. though covid-19 pandemic has been an unsettling experience for global health, healthcare systems and also for patients and hcws, we must not miss this chance to learn from such experience that has involved everyone firsthand. activity to learn from and prevent failures therefore needs to address their wider causes. this requires stretching beyond simple diagnostic j o u r n a l p r e -p r o o f activities and sharing lessons taken from incidents, to ensure that such lessons are embedded in practice. the distinction between passive learning and active learning is necessary in understanding why truly effective learning so often fails to take place. j o u r n a l p r e -p r o o f rsna covid-19 task force: best practices for radiology departments during covid-19, m. mossa-basha et al strategies for radiology departments in handling the covid-19 pandemic covid-19): emergency management and infection control in a radiology department is radiology ready? mass casualty incident planning, lee myers et al, acr infection control for ct equipment and radiographers' personal protection during the coronavirus disease (covid-19) outbreak in china radiology department strategies to protect radiologic technologists against covid19: experience from wuhan planning and coordination of the radiological response to the coronavirus disease 2019 (covid-19) pandemic: the singapore experience prokop: radiographers work in pairs for covid-19 scans (www.auntminnieurope.com) infection control against covid-19 in departments of radiology hospital readiness checklist for covid-19" world health organization regional office for europe italian network for safety in healthcare (insh) & international society for quality in health care (isqua) -12th clinical human factors group, a charity working for safer healthcare management of patients with suspected or confirmed covid-19 initial data from an experiment to implement a safe procedure to perform pa erect chest radiographs for covid-19 patients with a mobile radiographic in a "clean" zone of the hospital ward protecting health care workers in the front line: innovation in covid-19 pandemic chest ct for detecting covid-19: a systematic review and meta-analysis of diagnostic accuracy radiographer research in radiation protection: national and european perspectives covid-19 in the radiology department: what radiographers need to know, n. stongiannos et al, radiography summary strategies to optimize the supply of ppe during shortages guidance for wearing and removing personal protective equipment in healthcare settings for the authors provided final approval of the version to be published.the authors declare no conflict of interest.the authors declare that they had full access to all the data in this study and the authors take complete responsibility for the integrity of the data and the accuracy of the data analysis. key: cord-339517-93nuovsj authors: consolo, ugo; bellini, pierantonio; bencivenni, davide; iani, cristina; checchi, vittorio title: epidemiological aspects and psychological reactions to covid-19 of dental practitioners in the northern italy districts of modena and reggio emilia date: 2020-05-15 journal: int j environ res public health doi: 10.3390/ijerph17103459 sha: doc_id: 339517 cord_uid: 93nuovsj the outbreak and diffusion of the severe acute respiratory syndrome-coronavirus-2 (sars-cov-2) and coronavirus disease 19 (covid-19) have caused an emergency status in the health system, including in the dentistry environment. italy registered the third highest number of covid-19 cases in the world and the second highest in europe. an anonymous online survey composed of 40 questions has been sent to dentists practicing in the area of modena and reggio emilia, one of the areas in italy most affected by covid-19. the survey was aimed at highlighting the practical and emotional consequences of covid-19 emergence on daily clinical practice. specifically, it assessed dentists’ behavioral responses, emotions and concerns following the sars-cov-2 pandemic restrictive measures introduced by the italian national administrative order of 10 march 2020 (dm-10m20), as well as the dentists’ perception of infection likelihood for themselves and patients. furthermore, the psychological impact of covid-19 was assessed by means of the generalized anxiety disorder-7 test (gad-7), that measures the presence and severity of anxiety symptoms. using local dental associations (andi-associazione nazionale dentisti italiani, cao-commissione albo odontoiatri) lists, the survey was sent by email to all dentists in the district of modena and reggio emilia (874 practitioners) and was completed by 356 of them (40%). all dental practitioners closed or reduced their activity to urgent procedures, 38.2% prior to and 61.8% after the dm-10m20. all reported a routinely use of the most common protective personal equipment (ppe), but also admitted that the use of ppe had to be modified during covid-19 pandemic. a high percentage of patients canceled their previous appointments after the dm-10m20. almost 85% of the dentists reported being worried of contracting the infection during clinical activity. the results of the gad-7 (general anxiety disorder-7) evaluation showed that 9% of respondents reported a severe anxiety. to conclude, the covid-19 emergency is having a highly negative impact on the activity of dentists practicing in the area of modena and reggio emilia. all respondents reported practice closure or strong activity reduction. the perception of this negative impact was accompanied by feelings of concern (70.2%), anxiety (46.4%) and fear (42.4%). the majority of them (89.6%) reported concerns about their professional future and the hope for economic measures to help dental practitioners. from the beginning of 2020, a new pathogen spread from china to europe and around the globe, and in march 2020, the world health organization (who) had to officialize a pandemic alert. this highly infective new virus, named severe acute respiratory syndrome-coronavirus-2 (sars-cov-2), is a coronavirus responsible of an acute respiratory syndrome, often asymptomatic but potentially lethal [1] , named coronavirus disease 19 . sars-cov-2 has an incubation period of two weeks and covid-19 clinical manifestations mainly include cough, fever and dyspnea [2] , but also anosmia, ageusia and, in few cases, diarrhea have been reported [3] . recently, also cutaneous manifestations have been observed: acral areas of erythema with vesicles or pustules (often after other symptoms) (19%), other vesicular eruptions (9%), urticarial lesions (19%), maculopapular eruptions (47%) and livedo or necrosis (6%) [4] . airborne and direct contact contamination are the major infection pathways of sars-cov-2 [1] . airborne contamination is due to droplets released through exhalation, cough or sneeze [1] ; direct infection instead is due to contact with contaminated surfaces and eye, nose or mouth mucosa [5] . the distance and length of time that particles remain suspended in the air is determined by particle size, settling velocity, relative humidity, and air flow. droplets that are >5 µm in diameter can spread up to 1 m. the nuclei of the droplets which have a diameter <5 µm, create an aerosol which has a diffusion capacity greater than 1 m [6] . moreover, it has been reported that virus spread can also happen in absence of clinical symptoms [7, 8] . the outbreak and diffusion of sars-cov-2 and covid19 have caused an emergency status in the worldwide health system. italy has seen a rapid and massive diffusion of covid-19 and, as of the 7th of april 2020, italy registered the third highest number of covid-19 cases and the second official number of deceased subjects worldwide. the number of italian cases accounted for 9.47% of total cases worldwide, with 183,957 cases. of this sample, 94,067 were currently infected (69.37%), 24,391 (17.99%) had recovered, and 17,127 (12.63%) had died [9] . health care workers are the category with the highest diffusion of the contagion, as the italian national institute of health reports 13,121 cases of infection [9] . due to droplet production and exposure to saliva and blood, dental practitioners are at high risk of contagion during their routine procedures [1, 8, 10, 11] . sars-cov-2 transmission during dental procedures can therefore happen through the inhalation of aerosol/droplets from infected individuals or direct contact with mucous membranes, oral fluids, and contaminated instruments and surfaces [8, 9, 12] . the aim of this study is to investigate dentist behavior and to analyze their reactions in relation to sars-cov-2 pandemic professional restrictive measures due to italian national administrative order of 10 march 2020 (dm-10m20). an online structured survey composed of 40 questions has been sent to dental practitioners in order to investigate dentist behavior and to analyze their reactions in relation to sars-cov-2 pandemic restrictive measures introduced by the italian national administrative order of 10 march 2020 (dm-10m20). the survey focuses mainly on a specific geographical area, the provinces of modena and reggio emilia (the relevant area of our academic institution), one of the areas most involved in the covid-19 epidemic in italy. through the lists of local dental associations (andi -italian dental association, cao -commissione albo odontoiatri) it was sent to all dentists in the area and 40% of them replied. the survey was created using the free-access google forms application and the link to the online survey was sent through an anonymous mailing list to all dentists registered in the dental board commission (cao) of modena and reggio emilia district. participants provided their informed consent before completing the survey. data collection took place in the time period from 2 april to 21 april 2020. the structured survey was composed of 40 questions, divided into five sections (table 1) . section 1 included questions aimed at gathering demographic data (age and gender), and assessing the type of activity and level of experience of the respondents. section 2 was composed of questions assessing whether practitioners closed their dental practice or reduced their clinical activity following the outbreak of the emergency, whether this occurred before or after the restrictive measures introduced by the italian government in 10 march 2020 (dm-10m20), which modalities were used to inform patients, and whether patients understood the reasons for the closure/activity reduction. section 3 was composed of questions investigating the impact of the covid-19 outbreak on dental practice, which were the most common protective personal equipment (ppe) used before the covid-19 outbreak and whether habitual ppe had been changed after the outbreak. section 4 assessed practitioners' direct or indirect contact with covid-19, the feelings and emotions experienced while thinking at the covid-19 outbreak, the dentists' perception of infection likelihood for themselves and patients. it also assessed the presence of symptoms of anxiety by means of the generalized anxiety disorder 7-item (gad-7) scale [13] , which is commonly used to assess the presence of general anxiety symptoms across various populations and settings. it consists of seven items assessing how often, considering the previous two weeks, individuals have been bothered by covid-19 related problems: (1) feeling nervous, anxious, or on edge; (2) being able to stop or control worrying; (3) worrying too much about different things; (4) trouble relaxing; (5) being restless; (6) becoming easily annoyed or irritable; (7) feeling afraid as if something awful might happen. finally, section 5 of the survey assessed the practitioners' main concerns about the professional future, which measures they considered as helpful to support practitioners during and after the emergency, which protective measures they intended to use in the future to prevent the risk of infection for themselves and patients, and whether they believed the emergency situation could lead to improvements. given the nature of our survey we computed descriptive statistics for most of the questions. for each question, we computed the percentage of respondents that gave a particular answer with respect to the number of total responses to the question. for the questions "how worried are you of contracting covid-19 during your clinical activity?", "in your opinion, how likely is it that a patient can contract covid-19 during a dental service?", "how much do you think your patients are worried of contracting covid-19 during a dental service?" and "how worried are you for your professional future?", response categories were assigned a score ranging from 0 to 4 (0 = "not at all"; 4 = "extremely"). for the question "which of the following emotions (fear, anxiety, threat, concern, sadness, anger) do you feel when thinking about covid-19?" response categories were assigned a score ranging from 0 to 4 (0 = "i do not feel it", 4 = "i feel it intensely"). for each of the 7 items of the gad-7 scale, we assigned the scores 0, 1, 2, and 3 to the response categories "not at all," "several days," "more than half the days," and "nearly every day", respectively. the scores for each item were then summed to obtain a total score ranging from 0 to 21. scores from 0 to 4, from 5 to 9, from 10 to 14 and from 15 to 21 are indicative of minimal, mild, moderate and severe anxiety, respectively. we computed the pearson correlation coefficient to investigate the association between general anxiety level, as indexed by the gad-7 general score, level of concern for the professional future, level of concern of contracting the covid-19, perceived patient's likelihood of contracting the infection, and the level of concern of contracting the infection attributed to the patient. we also investigated the association between the impact of covid-19 on dental practice and level of concern about the professional future. furthermore, to assess potential differences between age groups, we submitted the mean scores obtained in the questions reported above and the gad-7 score to a one-way analysis of variance (anova) with age group (<35 years, 35 and 55 years, and >55 years) as a between-participants factor. statistical analyses were performed using the spss version 26.0 statistical software. the survey was sent to 874 practitioners and 356 of them completed it. with this sample size, the margin error at a 95 level of confidence is lower than 5%. of the respondents, 60.4% were male and 39.6% were female. the majority of participants were aged between 35 and 55 (48.6%); 34.8% were over 55 years old, while only 16.6% of them were under 35 years old. consequently, most had been working for more than 15 years (61.2%), 28.4% had been working for 6-14 years, while 10.4% had been working for less than 5 years. a large number of dentists (226; 63.5%) reported working 30-40 h or more per week, while the remaining 130 (35.5%) reported working less than 30 h per week. the majority of the compilers were practice owners (64.3%), while the others were private (34.6%) or public (1.1%) structures employees ( table 2) . all of the respondents closed or highly reduced their activity to urgent procedures, 38.2% before and 61.8% after the dm-10m20. patients were contacted mainly by phone (95.8%), only 4.2% through social channels or websites. most of them understood the reasons for the closure of dental practices or for the reduction in clinical activity (93%). a high percentage of patients (92.7%) canceled their previously-taken appointments after the dm-10m20. a large number of dentists (342, 96.1%) guaranteed telephone availability for dental emergencies. almost the totality of compilers (321, 90.2%) reported the willingness to personally take care of emergency situations. when an emergency occurred, 45% of respondents took care of it alone, and 55% of them were helped by an assistant. approximately 70% of practice owners reported an average number of 6 to 15 patients a day before the pandemic, that shifted to 0 to 5 a week in 90% of the sample. each practitioner asserted a routinely use of the most common protective personal equipment (ppe), such as gloves, masks, disposable gowns and protective glasses before the sars-cov-2 pandemic (table 3) . however, they also admitted that they had to increase the use of ppe or to modify kinds of ppe during the covid-19 pandemic (77%), or that they were still awaiting directives to do so (12.9%). only 10% have not changed their ppe, probably because they were already applying maximal ppe before the pandemic. since the beginning of coronavirus pandemic, 86% of the respondents reported difficulties in finding ppe, and 57.9% reported problems in the delivery time of dental materials. most of the interviewees (279, 78.4%) report having held information sessions dedicated to the staff on the correct use of ppe, 13.2% did not, but 8.4% said that they will soon. fortunately, only four (1.1%) respondents contracted covid-19, while 68.6% knew at least one person who has been infected. in total, 20.8% did not know anyone who has contracted the disease. for 74.4% of the respondents, covid-19 was having a highly negative impact on their professional activity (mean (m) = 3.7, standard deviation (sd) = 0.7) and the majority of them (89.6%) was quite concerned about their professional future (m = 2.7, sd = 1.02), mostly due to the uncertainty about the end of the emergency situation. the level of concern about the future was positively correlated to the reported level of negative impact (pearson's correlation index: r = 0.17, p < 0.001). dentists reported being quite concerned of contracting covid-19 during their clinical activity (m = 2.52, sd = 1.02). more precisely, 20.2% were extremely concerned, 29.2% were very concerned and 35.7% quite concerned. only 12.6% were little concerned while 2.2% were not concerned at all. 38.2% of them believed patients' concern of contracting the infection during a dental visit was quite high (m = 1.73, sd = 1.06), even though they overall considered the patient's likelihood of infection as low (m = 1.25, sd = 1.11) ( table 4 ). table 4 . dentists' concern of contracting covid-19, perception of the infection likelihood for patients and level of concern attributed to patients. when thinking about covid-19, only 4.2% of the respondents reported to experience fear intensely, while the majority reported to feel lightly (41%) or moderately (23.9%) scared. only 6.2% reported to experience anxiety intensely, while the majority reported to feel lightly (37.4%) or moderately anxious (23.6%). only 16% reported to experience concern intensely, while the majority reported levels of concern ranging from light (26.4%) to moderate (29.8). only 12.6% of respondents felt intensely sad, while 25.3% did not experience sadness at all. anger was experienced in an intense way by only 9.3% of respondents, while 44.1% of respondents did not experience anger at all. overall, these results indicate that thinking about covid-19 mostly caused concern (m = 2.23, sd = 1.11) ( table 5 ). the mean gad-7 score was 6.56 (sd = 4.48) indicating an overall mild level of general anxiety. more precisely, 42.7% of the respondents showed minimal anxiety (score 0-4), 33.3% showed mild anxiety (score 5-10), 15.2% showed moderate anxiety (score 10-14), while 8.7% showed a score indicative of a severe level of anxiety (score [15] [16] [17] [18] [19] [20] [21] . the gad-7 score was positively correlated to the level of concern about the professional future (r (356) = 0.32, p < 0.001), the level of concern of contracting the covid-19 shown by the dentists (r (356) = 0.26, p < 0.001), the perceived patient's likelihood of contracting the infection (r(356) = 0.23, p < 0.001), and to the level of concern attributed to patients (r(356) = 0.28, p < 0.001). the one-way anova showed a main effect of age group for perceived patient's likelihood of contracting the infection (f 2,353 -statistic = 1157, p < 0.001), and reported levels of concern about the professional future ( to the question "during clinical activity, which measures do you use to prevent covid-19 infection?", dentists replied highlighting a good knowledge of what is reported in the most recent indications from the literature. this question could be answered by placing multiple preferences: the highest frequency of answers concerned "reduction of number of patients in the waiting room" (87.1%) and "telephone screening/anamnesis to exclude covid-19 related symptoms" (86.5%). less frequently, "environment aeration" (77.5%), "use of ppe" (73.3%) or "disinfectant agents and surgical mask supply to all patients while waiting in waiting room" (68.8%) were indicated. other indications, provided by medical organizations and media-"environment sanitation" and "telephone screening/anamnesis to identify possible critical cases"-received 65.5% and 43.5%, respectively. the answer "body temperature measurement" received the lowest frequency of preferences (21.3%). the same question, repeated at the end of the questionnaire with reference to future behaviors, highlighted percentage variations: "reduction of number of patients in the waiting room" (84.8%), "use of ppe" (82.6%), "telephone screening/anamnesis to identify possible critical cases" (78.4%), "environment aeration" (75.3%), "environment sanitation" (74.7%), "disinfectant agents and surgical mask supply to all patients while waiting in waiting room" (66%) and "body temperature measurement" (35.7%). to the question "which aids do you think could help dental professionals during covid-19 pandemic?", for which two preferences could be expressed, the dentists replied indicating "economic relieves from italian government" (65.7%), "social security institutions support and subsidy" (44.1%)," economic relieves from dental associations" (32.1%) and "improvement of communication with patients" (8.1%). the answers to the successive question, which analyzes the category aid measures to be adopted after the emergency, maintained almost the same order of frequency in the answers. there was a decrease in the percentage for "social security institutions support and subsidy" and 9.6% for "bank account support", which was not represented in the answers to the previous question. in descending order, the percentages were: "economic relieves from italian government" (73.9%), "economic relieves from dental associations" (31.2%), "social security institutions support and subsidy" (26.1%), "improvement of communication with patients" (16%) and "bank account support" (9.6%). greater importance was given to communication campaigns with patients. the last question asked "which improvements do you think can result from the covid-19 emergency?" and multiple answers could be indicated. most of the interviewees considered "prevention procedures standardization" very important (66.9%) and a high percentage answered that there will be a "professional rhythm slow down" (36.8%) and "improvement of communication with patients" (23%). lower preferences resulted for "no improvements" (19.9%) and "stabilization of relationship with dental associations" (16.9%). dentists considered the "reduction of dental practices competition" irrelevant, which received the smallest number of indicated preferences (5.1%). since the sars-cov-2 pandemic, other surveys have been proposed by other international institutions, aimed at measuring the impact of this turmoil on dental professionals. one inquiry was performed in israel [14] , a nation where the impact of the covid-19 has been much more contained than in italy. another survey, form saudi arabia [15] , had a more global reach: 650 dentists spread out in many countries, mostly in pakistan, india and malaysia, where the dental setting might differ from western standards and where the majority of the colleagues are employed in public settings. our survey is exclusively focused on a specific geographical area, the province of modena and reggio emilia (the pertinent area of our academic institution) in northern italy, one of the most involved areas in the covid-19 outbreak in italy and, perhaps, in europe. it reached out to 874 dentists, through the lists of the local dental associations (andi, cao), and 40% of them responded. the questions on the survey were developed after reviewing pertinent literature and international guidelines [10, [14] [15] [16] . the questionnaire was designed in the italian language and comprised of questions pertaining to socio-demographic characteristics, dentists' attitudes and perceptions toward covid-19 and infection control in dental clinics. moreover, the investigation was also focused on the psychological impact and changes on the everyday dental practice. the survey was a structured multiple-choice questionnaire divided into four sections. section 1 section centered on practice and owner socio-demographical characterization: age, gender, years of service, number of operative units, number of dental assistants and collaborators. among respondents, the majority were male (60.4%) and private practice owners (64.3%), working on average in 2-3-unit offices, whilst the other part were private or public structures employees. almost half of the sample was aged between 35 and 55. young dentists, aged 35 years old or less, accounted for 16.6%. section 2 is focused on the actual and real impact of the covid-19 outbreak on dental practice nowadays: the totality (100%) of owners closed their dental offices (38.2% before the dm-10m20 and 61.8% after), assuring telephone availability in 96.1% of cases. it was not only the colleagues that were afraid of the situation, but also patients were probably aware of the risks in the dental office, since 92.7% reported cancellation directly from patients, just before the dm-10m20. as a matter of fact, three-fourths of the interviewees reported that there has been an extremely negative impact on their practices. section 3 is about the adaptive behavior to the pandemic outbreak and risk perception. this has been evaluated through the need for ppe implementation, the need for informative sessions about their correct utilization and through a generalized anxiety disorder-7 test (gad-7). sars-cov-2 has been demonstrated to remain aerosolized for 3 h after contamination and on plastics and stainless steel for up to 72 h [17] . this makes the dental community a relatively high-risk population [1] . there are practical guidelines recommended for dentists and dental staff by the centers for disease control and prevention (cdc), the american dental association (ada) and the world health organization to control the spread of covid-19 [18] [19] [20] . like with other contagious infections, these recommendations include personal protective equipment, hand washing, detailed patient evaluation, rubber dam isolation, anti-retraction handpiece, mouth rinsing before dental procedures, and disinfection of the clinic. in our survey, the vast majority performed a telephonic triage the day before the appointment, along with a full-body protection during the operative procedure. the necessity to reduce the number of incoming patients in the waiting room was held important by 87.1% of the colleagues. the way patients are received in the dental office has been modified as well, since 68.8% is providing patients with surgical mask and hand sanitizer upon arrival. surprisingly, only a small minority is considering the body temperature check upon entrance as a valid method for critical case detection notwithstanding the low cost and the good reliability of this procedure. it must be remembered that the current approach to covid-19 is to control the source of infection; use infection prevention and control measures to lower the risk of transmission and provide early diagnosis, isolation, and supportive care for affected patients. based on relevant guidelines and research, dentists should take strict personal protection measures and avoid or minimize operations that may produce droplets or aerosols [21] . only 1.1% of the practitioners referred positivity to covid-19, whereas 68.6% has at least one patient/collaborator/friend that tested positive, so this pandemic is definitely a reality in our settings. it is of interest to note that the majority of practitioners fear infection, but only a minority group is concerned about the possibility that their patients might acquire the infection. the fear of contracting covid-19 from a patient is strongly associated with elevated psychological distress. similar results are reported in a survey conducted in israel: dentists' responses to prevention measures seem better for personal protective equipment, disinfection and sanitation procedures than for measures applied to patients [14] . this could mean that the majority of the interviewees are more concerned about protecting themselves than their patients. measuring anxiety by the means of self-report questionnaires is useful [22] and has been already performed among dental practitioners and patients [23] . in this survey, fear, anxiety, concern, sadness and anger are commonly reported, but fortunately only a minority group reported intense feelings of anger (9.3%) and, as resulting from the gad-7 scale, inability to manage anger and anxiety (10.3%). overall, only 8.7% of the respondents showed a score to the gad-7 scale indicative of a severe level of anxiety. the overall level of general anxiety can be considered as mild (mean gad-7 score was 6.56, sd = 4.48). these data are consistent with those reported by another survey in israel in which elevated psychological distress was found in 11.5% of the sample [14] . what is most expected is the receipt of prompt support from both the national government and the physicians' social security institution (enpam-ente nazionale di previdenza ed assistenza). informative communication for patients is believed to be important to let them know how problems in dental offices are being ameliorated. section 4 of the essay is about the perception of our professional future. a pandemic often brings economic recession, and this is what happened during the first quarter of 2020. this pandemic will have an impact on every aspect of our global economy. some analysts have predicted that-owing to the measures enacted to stop the spread of this pandemic, such as large-scale quarantines, travel restrictions, and social-distancing measures-there will be a sharp decrease in consumer and business spending capacity until the end of 2020 and part of 2021 [24] . this will ultimately lead to a global recession. as health-care professionals, dentists have responsibilities and should explore long-term measures to avoid recrudescence and future outbreaks. this situation will be challenging for medicine and dentistry, and the financial impact on dental practices will be experienced in both the shortand long-term. it is important to note that the vast majority of the respondents reported apprehension about the professional future. what is alarming the most is the inability to prevent the end of the pandemic, followed by the impaired economy that might affect future patient turnover and the capability to pay for the dental practice expenses. moreover, one third of the interviewees expressed concern about the need to buy further devices and to adequate to new clinical protocols to counteract the spreading of sars-cov-2. this will probably result in some physicians and dentists going out of business, especially the oldest (and more experienced) ones, and might also prevent new generation dental practitioners to get into business. dentists aged between 35 and 55 years were the most concerned about their professional future. what colleagues expect as a support to adequately face their professional future is the receipt of benefits from the italian government and social security institutions, as well as from italian dental associations (cao, andi). the government will pay laid off staff for a period; however, this is only a portion of most doctors' overall costs. the dental private sector is already facing a financial crisis and this is expected to worsen, primarily due to the need of providing a better and safer working environment to our patients, staff, and ourselves. this will potentially increase business overheads and reduce profit margins even further. alternatively, professionals could start to conceptualize new paradigms and a new vision about their profession. telehealth has become an essential tool for providing care to patients [10] . it is already allowing physicians to connect with patients sparing costs and time. its use will definitely exponentially increase over time and it might become an interesting tool for dental care providers as well. dentists and oral surgeons could integrate it into their clinical practice. potential uses include preoperative and postoperative visits as well as follow-up controls, thus reducing patient coming and going in our offices. this innovation has actually received good acceptance from patients, government and health-care providers in the u.s. and can represent a new business opportunity for our colleagues [25] . the general feeling among our respondents is such that their profession will change for a long time: harsh preventive measures are felt to be necessary in the near future, such as access limitation to the waiting room, more adequate protection devices, decontamination of the working environment, but still, the body temperature check, upon patient arrival, is considered necessary only by a minority of colleagues. the answers collected by our survey are quite consistent with general recommendations provided to dentists and to other health-care providers world-wide [10, 16, [18] [19] [20] [21] . patients should be asked about their health status and any history of recent contact or travel; patients and their accompanying persons should be provided with medical masks upon entry to the clinic. patients with body temperature >37 • should be registered and referred to designated family doctors. if a patient has been to any epidemic regions within the past 14 days, quarantining for at least 14 days is recommended. at last, our survey is focused on the perception of the professional improvement: what could positively change as a consequence of the pandemic. only less than 20% believe that no improvements will occur. the majority believes that some ameliorations will arise: new standardized preventive procedures, a slow-down in the working-schedule, improvements in communicating with patients and even a diminished competition between dental practices. it is possible to foresee a better awareness about new and strict preventive protocols among dentists as a positive achievement for the category. the aids pandemic resulted in acceptance of solutions that revolutionized the standard of care throughout medicine. prior to hiv/aids, dentists did not commonly wear gloves, masks or eye protection [26, 27] . in the late 1980s and early 1990s, in an attempt to protect health care workers, cdc proposed guidelines to reduce exposure to blood-borne pathogens such as hiv and hepatitis b [28] . dentistry curbed this change at every step but these standards of protections are widely accepted and used nowadays. what will come of this pandemic? commercial air purifiers and air exchange devices are also being explored for dental settings [29] . creating negative pressure operatories may seem a drastic and expensive approach now, but it may become a normal standard a few years from now. despite the findings discussed above, it is important to stress that this survey had a major limitation, due to the fact that our investigation regarded a relatively small area in north italy-the province of modena and reggio emilia-and this prevents us being able to generalize our results. the covid-19-related emergency condition is having a highly negative impact on dental practices in the area of modena and reggio emilia-the area of our academic institution. all of the dentists that completed the survey reported practice closure or reduction, a high level of concern about the professional future and the hope of economic funding for all dental practitioners. concerns related to professional activity were accompanied by severe anxiety levels for a small percentage of respondents. this essay must be contextualized with the geographical area, northern italy-one of the most involved in terms of pandemic-and was delivered during the most critical period of the pandemic. this might have brought a sort of bias in the psychological profiling: probably more pessimistic answers could be anticipated. importantly, some improvements are expected to be derived from the actual emergency situation, such as the adoption of standardized preventive procedures, a slow-down in working-schedule, and even diminished competition between dental practices. transmission routes of 2019-ncov and controls in dental practice epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study anosmia and ageusia are emerging as symptoms in patients with covid-19: what does the current evidence say? classification of the cutaneous manifestations of covid-19: a rapid prospective nationwide consensus study in spain with 375 cases surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (covid-19) the severe acute respiratory syndrome coronavirus-2 (sars cov-2) in dentistry. management of biological risk in dental practice clinical features of patients infected with 2019 novel coronavirus in being a front-line dentist during the covid-19 pandemic: a literature review covid-19 transmission in dental practice: brief review of preventive measures in italy coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine high expression of ace2 receptor of 2019-ncov on the epithelial cells of oral mucosa persistence of coronaviruses on inanimate surfaces and its inactivation with biocidal agents a brief measure for assessing generalized anxiety disorder covid-19 factors and psychological factors associated with elevated psychological distress among dentists and dental hygienists in israel fear and practice modifications among dentists to combat novel coronavirus disease (covid-19) outbreak cross-infection and infection control in dentistry: knowledge, attitude and practice of patients attended dental clinics in king abdulaziz university hospital aerosol and surface stability of sars-cov-2 as sompared with sars-cov-1 clinical management of severe acute respiratory infection when covid-19 is suspected centers for disease control and prevention. cdc recommendation: postpone non-urgent dental procedures, surgeries, and visits the american dental association. coronavirus frequently asked questions the american dental association. ada recommending dentists postpone elective procedures dental phobia in dentistry patients self-assessed bruxism and phobic symptomatology the socio-economic implications of the coronavirus and covid-19 pandemic: a review the future of our specialty: is oral and maxillofacial surgery in jeopardy? gloves: some unknowns evaluation of the permeability of latex gloves for use in dental practice occupational exposure to bloodborne pathogens: osha-final rule respiratory protection against bioaerosols: literature review and research needs funding: this research received no external funding. the authors declare no conflict of interest. key: cord-333554-0wlgg450 authors: curzen, nick title: an extended statement by the british cardiovascular intervention society president regarding the covid-19 pandemic date: 2020-04-16 journal: interv cardiol doi: 10.15420/icr.2020.10 sha: doc_id: 333554 cord_uid: 0wlgg450 nan and uncertainty about how we will be able to maintain the highest standards of clinical care. as a group, our reaction to the challenges thrown at us by needs to be reasoned, calm, positive and energetic. as before, the hottest issues remain: • what is the appropriate nature and application of ppe? • are there some categories of patient who should not be offered treatment that we would normally consider (e.g. out of hospital cardiac arrest ventilated patients) or who should be offered the presidents of bcs and bcis have released a joint statement of support and advice to our members, and have contributed to an nhs england statement about recommendations for ongoing cardiology activities. 2,3 consistent with these guidelines, bcis recommends that all our members follow some general principles, outlined here. • members should adopt, and comply with, national and local policies for testing, self-isolation and ppe compliance (see below). • members should develop local plans for possible scenarios in which their cath lab cannot provide emergency cover, whether due to staff absence or inadequate facilities/resources. we suggest that clinical leads/senior cath lab staff have discussions across local networks regarding potential cross cover for emergency patients between local centres, in case this becomes necessary. • be cautious about the implications of changing treatment pathways as a reflex response to this crisis. to this end, the nhs england guidance continues to recommend primary pci for stemi and angiography with a view to revascularisation for all non-st-elevation mi (nstemi) patients, except perhaps the lowest risk group. this advice is based upon the assumption that the access to the cath lab and its specialised staff will remain stable. clearly, in circumstances in which lab access is compromised by staff shortage or case load, hard alternative choices will need to be made. but the fact is that primary pci for stemi is associated with the best outcome for these patients, with the lowest mortality, fewest complication rates and shortest hospital stay. the same is true of a high-risk nstemi case. making a rapid diagnosis using angiography and providing effective revascularisation, as appropriate, is again associated with a shorter admission, with a much lower reinfarction and subsequent revascularisation rate. by contrast, deferring nstemi patients may the early variation in practices around the uk for ppe at all stages of patient contact was pretty alarming at the beginning of this crisis, but is becoming more uniform as nhs england catches up with the rapid spread of the virus and lessons learned from other countries. all patient exposure should now be associated with some form of ppe according to the latest national advice, a policy welcomed almost universally. however, for bcis members, it is the optimal ppe for cath lab procedures, especially primary pci for stemi, that has raised most anxiety and contention. table 1 . this guidance adopts an approach in which the ppe strategy is ward environments are covered within the phe guidance. for cath lab procedures the phe guidance can be applied to the individual case by the assessment of the senior clinician, together with senior cath lab staff, taking into account (a) the likelihood that the patient has the virus and (b) the chance the procedure will be agp. we will all continue to face the challenges offered up to us by this for patients admitted to the lab already intubated or where there is felt to be a very high risk of arrest with prolonged resuscitation, then all those in the lab to wear type 2 ppe. for other situations the cath lab, when deemed low risk of agp, can be regarded as an inpatient area or operating theatre with suspected or confirmed covid-19 cases, and type 1 ppe is recommended for all those with direct patient contact. british cardiovascular intervention society. statement by bcis regarding the covid-19 pandemic british cardiovascular intervention society. cardiology services during the covid-19 pandemic clinical guide for the management of cardiology patients during the coronavirus pandemic key: cord-352233-avov4yxv authors: liu, antonio title: philanthropy and humanity in the face of a pandemic – a letter to the editor on “world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19)” (int j surg 2020; 76:71-6) date: 2020-05-12 journal: int j surg doi: 10.1016/j.ijsu.2020.05.012 sha: doc_id: 352233 cord_uid: avov4yxv nan 1 dear editor, i read with great interest the article by sohrabi et al. on lessons we learnt from this outbreak crisis [1] . since the very beginning of the covid 19 pandemic, the health care industry has been forced to confront an invisible enemy -the shortage of personal protected equipment (ppe). the enormous pressure and struggles to secure sufficient and appropriate ppe for the front -line workers in order to provide safe and compassionate care to the covid patients inevitably add to the tremendous difficulty we face in combating this aggressive and vicious disease, not only at home in the united states, but also resonating around the world. with no clear indication or assurance of assistance coming from the government, many institutions and organizations have ramped up their philanthropy effort to secure proper equipment and protective gears for their staff. as the medical director for two primary stroke centers at downtown los angeles, i get to experience first-hand the psychological and physical impacts of the perceived shortage of ppe have on our front-line workers. my call of duties to help tackle this challenge strengthens every day when i witness my colleagues selflessly caring for their covid patients with inadequate ppe. hospitals i worked at had already worked tirelessly to secure the necessary equipment and protective gears from their supply chains as this pandemic unfolds on our shores. however, most of these supplies are manufactured and imported from china and the whole world has turned to china competing for ppe. this competition is further complicated by the fact that the chinese manufacturing plants have been halted for months to combat the disease. in retrospect, when this pandemic first hit china, social media platform becomes a useful tool for us to connect with the rest of the world and stay informed about the current situation. in late january, we started taking part in several donation chat groups on facebook and wechat to solicit ppe to donate to our colleagues in china and other asian countries, and those efforts turned out to be fruitful. our participants include physicians, dentists, nurses, other health professionals, as well as entrepreneurs from private and public sectors all around the world. when covid hits home not long after, we decided to swiftly reverse the direction of donation and the idea of "reverse engine, full throttle" was born and announced to our donation group. when words spread rapidly among the group participants and beyond, responses to our call for ppe donation started pouring in. the first significant lead came from an asian entrepreneur donor who is a friend of a researcher working in a well-known research institution on the east coast. the researcher is a member in our donation chatgroup. donor pledged over 1,000,000 surgical face masks and equal amount of n-95 face masks to every hospital in the united states on a first-come, first serve basis. quite frankly, it sounded too good to be true initially. nonetheless, i decided to jump on the bandwagon and give it a shot. i promptly connected with the charitable foundation and administrations from our hospitals and they all expressed interests. after careful vetting and involvement of legal department from the hospitals, signed consents were sent to the donor. it took numerous rounds of communications and meticulous coordination between the donor, the organizer and the administrators from our hospitals before we got the news that the cargo plane was finally heading to the west coast. after two weeks of anxiously waiting and more communications back and forth, the shipment finally arrived. to proceed with caution, we took a random sample of the donations to our quality control department for close inspection and quality assurance before we were finally able to release these supplies to our ppe arsenal. i truly feel the moment we received the news that all the ppe are qualified to be used was one of the most memorable and accomplishing time in my professional career, to say the very least. i was absolutely thrilled that our efforts have come to fruition in the most critical time. other channels of donation also proved to be resilient and encouraging: a significant number of surgical masks, n-95 masks, face shields and surgical gowns were donated from retired physicians, dentists, hmos, bowling and ice-skating organizations, and even friends and families of the chat group members. local businesses in the la metro areas with connections to businesses in the pacific rim were able to facilitate various ppe shipments from government-approved suppliers in china and southeast asia, and donations continue to trickle in. another innovative approach was to enlist local garment shop and volunteers to start producing gowns from suitable material. one boeing engineer from the chat group connected with us after she designed a prototype of the water-proof disposable gown that is like what we use in the hospital. after approval from the infection control department, we were able to start producing a small quantity of disposable gowns to ease the shortage. feedback from frontline nurses and staff are very positive. the donation process has been an amazing reflection of solidarity, humanity and philanthropy from people all around the world during this pandemic. to date, we are delighted to have collected more than 8,000 units of n-95 masks, 70,000 surgical masks, 1,500 face shields and 1,000 gowns. they are all donated to our hospitals according to their needs. in time of adversity and uncertainty, the spirit of giving and using innovative approaches to tackling challenges have again shone a bright light on this unforgettable journey. acknowledgement: author wish to thank prissilla xu, pharmd for assistance in the donation process and manuscript preparation. not commissioned, internally reviewed world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19) there is no data to submit. key: cord-329921-mi71bet3 authors: ogoina, dimie; james, hendris; ominabo, dickson; oyeyemi, abisoye; wisdom, olomo tudou title: covid-19: the need to redesign head coverings of personal protective equipment for manual stethoscopes date: 2020-08-11 journal: trans r soc trop med hyg doi: 10.1093/trstmh/traa063 sha: doc_id: 329921 cord_uid: mi71bet3 nan covid-19 is primarily a respiratory disease characterised by features of respiratory tract infection, among other non-specific symptoms. 1 a stethoscope is required for complete clinical evaluation of covid-19 patients, especially to auscultate the lungs to identify features of pneumonia and other associated lung pathologies. to prevent exposure to potentially infectious body fluids and secretions, clinicians often wear full personal protective equipment (ppe) during the examination and care of covid-19 patients. unfortunately, the head covering of the ppe worn by clinicians is not designed to accommodate the earpiece of a manual stethoscope. placing the earpiece of the stethoscope on the surface of the head covering close to the ears is not helpful, as little or no sound is heard through the fabric of the ppe. when the earpiece of a manual stethoscope is introduced directly into the ears, the ear tubes of the stethoscope displace the hood of the coverall, exposing most parts of the face and increasing the risk of contamination of the face. as a result of these risks and difficulties, clinicians managing covid-19 patients are forced to abandon the use of manual stethoscopes in favour of alternative technologies such as wireless stethoscopes, portable ultrasounds and x-ray machines to define the lung pathologies of their patients. 2,3 however, when these alternative technologies are not available or affordable, especially in developing countries such as nigeria, the chest signs of covid-19 patients may remain undefined. the niger delta university teaching hospital (nduth), okolobiri, is one of the designated treatment centres for covid-19 patients in bayelsa state, nigeria. in light of the absence of alternative technologies, and the need to define the chest signs of severe covid-19 cases upon admission to our isolation ward, we explored redesigning the head covering of some of our ppe to enable auscultation of the lungs and hearts of covid-19 patients using manual stethoscopes. we used the fabric obtained from surgical masks to create ear pouches on both sides of the ppe hood. the mask's fabric was neatly sown on the hood, creating a complete seal both inside and outside the ppe (figure 1 ). these procedures were undertaken while observing strict hygiene and infection prevention and control measures. the redesigned head covering is worn by a clinician, who can easily place the earpiece of the manual stethoscope into both ears through the refashioned ear pouches of the hood (figure 1 ). this way, the clinician can listen to the auscultatory sounds of a patient and identify any abnormal sounds indicative of lung disease. in our facility, the chest piece and tubing of the stethoscope are decontaminated with spirit swab between examinations of different patients. in resource-limited settings where alternative technologies may be lacking, clinicians managing covid-19 patients should consider redesigning the head covering of ppe to make provisions for the use of manual stethoscopes. however, this suggested modification of ppe must be undertaken while adopting strict hygiene and standard infection prevention and control measures, to avoid contamination of the ppe and the face masks. manual stethoscopes are readily available, affordable and easy to use and can be used for repeated examinations of patients, as well as to identify evolving bedside clinical presentations before further definitive imaging studies. manufacturers of ppe should also consider creating ear pouches as part of the product design of head coverings to allow for the routine use of manual stethoscopes during the care of contagious infectious diseases such as covid-19. d. ogoina et al. world health organization. clinical management of severe acute respiratory infection when covid-19 is suspected severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected we would like to thank members of the nduth covid-19 response team for useful suggestions and assistance in the implementation of this project.funding: none. authors' contributions: do conceived the idea and all authors made a substantial contribution to the development and writing of this article. do, acting as the corresponding author, had the final responsibility for the decision to submit for publication. we declare no competing interests.ethical approval: key: cord-323008-xk89ew1b authors: rama, asheen; murray, andrea; fehr, james; tsui, ban title: individualized simulations in a time of social distancing: learning on donning and doffing of an covid-19 airway response team date: 2020-08-30 journal: j clin anesth doi: 10.1016/j.jclinane.2020.110019 sha: doc_id: 323008 cord_uid: xk89ew1b nan we read the article by zhang et al. [1] regarding strategy of using protective personal equipment (ppe) during the covid-19 pandemic with great interest. we concur that "personnel education and experience play important roles in efficacy of ppes". recently, common biosafety breaches during donning and doffing of protective personal equipment (ppe) have been reported [2] . in the midst of pandemic, simulation not only may play a vital role in supplementing both education and experience needed with minimizing the risk of infecting healthcare workers (hcws), but also allows educators to provide constructive feedback to providers. with the approval and wavier of institutional irb, we report here our findings of examining our staff training regarding the common biosafety breaches in donning and doffing for aerosols generating medical procedures (agmps) based on key areas identified by munoz-leyva and niazi [2] . prior to reviewing the findings, we also encourage the reader to participate in gamification to enhance their learning [3] by viewing the drawing on the left in fig. 1 , and determine if the drawing represents optimal ppe. the reader may then refer to the summary table on the right which highlights optimal ppe. covid-19 airway response team consists of experienced anesthesiologists that are interested and knowledgeable in managing airway of covid-19 patients. ten participants from our division's covid-19 airway response team were presented with a simulation scenario in which a covid-19 patient required urgent intubation. participants donned ppe in an anteroom before entering the patient's adjoining room to prepare for a potential intubation. then, participants were instructed to doff their ppe and exit the patient's room. the entire process was recorded, and personalized video-playback was given during debriefing. of note, participants on numerous occasions were at risk for or did in fact self-contaminate. some anesthesiologists only utilized equipment provided at the donning station while others requested additional ppe: (a) eye protection; during the donning process, a variable amount of time was spent hand sanitizing, thus debriefers emphasized the 20 s rule [4] with alcohol-based sanitizer. a variable amount of sanitizer was used, often of insufficient volume to last for the recommended 20 s. the time required to don ppe ranged from 2 to 4.5 min which emphasized the need for process familiarity as emergent intubations are commonplace, such as in cases of self-extubations which occurs in up to 22.5% of patients in the icu [5] . several participants did not double glove and several participants wore the n95 mask incorrectly. the doffing process was seen as more challenging by participants and was critiqued, referring to cdc and institution guidelines for best practices. many participants contaminated the anteroom by doffing in this room rather than inside the patient's room. participants were recommended to stand more than 6 ft away from the patient during doffing and removing the gown in a leaning forward, rolling inside and out fashion. several individuals self-contaminated themselves by touching the door handle after removing their gloves while others contaminated their scrubs below the knees as they attempted to maneuver over patient monitoring cables. during debriefs, it was possible to critique donning and doffing practices and collectively brainstorm improvements to the covid-19 airway response system. the debriefs further emphasized the need for a buddy system in which a spotter could read off a ppe equipment list. only until recently, individual-based, personalized coaching simulation has reemerged and utilized for physician training in our institution. instead of group learning format, this personalized simulation system allows single participants, under the guidance of two simulation debriefers, to use the aforementioned guidelines and learn proper donning and doffing of ppe. given the vast number of hcws who are becoming infected with covid-19 [6] , it is of vital importance that we not only distribute knowledge on ppe in the form of protocols, guidelines, demonstrations, and videos, but also provide simulations with personalized feedback which improves staff safety in anticipation of potential second wave infection as the world reopens [6] . indeed, "equipment and protocols will surely briskly in the current crisis [1] ." none. strategy of using personal protective equipment during aerosol generating medical procedures with covid-19 common breaches in biosafety during donning and doffing of protective personal equipment used in the care of covid-19 patients simulation-based ultrasound-guided regional anesthesia curriculum for anesthesiology residents quantifying the effect of hand wash duration, soap use, ground beef debris, and drying methods on the removal of enterobacter aerogenes on hands minimizing self-extubation beware of the second wave of covid-19 key: cord-349008-x750xe8n authors: ertl-wagner, birgit b.; lee, wayne; manson, david e.; amaral, joao g.; bojic, zoran; cote, michelle s.; fernandes, joanne m.; murray, darlene; shammas, amer; therrien-miller, natalie; shroff, manohar m. title: preparedness for the covid-19 pandemic in a tertiary pediatric radiology department date: 2020-06-03 journal: pediatr radiol doi: 10.1007/s00247-020-04704-2 sha: doc_id: 349008 cord_uid: x750xe8n nan the outbreak of the novel coronavirus disease of 2019 (covid-19) has led to unprecedented challenges in health care systems worldwide. it was first described in wuhan, china, in december 2019 and rapidly spread across the world. the center for systems science and engineering at johns hopkins university publishes international case numbers daily [1] . at the time of writing, many countries were in an exponential phase of spread, so numbers were expected to steeply rise further in the next weeks to months [1] [2] [3] . there is evidence that substantial undocumented infection and community transmission facilitate the rapid dissemination of the novel coronavirus [4] . in the following, we use the term covid-19 regardless of the presence of clinical symptoms, even though this terminology is somewhat imprecise. radiology departments are at the crossroads of patient care. with high patient volumes, rapid patient throughput, a range from elective to high-urgency examinations, and often a mix of in-and outpatients, they face particular challenges in these unprecedented times. the radiological society of north america (rsna) and its journal radiology recently assembled a scientific expert panel on radiology department preparedness for covid-19 and published their perspective [5] . the situation continues to evolve rapidly. local, national and international rules and regulations vary widely and pediatric radiology departments are in a unique situation. pediatric patients generally tend to be less commonly affected and tend to have a less severe clinical course [6] . on the other hand, with children there is typically more patient interaction, a notable number of examinations require sedation, and children are usually accompanied by caregiversall factors that need to be taken into account for patient, caregiver and staff protection during this pandemic. we therefore summarized our current experience in departmental preparedness for covid-19 at a canadian tertiary pediatric radiology department. we are aware that the situation is fluid and rapidly evolving on a daily basis. recommendations valid today might become obsolete tomorrow, and new insights are bound to evolve in a short timeframe. nevertheless, we consider it important to have a description and analysis of current processes as a basis for discussion for pediatric radiology departments at this point in time. the department of diagnostic imaging of the hospital for sick children (sickkids), located in toronto, canada, is an academic tertiary pediatric radiology department that embraces the entire spectrum of pediatric imaging, including general pediatric radiology (with specialized cardiac and musculoskeletal imaging), neuroradiology, interventional radiology, nuclear medicine and imaging-based research. the department consists of 30 staff radiologists. it has a large education program that includes approximately 20 fellows and 5-6 rotating residents. front-line operational staff includes approximately 90 radiologic technologists and 30 registered nurses. sickkids is a standalone children's hospital affiliated with the university of toronto. it has approximately 300 inpatient beds and a very wide referral base, expanding across large parts of the province of ontario and even the country in some situations. the department of diagnostic imaging performs more than 140,000 examinations per year. prior to the covid-19 pandemic, the department of diagnostic imaging had developed a high-level departmental emergency preparedness plan to ensure effective and timely response in the event of a disaster and to minimize risks to the health and safety of patients, families, staff and visitors. the plan includes up-to-date fan-out lists, provides clear instructions on what to do during an emergency and is easily accessible to staff even when computer systems are down. the departmental preparedness plan was used and adapted during the severe acute respiratory syndrome (sars) outbreak in 2002-2003. although sars necessitated departmental preparedness, as well, there are notable differences to the covid-19 pandemic, making the current situation novel and necessitating new preparedness strategies. compared to covid-19, sars was characterized by an overall lower case number, more contained geographic distribution, and lower community transmission. the departmental emergency preparedness plan is fully aligned with the hospital incident management system and serves as a standardized framework for dealing with a wide range of emergencies and disasters. we adapted this plan for the covid-19 pandemic in terms of key operating principles that include but are not limited to having defined command structure; proactive risk management; streamlined, centralized and integrated communication pathways; clear roles and responsibilities; use of common terminology; defined action planning; and coordinated management of resources. compared to preparedness for other disasters, such as natural disasters or infrastructure collapse, planning for a pandemic situation such as covid-19 requires a much longer-term adaptation of processes. in the current preparedness planning for the covid-19 pandemic, change management and people management are of paramount importance. in the pre-pandemic phase, as information on covid-19 emerged initially from china and subsequently from other countries, preparations for a potential canadian epidemic or global pandemic began in our department ( table 1 ). the current literature emphasizes social distancing to be an important factor in disease containment [7, 8] . as information on covid-19 containment in china [9] and disease evolution in italy [10] and other countries was becoming available, we continuously updated and adapted our processes for pandemic preparedness. departmental preparedness in the pre-pandemic phase was planned in coordination with the general hospital preparedness while taking into account the radiology-specific contexts. during the pre-pandemic phase, services in all areas and modalities continued as per regular schedule. all employees were encouraged to meet with occupational health to update their n-95 mask-fitting requirements and immunization records. hand hygiene stations were properly placed and maintained. a skill-set inventory was created for all non-physician staff to allow for potential re-deployment to areas in need within (and potentially also outside) radiology. the infrastructure for virtual on-line conferencing was updated. opportunities for table 1 checklist of preparations in the pre-pandemic and pandemic alert phase measures of preparedness in the pre-pandemic and pandemic alert phase a ✓ ensure ongoing compliance with mask fit testing requirements ✓ ensure compliance with all mandatory staff training requirements ✓ re-educate staff on proper infection control protocols and donning and doffing of personal protective equipment (ppe) ✓ maintain appropriate stock of ppe and centralize distribution of departmental ppe supplies to prevent shortages ✓ ensure proper placement and maintain hand hygiene stations ✓ ensure that all fan-out lists are up-to-date and accessible to radiology leadership team ✓ schedule and complete regular updates of the radiology emergency preparedness plan ✓ ensure that downtime procedures are up-to-date and available to staff, and re-educate staff ✓ build infrastructure for video-conferencing and remote interpretation of images ✓ identify essential resources required to maintain delivery of services ✓ establish a radiology incident management team (imt) with clear roles and responsibilities ✓ coordinate all pandemic planning activities with the hospital imt ✓ increase situational awareness and involve staff in the pandemic planning process ✓ prepare for fully segregated isolation in collaboration with other programs ✓ determine and prepare for radiology role in the screening and diagnosis of pandemic patients ✓ create appropriate warning and room access control signage ✓ define activities that will be maintained during the pandemic and activities that will have to be discontinued ✓ establish a plan to manage staff absenteeism and to address service gaps ✓ complete an accurate skill set inventory for all non-physician staff ✓ identify opportunities for staff redeployment and designate back-ups for key roles ✓ designate rooms for rapid isolation of suspected cases and specify process steps ✓ determine standardized protocol for decontamination of equipment and imaging rooms ✓ develop pandemic communication plan and build redundancy into communications ✓ identify staff members that are particularly vulnerable to the pandemic a note that this is an abbreviated list as an excerpt from our pandemic preparedness plan. also note that parts were adapted as the situation evolved remote reporting were enhanced, and an increasing number of workstations for remote reporting were deployed. signage was created for the different patient areas. initially, this mostly pertained to patients and families with a recent travel history, but this was subsequently broadened as the situation evolved. screening tools and alerts were implemented within the hospital electronic medical record (emr) to provide centralized communication and information-sharing across distributed registration areas. specific alerts were created to recommend the use of ppe for aerosol-generating procedures for patients who may have been exposed to covid-19 or had had recent travels outside canada. the world health organisation (who) declared the covid-19 outbreak a pandemic on march 11, 2020 [11, 12] . as the global situation evolved into the pandemic period, our department followed a pandemic preparedness plan ( table 2 ). an inter-professional radiology incident management team (imt) was established, consisting of physician leaders, operational leaders, senior managers including quality and technology leaders, and nursing leaders. roles and responsibilities were assigned. virtual huddles of the imt via a videoconferencing system were established, twice daily on weekdays and once a day on the weekends. these imt huddles aimed to augment situational awareness, to allow for a centralized decisionmaking and to establish a consistent communication to the entire team. the responsibilities of the radiology imt were aligned with the hospital imt. in the following sections we discuss the processes we initialized in the current early pandemic phase. at the time of writing, the situation continued to evolve rapidly and we were still in the early phase. many of the concepts outlined might become obsolete. a critical post hoc analysis will be necessary after the pandemic phase subsides. as the covid-19 pandemic continues to progress rapidly, shortages of personal protective equipment (ppe) are becoming a reality in many countries and geographic areas. in addition, our knowledge about the novel coronavirus continues to grow. therefore, rules and regulations regarding ppe are bound to evolve further. they depend on local infection prevention and control guidelines and vary across institutions, regions and countries. at the time of writing the ppe recommendations in our institution were as follows ( fig. 1) : & during routine patient care for children without precautions only a surgical mask should be worn. goggles or face shields and gowns and gloves are generally not necessary, unless required by a specific procedure. measures of preparedness in the pandemic phase a ✓ implement and monitor standardized screening of patients prior to examinations ✓ implement and monitor standardized triaging and workflow process ✓ use standardized protocol for decontamination of imaging rooms ✓ ensure that all staff complete employee attestation document and retain a copy ✓ operationalize team rotations and separate patient streams to reduce exposure ✓ establish a team rotation system, where possible ✓ organize daily radiology incident management team (imt) meetings to manage resources and respond to the pandemic ✓ implement pandemic communication plan and keep staff, patients and families informed ✓ anticipate and address fear and anxiety, rumors and misinformation ✓ limit all non-essential activities and personnel in the department including research and teaching of pre-licensure students ✓ defer elective outpatient examinations; make decisions for deferral on a case-by-case basis in consultation with radiologist and referring physicians ✓ ensure that patients requiring urgent imaging will not be impacted ✓ aim to perform imaging at sites with less foot traffic and with fewer patients ✓ eliminate or reduce the possibility for staff to work using the same work stations ✓ wipe workstations, dictaphones and telephones before use ✓ ensure the most judicious use of personal protective equipment (ppe) and infection control supplies ✓ monitor inventory levels and order ppe and infection control supplies as required ✓ store ppe in areas not available to public or in areas that can be monitored ✓ apply a wide range of strategies to increase social distancing ✓ perform an ongoing assessment of risks from the interaction of all potential hazards ✓ take proactive steps to protect staff that are particularly vulnerable to pandemic ✓ assess the need to enact downtime procedures ✓ provide the ability for staff to work from home while balancing needs in the hospital ✓ use video-conferencing for necessary meetings whenever feasible ✓ show compassion and provide support to staff experiencing fatigue, burnout and distress ✓ sharpen and maintain focus on patient, family and staff safety during pandemic ✓ monitor evolving situation and rapidly respond to changing needs a note that this is an abbreviated list as an excerpt from our pandemic preparedness plan. also note that parts were adapted as the situation evolved & a surgical mask should also be worn for interacting with other staff or caregivers, when an appropriate social distance (6 ft) cannot be maintained. these regulations are likely to evolve and are likely to differ across institutions, and therefore we strongly advise consultation of the respective current institutional guidelines. the donning and doffing of ppe was re-trained at the beginning of the pandemic phase, and the hospital released an elearning module on this, which became mandatory across the organization. staff was encouraged to handle the masks with care and to minimize the amount of times masks are taken on and off. they were reminded that masks need to cover the nose fully and should not be hung around the neck and ears when taken off. we established an inventory of ppe and started monitoring supply and usage. staff was encouraged to bundle tasks where possible to preserve ppe. the number of staff requiring ppe was limited as far as possible (e.g., limiting the number of technologists to position patients). in addition, solutions to potential shortages needed to be considered, including the use of one mask for several procedures, sterilization and reuse of ppe, and 3-d printing methods. dedicated rooms are used for all imaging examinations or image-guided interventions in patients with confirmed covid-19 and those with respiratory symptoms and suspected covid-19 infection. additional rooms were identified and designated to serve for rapid isolation for when cases were identified. these rapid isolation rooms allowed for a secondary screening to determine the next steps. concepts regarding room disinfection and turnover as well as equipment decontamination continue to evolve and depend on local infection prevention and control (ipac) guidelines, which are likely to vary across institutions. standardized protocols were developed, implemented and adapted according to the current evidence for decontaminating imaging rooms. our room preparation processes are continuously adapted to our institutional ipac guidelines. when feasible, portable imaging of patients with suspected covid-19 is performed. the choice of modality used (e.g., ct vs. ultrasonography) depends on the specific situation, symptomatology and available resources. 1 diagram shows current guidelines on use of personal protective equipment (ppe) at our institution. please note that concepts are likely to evolve and vary depending on local and institutional regulations and availabilities. column 1 recommends n-95 mask, goggles or face shield, and gown and gloves for aerosol-generating medical procedures. column 2 demonstrates surgical face mask plus goggles or face shield, or a combination of mask and face shield, as well as gown and gloves as recommended for droplet/contact isolation. column 3 shows surgical masks only as recommended for routine cases, unless specifically required otherwise. column 4 recommends n-95 mask, goggles or face shield, and gown and gloves for all code blue situations in interventional radiology, the minimum number of people required for the procedure is allowed in the room. if possible, technologists control the angiography equipment from the control room. access to the room is limited to one entrance only. all interventional team members have to adhere to donning and doffing at the entrance of the room. personal radiation protection lead aprons have to be wiped with virucidal wipes containing 0.5% hydrogen peroxide after each procedure. because endotracheal intubation is an aerosol-generating medical procedure, special care needs to be taken. we made every effort to defer all elective, non-emergent and non-urgent examinations and interventions under general anesthesia. for people with pending covid-19 testing results and urgent imaging or image-guided interventions under general anesthesia, test results are expedited. induction for general anesthesia is to be performed in a designated contaminate area. crying and coughing should be reduced with sedative premedication. all unnecessary room equipment should be removed; drawers and shelves should be closed and surfaces covered with a clean sheet. traffic should be minimized. appropriate signage should be displayed. only necessary disposables should be taken out. a special tray should be used for placement of contaminated equipment, and a highefficiency particulate air (hepa) filter between the patient and the circuit should be used during mechanical ventilation. a pre-intubation/pre-procedure time-out should be done to ascertain that the required equipment is present, that personnel is limited to only those who are clinically required, that inand-out movement is minimized and that the correct ppe is donned. examinations or image-guided interventions should be completed expeditiously. a safety coach should be present before beginning the examination or imageguided intervention under general anesthesia or sedation to oversee actions and processes. this safety coach should remain outside the interventional/examination room. safety coaches are individuals with special training in infection control and the correct use of ppe. in our department, two senior registered nurses are trained as safety coaches. after the procedure, a post-intubation/post-procedure timeout should be done to verify that all soiled equipment and soiled medical supplies are properly disposed of. nondisposable personal equipment such as lead aprons should be cleaned, e.g., with appropriate virucidal wipes containing hydrogen peroxide 0.5%, after each use. there has been restricted access to the hospital since the beginning of the covid-19 pandemic. screeners at the hospital entrance triage whether access to the hospital is granted. employees have had to fill in an electronic attestation form prior to coming into the hospital since march 16, 2020; this includes an attestation not to have respiratory symptoms including but not limited to cough, runny nose or fever, not to come to work with respiratory symptoms, to adhere to return-from-travel regulations (14-day self-quarantine) and to access information regarding covid-19 on the website on a regular basis, among others. the list of symptoms was later adapted and broadened. the e-mailed confirmation of this attestation form has to be presented at the hospital entrance and employees are subsequently provided with special stickers to their hospital badges clearing them for access. pre-licensure trainees (e.g., medical students) and volunteers were no longer allowed on-site at the time of this writing. all patients, families and visitors have to present to special screening stations with glass windows. the number of caregivers accompanying patients is restricted to one (two in exceptional circumstances). specialized medical equipment representatives are only allowed in clinical areas if required to deliver supplies for urgent medical care. care was taken to allow for enough distance in the waiting areas of the radiology department. this was facilitated by the deferral of elective outpatient examinations outlined above and would have otherwise been very challenging. all communal toys and books were removed and, where feasible, seating areas (benches, chairs) were separated by 6 ft (2 m) in waiting areas. if outpatient examination numbers rise again in a continuing pandemic situation, different strategies might need to be discussed. among these is the potential solution to have patients and their caregivers wait either in their cars in the parking garage (where feasible) or in a larger but more remote waiting area and to call them into the examination area only shortly before the examination is to commence to avoid waiting and reduce traffic in imaging areas. on march 15, 2020, the radiology leadership in consultation with hospital leadership decided that all outpatient elective, nonurgent and non-emergent examinations should be deferred. the overarching aim for this measure was to primarily reduce potential exposure for patients, their families and staff, and to create additional capacity for potential surges in patients with covid-19. this created a considerable logistic challenge because the radiology department has a very large elective outpatient population and is one of the sole providers of sub-specialized pediatric imaging in a large and very populated area. even though it was considered preferable by the radiology imt to have the referring provider (being the most responsible provider, usually a physician and occasionally a nurse practitioner) prioritize the examinations for potential deferral, this was considered not feasible because examination deferral was expected to start the very next day. therefore, data from the electronic scheduling system were extracted and spreadsheets were created that included all elective outpatient examinations scheduled for the 3 weeks starting march 16, 2020, for each imaging modality. the spreadsheets were kept on a secure in-house server and contained the ordering information and medical record number for each examination. the excel spreadsheets were assigned to the radiology division head (body radiology, neuroradiology, interventional radiology, nuclear medicine). radiologists reviewed the ordering information, available imaging and electronic patient charts to decide whether an elective outpatient examination could be deferred. a standardized approach was chosen for the decisions on examination deferral. a small group of radiologists decided on the deferrals in their area of subspecialty based on urgency. electronic medical records and prior imaging studies were reviewed. categories for non-deferral of diagnostic examinations and interventional procedures included cancer care, acute infection/sepsis risk, risk of obstruction, severe pain management, acute risk of progression from delay, immediate diagnostic necessity, prevention of major surgery, time-sensitive treatment sequence, promotion of immediate hospital discharge, and urgent vascular access. deferred examinations to be reassessed in 3 weeks were specifically flagged. four columns were created for the division heads (or radiologists designated by them) to fill in: who reviewed the order, comments, whether the examination should be deferred (yes/no), and whether the examination should be re-assessed in 3 weeks (yes/no). the last of these columns was designed to indicate elective outpatient examinations that should be re-booked with priority as soon as the situation allowed for this. another four columns were created for the radiology administrator contacting the family to indicate: who contacted, when the contact was made, who was spoken to, and comments. four additional columns were made for the radiology administrator contacting the referring provider to show: who contacted, when the contact was made, who was spoken to, and whether a prioritized rebooking was requested. in addition, it was checked whether the radiologic examination was coordinated with any other in-house patient visits at sickkids. if so, the coordinating clinic was contacted, it was discussed whether to keep the booking, and the results were documented in the spreadsheet. in addition, referring providers were asked to provide lists of their most urgent patients and these lists were amalgamated with our spreadsheet to ensure timely examinations for more urgent indications. table 3 gives an example of the column headers with fictional data for illustration. a sample of standardized communication with parents/caregivers is provided under supplementary material. for the 3 weeks starting march 16, 2020, the elective outpatient examination requests were screened, labeled to be deferred and marked to be reassessed in 3 weeks for prioritized rebooking as follows: & for mri, 672 requests were screened, 581 (86%, 581/ 672) were labeled to be deferred and 178 of these (31%, 178/581) were marked to be reassessed in 3 weeks. & for ct, 89 requests were screened, 58 (65%, 58/89) were labeled to be deferred and 29 of these (50%, 29/58) were marked to be reassessed in 3 weeks. & for ultrasonography, 1,077 requests were screened, 598 (56%, 598/1,077) were labeled to be deferred and 23 of these (4%, 23/598) were marked to be reassessed in 3 weeks. & for interventional radiology, 108 requests were screened, 63 (58%, 63/108) were labeled to be please note that these numbers only reflect elective outpatient imaging requests with low urgency for the 3 weeks starting march 16, 2020. inpatient examinations, examinations referred by the emergency department and all urgent outpatient examinations were performed as before, so the actual number of examinations was markedly higher. for radiographic examinations, the schedule did not explicitly change. these are usually performed on a short-term notice without long-term advance scheduling. as the covid-19 pandemic evolved, the stream of walk-in patients with external orders for outpatient imaging and the requests for non-urgent radiographic examinations largely subsided as outpatient clinics were canceled and parents and caregivers were reluctant to come to the hospital. starting at the beginning of the second week (march 23, 2020), we created a process to have the referring providers decide on whether to defer an elective outpatient examination for all examinations scheduled for the 4 weeks starting on april 6, 2020. figure 2 outlines the process. almost 5,000 examination requests have been screened with over 600 referring providers. it will be important to monitor this process closely in the weeks to come. as the situation continues to evolve very dynamically, the time horizon of the deferrals and rebookings needs to be continuously monitored and adapted in a rolling plan. the rapid deployment of manual-entry dependent processes outside the hospital's emr is susceptible to human error and communication gaps. to mitigate the risk of an appointment being overlooked, a custom program was built in python to merge spreadsheets containing (1) radiologist prioritization, (2) provider phone calls and emails, and (3) patient/family confirmations, with emr extracts containing (4) previously scheduled appointments, (5) newly deferred appointments and (6) unexpected patient/family no shows because of covid-19 travel concerns. this daily reconciliation program further integrated ambulatory clinic cancellations to provide a master list, ensuring that all appointments scheduled during covid-19 were accounted for, and rescheduled in a timely manner. as the number of covid-19 cases continued to escalate both locally and worldwide, we decided that further measures were needed to brace for the impact of potential further surges in infections [1] , so we initiated a multi-team rostering approach. the overarching aims of this multi-team approach were to: (1) prevent contamination and spread of the virus, (2) allow for social distancing and (3) have a backup team in case of sick leaves or quarantines. the teams were formed within each subspecialty area (e.g., neuroradiology, body radiology, interventional radiology and nuclear medicine) and there were no overlaps between the two teams. each team was rostered to work for 1 week and be away from the hospital practicing social distancing and self-quarantine at home during the other week, with alternating schedules. radiology teams consist of staff radiologists and radiology fellows and cover day-service and on-call services for the given week. teams not in-house were asked to stay at home, practice social distancing, provide remote image reading, administrative help and academic work, and be available to be called into the hospital within 30 min, if the situation required it. it was also decided to protect especially vulnerable staff members while maintaining a high level of confidentiality. staff with preexisting conditions or immunosuppression and those who are more vulnerable because of their age were enabled for home reporting. they were removed from direct patient/caregiver contact. the roster was created for 2 weeks at a time; the multi-team approach will be continued if the situation continues to evolve. radiology residents usually rotate through various sites in toronto to gain a wide spectrum of experience. in the current pandemic situation, rotations were halted. each site now has a fixed team of residents covering weekday nights and weekends. daytime resident coverage was paused because it was not considered an essential service. other frontline staff was distributed into multi-team models where possible. the following guiding principles were considered to review and adapt staffing models based on personnel, equipment and patient streams. personnel considerations included shift length, frequency, team size and other personnel considerations (age, co-morbidities, dependants requiring care, recent travel, and illness/symptoms/rate of absenteeism). because the majority of frontline staff is compensated on an hourly pay model, care was taken to balance work hours. implementation varied by department. in some areas, teams moved to 10-or 12-h shifts, reducing their onsite presence to 4 or 3 days a week, respectively. where appropriate, staff members were redeployed into support or administrative work rotations that could be completed in a non-patient-facing or work-from-home capacity. staff members are expected to be available to be called into clinical duty within 30 min if the situation requires it (sick leaves or quarantines). equipment and modality room considerations were intended to minimize exposure among patients and were based on cleaning protocols (process and turnaround times), volumes of cases, potential downtime and location (i.e. portable vs. fixed rooms). where possible, patient streams are considered to rotate staff and protect vulnerable staff performing imaging on patients. as the pandemic situation started to evolve around the time of march school break in ontario, numerous employees were returning from travel. provincial regulations regarding selfisolation initially exempted health care workers, but eventually all employees with an international travel history within the last 14 days had to be in home self-isolation for 14 days following the date of their return to canada. this rule was also retrospectively applied. a notable portion of employees therefore had to be sent home to self-quarantine and the schedules and rosters had to be accommodated accordingly. the reading situation needed to be adapted to allow for social distancing. everyone was encouraged to use the same workstation throughout a shift and, where feasible, for the rest of the week. wherever possible, fellows are deployed to separate reading rooms. if more than one fellow needs to read in one large reading room, care is taken that adequate distancing is possible (at least 6 ft/2 m). as outlined, residents are only providing weekday night and weekend coverage and have separate reading rooms. staff radiologists are mostly using individual work stations in offices. options for home reporting have been expanded. depending on the subspecialty and service, home reporting for on-call situations had already been in place. this was further expanded in the pre-pandemic planning phase. for home reporting, full workstations with medical-grade imaging monitors are used in a three-monitor configuration, identical to the inhospital workstations. the workstations are connected to the hospital's picture archiving and communications system (pacs), radiology information system (ris) and emr system via a virtual private network (vpn). departmental networking resources had already been managed separately from the hospital-wide resources before the covid-19 pandemic and could be rapidly expanded. hand disinfectant and disinfecting virucidal wipes containing 0.5% hydrogen peroxide were distributed to all reading rooms. everyone was instructed to thoroughly wipe the workstation (keyboard and mouse), dictaphone and phone with a virucidal wipe prior to use and to use only one given workstation and phone throughout the shift and if possible throughout the week. staff and fellows are encouraged to read out over the phone, with both sitting in separate rooms at workstations and going over the cases on the phone. the fellow then creates the initial report in the radiology information system, and the report is reviewed and signed electronically by the radiology staff. access to the reading rooms is limited. within the firewalls of our hospital, consultations and clinical conferences are performed using microsoft teams, which allows for the sharing of pacs screens. the hospital also quickly moved to virtual clinics via the province-wide ontario telemedicine network. the current pandemic situation creates a high degree of uncertainty among employees, trainees, patients and their families. communication needs to find a fine balance between informing, supporting and encouraging on the one hand, and not overwhelming with information on the other. ideally, the information should be timely and clear, top-down and consistently from the same source. however, in this unprecedented and highly dynamic situation, information changes rapidly. what holds true one day might not be relevant the next. this needs to be acknowledged and openly dealt with. provincial return to travel policies, for example, rapidly changed in ontario, and communication to employees necessarily had to be updated in rapid succession. it will be important to regularly communicate and update the information and policies for the weeks to come. fear and anxiety, rumors and misinformation need to be anticipated and addressed. care must be taken to ensure that communication is as consistent as possible. communication for clinical rounds has also rapidly changed with the need for social distancing and tight limits of people in one room. clinical rounds are now held electronically. it is important to follow data protection guidelines for protected health information, which may vary among provinces, states and countries. at sickkids, an institution-wide license allows us to use secure microsoft teams for discussing patient information at clinical case conferences and multidisciplinary rounds (e.g., neonatal intensive care unit rounds, oncology rounds); these have been successfully conducted from within the hospital or via vpn connection from home. teaching rounds have been continued using a wider variety of web conferencing solutions with videoconferencing options and shared screens. it is important to remember that these teaching rounds should not contain any protected health information. last but not least, communicating a sincere thank you to the teams regularly is important as we all struggle together to get through this unprecedented situation. daily leadership walkarounds were instituted in the department to support and boost morale. these leadership walk-arounds are also conducted on the weekends and care is taken to maintain social distance. during this pandemic situation, staff and trainees may experience stress, fatigue and challenges regarding self-isolation, provision of additional clinical services, exam postponements, or child care in the face of the school closings. several resources are available to provide support for staff, physicians and trainees through the hospital, university and medical association such as the wellness office and physician health program. while we are all desperately waiting for the post-pandemic time, this period will bring specific challenges, and preparing for these challenges is of utmost importance ( table 4) . one of the major challenges will be to catch up with the large number of elective outpatient examinations that were deferred. waiting lists are already long, especially for examinations under general anesthesia, and extra shifts will become necessary to make up for the deferred examinations. plans need to be developed and implemented to prioritize and address this backlog of examinations. currently, we are operating on a rolling plan, in which deferred elective examinations are continuously reassessed for prioritized re-booking. deferred elective examinations that need to be reassessed after 3 weeks are specially flagged. it will be crucially important to develop a process to rebook the deferred appointments without any patient being lost to follow-up. this process will need to be continuously monitored. teams should be recognized and rewarded for their exemplary performance and dedication during challenging times. in addition, a post hoc analysis of our response and processes during the pandemic should be performed and lessons learned should be documented. the pandemic preparedness plan should be updated and adapted as required because it is uncertain when another pandemic may arise. we are in a highly dynamic situation that is bound to evolve further. our processes outlined here are expected to develop table 4 checklist for the post-pandemic phase measures of preparedness in the post-pandemic phase a ✓ ramp up activities and services in all modalities to appropriate levels ✓ assess and address radiology inventory needs related to equipment and supplies ✓ rebook canceled or deferred appointments due to pandemic ✓ initiate communication and consultations with referring physicians as required ✓ develop and implement plans to prioritize and address the backlog ✓ conduct post hoc analysis of the pandemic response and document lessons learned ✓ improve processes and update pandemic plans as required ✓ initiate strategic planning for innovative models of diagnostic imaging operations ✓ recognize and reward teams a note that this is an abbreviated list as an excerpt from out pandemic preparedness plan and change. new processes are likely to become necessary. we provided a snapshot and analysis of our status quo situation at the time of writing and of the changes we implemented thus far. the literature suggests that swift measures are vital in containing the pandemic spread [2, 4, [9] [10] [11] [12] and radiology departments play a major role in this. we need to monitor the situation continuously and to react and adapt to the changes around us rapidly. in all the uncertainty, we need to stay focused, alert and informed and need to stand together and united to master this unprecedented challenge. coronavirus covid-19 global cases by johns hopkins csse covid-19: towards controlling of a pandemic rapidly increasing cumulative incidence of coronavirus disease (covid-19) in the european union/european economic area and the united kingdom substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov2) radiology department preparedness for covid-19: radiology scientific expert panel epidemiological characteristics of 2,143 pediatric patients with 2019 coronavirus disease in china covid-19 and community mitigation strategies in a pandemic isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus (2019-ncov) outbreak successful containment of covid-19: the who-report on the covid-19 outbreak in china covid-19 and italy: what next? who declares covid-19 a pandemic covid-19: who declares pandemic because of "alarming levels" of spread, severity, and inaction publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgments we would like to acknowledge dr. marie-louise greer, dr. elaine ng and logi vidarsson, phd, from the hospital for sick children, and dr. marc ossip from william osler hospital in brampton, ontario. we would also like to sincerely thank the hospital leadership, the entire team of the department of diagnostic imaging, all employees of the hospital for sick children as well as all our patients and their families for their courage, caring, patience and stamina in these challenging and unprecedented times. conflicts of interest none key: cord-311401-7ugqjg5c authors: alser, o.; alghoul, h.; alkhateeb, z.; hamdan, a.; albaraqouni, l.; saini, k. title: healthcare workers preparedness for covid-19 pandemic in the occupied palestinian territory: a cross-sectional survey date: 2020-05-13 journal: nan doi: 10.1101/2020.05.09.20096099 sha: doc_id: 311401 cord_uid: 7ugqjg5c background: the coronavirus disease 19 (covid-19) pandemic threatens to overwhelm the capacity of the vulnerable healthcare system in the occupied palestinian territory (opt). sufficient training of healthcare workers (hcws) in how to manage covid-19 and the provision of personal protective equipment (ppe) to enable them to do so will be key tools in allowing opt to mount a credible response to the crisis. methods: a cross-sectional study was conducted using a validated online questionnaire. data collection occurred between march 30, 2020 and april 12, 2020. the primary outcomes was ppe provision and the secondary outcome was hcws preparedness for the covid-19 pandemic. results: of 138 respondents, only 38 hcws (27.5%) always had access to facemasks when needed and 15 (10.9%) for isolation gowns. the vast majority of hcws did not find eye protection (n=128, 92.8%), n95 respirators (n=132, 95.7%), and face shields (n=127, 92%) always available. compared to hcws in west bank, those in the gaza strip were significantly less likely to have access to alcohol sanitizers (p=0.026) and gloves (p <0.001). on average, governmental hospitals were significantly less likely to have all appropriate ppe measures than non-governmental institutions (p = 0.001). as for preparedness, only 16 (11.6%) surveyed felt confident in dealing with a potential covid-19 case. with 57 (41.3%) having received any covid-19 related training and 57 (41.3%) not having a local hospital protocol. conclusion: hcws in opt are underprepared and severely lacking adequate ppe provision. the lack of local protocols, and training has left hcws confidence exceedingly low. the lack of ppe provision will exacerbate spread of covid-19 and deepen the crisis, whilst putting hcws at risk. with the ongoing coronavirus disease 2019 (covid-19) pandemic, the humanitarian and healthcare crisis in low-to-middle income countries (lmics) such as the occupied palestinian territory (opt) is expected to be amplified and this will further cripple the healthcare system. as of may 7, 2020, the world health organization (who) has recorded 547 confirmed cases of covid-19 in the opt; 527 in the west bank and 20 in the gaza stripwith 4 fatalities. (1) the united nations relief and works agency (unrwa) has been unable to support palestinians' covid-19 response needs at their full capacity at the consequence of funding cut and legal restrictions that were in place prior to the pandemic.(2) multiple covid-19 testing sites serving palestinians in east jerusalem have been closed by the israeli authorities. ( 3) the west bank is particularly vulnerable due to checkpoint closures, halt of the transportation of patients to hospitals, and redistribution of clinical supplies. the gaza strip is one of the most densely populated places on earth with 2 million inhabitants, mostly refugees, live in 365 sq. km 2 , allowing for an accelerated spread of disease should a covid-19 outbreak manifest. (4) other lmics in the middle east and africa have also reported scarcity of personal protective equipment (ppe) for front line healthcare workers (hcws).(5, 6) we hypothesize that (hcws) in the opt are largely underprepared to address covid-19 related needs of the palestinian population in both the west bank and gaza strip. shortages of ppe pose a serious threat to covid-19 containment in the opt. it is also expected that hcws in the opt have likely received insufficient training on how to address spread and containment of covid-19; institutions themselves may not have yet been equipped to draw up or implement preventative or management protocols. to the best of our knowledge, there have been no studies evaluating the preparedness of the hcws to face covid-19 pandemic. in this study, we aim to evaluate the availability of ppe and the level of preparedness among the hcws in the opt. we conducted a cross-sectional study using an online survey tool. our survey (supplementary material) was modified from two validated questionnaires; the first was utilized during the h1n1 influenza pandemic (7) and the second one was the personnel, infrastructure, procedures, equipment and supplies (pipes) surgical capacity assessment tool. (8) our modified questionnaire consisted of 22 questions divided into 3 different sections (respondent and healthcare facility characteristics, availability of ppe and hcws preparedness). availability of ppe and hcws preparedness were assessed on a 5-point likert scale. the questionnaire was distributed to hcws in the opt through convenient sampling between march 30, 2020 and april 12, 2020. e-mail lists for participants in an educational link (oxpal) and social media (facebook, twitter, and linkedin) groups of hcws in opt were used to disseminate the questionnaire. participants were required to sign in to limit the number of responses to one per respondent. . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may 13, 2020. . https://doi.org/10.1101/2020.05.09.20096099 doi: medrxiv preprint the primary outcomes assessed were availability of ppe and hcws preparedness in opt in the era of covid-19 pandemic. the secondary outcome was to assess the differences between gaza strip and west bank, and between governmental and non-governmental in opt in terms of availability of ppe and hcws preparedness to face the covid-19 pandemic. respondent characteristics were summarized using descriptive statistics. for continuous data, mean and standard deviation (sd) were used to report normally distributed data, while median and interquartile ranges (iqr) were used for non-normally distributed data. for categorical data, results were summarized as counts (n) and percentages (cumulative incidence). univariate analysis (chi-squared and fisher's exact tests) was also used to compare participants' profession, geographical location, and responses to questions related to the availability of ppe and hcws preparedness for the covid-19 pandemic. likert scale variables were converted from 5-point to binary variables for univariate analysis. for example, often available, sometimes available, rarely availably and never available were grouped together as 'not always available'. strongly agree and moderately agree were grouped into 'agree' variable compared to 'neutral' and 'disagree' categories. missing data were considered missing completely at random, therefore we performed complete case analysis. all statistical analyses were performed using ibm corp. released 2019. ibm spss statistics for windows, version 26.0. armonk, ny: ibm corp. of 140 completed surveys, two were excluded from the study as they were either working outside the opt or in a non-medical profession. of 138 hcws included in the study, 97 respondents (70.3%) were from gaza strip and 41 (29.7%) were from the west bank. the median (iqr) age was 28 (24-35) years with a range from 19 to 57 years old. 85 respondents (61.6 %) were males. exactly half of respondents were medical doctors, with approximately 35 (25.4%) in nursing and the remaining quarter in physiotherapy, dentistry, or another health-related profession. 20 (14.5%) of the respondents worked in emergency medicine and 19 (13.8%) in surgery, 14 (10.1%) in primary care and 13 (9.4%) in internal medicine. with regards to place of work, 63 (45.7%) of the respondents worked in a tertiary hospital, 29 (21%) in a secondary facility and 43 (31%) in a primary healthcare center or clinic. one respondent worked in a covid-19 isolation center. 98 (71%) worked in a governmental institution operated by the ministry of health, 26 (18.8%) worked in a private hospital and 13 (9.4%) in a non-governmental organization (ngo) or mission-based place of care ( table 1) . only 67 (48.6%) and 71 (51.4%) of hcws surveyed indicated that they always had alcoholbased sanitizer and gloves available in their institutions, respectively. only 38 (27.5%) of respondents indicated that regular face masks were always available when needed, and just over 15 (10.9%) of respondents reported that isolation gowns were always available in their . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 13, 2020. . https://doi.org/10.1101/2020.05.09.20096099 doi: medrxiv preprint institutions. over 128 (92.8%), 132 (95.7%), and 127 (92%) of respondents indicated that eye protection, n95 respirators, and face shields were not always available to them at their institutions, respectively. 57 (41.3%) of hcws surveyed indicated that their hospital did not provide a local protocol for the management of covid-19. only 57 (41.3%) of respondents had received any covid-19 related training courses by the time of survey administration. 16 (11.6%) of hcsw surveyed agreed with the statement of feeling confident or well-prepared to deal with a potential covid-19 case ( table 2) . compared to the west bank, respondents from the gaza strip reported significantly greater lack of alcohol-based hand sanitizers (p=0.03) and gloves (p<0.001), but no meaningful differences were observed between regions on other ppe or infection control readiness (table 3) . on average, governmental hospitals run by the moh were also reported by respondents to be significantly lacking in sanitizer, gloves, facemasks, eye protection, and face shields compared to non-governmental institutions (p<0.05) ( table 4 ). our study demonstrates that the availability of ppe in both gaza and the west bank is insufficient to support the covid-19 response needs of the opt. alcohol-based hand sanitizers, gloves, face masks, eye protection, isolation gowns, n95 respirators and face shields were reported to be inconsistently available, despite being internationally recommended as critical equipment needed for protecting health care workers from infection.(9) governmental hospitals, as opposed to non-governmental settings, appear to be particularly lacking in equipment. lessons from prior outbreaks have underlined the importance of ppe in infection control. (10) recommendations from the who suggest the inadequate supply of infection prevention and control measures is vital to address immediately, with assistance from international partners if necessary.(11) the who specifically mentioned supplies needed to implement recommended protocols, such as ppe, being a key resource to all national authorities currently not producing sufficient volumes themselves. suggestions for other methods of procurement, conservation and management of ppe have been extensively covered in the literature during the pandemic. (12) many of these suggestions may not be viable in the geopolitical and economic context in which opt operates. however, methods such as governmental coordination of all ppe supply, extending or creating new supply through 3d printing all provide viable means of blunting the dearth of ppe in opt currently. (13, 14) our study showed that most hcws surveyed did not receive adequate training on local protocol or measures to address covid-19 spread from an institutional perspective. comparing the preparedness of hcws in opt to those around the world, will be a vital element of the debrief from this pandemic and important in developing strategies to ensure the opt have protocols in place for future public health crises. the lack of current data makes this comparison impossible, . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 13, 2020. . https://doi.org/10.1101/2020.05.09.20096099 doi: medrxiv preprint currently. in previous pandemics, clinicians in other countries have been substantially more confident in their clinical ability to manage infected patients than what our results reflect; for example, chinese icu hcws during the 2009 h1n1 pandemic were substantially more confident in their preparedness. (15) this may partly be due to a far greater provision of ppe amongst these workers, that permits greater clinical confidence. our study has some important strengths. to our knowledge, this study represents the first attempt to assess the availability of ppe in opt and the preparedness of hcws to face the covid-19 pandemic. we provided a comprehensive evaluation of most ppe described in the literature and used clinically. participants were well-represented across gender, geographic region, department/specialty, level of training, profession and type of health care facility. potential limitations of this study include small sample size, which may impact generalizability to the greater population of palestinians. another weakness of our study was the failure to elicit whether the lack of appropriate ppe was one of the driving factors in reducing hcw confidence in their preparedness. this would then imply attempts to target increasing ppe provision could both protect hcw and improve clinical confidence in managing covid-19 patients. potential selection bias arises due to sampling method. most study participants were recruited from social media posts and emails to the networks of the researchers involved, which may limit some of the study's generalizability. however, other studies have demonstrated the viability of social media recruitment and snowball sampling to access difficult to reach populations.(16) additionally, participants were asked to report on their individual experiences and thus may or may not be wholly representative of the institutions in which they are employed. the cross-sectional nature of this study is also by definition unable to take into account any changes in equipment or training preparedness over time and is only representative of the point-in-time data were collected. these limitations were acknowledged by the authors during study enrolment due to the need to publish findings within the international community in a time-sensitive manner and address the gap in literature regarding covid-19's unique impact on the population in the opt. low-to-middle income countries (lmics) are particularly vulnerable to the spread of disease because they often grapple with detrimental resource and financial constraints that existed prior to the spread of pandemic. opt and other lmics often not only lack proper infrastructure and resources, but also have to navigate restrictions on movement, travel and transportation of essential supplies. in this global pandemic, procurement of adequate supply of ppe and the development of necessary protocols specific to the unique needs and challenges of the region are urgently needed. ethical approval: ethical approval was not needed as the study did not involve patients or animals. however, participants consented to share their responses for research purposes. we declare no conflict of interest. . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 13, 2020. . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 13, 2020. . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 13, 2020. . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 13, 2020. . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 13, 2020. is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may 13, 2020. . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may 13, 2020. . https://doi.org/10.1101/2020.05.09.20096099 doi: medrxiv preprint coronavirus disease (covid-19) situation update 27 israel restricts unrwa coronavirus efforts in jerusalem refugee camps 2020 israel shuts palestinian coronavirus testing clinic in east jerusalem shortage of personal protective equipment endangering health workers worldwide 2020 personal protection prior to preoperative assessment-little more an anaesthesiologist can do to prevent sars-cov-2 transmission and covid-19 infection the use of personal protective equipment for control of influenza among critical care clinicians: a survey study strategies to optimize the supply of ppe and equipment personal protective equipment: protecting health care providers in an ebola outbreak novel coronavirus (2019-ncov): strategic prepardness and response plan sourcing personal protective equipment during the covid-19 pandemic awareness and preparedness of hospital staff against novel coronavirus (covid-2019): a global survey -study protocol self-reported use of personal protective equipment among chinese critical care clinicians during 2009 h1n1 influenza pandemic using social media and targeted snowball sampling to survey a hard-to-reach population: a case study key: cord-342642-qzoowc97 authors: garcía-méndez, nayely; lagarda cuevas, juan; otzen, tamara; manterola, carlos title: anesthesiologists and the high risk of exposure to covid-19 date: 2020-05-04 journal: anesth analg doi: 10.1213/ane.0000000000004919 sha: doc_id: 342642 cord_uid: qzoowc97 nan (1) ppe are all the set of elements and devices, that are specifically designed to protect the hcp against accidents and illnesses that could be caused by agents during the performance of their daily basis activities as well as in the emergency care; and (2) the occupational risk related to the exposure of the hcp must be identified and analyzed. 3 the joint commission international (jci) emphasizes that current status of ppe supplies remains inadequate to achieve minimum standards in most hospitals. the jci has been calling for action at all government levels to address the shortage and protect those who work heroically to care for infected patients with covid-19. we can confirm that in mexico, there have been "hospital outbreaks" with 329 hcps who have been infected with covid-19 throughout the country. planning an adequate distribution of ppe to health workers and developing appropriate strategies in clinics can diminish the impact of this pandemic on hcps. personal protective equipment for care of pandemic powered air purifying respirator prevención y control de infección en enfermedades respiratorias agudas con tendencia epidémica y pandémica durante la atención sanitaria pautas. available at: www.paho.org/es/documentos/ prevencion-control-infeccion-enfermedades-respiratoriasagudas-con-tendencia-epidemica para la vigilancia epidemiológica anesthesiologists and the high risk of exposure to covid-19 key: cord-316718-7gtgqmcn authors: murphy, d. l.; barnard, l. m.; drucker, c. j.; yang, b. y.; emert, j. m.; schwarcz, l.; counts, c. r.; jacinto, t. y.; mccoy, a. m.; morgan, t. a.; whitney, j. e.; bodenman, j. v.; duchin, j. s.; sayre, m. r.; rea, t. d. title: occupational exposures and programmatic response to covid-19 pandemic: an emergency medical services experience date: 2020-05-24 journal: nan doi: 10.1101/2020.05.22.20110718 sha: doc_id: 316718 cord_uid: 7gtgqmcn background rigorous assessment of occupational covid-19 risk and personal protective equipment (ppe) use are not well-described. we evaluated 9-1-1 emergency medical services (ems) encounters for patients with covid-19 to assess occupational exposure, programmatic strategies to reduce exposure, and ppe use. methods we conducted a retrospective cohort investigation of lab-confirmed covid-19 patients in king county, wa who received 9-1-1 ems responses from february 14, 2020 to march 26, 2020. we reviewed dispatch, ems, and public health surveillance records to evaluate the temporal relationship between exposure and programmatic changes to ems operations designed to identify high-risk patients, protect the workforce, and conserve ppe. results there were 274 ems encounters for 220 unique covid-19 patients involving 700 unique ems providers with 988 ems person-encounters. use of full ppe including mask, eye protection, gown and gloves (megg) was 67%. there were 151 person-exposures among 129 individuals, who required 981 quarantine days. of the 700 ems providers, 3 (0.4%) tested positive within 14 days of encounter. programmatic changes were associated with a temporal reduction in exposures. when stratified at the study encounters midpoint, 94% (142/151) of exposures occurred during the first 137 ems encounters compared to 6% (9/151) during the second 137 ems encounters (p<0.01). by the final week of the study period, ems deployed megg ppe in 34% (3579/10,468) of all ems person-encounters. conclusion less than 0.5% of ems providers experienced covid-19 illness within 14 days of occupational encounter. programmatic strategies were associated with a reduction in exposures, while achieving a measured use of ppe. the first case of 2019 novel coronavirus disease in king county, washington was reported on february 28, 2020. incidence rose exponentially in subsequent weeks. 1 emergency medical services (ems) are the front line of the healthcare system, responding with incomplete information to provide care in heterogeneous, often uncontrolled, circumstances. the covid-19 pandemic challenges healthcare worker safety in part because of limited supplies of personal protective equipment (ppe). ideally, ems strategies would incorporate covid-19 risk assessment and target use of the limited ppe resource in order to achieve ems provider safety, extend the supply of ppe, and support high-quality patient care. the us centers for disease control and prevention (cdc) established criteria for covid-19 testing and case management based on history and recent travel to a high-risk area, contact with known or suspected covid-19 cases, and presence of fever and signs/symptoms of lower respiratory illness. 2 based on national guidelines, our regional ems system initially adopted a screening framework based on travel, exposure to known cases, and specific symptoms. during the initial days and weeks of the outbreak, we identified long-term care facilities (ltcf) as highrisk locales and appreciated the atypical presentations involving covid-19 illness. 3, 4 as a consequence, we implemented a series of iterative protocol changes with regard to covid-19 risk assessment and ppe use based on the patient's clinical profile and response location. approximately 4,000 ems providers in king county. the study was approved by the university of washington institutional review board. the study population are ems providers who cared for patients with confirmed covid-19 by rt-pcr tests. ems is administered by public health-seattle & king county, enabling direct engagement between ems and public health to undertake covid-19 surveillance. to identify ems encounters with covid-19 patients, we linked local and state covid-19 surveillance systems with ems electronic records using the patient's name and date of birth. patient encounters were included if they occurred within a hierarchical, predetermined transmission window of 3 days prior to symptom onset (if known) or 14 days prior to or after the diagnosis date. each match was independently verified by an epidemiologist and physician. a physician reviewed each matched encounter for potential ems exposure in the electronic health record. if the documented ppe was not a complete ensemble of mask, eye protection, gown, and gloves (megg), the case was further investigated by the ems agency's appointed health officer ( figure 1 ). health officers contacted individuals with possible exposure to understand the specific circumstances of patient involvement and clarify ppe use. the health officer in consultation with physician leadership then made the final determination of exposure and whether quarantine or isolation was indicated according to the cdc risk assessment matrix. 7 an encounter was defined as a 9-1-1 ems response to a patient confirmed to have covid-19. an occupational exposure to covid-19 was defined as a provider-level encounter with inadequate ppe for the patient contact. in addition to eye protection and gloves, a surgical mask was judged to be sufficient for routine patient encounters. however, an n95 mask was required ppe for aerosol generating procedures. for any physical contact with the patient, a gown was required. ems agencies implemented regular employee symptom screening upon arrival at work and during the shift. anyone who felt unwell for any reason returned home until they were asymptomatic and fit for duty per their agency return to work guidelines. ems providers who became ill regardless of exposure status were deemed symptomatic, placed on isolation, and prioritized for covid-19 rt-pcr testing through dedicated first responder testing sites. these rt-pcr tests were performed by the university of washington virology laboratory using an assay shown to have a low false negative rate. 8 each ems agency assessed quarantined providers daily. the current investigation used information from both the health officer monitoring program and the public health surveillance to ascertain any covid-19 tests performed among the ems provider cohort. prior to the first lab-confirmed case of covid-19 in king county on february 28, 2020, ems medical direction issued directives for covid-19 screening and patient care on february 6 and february 27, 2020. beginning march 4, ems providers were advised to don full megg ppe if covid-19 screening included (1) a person with febrile respiratory illness and travel from an all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 24, 2020. . endemic area (initially wuhan, then broadened to china, south korea, iran, or italy) or (2) febrile respiratory illness and known contact with a confirmed covid-19 patient. after february 28, ems updated the high-risk criteria to include the first ltcf where initial cases were identified, with dispatch to alert "ppe advised" for any response to the address. after additional cases were identified at a second ltcf and a dialysis center, these sites were added as high-risk locations for dispatch. a growing list of ltcfs and congregate living centers soon followed. beginning march 7, ems began to treat all ltcfs (skilled nursing facilities, assisted living facilities and adult family homes) as high-risk requiring full megg ppe, regardless of clinical illness profile. with evidence of community transmission, the requirements for travel history or covid-19 contact were eliminated as criteria to don megg ppe during the first week of march. medical record review determined that ems covid-19 patients did not consistently demonstrate a febrile respiratory illness; criteria were expanded to include any respiratory or fever symptoms beginning march 11. case review indicated that initial symptom classification-often derived from dispatch reporting-did not adequately characterize illness and the potential for covid-19 illness. in response, ems was using large quantities of ppe to address this uncertainty, though the prevalence of confirmed covid-19 ems encounters was estimated to be less than 5%. 1 hence, ems leadership implemented a "scout program" beginning march 14 in which one or two ems providers donned full megg ppe and entered the "hot zone" to perform the initial in-person evaluation while additional crew remained in the "cold zone," maintaining sight or voice contact, with scout responder(s). the scout evaluation informed the need for remaining ems crew to don ppe to assist. conversely, risk assessment was often not feasible in high-acuity, time-sensitive cases. all cardiac arrest cases and cases requiring aerosol-generating therapies required full megg ppe with n95 masks. we used a uniform methodology to review the narrative and formatted data fields from dispatch and ems records. dispatch records were abstracted to characterize 9-1-1 patient concern and pre-arrival notifications. ems records were abstracted to describe patient characteristics, location, initial vital signs, disposition, clinician impression, and ppe use. ppe use was assessed through review of the ems report narrative and discrete data fields. following the first recognized case of covid-19 in king county, the ems leadership directed reporting of full ppe use in the electronic record. beginning march 20, mandatory, item-specific ppe reporting became available through the electronic health record (eso solutions, austin, tx) for all ems responses. ems provider quarantine dates and results from covid-19 testing were recorded. we evaluated the number of covid-19 patient encounters, ppe use, consequent exposures due to inadequate ppe, resulting quarantine, and positive covid-19 tests among ems providers. descriptive analyses were performed at the ems encounter and ems provider levels. ems encounters were stratified by level of transport while provider level assessments were stratified at the chronologic midpoint of ems encounters. due to a subset of providers with multiple patient encounters, we report provider level assessments as both total ems provider encounters and as unique ems providers. we used logistic regression to determine if calendar time was associated with a temporal trend in adequate ppe use and ems provider exposure. to estimate the potential conservation of ppe relative to an indiscriminate megg ppe deployment strategy (megg for all ems personnel for all calls), we determined the actual ppe use during the week of march 20-26 among the total number of ems providers involved on 9-1-1 responses. sas (version 9.4; sas institute) was used to conduct analyses. there were 220 unique patients with confirmed covid-19 in seattle and king county with 9-1-1 ems encounters in the 14 days prior to, and first 28 days after, the sentinel lab confirmed case in king county. of these 220 individuals, 54 had two ems encounters for a total of 274 distinct ems encounters. half were female (53%), and the mean age was 74 years. the dispatch complaints were heterogenous; difficulty breathing was the most common complaint, accounting for about 25% ( table 1 ). the mean initial pulse oximetry reading was 90%. the most common ems impressions included suspected covid-19 illness (26%), flu-like symptoms (17%), respiratory distress (17%), and weakness (14%). among the 274 ems encounters with covid-19 patients, there were 429 responding units, involving 700 unique ems providers with a total of 988 ems provider encounters (table 2) . based on initial ems record review, use of ppe during patient contact was full megg (66.9%), basic gloves and eye protection (29.3%), delayed application or partial megg (3.1%), or unknown (0.7%), resulting in 327 possible ems provider exposures. after health officer investigation and physician consultation, 151 ems provider encounters were determined to have an exposure. as a result, there were 129 unique ems providers placed on quarantine: 107 after a single exposure and 22 with two exposures. of the 700 unique ems providers caring for patients with confirmed covid-19, 3 (0.4%) tested positive during the 14 days following an encounter (table 3 ), yet none of these three had a documented occupational exposure. the series of practice changes involving dispatch advisement, patient covid-19 risk criteria, and initial ems scene deployment were associated with a temporal increase in adequate ppe use and conversely a decrease in ems provider exposures (figure 2, p<0.01) . when stratified at the encounters midpoint, 94% (142/151) of exposures occurred during the first 137 ems encounters compared to 6% (9/151) during the second 137 ems encounters (table 2, p<0.01).the number of ems providers quarantined each day increased to a peak of 69 on march 13th and then declined (figure 3 ). during the final week of the study (march 20-26), there were a total of 3,704 ems incidents involving 10,468 ems providers. of the 10,468 opportunities for ppe deployment, megg ppe was used in 3,579 (34%) ems provider encounters. in this population-based observational investigation of 274 ems encounters for patients with covid-19 involving nearly 1,000 ems provider-encounters, three ems providers subsequently tested positive for covid-19 during the 14 days following the patient encounter. iterative dispatch and operational ems responses to covid-19 risk identification and ppe use were associated with both a temporal decrease in ems provider covid-19 exposure and conservation of ppe. based on these programmatic efforts, full megg ppe was deployed in about one-third of all potential ems provider uses by the end of the study period. although healthcare workers (hcw) seem to be at higher risk to contract covid-19, rigorous assessment of exposure and transmission is largely lacking. epidemiological reports from china and italy highlight the substantial burden of illness in hcws. [9] [10] [11] locally, in washington state, a large portion of ltcf staff tested positive for covid-19. 3 a preliminary report from cdc regarding the burden of covid-19 infection among us healthcare personnel suggest hcws account for 11-19% of national case burden, but did not discern specific type of employment or evaluate the potential source of exposure. 12 other reports involving high-risk circumstances involving aerosolizing procedures however have not observed substantial rates of transmission to hcws. 13 similar to our findings, a taiwanese study reported a secondary attack rate of 0.9% among the subset of covid-19 exposures occurring in the healthcare setting. 14 none of these experiences have reported risk to ems providers, though ems care appears to be integral for sicker covid-19 patients. in the 2009 sars outbreak, the overall incidence of infection was 1.3% in the taiwanese ems workforce, which was >100-fold higher than the general public. 15 in the current investigation, ems had substantial involvement with covid-19 illness. the 220 patients represented 14% of all covid-19 diagnoses in king county, wa through march 26. ems was typically involved in care for older adults who often presented with heterogeneous symptoms and a range of clinical presentations. covid-19 in king county was first detected in a clinical population not considered high-risk according to national guidelines at that time, which accounted in part for the fact that 18% of ems providers in the study had an exposure. indeed, 85.4% of patients had not been diagnosed with covid-19 at the time of their ems encounter. the high rate of quarantine early on motivated the ems system to move quickly to adapt to the evolving clinical features and local epidemiology of the covid-19 outbreak. ems leadership engaged dispatch and operations to expand covid-19 risk criteria and to stage patient assessment. the set of measures was associated with a marked reduction in the risk of exposure over the course of investigation. certainly, there was a learning curve that may have also contributed to reduction in exposure. the collective effect appears to be a temporal reduction in ems worker quarantine, even though the number of provider encounters with covid-19 increased over time (figure 2 ). all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 24, 2020. . we observed that three of the 700 ems providers (0.4%) with covid-19 encounters subsequently tested positive for covid-19. one case occurred at the outset of the outbreak with onset of provider illness occurring on the same date of covid-19 encounter. the cdc investigated this case and determined that the 9-1-1 incident that qualified the provider for study inclusion was not responsible for disease transmission. nonetheless, the provider may have had a patient exposure in the days prior to identification of covid-19 cases in king county, as further review confirmed care for patients with acute respiratory illness. the providers in all three cases had megg ppe during their qualifying encounters. we cannot determine whether transmission occurred during these patient-specific exposures, other occupational activities, or community transmission. overall, the cumulative lab-confirmed prevalence in this ems cohort of 700 unique providers (0.4%) is comparable to the community prevalence (0.2%) during this time frame. 1 taken together, these findings suggest that occupational risk can be relatively low and that protective measures can potentially limit disease transmission. the anecdotal experiences in other regions reporting high rates of covid-19 among ems providers may be related to the higher prevalence of disease paired with limited availability and use of ppe. there is an inherent tension between proactive measures to don adequate ppe and conservation efforts due to limited supplies. if ppe were limitless, then indiscriminate use by all providers for every call would help assure ems provider protection. however, our system had limited supply that was coupled with uncertainty about the severity and duration of the pandemic. thus, the ems system strived to target the use of ppe to risk positive patients. the scout strategy for stable patients enabled more deliberate decisions regarding ppe. in contrast, time-critical events such as cardiac arrest required comprehensive ems ppe given the need for care prior to evaluating covid-19 risk. the current targeted strategies for megg utilization appear to be a viable means to protect ems providers and conserve ppe. the retrospective methodology used to assess ppe is imperfect, relying on documentation and case-specific investigation; the two-stage process however enabled detailed provider interviews to assess potential exposure. provider documentation may introduce bias, although providers were motivated to accurately document ppe. providers received training and education on bestpractices of donning and doffing of ppe, but there was not a dedicated observer to document the quality of the process. the study could not report on the temporal use of ppe across the system, but rather the status after implementation of various interventions designed to better assess covid-19 risk and responsibly use ppe. documentation of quarantine evolved during the study period to use a central monitoring database. thus, quarantine decisions early in the outbreak may be an underestimate of quarantine. we relied on the statewide washington disease reporting system database to identify covid-19 positive patients. there likely were patients ill with covid-19 who interfaced with ems but were not tested. alternatively, ems encounters with covid-19 positive patients may exist that were not captured due to failed linking of identifiers between ems and surveillance databases. the study relied on ems agency health officers and the washington disease reporting system database to identify ems providers tested for covid-19. although unlikely, this dual approach may have missed a lab-confirmed infection in an ems provider. ems providers may also have all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 24, 2020. . chosen not to get tested or had asymptomatic infection, though symptomatic providers were motivated to be tested and had prioritized access to testing. we cannot confirm the source of the infectious exposure-patient-specific, other occupational, or community transmission-among the few providers with positive tests. in conclusion, less than 0.5% of ems providers experienced covid-19 illness within 14 days of caring for a patient with lab-confirmed covid-19. programmatic risk mitigation strategies were associated with a reduction in occupational exposures to covid-19 among ems providers, while achieving a measured use of ppe. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 24, 2020. . all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 24, 2020. . public health-seattle & king county. covid-19 data dashboard update and interim guidance on outbreak of coronavirus disease 2019 (covid-19) clinical characteristics of coronavirus disease 2019 in china epidemiology of covid-19 in a long-term care facility in king county, washington cryptic transmission of sars-cov-2 in washington state first death due to novel coronavirus (covid-19) in a resident of king county guidance for risk assessment and public health management of healthcare personnel with potential exposure in a healthcare setting to patients with coronavirus disease (covid-19) occurrence and timing of subsequent sars-cov-2 rt-pcr positivity among initially negative patients clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention case-fatality rate and characteristics of patients dying in relation to covid-19 in italy characteristics of health care personnel with covid-19 -united states covid-19 and the risk to health care workers: a case report contact tracing assessment of covid-19 transmission dynamics in taiwan and risk at different exposure periods before and after symptom onset emergency medical services utilization during an outbreak of severe acute respiratory syndrome (sars) and the incidence of sars-associated coronavirus infection among emergency medical technicians we wish to acknowledge public health -seattle & king county, the washington state department of health, the centers for disease control, and the telecommunicators and ems professionals of seattle and greater king county. all rights reserved. no reuse allowed without permission. key: cord-314492-483rn3aw authors: gallagher, jennifer e.; johnson, ilona; verbeek, jos h.; clarkson, janet e.; innes, nicola title: relevance and paucity of evidence: a dental perspective on personal protective equipment during the covid-19 pandemic date: 2020-07-24 journal: br dent j doi: 10.1038/s41415-020-1843-9 sha: doc_id: 314492 cord_uid: 483rn3aw the global covid-19 pandemic, caused by the sars-cov-2 virus, has highlighted the importance of personal protective equipment (ppe) for health and social care personnel. this is a really important issue for dentistry, where we place great emphasis on infection control and universal precautions, given the nature of care provided. cochrane have recently updated their review of ppe for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. it examined evidence on which type of full body ppe and which method of donning (putting on) or doffing (removing) are most effective, while having the least risk of contamination or infection for healthcare workers, as well as which training methods increase compliance with ppe protocols. the objective of this paper is to raise awareness of the above review of ppe, its findings and their relevance to dentistry as outlined in the cochrane oral health website. the available evidence comes from healthcare generally, mostly involving simulation exercises, and is of low or very low certainty. none of the evidence specifically comes from dentistry. the findings in relation to the nature of ppe, methods of donning and doffing, and the importance of training are all of practical relevance to dentistry. research is critically important to provide evidence for future decision making in support of patients and staff. the global covid-19 pandemic, caused by the sars-cov-2 virus, 1 has highlighted the importance of personal protective equipment (ppe) for health and social care personnel. it is important to acknowledge from the outset that ppe has proved a contentious issue across health and social care generally across the united kingdom (uk), and beyond, and is one that will need to be resolved practically moving forwards. this is of critical importance to dentistry, where we have historically placed great emphasis on infection control and universal precautions, given the nature of care provided. based on evidence to date, the world health organisation suggests that transmission of the sars-cov-2 virus is mainly via respiratory droplet and contact routes, with transmission being possible through aerosol generating procedures (agps). 2 droplet transmission occurs when a person is in close contact (within 1 m) with someone who has respiratory symptoms (for example, coughing or sneezing) and is therefore at risk of having his/her mucosae (mouth and nose) or conjunctiva (eyes) exposed to potentially infective respiratory droplets. person-toperson transmission routes for covid-19 disease can involve direct and indirect contact, 2 and it is important to recognise that this coronavirus is present in saliva. 3, 4, 5 sars-cov-2 is a novel coronavirus and, because of the nature of their occupation, healthcare workers (hcws) are often at greater risk of infection than the general population. 6 deaths of colleagues across healthcare have highlighted these risks, leading to concern and calls for greater protection for staff. appropriate ppe offers an important way of reducing the risk of infection during the provision of healthcare. highly infectious diseases due to exposure to contaminated body fluids, in healthcare staff ' . 8 it reviewed contemporary evidence on 'which type of full-body ppe and which method of donning (putting on) or doffing (removing) ppe have the least risk of contamination or infection for hcw, and which training methods increase compliance with ppe protocols' . 8 the evidence from this review is of great importance where there is a risk of highly infectious diseases, and even though covid-19 is no longer considered to be a high consequence disease in the uk, 9 its findings remain relevant to the current pandemic 10 and continue to be updated. the objective of this paper is to raise awareness of the findings of the above review of ppe 8 and explore their relevance to dentistry, building on our commentary presented on the cochrane oral health website. 10 cochrane synthesises the best available evidence using rigorous methodology to answer specific research questions, thus drawing on the body of evidence available to inform decision-making, 11 using thorough methods. 12 the covid cochrane group are prioritising questions related to covid-19, 13 reviewing the literature and synthesising wide-ranging data in a matter of weeks rather than the usual extended period of at least two years. 14 groups have prioritised this task and are collaborating where interventions are common across profession groups or health conditions. it involves rapid peer review of protocols and search strategies, working many extra hours to complete them as quickly as possible without compromising their quality, with final peer review and editing before publication. one example is the fast-tracking of this review of ppe for all hcws. 7,8 current work by cochrane oral health includes rapid reviews of mouthwashes and nasal sprays, and methods to reduce aerosols produced during agps, as well as a rapid review of international dental guidelines for return to dental services. 15 the ppe review questions for hcws are relevant to the practice of dentistry and all dental professionals working in clinical settings, including dentists, dental hygienists, dental nurses, dental therapists, orthodontic therapists, dental technicians and clinical dental technicians, along with reception and cleaning staff and practice managers. 10 clinical members of the dental team work in close proximity, usually face-to-face, with patients and often for sustained periods of time. over and above the risk associated with proximity to potentially infected individuals, during routine care, they are exposed to saliva and blood and carry out agps (for example, use of high-speed air rotors and ultrasonic scalers). for covid-19, personal protection entails preventing droplets from entering their mouth, nose or eyes and preventing them from contaminating the skin elsewhere. this makes the findings of the review highly relevant to the dental profession. although there is no evidence to say that dental procedures increase the likelihood of patients coughing, if they do, clinicians are in close proximity. this further increases the chance of aerosol and droplet generation, as well as infected material settling on environmental surfaces and on ppe. while the search included a broad range of hcws, only 24 studies (controlled studies, either randomised or non-randomised) were included, most from simulation exercises and none directly associated with dentistry. 8 in the midst of an acute situation where the primary evidence is difficult, and probably impossible to generate with enough speed to be useful, a judgement has to be made on how confident we are that the findings of this review can be applied to the dental care setting. however, in the absence of direct evidence from studies situated in a dental setting, we have to take note of, and realistically apply, the general evidence. it is important to note that 'the certainty of the evidence presented in the review, 8 across all comparisons, was judged to be low or very low' 10 for a range of reasons. this related to the paucity of research addressing each of the questions, together with the fact that much of the available research involved simulations of exposure rather than research in real-life conditions, small sample sizes, high or unclear risk of bias and insufficient detail on whether the ppe used fitted international standards for protective clothing. 8, 10 furthermore, most of the research understandably used harmless microbes or fluorescent markers rather than microbes or viruses of concern. 8,10 nonetheless, its key findings, against which the questions were relevant to dentistry, are important given the above caveats (box 1). while it is important to acknowledge that 'members of the dental team are very experienced in the use of standard ppe, most work within primary care settings, and may be less familiar with the more extensive forms of ppe' , 10 although this is rapidly changing. the cochrane review suggests that 'covering more of the body' leads to 'better protection.' 8 this included gowns providing better protection than just an apron. 8 the evidence suggests that added coverage provided by a coverall (one-piece suit) when compared with a gown comes at a cost in terms of increased 'difficulty in doffing' such ppe. 8 while there were initial concerns that challenges with doffing increased the risk of contamination, current evidence suggests that, in 'more recently introduced full-body ppe ensembles, there may be no difference in contamination' . 8 the review also suggests that 'ppe made from more breathable material may help increase user satisfaction, with little impact on contamination. ' 10 the head and neck areas of the dental team are particularly at risk for hcws during clinical dental procedures. 10 thus, ensuring ppe coverage is adequate to protect these areas is an important aspect of its effectiveness; in addition, 'better fitting ppe' in this region, 'sealed gown and glove combinations' to protect wrists, and certain design features such as 'tabs to "grab" during doffing and donning' may help to reduce the risk of contamination. 8, 10 overall, ppe should provide full coverage but not be too cumbersome. it is important not to make the mistake of assuming that just 'having' face masks and other elements of enhanced ppe is 'good enough' . dental professionals also need to be aware of the risks of contamination associated with donning and, in particular, doffing ppe. space for these processes will need to be considered as part of dental surgery organisation where care is being delivered, as well as the time involved. training in donning and doffing is particularly important for dental teams who may not wear this type of ppe for routine practice or who may need to learn new, safer habits carefully. the presence of an observer, in particular for doffing ppe, should be considered. teams should consider face-toface training opportunities as they may reduce the likelihood of errors, alongside computer simulation or videos which may also support these skills. 8,10 the cochrane review makes a strong case for building evidence to inform decisions on the 'most appropriate manageable protection' , 8 including 'modifications for hcws' . 8 we concur that this is essential for dentistry, if dental teams are to deliver care safely. 10 it also 'provides helpful insights on the research required, and the importance of registering and coordinating research with comparable outcomes' . 10 we need to consider how we can best do this across the four nations of the uk and connect with our global partners who are also facing the same issues. there is an opportunity, during this covid-19 outbreak, to use the natural experimental setting that dental care centres provide to create the evidence we need on health outcomes and personnel involved. 10 these opportunities include, but are not limited to, the issues of viral transmission rates, those related directly to the training, education and use of ppe, as well as how this affects patient care. 8, 10 trials in dental care settings safe provision of dental care requires a deep understanding of pathogen transmission and how it relates to the various types of care provided; for example, agps and non-agps. 10 trials using high-quality and standardised methodology considering the spread and settle of demonstration pathogens or surrogate measures in dental settings are key, and these should consider the array of different procedures that are considered to generate aerosols. it is worth noting that fluorescent dyes or harmless bacteria and viruses have been used for much of the higher quality simulated research in the past. 8 they should include all relevant settings and consider single and multiple surgeries as well as laboratories and domiciliary care. 10 studies should be well-designed and of sufficient sample size, with agreed outcomes. 8 crossover studies should be conducted where possible. details of education and training, fit testing, equipment used (including standards), dental examination and special investigations and procedure(s), length of appointment, nature of patient(s), technique of dental care, donning and doffing processes, environment and a range of outcomes should be recorded. 10 we need to know the most appropriate type of ppe for clinical encounters with different potential exposure levels. for example, it would be helpful to confirm whether standard ppe is adequate for an oral examination while more elaborate ppe, even with its drawbacks, is necessary for treatments where aerosols are actively generated during the procedure. also, are the types of ppe required for dental professionals carrying out routine care during peak phases of the covid-19 pandemic still required for the post-peak phase? in addition, there needs to be an understanding of the amount of time that recommended ppe can be worn comfortably. simulation exercises involving comparison of different levels of ppe will be particularly helpful to inform standard requirements for different aspects of dental care. 10 this includes the effect of masks, face shields and goggles. 10 furthermore, we will also need to consider shielded patients and the best way of affording them the necessary protection as well as staff. while we have considered the review in a dental context, we currently lack critical knowledge on whether viral load and shedding are similar in asymptomatic individuals 16 and to what extent this presents a risk in dentistry. 17 evidence in these areas would allow better understanding of appropriate ppe. we also need to deepen our understanding of aerosol generation generally, 18 as well as specifically in relation to viruses in dental settings. given the burden of oral disease 19 and the evidence that transmission of sars-cov-2 by seemingly well individuals (pre-symptomatic and asymptomatic), we need to seriously consider how our patient and population needs are best met for the future. models indicate that pre-symptomatic individuals alone may account for 30-62% of events (confirmed covid cases). 20, 21, 22, 23 it is important to remember that most patients attending for dental care will be covid-negative. important questions are being debated regarding the nature and extent of universal precautions, and whether we should adopt a precautionary principle to protect our dental teams and patients until more is known and these can be confidently relaxed. measures such as self-isolation and testing are now being suggested to reduce risk associated with planned and urgent care in key findings: • coverage: there is better protection from covering more parts of the body, but this has to be balanced against the possible increase in risk of contamination associated with difficulty donning or doffing, as well as less user comfort hospital settings. 24 ppe should be considered after risk assessment and as just one issue in a larger preventive approach, including aerosol, droplet and splatter reduction and ventilation. risk reduction must be considered along with other major challenges to our staff 's health and wellbeing, including the nature of care and the complex business of dentistry. we do not have all the answers about universal precautions for the future, but all dental professionals will need to take action in identifying and managing risk in line with national guidance and learning from our colleagues around the world. we have to be able to justify our actions in managing risk, and collect evidence and be prepared to adapt where necessary. having ppe is important, but so is wearing it properly and removing it safely; it is important to remember that ppe is just one way of protecting dental professionals and patients, all of which require careful consideration and research to inform our journey back to what may become a 'new normal' . naming the coronavirus disease (covid-19) and the virus that causes it modes of transmission of virus causing covid-19: implications for ipc precaution recommendations temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by sarscov2: an observational cohort study consistent detection of 2019 novel coronavirus in saliva human saliva: non-invasive fluid for detecting novel coronavirus (2019-ncov) epidemiology of and risk factors for coronavirus infection in health care workers personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff high consequence infectious diseases (hcid) -status of covid-19 personal protective equipment: a commentary for the dental and oral health care team about cochrane reviews cochrane handbook for systematic reviews of interventions half of cochrane reviews were published more than two years after the protocol available at https:// oralhealth.cochrane.org sarscov2 viral load in upper respiratory specimens of infected patients bacterial aerosols in dental practice -a potential hospital infection problem? editor's commentary: rapid reviews of ppe -an update global burden of oral conditions in 1990-2010: a systematic analysis quantifying sarscov2 transmission suggests epidemic control with digital contact tracing substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov2) estimating the generation interval for covid-19 based on symptom onset data temporal dynamics in viral shedding and transmissibility of covid-19 operating framework for urgent and planned services in hospital settings during covid-19 professor a. m. glenny, cochrane oral health. key: cord-341715-8h57tppr authors: sernicola, alvise; chello, camilla; cerbelli, edoardo; adebanjo, ganiyat adenike ralitsa; parisella, francesca romana; pezzuto, aldo; luzi, fabiola; de marco, gabriella; rello, jordi; tammaro, antonella title: treatment of nasal bridge ulceration related to protective measures for the covid‐19 epidemic date: 2020-05-07 journal: int wound j doi: 10.1111/iwj.13397 sha: doc_id: 341715 cord_uid: 8h57tppr nan health care workers (hcws) in the front line against covid-19 are exposed to skin barrier damage. effective use of personal protective equipment (ppe) is of paramount importance to reduce the rates of infection among medical personnel, which is a leading cause of nosocomial spread among hospitalised patients and of loss of response capacity for health facilities, with hcws constituting up to nine percent of total covid-19 cases. 1, 2 cleaning-and glove-related hand protection and maskand goggles-related face protection play a substantial role in preventing the spread of the virus not only from respiratory droplets directly to mucosa but also from indirect surface contact through hand-to-face touching. 3 skin damage related to protective measures is common, occurring in up to 97.0% of frontline hcws; the main target skin site is the nasal bridge, which is involved in 83.1% of subjects. 4 it is thought that the pressure and abrasive effect of goggles combined with the n95 mask are responsible for lesions observed in this site, ranging from mild irritations to erosions and ulcers. 4 in addition, some individuals may be sensitised to components of n95 masks requiring the use of different full-face equipment that may not be widely available. 5 risk of skin lesions in hcws increases for n95 masks or goggles when they are worn for over six consecutive working hours, but not for full-face shields. 4 also, hcws commonly wear face masks after shifts. discomfort due to irritation may lead to improper ppe use or inadvertent face touching while damaged skin barrier adds an entry route for covid-19. 6 what measures can we adopt to treat and to ultimately prevent occupational injuries to the skin and related risk of infection that threaten to reduce the active hospital workforce during the covid-19 epidemic? we present the case of a nurse who consulted our dermatology department complaining itching ulceration of the nasal bridge developing after implementation of enhanced protective measures. the subject is employed in an inpatient ward of our hospital, requiring the continuous use of an n95 mask through daily 8-hour work shifts. no personal history of skin complaints or contact allergen sensitisation was reported. skin examination showed an area of non-blanchable erythema and abrasion involving the epidermis clinically suggestive for a superficial grade 2 pressure ulcer ( figure 1a) . we prescribed the application of a thin hydrocolloid dressing (duoderm cgf, convatec inc, greensboro, north carolina) cut to a diamond shape above the lesion in order to provide secure protection from mechanical injury and infection while encouraging healing processes. we reassessed the patient after 72 hours, appreciating the return to intact skin ( figure 1b) . burning sensation and itching associated with skin damage is reported in up to 71% of hcw wearing enhanced ppe during the current epidemic, according to a study involving 330 subjects. 7 cutaneous lesions range from mild erythema to papules and pustules to maceration of the skin. moreover, prolonged use of face protection may cause vesicles and blisters due to persistent friction that eventually rupture and expose the underlying skin to the entry of pathogens. masks and goggles must be firmly applied to the face to be effectively protected, further increasing the pressure on the nose. some authors suggest the application of emollient creams or of hydropathic gauze soaked in cold water or saline solution for about 20 minutes to maintain skin integrity and protect from the risk of lesions, while the use of iodopovidone dressing together with local antibiotics is recommended in case of injuries. 7 however, these measures do not protect against pressure injury, and incorrect application of moisturisers before and after wearing ppe may be responsible for an increased risk of infection. 8 patients requiring non-invasive ventilation (niv) provide an excellent study model for the management of pressure lesions on the nasal bridge as the high pressure generated by the ventilator mask for a prolonged time, together with the influence of shear stress between inspiratory and expiratory phases, determines a high risk of ulcer formation in this site. 9 a 2019 study analysed the use of hydrocolloid medication in patients requiring niv demonstrating a significantly reduced incidence of grade 2 pressure ulcers when a preventative hydrocolloid dressing was positioned on the nasal bridge compared with when the niv mask was directly applied. 10 hydrocolloids consist of dressings, with variable absorbability, elasticity, and strength that are made of hydrophilic particles, such as pectin, carboxymethylcellulose, and polymers, within a gelatinous substance. hydrocolloids are widely used in the treatment of ulcers with mild exudate, specifically those induced by pressure and those of the lower limbs. the application of hydrocolloids to the treatment and prevention of pressure ulcers of the nasal bridge is supported by the specific properties of these advanced medications. 11 dressings are self-adhesive to both dry and oily skin-such as that of the forehead, nose, and chin, which is particularly rich in sebaceous glands-, absorbent, reducing the risk of maceration, impermeable to gas, water, and vapour, reducing the risk of infection even through droplet transmission. in conclusion, during this period of emergency, all measures must be taken to limit virus spread in the hospital environment, and the effective use of ppe is of vital importance for the safeguard of hcws and patients. however, the correct application of devices to the face carries an increased risk of erosive and ulcerative skin lesions, which may result in reduced efficacy of protection protocols and risk of pathogen entry. we propose the use of a hydrocolloid dressing that successfully treated nasal bridge ulceration in our patient, to be applied as a simple and effective protection procedure in this setting, thanks to the specific properties of this advanced medication. what other countries can learn from italy during the covid-19 pandemic letter from the editor: occupational skin disease among healthcare workers during the coronavirus (covid-19) epidemic return to intact skin after application of a thin hydrocolloid dressing cut to a diamond shape above the lesion (b) face touching: a frequent habit that has implications for hand hygiene skin damage among healthcare workers managing coronavirus disease-2019 skin reactions following use of n95 facial masks rational hand hygiene during covid-19 pandemic consensus of chinese experts on protection of skin and mucous membrane barrier for healthcare workers fighting against coronavirus disease 2019 behavioral considerations and impact on personal protective equipment (ppe) use: early lessons from the coronavirus (covid-19) outbreak determinants of skin contact pressure formation during non-invasive ventilation the preventative effect of hydrocolloid dressings on nasal bridge pressure ulceration in acute noninvasive ventilation dressings and topical agents for preventing pressure ulcers key: cord-345210-6f8niif5 authors: tadavarthy, silpa n.; finnegan, kerriann; bernatowicz, gretchen; lowe, elisha; coffin, susan e; manning, marylou title: developing and implementing an infection prevention and control program for a covid-19 alternative care site in philadelphia, pa date: 2020-07-19 journal: am j infect control doi: 10.1016/j.ajic.2020.07.006 sha: doc_id: 345210 cord_uid: 6f8niif5 background: on march 27, 2020, the city of philadelphia was given permission by temple university to convert the liacouras center gymnasium to an alternate care site (acs) to treat low-acuity covid-19 patients. acs's, especially those created to specifically care for infectious patients, require a robust infection prevention and control (ipc) program. methods: the ipc program was led by a physician and nurse partnership, both of whom had substantial experience developing ipc programs in u.s. and low-resource settings. the ipc program was framed on a previously described conceptual model commonly referred to as the “4s's”: space, staff, stuff, and systems. results: the gymnasium was transformed into red, yellow and green infection hazard zones. the ipc team trained 425 staff in critical ipc practices and personal protective equipment (ppe) standards. systems to detect staff illness were created and over 3550 staff health screening surveys completed. discussion: use of existing guidance and comprehensive facility and patient management assessments guided the development of the ipc program. program priorities were to keep staff and patients safe and implement procedures to judiciously use limited resources that affect infection transmission. conclusion: planning, executing and evaluating ipc standards and requirements of an acs during a pandemic requires creative and nimble strategies to adapt, substitute, conserve, reuse, and reallocate ipc space, staff, stuff and systems. on january 21, 2020, the first case of laboratory-confirmed infection due to the novel virus severe acute respiratory syndrome coronavirus 2 (sars-cov-2) in the united states was identified in seattle, washington. six weeks later, in early march, the first person in pennsylvania was diagnosed with coronavirus disease-19 (covid-19) disease. the subsequent rapid growth in covid-19 cases in the philadelphia region led most acute care hospitals to suspend non-urgent procedures and hospitalizations by mid-march. very quickly, hospitals were required to assess their surge capacity in preparation for a possible largescale, public health emergency. 1 despite individual facilities' efforts to accommodate a surge in patients with moderate-to-severe covid-19, multiple acute care hospitals in philadelphia began to experience a surge in demand just three weeks after the first confirmed case was identified. on march 27, temple university granted the city of philadelphia permission to use the liacouras center as an overflow medical facility for low-acuity covid-19 patients. 2 setting: philadelphia is the sixth largest city in the u.s. with a population of over 1.5 million people. it is also the poorest large city in the country. most hospital beds are in facilities that are members of extensive healthcare networks. according to 2018 data, philadelphia county has approximately 5,320 adult staffed medical-surgical beds and 940 intensive care unit (icu) beds, 3 although pandemic planning included identifying additional hospital beds in each facility in the event of a surge of demand. 4 the temple university liacouras center is known as a premiere basketball facility and provides a unique and flexible space, which is also used for concerts, banquets and trade shows. it is one of the largest indoor, public assembly venues in philadelphia. the initial material assets of the csf-l were provided by fema. key materials included: cots, commodes, walkers, bathing equipment, medical monitoring equipment, portable non-plumbed sinks, sharps containers, infectious waste receptacles, alcohol-based hand rub, and personal protective equipment (ppe). method: we utilized a previously described conceptual model to assess disaster responses and surge capacity, commonly referred to as the -4s's‖: space, staff, stuff, and systems. [5] [6] [7] this framework guided our development of a novel ipc program for this surge facility. in this article, we describe the -4s's‖ of our program developed for the csf-l and the related challenges at a covid-19 alternative care site. the rapid creation and unusual configuration of this facility, together with the challenges of new clinical teams unfamiliar with one another, and working together in uncomfortable ppe to provide high-quality patient care, necessitated some basic approaches to the development of our ipc program. these included: 1. use of existing guidelines and other resources from expert groups whenever available 8, 9 2. adapt existing guidance to apply to the unique conditions of the surge field hospital 3. standardize ipc processes to ensure the safety of patients and staff because the liacouras center was neither designed nor engineered to care for patients, a comprehensive environmental and occupational risk assessment was undertaken prior to facility opening. environmental health and safety experts, together with leaders of the ipc team, conducted an -all-hazard‖ risk assessment of the site for actual or potential risks to patients or staff; this team produced a comprehensive health and safety plan for the csf-l. the plan identified the need for engineering controls (e.g. specifications for heating, ventilation, and air conditioning systems) and specified occupational ipc health and safety requirements, including ppe standards, daily monitoring of staff for acute illness, sanitation standards for both hand hygiene and equipment sanitation, as well as laundry and waste management recommendations. the identified ipc hazards and risk reduction plans, priorities and progress were reported and addressed by the csf-l team before the facility moved forward in development. a facility map was created that designated -red, yellow, and green zones,‖ each with a different level of infection risk and expectation for ipc practices and ppe use. colored tape was placed on the floor to provide visual cues. separate entrance and exit paths were designated for both staff and patients. the patient care and decontamination areas were designated as -red zone‖, requiring the highest level of ppe and to which physical access was strictly controlled. the -green zone‖ included the facility entrance and hallways leading to the staff locker room; only surgical masks were required while in these areas. the -yellow zone‖ was the interface between -red zone‖ and -green zone‖ where staff donned and doffed ppe. nearby liacouras offices were converted into ppe storage and distribution rooms. the ipc team was led by a member of the pdph's healthcare-associated infections and antimicrobial resistance team (sec) and a highly experienced nurse certified in ipc (mlm). collectively, these coleaders have over 50 years of experience serving as local, national and international consultants and trainers for ipc programs. additional critical ipc team members included temple university medical students (st and kf), a nurse practitioner experienced in family medicine and college health and a registered nurse experienced in ipc (gb and el). our team worked in concert with the pdph and oem staff onsite as well as the csf-l leadership team. given the unique setting, heterogenous background of staff and challenges preventing nosocomial transmission of the sars-cov-2 virus and other potential healthcare associated infections, infection preventionist (ip) coverage of the -red zone‖ on all shifts was considered an integral component of the ipc plan. a call for volunteers from the local chapter of the association for professionals in infection control and epidemiology (apic) was released via the chapter listserv. interested and available ips were instructed to register through the philadelphia mrc website. however, recruiting these ips was a lofty goal given the intense increase of ip workload in their own facilities, so we began to seek ip designees, such as nurses or public health experts with advanced ipc knowledge. 10 monitor. it was important to have a core group of individuals assigned to these roles as their responsibilities included being familiar with policies and providing focused coaching to ensure staff adherence to essential infection prevention practices. the fema medical station cache provided resources for a 250-bed facility. the included ipc resources included 1,070 n95 respirators of various sizes and models, 3 fit test kits, 900 surgical masks, 300 disposable isolation gowns, 192 face shields, and over 100 boxes of non-sterile examination gloves of various sizes. the cache also included 5 portable, non-plumbed sinks and alcohol-based hand rub. additional ppe resources were continuously being sought and obtained through vendors as well as private and public donations. the availability and maintenance of the ppe inventory was critical for csf-l operation. prior to opening, a baseline inventory of every item was established and the ppe distribution room was organized to maximize space and to improve the efficiency of distribution. it was staffed 24 hours per day by a consistent group of registered nurses and two members of the dod to standardize the process. all staff entering the patient care area (-red zone‖) received an isolation gown, a face shield, and a fit-tested n95 respirator from the ppe distributor. their name and the items they received were recorded by hand in the ppe distribution log. this process was repeated each time the staff member entered the patient care area at the start of their shift and after each scheduled break. staff received a new or reprocessed n95 respirator each time they entered or re-entered the -red zone.‖ a running count of all items distributed was recorded every six hours on the daily ppe inventory tracking form. stock delivered to the ppe distribution room and items returned to stock after reprocessing were also recorded here. the numbers from the previous 24 hours were reconciled at the start of each day and entered by hand into the master inventory spreadsheet. key process indicator reports outlining the number of days on hand of each item were generated daily and shared with the leadership team. all ppe, except gloves and surgical masks, was reprocessed. face shields, safety glasses and goggles were disinfected on site by the decontamination staff in a designated, well-ventilated area away from patient care and all other activities, with a hospital-grade disinfectant. n95 respirators were reprocessed using a bioquell hydrogen peroxide vapor decontamination facility developed by a local hospital to maintain their own ppe supply. the used n95 respirators were prepared and packaged for transport by the waste management staff and were transported to and from the reprocessing facility every other day. isolation gowns were reprocessed daily by a medical laundry service. all reprocessed items were then returned to the ppe distribution room and logged into the inventory tracking form. one point of entry into csf-l was established for all staff to ensure security and facilitate health screening. this area was staffed 24 hours per day by security personnel and a staff entrance surveillance monitor. staff entering the building were required to wear a personal face mask and remain six feet apart from other personnel at all times; if someone did not have a mask, a surgical mask was provided. surveillance was intended to identify individuals with clinical signs or symptoms suggestive of covid-19 or other acute illness, or recent exposure to sars-cov-2. the daily entrance survey was accessed and completed by volunteers and staff using a qr (quick response) code on their smartphone or if they had no smartphone, on a paper survey. staff monitors verified that the survey was complete, asked about any positive answers and took each volunteer's temperature using a no-contact infrared thermometer. the names of all individuals who reported symptoms of an acute illness or a temperature >100.4°f were recorded for investigation; ill staff were instructed to return home and given instructions for self-monitoring and when to seek care. staff who cleared the screening process signed in, performed hand hygiene using an alcohol-based hand rub, and proceeded into the facility. staff entrance screening began on april 10 and responses were monitored daily through may 7. during that time period approximately 3,550 surveys were completed. no staff were noted to have a fever upon temperature check or a positive symptom screen at facility entry. staff were recruited from the philadelphia mrc (a group who serve the city during public health emergencies and large-scale events), contracted staffing agencies and vendors, and the dod. this meant clinical staff came with varying experiences and approaches to infection control and nonclinical/support staff had little to no experience with ipc measures. we operated under the assumption that all staff needed training in csf-l-specific ipc standards and measures. thus, we developed orientation materials and training procedures in order to ensure that staff would be adequately protected and trained. we created an -infection prevention and control orientation‖ presentation that described proper protocols for entering the csf-l with the screening survey, hand hygiene, ppe standards and processes, mask use and reuse, cleaning and disinfection, sharps safety and occupational exposures, including needlesticks. this presentation also included videos from the cdc demonstrating proper donning and doffing technique. the ipc presentation and live ppe demonstration took approximately 30 minutes and was included with other ori-entation presentations on the facility and its mission, safety measures and a tour of the patient care area. after completion of the orientation, clinical staff were fit tested using osha respirator fit testing protocol by environmental health and safety consultants for the available n95 respirators. they were required to don and doff the ppe that would be available at csf-l with trained ipc team members assisting and observing the techniques. eleven orientation sessions were held between april 13 and april 23 and were attended by 425 staff. given the unique clinical environment, rapidity of development of ipc standards, and challenges with equipment procurement, we used a process of rapid cycle tests of change to adapt the ppe process, while remaining aligned with current cdc guidelines. during the duration of the csf-l development and use, every person on site was required to wear a face covering (either a cloth face covering or surgical mask). plastic full-face shields were the standard eye and face protection for every person working in the patient care area. safety glasses and goggles were provided as an alternate strategy for eye protection. following the ppe standards obtained from the emergency field hospital opened at the jacob k. javits convention center in new york city and the most current cdc recommendations, the ipc team initially recommended that only providers of hands-on patient care would wear n95 respirators, while non-patient care staff, such as environmental services, would wear a surgical mask. after further consideration of the open patient care environment, uncertainty of the infectivity of the patients, and goal of providing as much assurance of safety as possible to staff, we established a standard that all staff present in the patient care area (-red zone‖) would wear an n95 respirator and eye protection. because the number of disposable isolation gowns was limited, the ipc team, with support from a vendor, was able to obtain 500 reusable, fluid resistant isolation gowns for use by all staff while in the patient care area. hand hygiene with alcohol-based hand rub was required before donning gown and gloves and after doffing gloves and gown, face shield and n95 respirator. clean, intact gloves were required to be worn by all volunteers present in the patient care area. hand hygiene with alcohol-based hand rub and glove change was required between each patient contact and when moving from dirty to clean activities. although portable, non-plumbed sinks were available, they were ultimately not used in the patient care area because they had only a fivegallon reservoir of water and therefore posed more challenges than benefits including needing to be refilled and cleaned often. thus, wall mounted alcohol hand rub dispensers were placed on the headwall of each bed space and table top dispensers were available at nursing stations and other staff work areas. safety and inventory were two guiding principles used in creating quality improvement measures at the csf-l. when we experienced a 53% loss of n95 respirators during the first round of reprocessing, primarily due to makeup use, we added a strongly worded request to the orientation that all staff refrain from make-up use while in the facility. we also provided makeup removal wipes and posted reminders to not wear makeup along with our respirator loss rate in the locker room and staff lounge restrooms. after implementing these interventions, our respirator loss rate significantly decreased to <1%. due to some variability in ppe donning/doffing training received by staff during different orientation sessions (as a result of rapidly and continuously evolving cdc guidelines and best practice standards) a ppe and hand hygiene quality improvement donning/doffing evaluation tool was developed. the purpose was to assess proper donning and doffing procedures use by each staff member entering and leaving the -red zone‖ as well as correcting staff when needed. this was completed by the donning/doffing assistant and included 1) assessment of an n95 respirator seal check, 2) proper hand hygiene use during donning, 3) use of the appropriate ppe doffing sequence, 4) hand hygiene at appropriate moments during doffing sequence, and 5) verification that no ppe other than a personal mask was worn in the -yellow zone‖ and -green zone‖. when it was realized that there was confusion and concern around proper hand hygiene in the -red zone,‖ we developed a hand hygiene quality improvement evaluation tool to be completed by the red zone infection preventionist. this tool assessed the proper doffing of gloves, use of hand hygiene (alcoholbased hand rub for 20 seconds), and donning of new gloves between patients by providers. although we designed these measures with the intention to implement all of them, we were unable to do so due to the lack of further need for and closure of the csf-l. in this report, we describe the development, implementation and management of an ipc program for a covid-19 acs. key lessons learned included the need to: develop strategies to cope with real and potential shortages of critical supplies; adapt existing guidance for unique sites of care; standardize and continually assess staff use of ppe and fundamental ipc practices; and the importance of communication of ipc principles and concerns throughout the planning and management of this covid acs. a critical component of preparedness plans is surge capacity or the ability to adequately care for a significant influx of patients and be prepared for demands on supplies, personnel and physical space. 6 although much of disaster and surge capacity planning focuses on hospital-based care, the covid-19 pandemic required various buildings and structures of opportunity across the country be converted to temporary field hospitals with the goal of increasing healthcare capacity and capability as needed. 8 the liacouras center in philadelphia was such a structure and rapidly converted to function as an acs to assist regional health care facilities by providing non-acute care for adults with mildly to moderately symptomatic covid-19. the csf-l ipc team, reporting to the chief nursing officer, was quickly established. the team leaders had previously worked together, were well-versed on cdc ipc guidelines, and had extensive experience in establishing ipc programs in non-traditional and resource-limited settings nationally and internationally. this worked to the team's advantage as we quickly identified program aims and delineated priorities. the team relied on real-time, action-oriented learning using the plan-do-study-act (pdsa) cycle for testing our initiatives -by planning it, trying it, observing the results, and acting on what is learned. this approach led to quick, early successes. for instance, we quickly realized that although fema provided resources for a 250-bed facility, only 152 beds could be set-up in order to maintain at least six feet of distance between patients. another example, one of our first tasks was to establish the staff wellness check-in/surveillance procedure. working closely with our facility operations and security colleagues, a single point of building entry was identified. the ipc team explored several options for collecting volunteer screening data. based on convenience and ease of use we selected the free online qr code generator to create a code for the survey, while concurrently configuring the physical space to accommodate the related activities. we conducted multiple pdsa cycles to improve the original concept, resulting in an efficient, effective, standardized process. a similar approach was used to standardize ipc staff orientation and ppe donning and doffing competency check-offs. pdsa cycles were also used to navigate the ipc implications of the proposed system for facility access and flow of patients and for the support services of pharmacy, respiratory therapy, laboratory, patient linen and laundry, patient and staff food delivery, and waste (including medical waste and sharps) and garbage removal. predictably, the greatest challenge centered on managing ppe standards and clinical staff expectations. due to the critical shortages of ppe and alcohol-based hand rub across the country, the cdc revised its recommendations for the safe and appropriate use of ppe several times during our planning stages. this dynamic combined with the initial uncertainty of the resources available to the csf-l, made it difficult to develop ipc policies and procedures specific to this setting at the outset. there were also significant clinical staff concerns and anxieties surrounding ppe use. staff from throughout the us, varied practice settings (e.g., intensive care units, emergency departments, medical-surgical units) and without prior experience working together had to adapt to the csf-l ipc policies and procedures. having an ip or ip designee present 24 hours a day, seven days a week in the -red zone‖ was invaluable in managing staff ipc expectations. they provided real-time staff ipc adherence monitoring, education, coaching, support and csf-l updates. in addition, a frequently asked question sheet with answers and rationale to many commonly asked questions was created. it included questions such as -why are we not double gloving?‖, -why are we not using hand sanitizer on top of gloves?‖, -why are we not wearing a surgical mask over the n95 respirator?‖ two factors underscored the importance of standardizing ipc practices in the csf-l. first, the risk of exposure to covid-19 in the csf-l environment was possibly increased as com-pared to other practice settings given the open ward structure and minimal engineering controls available. additionally, it was critical to establish a shared model of safe practice given the diversity of staff knowledge and experience with general and covid-19 specific ipc practices. less expected, was the complexity of ppe inventory management. there was no computer access in the ppe distribution area, so inventory management was a labor-intensive, manual process prone to error. this risk was mitigated by assigning designated staff to the ppe distribution room. had the csf-l remained opened, tools such as the the national institute for occupational safety and health (niosh) ppe tracker mobile app could be used. however, future acs's should utilize computerized inventory management systems, staffed by skilled personnel, to track all inventory. one of the most important aspects of disaster and emergency response is ensuring effective, frequent and timely information exchange. information exchange and management should be based on a system of collaboration, partnership, and sharing. 11 while collaboration and partnership were a part of preparing the csf-l for patients, real-time information sharing to increase the ipc team's situational awareness of csf-l's capabilities and resource needs, was at times challenging, given the plethora of agencies, personnel, and teams working independently, yet simultaneously in an effort to prepare for occupancy. 12 all acs, particularly those developed in response to an emerging infectious threat such as sars-cov-2, will benefit from close partnerships between leaders, front-line and support staff, and ipc experts. finally, we believe our approach may have utility beyond the pandemic. use of the -4s's‖ framework, coupled with actionoriented learning using pdsa cycles, could be used in other surge situations. the ipc team worked quickly and efficiently to manage the constantly evolving circumstances and the time constraints that accompanied the opening of a covid-19 pandemic acs. despite the growing scarcity of ppe, the csf-l goals of ensuring an adequate supply of ppe and provid-ing the safest environment for both patients and staff were achieved. the ability to leverage our collective ipc knowledge, skills, abilities and energies to this situation has been extremely rewarding. in the spirit of volunteerism, we had the opportunity to work with an extraordinary group of people dedicated to a common goal. agency for healthcare research and quality: surge capacity-education and training for a qualified workforce city provides update on covid-19 for friday the pennsylvania department of health &the hospital and healthsystem association of pennsylvania (2020) exploring the concept of surge capacity. ojin:the online journal of issues in nursing factors associated with preparedness of the us healthcare system to respond to a pediatric surge during an infectious disease pandemic: is our nation prepared? hospital surge capacity: the importance of better hospital pre-planning to cope with patient surge during dengue epidemics -a systematic review considerations for alternate care sites infection control in healthcare personnel: infrastructure and routine practices for occupational infection prevention and control services hospital infectious disease emergency preparedness: a 2007 survey of infection control professionals pan american health organization. information management and communication in emergencies and disasters: manual for disaster response teams critical care surge response strategies for the 2020 covid-19 outbreak in the united states key: cord-333509-dnuakd6h authors: chan, hui yun title: hospitals’ liabilities in times of pandemic: recalibrating the legal obligation to provide personal protective equipment to healthcare workers date: 2020-10-17 journal: liverp law rev doi: 10.1007/s10991-020-09270-z sha: doc_id: 333509 cord_uid: dnuakd6h the covid-19 pandemic has precipitated the global race for essential personal protective equipment in delivering critical patient care. this has created a dearth of personal protective equipment availability in some countries, which posed particular harm to frontline healthcare workers’ health and safety, with undesirable consequences to public health. substantial discussions have been devoted to the imperative of providing adequate personal protective equipment to frontline healthcare workers. the specific legal obligations of hospitals towards healthcare workers in the pandemic context have so far escaped important scrutiny. this paper endeavours to examine this overlooked aspect in the light of legal actions brought by frontline healthcare workers against their employers arising from a shortage of personal protective equipment. by analysing the potential legal liabilities of hospitals, the paper sheds light on the interlinked attributes and factors in understanding hospitals’ obligations towards healthcare workers and how such duty can be justifiably recalibrated in times of pandemic. the onslaught of covid-19 has led to a worldwide race for personal protective equipment ("ppe") ranging from protective goggles, gloves, full face shields, fluid repellent gowns, aprons, surgical masks, and medical equipment such as ventilators and respiratory machines. 1 the british medical association has repeatedly issued urgent pleas to the uk government for the timely supply of ppe for frontline healthcare staff in delivering patient care. 2 frontline healthcare workers without ppe continue to face severe infection risks posed by ppe shortage constitutes a pressure point for healthcare systems, with strong correlations between its scarcity and high covid-19 infections and death among healthcare workers. 4 covid-19 has claimed more than 300 healthcare workers' lives, and infected more than 60,000 in the usa, 5 while ppe shortage and substandard ppe in spain have resulted in more than 31,000 healthcare workers becoming infected. 6 reports of heightened stress experienced by frontline staff are not new; either from the fear of being infected or in transmitting the infections to their families. 7 the shortage has prompted drastic reactions from some governments in downgrading ppe protection standard inconsistent with who advice, inevitably raising questions about harm to healthcare workers. 8 this measure in turn produced several adverse effects on care provision. it has created an exodus of critical healthcare staff due to their inability to continue working. clinical decisions were made to either delay care or minimise the risks of harm (while still working in high risk environments), underscoring rationing in action, and making difficult situations more taxing. although they are not compelled to continue treating patients, the inability to do so generated moral guilt as they see their colleagues on the frontline operating in hazardous conditions. recent developments have witnessed strong responses from the public and healthcare workers, ranging from pursuing legal actions against the government or their employers (hospitals) for breaching their obligations of care towards employees to calling for a full public inquiry into pandemic management, including the status of the ppe stockpile. 9 specific claims by healthcare workers include the legality of guidance on reusing ppe and permitting patients to be treated without ppe in contravention of their right to protection of health and safety at work. 10 this development is not only confined to the uk, as doctors in spain have launched legal actions against the health authorities for breach of duty in ppe procurement failure. 11 considerable coverage continued to be given to issues concerning allocation of scarce resources, the clinical and moral dilemma to treat, and the urgent need to have protective gears for frontline staff. 12 the pressing legal considerations regarding employer's failures in procuring sufficient resources for pandemic purposes remain under-explored. this paper examines how the pandemic affects the obligations of hospitals as employers towards their frontline healthcare staff in fulfilling their responsibilities during pandemic, and the impetus on re-evaluating existing and future legal obligations. it considers the extent to which hospitals have breached their obligations in failing to take appropriate measures to safeguard the health and safety of their employees and to prevent them from being exposed to avoidable risks. while convincing justifications are available regarding the difficult roles of hospitals during pandemic, significantly persuasive arguments can be made for hospitals' liability in breaching their duty to ensure the safety of healthcare workers. these claims will be considered in determining the extent to which such liability can be recalibrated in times of pandemic. while the analyses are drawn from the uk context, the substantive importance is equally relevant as the battle for critical medical supplies is felt across the world. an employer's duty is personal and non-delegable. the employer's duty is one of reasonable care and skill, to provide a safe place and system of work, with adequate plant and equipment, including competent employees and resources, according to the industry and environment in which they operate. 13 such obligations extend to maintaining the equipment and ensuring that they are of sufficient quantity, necessitating regular inspections and monitoring. 14 providing a safe system of work signals a gamut of considerations; ranging from ensuring proper working systems, arrangements and instructions, identifying the purpose of the work, specific tasks and scope to assess risks and install precautionary measures for the employees' health and safety. a system of work thus encompasses an assessment of the adequacy for the "whole course of the job or it may have to be modified or improved to meet circumstances which arise." 15 the consequence of this duty is that the system ought to be reasonably safe, and not perfectly safe, through assessing the inevitable dangers associated with the work, guided by industry norms. 16 these norms often evolve through time and employers must be aware of such developments in updating their 12 emanuel et al. (2020) , ranney et al. (2020) . 13 wilsons & clyde coal company v english [1938] ac 57, lunney et al. (2017, p 560 safety standards to reflect current knowledge based on best scientific evidence. 17 consequently, though it can be suggested that the science of covid-19 is still developing, the lack of knowledge regarding its effect may not automatically preclude employers from being liable. doctors, surgeons and nurses employed in the service of hospitals are treated as employees under the law and hence they are owed a duty of care. 18 the common law duty of care identified above thus obliges hospitals to provide competent staff, adequate material and a safe, proper system and effective supervision. the extent to which employers ought to provide for ppe invites considerations such as the risk, likelihood, magnitude and consequences of the injury, and the availability and costs of providing such protective equipment. 19 in hospitals, the provision of adequate plant and equipment signifies ppe such as gloves, masks, full length gowns, shields and goggles. hospital working zones have become "contagion hubs" with streams of patients (symptomatic and asymptomatic) receiving care and treatment from healthcare workers. it is reasonably anticipated that healthcare workers are continuously exposed to significant infection risks from treating these patients. the provision of ppe is directly relevant to the work for which healthcare workers are employed to do, and which are normally and reasonably expected to be provided with, consistent with who guidelines for treatment of infectious diseases. the omission to provide ppe to frontline staff unavoidably attracts questions of hospitals' negligence. in determining whether the employers are negligent in failing to remedy the lack of ppe, reference is made to a number of important factors under the common law and statutory instruments. factors that illuminate the liability of the parties, such as the nature of the work, its inherent risks, the (im)possibility of establishing precautionary measures in preventing or reducing the likelihood of risks materialising, the extent to which such measures commensurate with the means and ends, are examined. risk assessments, particularly whether the risks are amplified by the failure to provide in an otherwise acceptable risk in employment, common practices, and resources similarly influence the determination of duty. statutory duties under the health and safety act, regulations on ppe 1992, the relevant guidance issued by the department of health and social care and public health england to healthcare workers are relevant considerations. risk assessment is an important feature in determining the likelihood of injury and whether a breach has occurred in a system of work. it sets the level of reasonableness of precautionary measures against the health and safety risks employees may encounter in the course of their employment. 20 the firemen assuming risks associated with not having a jack fitted in the truck, thus precluding their employers from liability. it has been questioned whether this approach has unjustly discriminated claimants from emergency services that continue to assume risks for the greater good 22 but is otherwise uncompensated for the injuries sustained. there is considerable force in this reasoning that applies to frontline healthcare workers. they face prolonged risks on a daily basis, which includes periods of emergency and hours with clinical rotations between high and low infection risks zones in hospitals. their purpose is to save lives, but without ppe they are putting the lives of patients at risk. the likelihood of injury is real and the gravity of the consequences is magnified. while there are risks inherent in patient treatment, infectious diseases attract extra hazardous elements into the work. the seriousness of harm caused to healthcare workers is not considered small. infected healthcare workers would be off sick, unable to treat, and face the possibility of death. the risks of infection are higher without ppe compared to those with basic ppe. standard public health practices require healthcare workers to don appropriate ppe. this in turn invites questions on cost and practicability 23 in addressing the risks that persist in daily clinical encounters. although frontline healthcare work is not intrinsically dangerous compared to crane workers in the building industry, the cumulative risks arising from covid-19, and other preventable factors could potentially render such employment dangerous. healthcare workers combating infectious diseases accept the associated risks that are intrinsic to the work; that does not mean that they have voluntarily assumed all those risks which could be prevented or reduced with the exercise of reasonable care by the hospitals. 24 the example of healthcare staff at weston hospital in england who tested positive after contact with infected patients only goes to demonstrate the severity of the situation. 25 if we accept that covid-19 is hazardous, then it justifies the protection from the risks of infection through ppe provision. ppe constitutes the first line of protection against infections, as they need to be in close proximity to patients. ppe thus can reduce the chances of infection and in some cases prevent further infections among healthcare workers. such risks clearly outweighed the cost of providing ppe, and the omission to provide is obvious. while the likelihood of the majority of the healthcare workers to succumb to the virus is small owing to the age and health demography, the consequences of such infection materialising are grave if they were infected. courts usually take into account established practices in assessing whether the defendants have breached their standard of care given the circumstances prevailing at the time. 26 it can be reasonably said that ppe is a common practice; logical and of common sense in treatment of infectious diseases. hospitals should act in 22 accordance with such approved, common practice of ensuring adequate ppe supply. the most practical preventive measure, which is providing ppe is not onerous, compared to the risks of injury to healthcare workers. while cases have shown that employers have not breached their duty in failing to provide protective screens or suitable emergency vehicles for the employees at wartime, 27 ultimately, balancing these risks against the measures to remove the risk requires a consideration of the end to be achieved. 28 the end to be achieved in the pandemic context is the dual outcomes of protecting public health and maintaining the health and safety of healthcare workers in the course of their employment. statutory instruments have given the duty of care a stronger emphasis. the personal protective equipment at work regulations 1992 ("ppe regulations") under the health and safety at work act 1974 clearly set out the types of legal responsibilities that employers should follow. ppe under the regulations means "all equip-ment…intended to be worn or held by a person at work and which protects the person against one or more risks to that person's health or safety, and any addition or accessory designed to meet that objective." 29 consequently, ppe in the hospital context is broad enough to include all equipment that protect healthcare workers from infectious particles arising from aerosol generating procedures, ventilators, respirators or testing facilities with high concentrations of droplets or airborne diseases. regulation 4(3) provides the litmus test for the suitability of such ppe. ppe are considered "suitable" relative to the risks involved for the purpose of carrying out the work, the conditions and duration of exposure, the state of health of the wearer, the workstation's characteristics, and practicable in controlling the risks. ppe has to be hygienic and for the sole use of the wearer, thus the guidance to reuse them may raise questions, unless they are addressed by having adequate measures that ensure the hygiene is not compromised where reuse is needed. 30 such ppe should also be maintained and replaced. 31 the exposure to covid-19 infections is directly workrelated, and employers have the means to protect and implement control measures to reduce the chances of risks materialising. these circumstances directly oblige hospitals to ensure that ppe stockpiles are sufficient so that they are readily at hand when they are needed by the healthcare workers. the difficulty arises when there is a disparity between the actual supply and provision of ppe, and meeting compliance with the legal requirements. recent public health england 32 (phe) guidance has emerged in response to the pandemic in advising hospitals on establishing a safe system of work through 27 yorkshire traction company limited v walter searby [2003] ewca civ 1856; in daborn v bath tramways ltd [1946] 2 all e.r. 333, at 336, the driver of ambulance with left-hand drive was found not negligent when, in wartime, she turned to the right without giving a signal. 28 watt v hertfordshire [1954] 2 all e.r. 368. 29 regulation 2(1)(a). 30 for example the phe guidance noted that some ppe may be reused, subject to effective cleaning system. 31 regulations 5 and 7. 32 phe is tasked with national oversight and leadership on public health issues, and in this capacity support nhs, manage national public health service and support the public health workforce development, see also herring (2016, p 54). organisational means, ranging from suitable work processes, engineering controls, environment, and provision and use of both work equipment and ppe (single sessional use of particular ppe, reusable ppe) and decontamination procedures. 33 the guidance recognised the employers' legal obligation to protect workers from health and safety risks in controlling and limiting infection transmissions, including assessing risks associated with patient influx, and reduced staff numbers due to illness. this aspect corresponds with regulation 5 in assessing the risks of injury and the purpose and adequacy of such gears where available. however, developing phe guidance, in addressing ppe shortage highlighted "the compromise needed to optimise the supply of ppe in times of extreme shortage… protect stock levels from unnecessary use and support staff to use the right equipment." 34 such modifications mean that ppe are used throughout the session unchanged between patients, "as long as it is safe to do so", which differ from the who guidance. other modifications, such as lower grade face masks reflect a standard which is lower than the who recommendation. while reusing gloves should be avoided, some ppe such as face masks, gowns and eye protection are only liable to be changed when they are visibly contaminated or damaged. the implication is that such ppe would have lost the protective function, putting the healthcare workers at risk under the guise of protection. the direct correlation between staff engagement and patient experience demonstrates the close association between the quality of care patients received and the provision of treatment by healthcare workers. 35 the nhs, a government-funded healthcare service under which hospitals in the uk operate sets the standards for service provision and professionalism. in essence, it commits to provide high quality, safe and effective care, and recognises that a valued and supported workforce will translate to quality patient care. 36 the nhs constitution, which outlines the basic principles and values of the nhs governing the relationships between healthcare workers, patients and the public generally, illuminates particular rights under employment laws, and nhs pledges to their staff, with the overarching priority of delivering patient centred care. patients have the right to be treated professionally by qualified healthcare workers as part of a safe system of work in a clean and secure 34 public health england, department of health and social care and nhs england (2020). 35 guidance: handbook to the nhs constitution for england (2020). 36 nhs, the nhs constitution for england (2020). 33 several guidance were published advising hospitals of rapid changes to ppe use and disposal: guidance: introduction and organisational preparedness 21 may 2020 https ://www.gov.uk/gover nment /publi catio ns/wuhan -novel -coron aviru s-infec tion-preve ntion -and-contr ol/intro ducti on-and-organ isati onal-prepa redne ss; guidance: covid-19 personal protective equipment (ppe) 20 may 2020 https ://www.gov.uk/ gover nment /publi catio ns/wuhan -novel -coron aviru s-infec tion-preve ntion -and-contr ol/covid -19-perso nalprote ctive -equip ment-ppe produced jointly by department of health and social care (dhsc), public health wales (phw), public health agency (pha) northern ireland, health protection scotland (hps), public health england and nhs england. environment, signalling the necessity of an appropriately equipped and maintained environment. the cyclical nature of patient care and duty to staff is clearly reflected, with explicit recognition that staff should be provided with the resources and support to deliver quality patient care and for healthcare workers to identify and eliminate risks to patients. the failure to provide ppe for healthcare workers has significant relevance and broader implications to patient care. healthcare workers with substandard or without ppe are exposed to infection risks, rendering them susceptible to absence from work for at least 14 days, resulting in workforce depletion. this is especially critical for healthcare workers functioning in high risk zones. healthcare workers operating in other units would be asked to support the continuity of care for covid-19 patients, thus creating a void in patient care in less critical areas. frontline healthcare workers face immense pressure treating patients under crisis. while there is an expected level of stress 37 that corresponds with the nature of the work in providing care, transferring workers from other specialty units to assist their frontline colleagues may prove exacting, given that their training and competency for the job can vary. the rerouted human resources meant that patients in other units are inadvertently neglected due to reduced staff. another serious, adverse outcome is the risks of transmitting the infection to patients where healthcare workers are unaware that they have been infected; particularly in asymptomatic situations. ppe greatly reduce the risks of infection in the first place, for both the health and safety of the healthcare workers and patients. the strong correlation between the augmented risks of infection and ppe shortage creates a system where patients are harmed. the commitment to deliver quality patient care and a good working environment has, unfortunately, become questionable in this environment. while the nhs constitution provides for avenues of complaints to line managers, the bureaucracy meant that staff will continue to face infection risks unless they refuse to treat patients. 38 prior insights from previous pandemic and the lack of remedial measures to address the weaknesses identified in the healthcare system during national pandemic simulation exercises may raise valid concerns regarding errors of judgement that resulted in the inability to provide ppe in a timely manner. public authorities hold and exercise discretionary powers within the constraints of complex decisions, social utility and organisational objectives. however, are we setting a standard too high for the nhs managers in procuring ppe, given the prevailing circumstances? are there any exceptions to this duty in times of pandemic, where it can be reasonably anticipated that healthcare systems may become inundated, resulting in the necessity of working within a less than optimal environment? the following sections consider arguments 37 see walker v northumberland cc [1995] 1 all er 737. 38 bowcott (2020) . and counterarguments limiting hospitals' legal obligations towards healthcare workers. the characteristics of covid-19 are essential in understanding the severity of the pandemic, its impact on the healthcare systems, and why particular focus on the legal obligations of hospitals towards healthcare staff becomes significant now and in the future. the morphology of covid-19 has garnered international attention, with scientists investigating its biochemical components for preventive, containment and vaccine trials purposes. it was first reported in wuhan, hubei province of china on 31 december 2019, with origins traced to the 1960s as common viruses that infect humans, particularly in respiratory functions. 39 the transmission methods and survival on various surfaces have been the subject of intense scrutiny with findings that the virus can be detected on surgical masks for up to seven days. hospital working areas such as intensive care units, self-isolation wards, doorknobs and keyboards are found to carry high concentration of viruses. viruses were present in the body for more than a week prior to visible symptoms with the highest virus load found in the early stages of infection, suggesting that asymptomatic individuals could be more infectious than symptomatic ones as sources of population transmissions. 40 these findings are crucially linked to the recommendations for use, reuse and disposal of ppe and its effect on healthcare workers who were infected. around 10% of infections in england recorded between april and june 2020 were found in health and social care workers resulting from their direct interactions with patients in hospitals. 41 spain, italy, china and the usa have reported between 10% and 20% of infection cases from healthcare workers while treating infectious patients. this underscored the detrimental effects of ppe shortage on healthcare workers. 42 the lack of ppe has cast the spotlight on augmented risks to healthcare workers. such risks of harm are widely acknowledged. 43 healthcare workers experienced psychological and moral distress, frustrations and anxiety in carrying out treatment decisions, fear of risking their health, and infecting their families and patients. they are similarly exposed to emotional harms from being prevented to voice their concerns on health and safety, or compelled to provide care under unsafe circumstances. the british medical association has repeatedly supported the position that healthcare workers should not continue working with substandard ppe or without basic ppe that could prevent them from avoidable harm. 44 however, this has not allayed the harmful consequences to healthcare workers. 40 ibid. 41 wilson et al. (2020) . 42 who (2020). 43 british medical association (2020), carrington (2020), smyth (2016) . 44 british medical association (n 43, p 7). 39 european centre for disease prevention and control (2020). the force of the covid-19 exigency poses an arguably persuasive factor in limiting employers' liability. while covid-19 is frequently hailed as unprecedented, the nature of influenza pandemic is not completely unknown. history has revealed examples of pandemic that occurred across centuries with various degrees of severity. 45 once the who declared covid-19 as a pandemic, ppe became global focal points. countries rushed to secure additional ppe, with demands far exceeding supply within an asymmetrical circulation of medical resources. although the challenge of scarce resources is a common predicament affecting hospitals, simulation exercises (e.g.: public health england 2016) undertaken in some developed countries provide ample opportunities for advance preparatory measures. the experiences of frontline healthcare workers from other countries several months before the pandemic reached the uk would have constituted sufficient notice of the gravity of the situation. hospitals have grown in complexity through centuries. the extent to which institutional structures, devolved administrations and resourcing constraints provide justifications for their omission needs to be determined within their role as public authorities. the nhs structure is represented by a complex matrix of quasi-government, private entity with specific powers and responsibilities, thus affecting their liability to healthcare workers as employees, moving beyond the simplicity of hospitaldoctor employment relationship. it has been said that "to describe the structure of the nhs is not an easy task…partly because it is a labyrinthine and partly because the nhs has been and still is undergoing enormous structural changes with bodies being created, merged and destroyed at an astonishing rate." 46 the nhs is funded from taxes, with allocations approved by parliament, and expenditures controlled by clinical commissioning groups. 47 nhs managers work in a complex environment, from purely administrative to larger roles of system management and leadership with accountability to frontline healthcare workers, the department of health, private providers, and subject to public scrutiny. 48 nhs managers are expected to balance several competing rights, among others the public health, healthcare workers' rights and organisational constraints. 49 the creation of internal market supported by the health and social care act 2012 has been critiqued as one of the structural problems permeating nhs 50 which produced a considerably weakened responsive capability during pandemics. continuous public sector changes, marketisation strategies 45 walsh (2020) . 46 and funding cuts have led to the government's reliance on private firms to provide services during public health emergencies. 51 suggestions that phe decisions were politically influenced have led to allegations that ppe guidelines were not necessarily led by public health science, as seen in the case of lowering ppe standards due to shortage, contrary to who recommendations. hospitals performed their functions within the wider framework of organisational complexities, decision-making hierarchies and limitations, and political willpower. they often have statutory responsibilities involving difficult and sensitive judgements to make. 52 they also inadvertently suffer from particular authority or financial barriers, which puts them in unenviable positions when faced with claims of negligence in equipping employees with ppe. the discretionary powers available for public authorities, other remedial options and consequences for public service delivery influence how standards are determined. 53 a finding of liability may result in obstructions with the exercise of discretionary powers guided by particular reasoning within the system for purposes of efficient and necessary governmental machinery. 54 the structural determinants illuminate the systemic failures that plagued these entities. as christian witting accurately observed 55 : "in some cases, decisions made at a high political level inevitably entail difficulty in meeting service targets or in under-servicing, and must be expected to result in failures in care. the failures in care that result are systemic in nature. their acceptability is politically pre-determined and courts might have little authority to redress them." resource availability within public authorities remains a pressure point among competing sets of considerations. 56 it indicates the dilemma of meeting social needs for the effective functioning of society within a finite environment of resources. public authorities traverse the boundaries of public and private law in judicial applications of the law of negligence, human rights and statutory powers. 57 this is reflected in the nhs context, which represents one of the most politically charged and publicly contentious issues of all times. 58 daborn demonstrated that in cases of national emergency, the lack of available transportation resources, the inherent limitations of the ambulance and the need for continuity in emergency services precluded the defendant from further duties. while not a complete defence, public service liability is 51 closely connected to resource constraints, weighing against the finding of liability. 59 cases have shown that although public body should not be treated any differently from commercial employers, financial constraints and rigidity in decision-making are relevant factors. 60 this signifies the balance between resource availability and cost and practicability of preventing workplace injury. the issue of how far the duty should go when it comes to omissions to provide ppe in a pandemic context is unresolved. given the public health crisis precipitated by the pandemic, it is likely that hospitals would be 'forgiven' for their failure in fulfilling their legal obligations on the basis of emergency and their constraints as public authorities. however, hospitals are the linchpin in delivering frontline healthcare services and maintaining public health in an infectious disease setting. it is argued that hospitals should depart from an approach that expose healthcare workers to infection risks, harm public health and is inconsistent with the core nhs patient centred care principle. the provision of ppe is fundamental to healthcare workers in carrying out their work. ppe protect healthcare workers, and in turn enable them to deliver crucial care especially in times of pandemic. it is not an infallible method, but without these ppe they are most likely to suffer from injury and harm from the risks of infection. the failure to provide ppe to healthcare workers is a failure to deliver care to patients at critical points. the size, capacity and resources available to hospitals are influential considerations; nevertheless, they are not determinative to the extent of justifying the omission to provide ppe. a comparison can be drawn to ppe provision during normal times and in times of emergency. in normal times, the impact, while it may be felt, may not be acute for patient delivery care because the limit has not been breached. however, in emergency times, the impact of the failure to provide ppe to healthcare workers is severe. the daborn and watt v hertfordshire cases had established the importance of the end to be achieved in saving lives, consequently such emphasis can be inferred as recalibrating the obligations of essential services and balancing the rigidity and prescribed exclusion of liability. when the objectives are to save lives and ensure the continuity of vital healthcare delivery, it would appear contradictory to omit the provision of ppe that directly enable the treatment and care of patients. the lives of frontline healthcare workers and patients justified the provision of ppe. these arguments deviate from the standard argument of resource constraints, but they offer a strong reasoning why they should not be precluded. imposing the duty to provide ppe is therefore central in ensuring healthcare workers are protected from the risks of infection and to realise the aim of delivering patient-centred care to the public. thus, this duty should be adjusted to the extent of meeting the requirement of basic provision of ppe and ensure the continuity of such ppe supply in spite of the pandemic. this argument may seem contentious because there are persuasive cases that will preclude the finding of liability in a situation where resources are scarce and that individuals are expected to endure the crisis. however, hospitals need to demonstrate that they have proper mechanisms in place to address shortages in prolonged crisis instead of relying on arguments of budgetary limitations and hierarchy in decision-making. these points need to be identified at each step along the way to determine if the standard of care has been reasonably met. while cases involving public authorities often lend weight to the exclusion of liabilities; they can be distinguished from the current situation in several ways. first, the shortage in question is remedied by the availability of vehicles for the continuity of services, despite not the usual vehicle (e.g.: left-hand drive in daborn). the covid-19 situation represents a context where healthcare workers have exhausted these basic supplies and faced the consequences of no ppe for the remaining clinical encounters. second, covid-19 is not a singular incident but an event that is urgent in nature and continues on a daily basis. the severity of the harm meant that without any protection they face a high likelihood of being infected. the lowered standards of ppe use and recommendation for reusing ppe are attempts at remedying the complete shortage. the argument is that some protection is better than no protection. although hospitals are attempting to meet their obligations; ppe which are visibly damaged would cause harm under the guise of protection. the persistent lack of funding to hospitals has contributed to an environment where ppe shortage is tolerated and accepted as standard (though not reasonable) practice. ppe guidelines that decrease the health and safety standard exemplifies resource consideration. it is difficult to comprehend, even at the basic level, for employers not to provide essential ppe for protection against known risks within standard public health measures. covid-19 is an infectious disease, and the reasonable response is to provide ppe that eliminate or reduce the risks from exposure to such infections. while the purpose of the work is such that infections are incidental to the nature of the employment, ppe is an indispensable and cost-effective measure in minimising such risks. in spite of the difficulty in functioning within a resourcelimited environment, ppe is not purely best practice, but fundamental medical practice. an implication flowing from these considerations is recalibrating the mutual obligations between hospitals and their employees, underpinned by effective healthcare delivery consistent with the nhs constitution. a blanket approach to the finding of liability may be unsuitable, as not all hospitals are similarly equipped, though it remains incumbent on hospitals to fulfil their basic obligations without jeopardising the safety of healthcare workers. parallels can be drawn to the established standards and practices relating to ppe for employees working with hazardous materials. ppe can be modified but only to the extent where they are capable of providing full protection to healthcare workers, and not lower than the recommended standards. ppe availability inculcates a sense of assurance that frontline healthcare workers are valued and appreciated, both by the public and their employers, and for the workers, the confidence in carrying out their roles in treating and caring for infectious patients. system deficiency may be influential in determinations of liability, but it does not always prevail over what is reasonably expected from hospitals. hospitals have the moral duty to take care where their actions will affect those who might be affected by the failure to provide adequate and safe ppe: staff and patients. such duty falls within the remit of nhs managers. as covid-19 progresses, hospitals ought to have foreseen the impact of ppe on healthcare workers and patients; given the length of the pandemic, rather than a singular emergency. not all finding of liability will automatically result in floodgates, trivial claims or become burdensome for public authorities. 61 rather, it reflects the social and public expectations of what is fair and reasonable. the legal claims filed by healthcare workers for ppe shortage reflect societal expectations of what ought to be done in ensuring healthcare workers are provided with sufficient ppe. departing from this standard would have stretched the limits of acceptable assumption of risks. the public, while accepting that covid-19 is an unprecedented health threat to the population, will not be kind in their assessment of the measures to contain the pandemic, particularly in response to the dearth of vital medical resources in times of crisis. it becomes imperative to recognise their vulnerabilities and to keep healthcare workers safe. systemic failures may well be compelling, but it is unsatisfactory to then say, there is nothing hospitals could do. reports have continuously demonstrated the correlation between the lack of ppe and higher risks of infection for healthcare workers compared to the public. 62 this naturally translates to poor patient care as they become sick. there is clear neglect in ensuring stockpiles of ppe in meeting the basic requirement of ensuring workers' health and safety. the lack of clear direction and protocols in management and leadership has contributed to the failure of establishing a safe system of work. what would a reasonable healthcare provider do? it is to provide adequate ppe when it is needed and to have processes in place to supplement the stockpile. the saving of lives is a continuous emergency, reflected by the number and severity of patients healthcare workers treat daily. the discretionary power should be exercised towards ensuring resources are allocated towards meeting the obligations of hospitals during pandemic, in preparing sufficient ppe for healthcare workers. for example, the procurement team of the nhs trust is responsible for purchasing supplies and equipment for the hospital, where specific purchasing rules and budgetary limits apply. this translates to broader governmental responsibilities within the decision-making authority which subsequently influenced the overall level of pandemic preparedness. the long-term deficiency in preparedness for a potential infectious diseases outbreak, and the failure to remedy ppe availability through systematic and appropriate procurement arrangements for continuous supply have contributed towards hospitals' inability to replenish severely dwindled ppe stocks in a timely manner. these cumulative factors have resulted in the breaching of ppe limits to the detriment of healthcare workers. the hesitance towards advance preparedness is remarkable, given the window period available to the uk with precedents from china and neighbouring european countries. 63 hospitals, especially the well-resourced ones, with the hindsight of previous experiences in treating patients under the deluge of pandemic could have 61 phelps v london borough of hillingdon [2001] 2 a.c. 619. 62 parshley (2020) . 63 hunter (2020), mahase (2020a, b, c, d). foreseen the need to install precautionary measures to safeguard the continuity of essential supplies and safe functioning of workplace for healthcare workers. adopting such preparatory measures would have enabled a safer response strategy for critical patient care in anticipation of increased burden on the frontline staff, adjusted according to the size and scope of the hospitals' operations and resources. the next section offers practical recommendations in pre-empting ppe shortage. the failure of hospitals in providing healthcare workers with ppe has resulted in concerted and self-help measures in procuring ppe. the most common preparation is stockpiling essential ppe. this comes as a benefit of hindsight; nonetheless valuable in preparation for second or third waves of infections, and as crucial planning for future pandemics. for example, prior to the onset of infected cases in new york, some hospitals have acquired millions worth of ppe as early as february 2020 on the basis that "you can never have enough." 64 this foresight paid off, enabling healthcare workers to continue working while protected. an appreciation for improved procurement procedures in place, such as the role of supply chains in ppe procurement is integral in successful pandemic preparation. the public-private procurement chain has ensured that new zealand has sufficient ppe for the healthcare workers and the population, with additional weekly supplies from local manufacturers. 65 the shortage in the uk remains acute. reports have emerged that care home workers were requested to continue caring for infectious patients without ppe in the event of extreme shortage. 66 local councils are responsible for delivering healthcare services (e.g.: care homes and community mental health services) which falls outside the nhs supply chain scope. this means that they are most likely to lack ppe in times of national emergency. jurisdictional divisions have, unfortunately hampered the effective cooperation for public health to the detriment of frontline healthcare workers and the public. 67 the systemic impediments in the nhs organisational structures might be difficult to overcome immediately, but the awareness of how ppe delivery is hampered by these institutional barriers can pave the way for alternative routes to remedy the situation. supply chain management and logistical issues are beyond the remit of employees personally, and those in charge of organisational operations should be responsible in fulfilling the obligations in ensuring that ppe are in stock and at hand when they are needed. this means having additional supplies for emergency purposes 64 ornstein (2020) . 65 covid 19 coronavirus: tonnes of ppe now in auckland warehouse 9 apr, 2020 https ://www.nzher ald. co.nz/nz/news/artic le.cfm?c_id=1&objec tid=12323 807. 66 taylor (2020) . 67 see further laurie and hunter (2009). while procurement for additional ppe is in progress to ensure continuity in supply for healthcare workers. consequently, measures include revisiting internal procedures in assessing the individual levels of preparedness in hospitals, and preparing alternative plans in redirecting patients to hospitals with more capability to deal with infectious patients if the scale and capacity of the local hospitals do not permit the proper treatment and availability of care to the patients without risking staff safety. it is equally valuable to treat the pandemic as akin to disaster response with mass casualties as it enables the operation of protocols and processes for such emergencies occurring for a substantial period of time. nhs managers must be aware of such developments, encompassing clinical and administrative appreciations of the effect global supply chain has on essential ppe procurement in planning and reducing the gap between stock depletion and arrivals. this entails building good, working relationships with relevant suppliers and producers. as resources are finite, having operational plans in advance at the institutional level would alleviate the burden of dealing with these issues during emergency when there are absolutely no ppe available. infrastructural planning, reorganisation and improvisation are essential to remedy the weaknesses that prevented hospitals from fulfilling their obligation in providing a safe system of work and adequate plant and equipment for the purpose of caring for patients. it is not advocated that there should be a perfect system but a functioning system at a fundamental level that ensures that employees' health and safety are not compromised in times of pandemic, and that risks are controlled within reasonable limits. longer term measures include instituting improved communication among hospitals within proximate areas in breaking the disease transmission chains locally and regionally. this approach will facilitate local capabilities in minimising the disease spread, especially in under-resourced and rural areas healthcare services. such regional networking approach has resulted in successful pandemic response among 15 hospitals in lombardy, italy in coping with patient surge. 68 the current decentralised decision-making approach in the nhs and the lack of effective communication policies in disaster management have led to critical resourcing issues. 69 processes and procedures that allow a centralised, consistent response mechanism in national emergency are essential in ameliorating some of the difficulties in pandemic response and management. for example, an emergency "clearinghouse" that acts as a centre is helpful to identify areas with high needs for ppe so that immediate actions can be taken to distribute ppe to these critical areas. 70 increasing local production capacity and supply in times of crisis are central in ensuring uninterrupted supply from local sources and less reliance on external producers during ppe scarcity. spain, for example has aimed to produce millions of masks and other essential ppe on a monthly basis to meet the needs of healthcare workers. 71 when the shortage was first reported, the local and national level 68 cavallo et al. (2020) . 69 hunter (n 63). 70 livingston et al. (2020) . 71 sappal (2020). communities in the uk were very supportive towards the healthcare workers in creating homemade ppe and supplying them to healthcare workers. although this is admirable, these supplies may not meet the adequate level of protection to ensure that infection risks are minimised. one way of overcoming the obstacle is to create a streamlined effort between local governments, charitable organisations and local volunteer groups to ensure they meet the safety requirements. this approach would help local and independent manufacturers to achieve local production capacity for the benefit of the communities within a shorter amount of time, and less dependent on outsourced procurement agencies or importation. it is also a stop-gap measure while awaiting incoming ppe supplies from centralised distribution centres. this move is advantageous to the local communities, as local hospitals can continue to treat patients without being forced to turn them away due to ppe shortage. reusing ppe is an option to ease the pressures of ppe shortage. however, the direction to reuse ppe can only be safely implemented where there are protocols for cleaning, disinfecting and storing reusable ppe and limited to ppe that are capable of being reused safely. such essential protocols must include appropriate laundry capacity, whether in hospitals or outsourced to commercial entities. 72 other options include repurposing suitable equipment into ppe that are safe to use for eye and face shields, such as gas masks or sports eye protectors. employees should not be put in an already vulnerable position without the minimum support and infrastructure to carry out their work. the pressing problem of insufficient ppe represents the tip of the iceberg. it reveals a fragile structure in the healthcare system, with the implications of covid-19 felt long after it has come and gone. the level of provision of care for the population in times of pandemic is closely connected to the health workers' risks and safety. the analyses bring to light the importance of implementing sustainable measures for population health. more innovative ideas are needed for producing and replenishing important resources to pre-empt the domino effect arising from a lack of resources in times of pandemic. 73 hospitals are obliged to be more forthcoming in providing clarity with regards to the supply of resources, and to accommodate the possible reluctance of healthcare workers in working in unsafe circumstances. frontline workers who are being prevented from airing their concerns on the severe lack of adequate ppe is detrimental to their functions in providing care. it could not be said to have met the aims of patient safety when staff are not equipped, valued, empowered or supported in carrying out their work. this paper has highlighted how the pandemic has affected the legal obligations of hospitals to healthcare workers in the provision of ppe. hospitals as employers have obligations towards healthcare workers, which include providing a safe 72 livingston, desai, and berkwits (n 70). 73 ibid; cavallo, donoho and forman (n 68). working environment and adequate equipment. the nature and extent of their duty are affected by their role as public authorities and in times of emergency. hospitals usually do not incur liability on the basis that they have service provisions that are influenced by resource constraints, limits in decision-making authority and bureaucracy. daborn and watt v hertfordshire exemplify the types of constraints public authorities face in providing social services, which weighed against the finding of liability. there are persuasive arguments from both perspectives in determining the extent of liability hospitals may incur in their failure to provide ppe in a timely manner. yet legal actions against governments and hospitals have opened up the possibility to reconsider the scope of liability, and the fulfilment of the expected standard under pandemic circumstances. the analyses show nhs managers would be in breach of duty for provision of ppe on the basis that the purpose of their activity is relevant in determining if an employer has breached a duty of care to an employee. while the negligence may be arguably excused during crises, the failure to meet the basic resourcing needs of frontline healthcare workers has breached the minimum standard and ethical imperatives in protecting them from life-threatening harm while they continue to treat an increased influx of patients. additionally, it has highlighted broader issues that plagued ppe procurement readiness preceding the pandemic. the analyses have indicated the extent to which the meeting of legal obligations in a pandemic can be undermined by external, underlying pressures arising from austerity policies introduced throughout the years, and an increasingly privatisation-oriented procurement practice, consequently weakening the public sector capacity in competently meeting public health threats. it is hard to dismiss the consistent pleas from frontline healthcare workers. such pleas strengthened the recognition of obligations to provide ppe. maintaining public health and safety in times of pandemic is of utmost importance; however the public can only be properly cared for where healthcare workers are able to continue working in a relatively safe environment in the midst of a pandemic. the fundamental need for ppe and the health and safety of healthcare workers must be prioritised. while this paper has gestured towards the obligations in providing ppe, the analyses have shed light on the inextricable implications of sound governance in meeting health priorities during a pandemic. it has canvassed a broader profile of underlying issues and proposed recommendations, emphasising the need for cohesive measures to address ppe shortage and alleviate the risks to frontline healthcare workers. the state may not be able to salvage the deaths and distress caused to frontline healthcare workers, but it can act more substantively to protect them and to restore public trust that the healthcare system would not collapse in times of pandemic. it has been argued here that hospitals ought to maintain their obligations to provide ppe to healthcare workers, because a failure to adequately protect them is also a failure to protect public health. supporting the health care workforce during the covid-19 global epidemic lacking beds, masks and doctors, europe's health services struggle to cope with the coronavirus apr bma. 2020. covid-19: ppe for doctors doctor couple challenge uk government on ppe risks to bame staff 24 covid-19-ethical issues. a guidance note uk strategy to address pandemic threat 'not properly implemented. the guardian hospital capacity and operations in the coronavirus disease 2019 (covid-19) pandemic-planning for the nth patient bereaved relatives call for immediate inquiry into covid-19 crisis doctors step up plea for adequate protection against coronavirus covid 19 coronavirus. 2020. tonnes of ppe now in auckland warehouse cecilia faulty batch of face masks prompts the isolation of more than a thousand spanish healthcare staff 21 doctors to file legal challenge to ppe guidance 21 fair allocation of scarce medical resources in the time of covid-19 european centre for disease prevention and control: an agency of the european union guidance: considerations for acute personal protective equipment (ppe) shortages 3 s-infec tion-preve ntion -and-contr ol/covid -19-perso nalprote ctive -equip ment-ppe. department of health and social care (dhsc) guidance: handbook to the nhs constitution for england bma demands urgent ppe solution after 50 italian doctors die from covid-19 oxford: oup. high proportion of healthcare workers with covid-19 in italy is a stark warning to the world: protecting nurses and their colleagues must be the number one priority 20 covid-19 and the stiff upper lip-the pandemic response in the united kingdom covid-19: doctors still at "considerable risk" from lack of ppe, bma warns mapping, assessing and improving legal preparedness for pandemic flu in the united kingdom how a decade of privatisation and cuts exposed england to coronavirus 1 sourcing personal protective equipment during the covid-19 pandemic text and materials, 6th ed global stocks of protective gear are depleted, with demand at "100 times" normal level, who warns covid-19: 90% of cases will hit nhs over nine week period, chief medical officer warns covid-19: hoarding and misuse of protective gear is jeopardising the response, who warns novel coronavirus: australian gps raise concerns about shortage of face masks protecting health care workers against covid-19-and being prepared for future pandemics covid-19: doctors' leaders warn that staff could quit and may die over lack of protective equipment nhs. 2020. the nhs constitution for england how america's hospitals survived the first wave of the coronavirus remember the n95 mask shortage? it's still a problem exercise cygnus report tier one command post exercise pandemic influenza press release: new personal protective equipment (ppe) guidance for nhs teams 2 up to 40% of staff tested at hospital after covid-19 patient contact had virus critical supply shortages the need for ventilators and personal protective equipment during the covid-19 pandemic spanish government faces legal action over lack of ppe for medics 1 spain gears up to manufacture 10 million masks a month as well as other vital covid-19 equipment stone, will, carrie feibel. 2020. covid-19 has killed close to 300 u.s. health care workers, new data from cdc shows care home staff could be asked to work without ppe under council plan 3 the changing role of managers in the nhs king's fund department of health with powers derived from national health service act 1977 national health service and community care act 1990 implementing the code of conduct for nhs managers here's how some of the countries worst hit by coronavirus are dealing with shortages of protective equipment for healthcare workers covid-19: the history of pandemics shortage of personal protective equipment endangering health workers worldwide who and countries are engaged in massive preparedness activities covid-19 news: uk could eliminate coronavirus entirely, say scientists 6 national health service rationing: implications for the standard of care in negligence street on torts key: cord-348614-im7qtr9k authors: yánez benítez, carlos; ribeiro, marcelo a. f.; alexandrino, henrique; koleda, piotr; baptista, sérgio faria; azfar, mohammad; di saverio, salomone; ponchietti, luca; güemes, antonio; blas, juan l.; mesquita, carlos title: international cooperation group of emergency surgery during the covid-19 pandemic date: 2020-10-13 journal: eur j trauma emerg surg doi: 10.1007/s00068-020-01521-y sha: doc_id: 348614 cord_uid: im7qtr9k purpose: the covid-19 pandemic has changed working conditions for emergency surgical teams around the world. international surgical societies have issued clinical recommendations to optimize surgical management. this international study aimed to assess the degree of emergency surgical teams’ adoption of recommendations during the pandemic. methods: emergency surgical team members from over 30 countries were invited to answer an anonymous, prospective, online survey to assess team organization, ppe-related aspects, or preparations, anesthesiologic considerations, and surgical management for emergency surgery during the pandemic. results: one-hundred-and-thirty-four questionnaires were returned (n = 134) from 26 countries, of which 88% were surgeons, 7% surgical trainees, 4% anesthetists. 81% of the respondents got involved with covid-19 crisis management. social media were used by 91% of the respondents to access the recommendations, and 66% used videoconference tools for team communication. 51% had not received ppe training before the pandemic, 73% reported equipment shortage, and 55% informed about re-use of n95/fpp2/3 respirators. dedicated covid operating areas were cited by 77% of the respondents, 44% had performed emergency surgical procedures on covid-19 patients, and over half (52%), favored performing laparoscopic over open surgical procedures. conclusion: surgical team members have responded with leadership to the covid-19 pandemic, with crisis management principles. social media and videoconference have been used by the vast majority to access guidelines or to communicate during social distancing. the level of adoption of current recommendations is high for organizational aspects and surgical management, but not so for ppe training and availability, and anesthesiologic considerations. in december of 2019, the world learned about the emergence of a new coronavirus outbreak, this time in wuhan, hubei province, china. initially termed 2019 novel coronavirus (2019-ncov), it would be known worldwide as the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) [1] . this new disease was termed as covid-19 and spread rapidly worldwide. on march 11, 2020 , the world health organization (who) declared the disease caused by the sars.cov-2 a worldwide pandemic [2] . the high transmissibility of the sars-cov-2 and the overwhelming magnitude of this pandemic forced surgery teams to reexamine workflow, organization, and management for surgical emergency cases [3] . these unprecedented challenges imposed swift changes to avoid the collapse of the health system and the workforce's compromise [4] . to prepare surgical teams for this infectious mass casualty scenario, several international surgical and anesthesia societies produced guidelines on emergency surgery, focusing on preventing the infection of its workforce and guarantee the best response [5] [6] [7] [8] [9] [10] [11] [12] [13] . these covid-19 dedicated protocols addressed surgical team organization, operating room (or) preparation, rational use of personal protective equipment (ppe), considerations on anesthesiology, and intraoperative management of emergency surgical pathology. several articles have been published focusing on the technical surgical aspects during the pandemic and surgical ward preparations [14] [15] [16] [17] . however, fewer have put the spotlight on individual countries' responses [18] , and none that we know have assessed the level of adoptions of current recommendations at an international level. this study aimed to obtain a global snapshot of the level of implementation of these new recommendations by the members of the international emergency surgery community during the covid-19 pandemic. an international cooperation group of emergency surgery during the covid-19 pandemic was formed with surgeons from brazil, chile, italy, portugal, and spain to study the pandemic's impact on emergency surgery teams at the international level. the group used the surveymonkey ® platform to develop a five-section structured questionnaire in english that assessed the adoption of updated recommendations for emergency surgery during the covid-19 pandemic. no specific identifying data were requested, six questions queried about demographic information, seven about team organization, 25 regarding ppe, 21 or adequation, anesthesia considerations, and surgical management. the questions were presented in such a way that respondents could agree or disagree with the specific statements. the online survey was issued prospectively, anonymously and voluntarily, from the 1st to the 14th of april 2020, to 680 members of emergency surgical teams from over 30 countries. the survey target population was selected using a non-probability method consisting of a convenience sample of five significant surgeons' associations, which included professionals ascribed to the spanish surgical association, european society for emergency and trauma surgery, international association for trauma surgery and intensive care, american college of surgeons, and the panamerican trauma society. subjects were invited through email invitations, mailing lists of some participating societies, and posted via personal networks and social media. survey results were analyzed using the surveymonkey ® online platform (svmk inc, san mateo, usa), calculating frequencies and percentages of the collected data. a total of 134 valid responses from 26 countries were obtained from 680 (20%) of the issued invitations, of which 119 (88%) were surgeons, 9 (7%) surgical trainees, and 6 (4%) anesthetists. the vast majority were males (72%), with ages ranging from 25 to over 60. respondents worked in 26 different countries, mostly from europe, with 85 responses from 8 different countries, followed by 42 responses from 12 american countries, five from four countries in the middle east, and two countries from asia, with one response each fig. 1 . 81% of the respondents got involved with the covid-19 surge planning taskforce, 93 (71%) developing clinical protocols, 91 (69%) implementing safety precautions, and 67 (51%) performing task management. social media and other online resources were employed by 122 (91%) respondents to obtain relevant covid-19 clinical guidelines fig. 2 . modification of shift handover routines and the use of video conference tools, to maintain communication while promoting social distancing within the working place, was reported by 88 (66%) of them fig. 3 . continuity performing their regular tasks was reported by 73 (54%) of the respondents, in contrast with the rest, whose newly assigned duties were to the emergency department covid-19 triage (25%), the intensive care unit (icu) activities (13%), or had to manage mechanically ventilated patients in the surgical ward (7%). another modification to their routines was in shift duration, as reported by 80 (60%), and over half of the total (52%) worked continuously for extended periods of 24 h or more. about half (51%) of the respondents had not received training in the use of ppe for airborne infectious risk while performing emergency surgical procedures before the pandemic, and roughly over one-third (37%) had it during the studied period. of all the respondents, 105 (78%) used surgical masks, and 38 (28%) wore n95/fpp2/3 respirators always in the ward, even without covid-19 hospitalized. over half (56%) had a specific area assigned for donning/ doffing the ppe, 53% employed checklist, and 60% performed routine buddy checks. three-fourths (75%) made mask fit tests while donning, one-third (34%) reported that fitting issues due to facial hair (beard), and out of these, half (51%) shaved it to obtain an adequate fit. the reported ppe used for emergency procedures was face shield (74%), double gloving (71%), surgical goggles (68%), long sleeve disposable gown (63%), and water-resistant shoe covers (35%) fig. 4 . data about the shortage of ppe (73%) and n95/fpp2/3 (77%), as well as the re-use of ppe components (55%), were collected fig. 5 . reuse or extended use of n95/ fpp2/3 beyond the lapse they were designed for was commented by 55% of the respondents fig. 5 . scarcity or even absence of parts of such equipment was reported by 53% fig. 6 . when asked if using ppe gave a sense of protection during the surgical procedure, less than half (48%) of the respondents felt protected with ppe. over three-fourths (77%) of the participants had covid operating areas (coa), or facilities prepared or modified for performing emergency surgery in covid-19 patients, and over two-thirds (69%) had a designated covid-19 trauma or. the vast majority (80%) cleared out unnecessary equipment form the or when performing surgery on covid-19 patients, and 78 (60%) protected monitors and other electronic equipment, including anesthesia machine, with plastic wraps; 70% used or alert signs during the procedure in covid-19-positive or suspected cases. however, only over one-fourth (26%) had surgical smoke evacuation systems available, and above two-fifths (43%) had to improvise such a device. when asked about the transport of emergency surgical cases to the or, almost two-thirds (64%) answered that covid-19 emergency surgical cases were escorted directly to the or, not stopping in the preoperative-postoperative anesthesia care unit (po/pacu). regarding anesthesiologic equipment preparations, less than half (40%) had a covid-19 resource box available for general anesthesia procedures (including cheat sheets and alert signs). only one-fourth (25%) said to have a specific covid-19 airway trolley at their institution, and of these, 27% had access to a printed intubation guideline. over one-third (38%) responded that the anesthesia team routinely used video laryngoscopy for orotracheal intubation (oti), and almost two-thirds did not know if rapid sequence induction (rsi) was the induction protocol used. almost two-thirds used a covid-19-specific checklist before surgery, and an equal number of respondents entered the or after patient intubation. less than half (44%) had performed emergency surgical procedures on covid-19 patients during the study, and only over one-fourth, 26% had performed emergency laparoscopic surgery on these patients. however, when asked which approach was preferred for acute appendicitis or cholecystitis, over half (52%), preferred the laparoscopic approach. when asked for preoperative screening methods, only one-third (32%) systematically performed covid-19 screening before emergency surgery. 50% of these used the reverse transcriptase-polymerase chain reaction (rt-pcr) test, the rest recurred to radiological screening, either thoracic ct scans (14%) or lung us (1%). when asked for the number of emergency cases evaluated in the emergency department, the vast majority (82%) perceived a lower frequency of emergency surgical emergencies during the studied period. while the novelty of this pandemic has generated many published papers on management recommendations [19] [20] [21] [22] [23] , few assess the degree of guidelines implementation by emergency surgical teams. this study provides an international snapshot of the level of adoption of the guidance for surgical team organization, adequacy of ppe availability and usage, or preparation, anesthesiologic considerations, and intraoperative management of emergency surgical cases during 2 weeks of the covid-19 pandemic. it should be noted that the study tried to capture the initial response when there was a steep curve of newly reported cases, but while that was the case in europe at the time of the survey, the american surge came weeks later. the study analyzed the recommendations for emergency surgical management of covid-19 suspected or confirmed cases, which may differ significantly between countries due to the variability of the number of newly diagnosed cases, resources available, and healthcare policies. increased awareness and adoption of international societies' recommendations for emergency surgical management with greater exposure to covid-19 were expected amongst surgeons with higher case exposure, but the study design did not allow this assumption. nonetheless, the study can help identify weaknesses in the surgical team response and areas of improvement, which could be useful to face the latest news that brings up attention like the possibility of a second wave of the pandemic [24] [25] [26] . regarding the surgical teams' organization, most of the published literature focuses on reducing the risk of infection by limiting the number of workforce members on each procedure [2, 27] . furthermore, the emphasis is made on rescheduling elective surgical procedures to rationalize hospital bed capacity. however, few mention surgical teams' leadership organizing the response to the pandemic [28] . we found out that over 80% of the teams' members have been doing so, either developing protocols (71%) and implementing safety precautions (69%), which confirms the capacity of emergency surgical to rapidly adapt to complex crises, organizing proactive medical responses when facing natural or human-made disasters [29] . the 2009 h1n1 pandemic revealed that communication dynamics are vital for crisis management, and the use of practical tools for the transmission of health recommendations increases compliance [30] . social media and online resources are now used by more than 3.8 billion, twitter, and other social media channels can be a reliable source of health-related information [31] . the covid-19 pandemic has demonstrated that emergency surgical teams and healthcare bodies could use online tools to disseminate guidelines and maintain communication in times of uncertainty [32] . our study reveals the use of these tools by 91% of the respondents and the utilization of video conferences by 66% to improve communication between team members during social distancing. they also had to adapt to new roles when they were assigned to the emergency department triage, icu, or the management of mechanically ventilated patients, 60% had to endure long working shifts, and 52% had 24 h or more in extremely stressful situations. focusing on ppe, current literature reports that there are four essential elements regarding ppe: training, availability, adequate use, and re-use strategies in case of shortage [33] [34] [35] [36] . our study reflects that following ppe recommendations had been a significant issue among respondents; over half expressed concerns for insufficient training, 71% have reported shortages, and 53% improvised part of their protective equipment. training of proper donning/doffing techniques is essential, it will lower the probability of selfcontamination, and educational campaigns must emphasize biosafety breaches to reduce surgical team members' exposure to it [37] [38] [39] [40] . a critical shortage of n95/fpp2/3 respirators was reported. this can be explained by the underestimation of equipment needs, coupled with the abrupt increase of its global demand. a recent survey about ppe supplies in the us reported that 91% of the 213 queried cities had inadequate face mask supplies, and 88% did not have enough ppe for medical personnel and first responders [41] . tabah et al. in a recent international survey among 2711 intensive care unit healthcare workers, reported widespread shortage and adverse re-use [42] . another aspect that stands out in our study is that over half (53%) of the population had to improvise ppe, undermining front-line workers' trust and confidence with their employer institutions [43] . additionally, equipment shortage, re-use, and improvisation elevate the risk of infection, adding to the sense of hazardous exposure, and increasing work-associated stress. concerning the operating conditions, 71% had prepared coa and most followed guidelines to adapt the existing conditions to the suggested recommendations [3] . information regarding negative pressure or suites was not addressed in the survey, but if available, negative pressure ors should be used to reduce the risk of viral spread and minimize infection risk [44] . one element that should be pointed out is the management of surgical smoke during the pandemic. at the beginning of the covid-19 outbreak, many guidelines recommended avoiding laparoscopy due to the possibility of viral aerosolization and team infection due to smoke inhalation. current publications have downsized these risks with measures of smoke/aerosol containment and proper smoke evacuation. however, only 26% reported to have purposed design smoke evacuation systems, and almost half had to improvise them using standard filters, and waters seal devices [45] , which could be useful for smoke and vapors generated electrosurgical and ultrasonic devices until more evidence-based research in this field is available. reported results of anesthesiologic protocol adoption by the emergency surgery teams reflect a significant lack of implementation of the official recommendations promoted by international anesthesia societies [46, 47] . our results suggest that improvements must be addressed, especially with equipment preparation during airway manipulation. the importance of having prepared an individual covid-19 airway trolley with printed airway guidelines should not be underestimated. we consider these elements essential since the use of ppe in the or has been associated with communication interference and visibility impairment [47] . using a specific trolley with printed instructions would help avoid errors and reduce team members' risks. because of the limited number of questions in this area and the reduced number of anesthetists participating in our study, we consider our finding as limited and that further analysis is needed. answers received about the operative management reflect the existing differences in the number of new covid-19-positive registered cases in the participating countries during the studied period. during april 2020, the number of new cases was counted by the thousands in several european countries, with spain and italy among them, while in america, it was only starting to be diagnosed. despite these differences, 44% of the respondents had performed emergency surgery on covid-19-positive patients. it is essential to highlight the need to use aerosol-generating procedures (agp) checklists in all emergency surgical procedures. soma et al. describe how an operative team checklist can potentially reduce risks, but above all, it reduces anxiety and helps maintain the team focused on the task [48] . results reflect the concerns with the laparoscopic approach and the risks of viral aerosolization. in our study, only 26% had performed laparoscopic procedures [49] . the low level of reported preoperative covid-19 screening (32%) is of serious concern, and efforts should be made to perform some screening for all emergency surgical cases. our study had some limitations that must be noted. first, the 2-week period studied reflected a global snapshot of the pandemic, and the number of newly reported cases between asia, europe, and america has not been homogeneous. second, the level of the reported adoptions of the continually changing recommendations reflects respondents' perceptions and opinions, which may not accurately represent actual practices. confirmation of the reported findings should be audited in future studies. this is particularly important with ppe since the massive demand worldwide had generated a global shortage of some equipment. also, the survey design might have introduced some bias and had a relatively small sample size. only 20% of the contacted participants; this is especially important regarding the small number of anesthetists included in the study (n = 6). finally, our sampling strategy recruited mostly european and american respondents, with very few emergency surgeons from asia and the middle east, so that results may be biased. despite these limitations, the findings reflect the leadership and level of involvement of surgical teams during the pandemic. it identifies the urgent need for more training and better endowment of ppe among emergency surgical teams worldwide. the addressing of these issues will allow better preparation for future similar scenarios and guarantee a better response in case of a second wave of the pandemic to be registered in the coming months. respondents exercised leadership through the development of surgical protocols and safety measures. social media and video conferences resulted in capital importance for accessing reliable clinical management guidelines and for team communication while maintaining social distancing. urgent measures to assure sufficient availability of ppe shortage, particularly n95/fpp2/3 respirators must be addressed by healthcare administrators and governments. even though operative room preparation was adequate, very few had a specific covid-19 airway trolley at their institution; improvements in airway management equipment are advisable. outbreak of pneumonia of unknown etiology in wuhan, china: the mystery and the miracle world health organization. who director-general's opening remarks at the media briefing on covid-19 -11 surgery in covid-19 patients: operational directives emergency surgery during the covid-19 pandemic: what you need to know for practice european society of trauma and emergency surgery (estes) recommendations for trauma and emergency surgery preparation during times of covid-19 infection intercollegiate general surgery guidance on covid-19 update american college of surgeons releases recommendations for surgical management of elective operations during covid-19 pandemic sages and eaes recommendations regarding surgical response to covid-19 crisis. released 3/30/2020 guidance for surgeons working during the covid-19 pandemic https :// www.rcsen g.ac.uk/coron aviru s/joint -guida nce-for-surge ons-v1 manejo quirúrgico de pacientes con infección por covid-19. recomendaciones de la asociación española de cirujanos emergency surgery and trauma care during covid-19 pandemic recommendations of the spanish association of surgeons american association for the surgery of trauma. covid-19 resources consensus guidelines for managing the airway in patients with covid-19: guidelines from the difficult airway society, the association of anaesthetists the intensive care society, the faculty of intensive care medicine and the royal college of anaesthetists surgery in times of covid-19-recommendations for hospital and patient management guidelines for the management of surgical departments in non-uniform hospitals during the covid-19 pandemic coronavirus pandemic and colorectal surgery: practical advice based on the italian experience open versus laparoscopic cholecystectomy in acute cholecystitis systematic review and meta-analysis emergency general surgery in italy during the covid-19 outbreak: first survey from the real life china medical treatment expert group for covid-19. clinical characteristics of coronavirus disease 2019 in china covid-19 outbreak and surgical practice: unexpected fatality in perioperative period emergency colorectal surgery in a covid-19 pandemic epicenter management of covid-19-positive pediatric patients undergoing minimally invasive surgical procedures: systematic review and recommendations of the board of european society of pediatric endoscopic surgeons what happened to surgical emergencies in the era of covid-19 outbreak? considerations of surgeons working in an italian covid-19 red zone beware of the second wave of covid-19. lancet covid-19: are we ready for the second wave? disaster med public health prep covid-19: risk of second wave is very real, say researchers surgical management of suspected or confirmed sars-cov-2 (covid-19)-positive patients: a model stemming from the experience at level iii hospital in emilia-romagna rapid response of an academic surgical department to the covid-19 pandemic: implications for patients, surgeons, and the community responding to crisis: surgeons as leaders in disaster response crisis communication in the area of risk management: the cricorm project social media can have an impact on how we manage and investigate the covid-19 pandemic covid-19: the doctors turned youtubers rational use of personal protective equipment for coronavirus disease (covid-19) and considerations during severe shortages: interim guidance center for disease control and prevention c recommended guidance for extended use and limited reuse of n95 filtering facepiece respirators in healthcare settings reasons for healthcare workers infected with novel coronavirus disease 2019 (covid-19) in china planning for epidemics and pandemics: assessing the potential impact of extended use and reuse strategies on respirator usage rates to support supply-and-demand planning efforts common breaches in biosafety during donning and doffing of protective personal equipment used in the care of covid-19 patients infection prevention and control during health care when novel coronavirus (ncov) infection is suspected. interim guidance effective strategies to prevent coronavirus disease-2019 (covid-19) outbreak in hospital the lancet covid-19. protecting health-care workers. lancet covid-19: the crisis of personal protective equipment in the us personal protective equipment and intensive care unit healthcare worker safety in the covid-19 era (ppe-safe): an international survey ppe guidance for covid-19: be honest about resource shortages preparing for a covid-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore. se préparer pour la pandémie de covid-19: revue des moyens déployés dans un bloc opératoire d'un grand hôpital tertiaire au singapour how to manage smoke evacuation and filter pneumoperitoneum during laparoscopy to minimize potential viral spread: different methods from some -a video vignette. colorectal dis covid-19 information for health care professionals canadian anesthesiologists' society. covid-19 recommendations during airway manipulation impact of personal protective equipment on surgical performance during the covid-19 pandemic operative team checklist for aerosol generating procedures to minimise exposure of healthcare workers to sars-cov-2 risk of virus contamination through surgical smoke during minimally invasive surgery: a systematic review of literature on a neglected issue revived in the covid-19 pandemic era we would like to acknowledge all the members of 1 general and gi surgery department, royo villanova hospital, salud, av. de san gregorio s/n. 50015, zaragoza, spain key: cord-327595-00fxzyhq authors: nan title: american geriatrics society (ags) policy brief: covid‐19 and assisted living facilities date: 2020-05-14 journal: j am geriatr soc doi: 10.1111/jgs.16510 sha: doc_id: 327595 cord_uid: 00fxzyhq this policy brief sets forth the american geriatrics societyʼs (agsʼs) recommendations to guide federal, state, and local governments when making decisions about care for older adults in assisted living facilities (alfs) during the coronavirus disease 2019 (covid‐19) pandemic. it focuses on the need for personal protective equipment, access to testing, public health support for infection control, and workforce training. the ags continues to review guidance set forth in peer‐reviewed articles, as well as ongoing and updated guidance from the us department of health and human services, the centers for medicare and medicaid services, the centers for disease control and prevention, and other key agencies. this brief is based on the situation and any federal guidance or actions as of april 15, 2020. joining a separate ags policy brief on covid‐19 in nursing homes (doi: https://doi.org/10.1111/jgs.16477), this brief is focused on alfs, given that varied structure and staffing can impact their response to covid‐19. alfs do not provide round-the-clock skilled nursing care and are neither considered nor licensed as medical facilities. they are residential settings that generally provide or coordinate personal and healthcare services to residents who live independently in their own homes in the building or complex. most alfs are apartment-type buildings where each resident leases an apartment or room and the rental package includes a limited number of services (eg, meals, cleaning). residents typically pay for additional services to be provided in their home (eg, assistance with bathing, dressing) as their needs dictate. alfs have emerged as an attractive option for older adults and their families because they typically offer group dining, transportation, and recreational activities (eg, weekly social hours, day trips, and clubs), in addition to a menu of supportive services that help older adults to remain at home and independent. alfs vary widely in the structure of available services; these may include 24-hour on-call assistance with activities of daily living and on-call nursing assistance. residents may also hire personal care assistants externally, and some alfs coordinate care with external home health agencies (eg, visiting nurse), depending on a residentʼs needs. this structure is not as conducive as nursing homes (nhs) to cohort residents. while residents could be restricted to their rooms, it would require significant staff to provide needed care, and residents would need to agree to adhere to such restrictions, which makes it difficult to enforce such universal precautions. some alfs specialize in the care of people with various forms of cognitive impairment and dementia, which might make isolating and cohorting even more challenging. "memory care" units or facilities have the added challenges that residents are often unable to follow physical distancing instructions, or are unable to adhere to interventions such as the wearing of masks or gloves. the vast majority of alfs are private pay, although increasing numbers of stays are being paid through medicaid waiver programs. alfs vary in cost and size, and there are no federal regulations that are specific and state regulations vary. unlike nhs, there are no requirements for a medical director, an admitting physician, or regular visits by a physician, advance practice clinician (eg, a nurse practitioner), or other health professional staff. some alfs have primary care clinicians come to visit residents, but this is the exception rather than the rule. the availability of nurses in alfs varies considerably. there are also no standard requirements for infection control or an infection control practitioner, as there are in nhs. alfs also differ widely in the amount of health information they collect from residents and the types of personal care, therapeutic, and health services they offer as part of their service menus. given how the vast majority of alfs are structured and staffed, alfs are not as well resourced to respond to the covid-19 outbreak as other care settings. though cms official guidance for nhs contains elements that alfs could adopt, alfs may have difficulty implementing much of this guidance. nationwide, over 800,000 americans live in alfs. of alf residents, 52% are 85 years and older and 30% are between the ages of 75 and 84 years. 1 this age group has increased susceptibility to the complications of covid-19, including respiratory failure and death. 2 these older adults live in more than 28,000 alfs that employ over 450,000 individuals. 3 direct care workers provide most of the paid hands-on care and support to alf residents. 4 direct care workers are essential to care for older adults and ensure overall well-being, especially during public health crises. jobs in aging services, in addition to being physically and emotionally demanding, are complex and best performed by persons trained or experienced in the care of older adults. these workforce needs are not recognized in pay scales or reimbursement rates, nor are these needs recognized in state regulations for alfs. states vary widely in whether they have regulations and requirements that address overnight staffing levels, number of licensed nursing staff, and workforce training. 5 the emergence of this new and deadly coronavirus significantly exacerbated existing gaps in expertise and systemic weaknesses in healthcare service delivery for older americans, particularly for the direct care workforce. staff recruitment and retention in this sector was difficult before the pandemic and will remain a challenge without increases in wages, provision of benefits, and development of career ladders. the increase in positive cases also impacts staff capacity, as staff may need time off to address childcare, tend to sick family members, or become sick themselves. as of april 8, 2020, at least 29 states reported covid-19 cases in alfs. one texas-based alf group with ownership or operations in over 120 older adult communities reported three outbreaks in its facilities. 6 in colorado, there are 69 older adult facilities with known covid-19 outbreaks as of april 11, 2020. one of the alfs is under investigation for its prevention efforts due to the substantial positive covid-19 test results among residents and staff (33 of 46 residents and 16 of 25 staff members). covid-19 has been confirmed as the cause of death for five of the cases. 7 as we have learned with nhs, outbreaks in alfs and other congregate living settings are a foreseeable consequence of covid-19, even when adhering to set guidelines. while some of this inevitability may be due to circumstances we can work to control-including the lack of available ppe and testing-other challenges will likely remain beyond our control. nonetheless, as the priority for ppe and funding is given to frontline medical staff caring for covid-19 patients, support for direct care workers outside the hospital has been insufficient. 8 alfs do not have the capacity or resources to implement full cdc guidance issued for medical facilities when there is a recognized pandemic. given asymptomatic shedding, ppe ideally must be available to all staff when caring for all residents in a facility with a known case of covid-19. ppe not only protects the care staff but also the residents. furthermore, staff may pass mandatory symptom and temperature screening procedures and still be infected, shedding enough virus to infect residents and other staff. without the needed tools, many other unnecessary outbreaks, such as the one in colorado and others that have been reported, will likely occurpossibly with high mortality rates. county departments of health can provide guidance, whether it be for testing, staffing, ppe, training, or funding, to help alfs in this crisis. we appreciate that the president has invoked the defense production act to increase the supply of ventilators and, more recently, ppe. however, there are current and potential shortages of equipment and supplies across settings. alfs, other congregate living settings (eg, nhs, residential care facilities for older adults, continuing care retirement communities), and home healthcare agencies (eg, visiting nurse association) must be included as priorities when estimating what is needed for the us coordinated response to covid-19. as states begin to develop plans to lift shelter-in-place restrictions, the need for an adequate supply of ppe and testing supplies is critically important to protecting the health of the public given the critical need for widespread screening. the existing and future shortfalls will only be addressed if the president fully exercises his authorities under the defense production act so that we can move quickly to increase production and distribution of: • ppe: this includes the masks, face shields, gowns, and gloves that all frontline healthcare professionals and direct care workers need to protect themselves against becoming infected and from spreading coronavirus within the resident population. ppe protects health workersʼ own safety, which is key to ensuring we have access to the healthcare workforce we need during this pandemic. • testing kits and related laboratory supplies: supplies for reliable diagnostic and serologic testing are integral to protecting the health and safety of residents and workers during this pandemic. • supplies for symptom management and end-of-life care: many residents of alfs may have multimorbidity or complex advanced illness. some of these residents may be enrolled in hospice or need access to hospice-level services during the covid-19 crisis. it is critical to prevent a gap in the supply of the medicines and equipment critical to symptom management, especially at the end of life. covid-19, particularly for people who develop the distressful and uncomfortable symptoms of respiratory failure, has resulted in an increase in demand for medications (eg, opioids) and equipment commonly used in symptom management and at the end of life. in light of this, the federal government should proactively monitor the available supply of medications and, if shortages are imminent, the president should fully exercise his authorities under the defense production act to ensure that there is an adequate supply. the department of defense (dod) has significant expertise and the requisite equipment to coordinate the supply chain with state and federal governments. the president should authorize the dod to work with the federal and state governments to: (1) coordinate the sharing of scarce resources within and across states; (2) deliver new resources to states and communities; and (3) help to prioritize alfs and other congregate living settings and home healthcare agencies (eg, visiting nurse association) for the tools and resources they need. the federal and state governments are beginning to plan for reopening the economy, and there is a critical need for widespread covid-19 testing and contact tracing. making the united states safe means slowing the rate of infection with coronavirus to a level that our health systems can address. we must dramatically scale up the availability of diagnostics that offer accurate, rapid results. this represents our best chance for identifying asymptomatic covid-19 carriers as well as confirming disease in those with covid-19 symptoms, reducing the number of people who need to be isolated, and protecting all americans. expert estimates of the us need for testing range from 750,000 tests per week to more than 22 million per day, with widespread and repeated testing of the population. [9] [10] [11] contact tracing to target covid-19 and track disease spread also will be vital as we start to loosen restrictions safely. for older adults residing in alfs and other congregate living settings, screening for covid-19 will be particularly important for protecting the health and safety of their communities. for individuals who test positive for covid-19 or are strongly suspected of having contracted the disease, several important factors will impact decisions on transitions between care settings. as recommended by the cdc, the first and best option is for covid-19-positive individuals to remain at home and quarantined unless their symptoms are so serious that they need care that is only provided in a hospital setting. for alfs, decisions to transfer a symptomatic or known covid-19positive resident should consider resident goals of care and be guided by a clinician (eg, registered nurse, nurse practitioner, physician assistant, or physician who is affiliated with the facility), who can work with the individualʼs primary care provider to manage conditions in place, if possible, without transferring the person. to the extent allowed by the state, the inclusion of a licensed home health service can provide a bridge for clinical support for the individual and the facility. at a minimum, the ability to care safely for and isolate the positive individual must be taken into account. residents discharged from other settings (eg, hospitals, skilled nursing facilities) who test positive for covid-19 should not be discharged back to an alf unless the alf can safely and effectively isolate the patient from other residents and has adequate infection control protocols and ppe for staff and residents. this includes the ability to isolate or cohort the resident(s) separately from the rest of the community and provide dedicated staff to meet increased care needs for people with covid-19. such transfers should be in accordance with current cdc guidance. state, county, and local health departments should immediately engage with alfs in their communities to offer assistance with taking steps to limit the spread of covid-19 in alfs. such support should include: 1. technical assistance with implementing policies and procedures for screening staff, visitors, and private-pay care assistants aligned with guidance from the cdc and updated regularly to account for situational change. infection among staff may be a major source of exposure for alf residents. isolation rules must be carefully considered so as not to quarantine staff unnecessarily or for too long a period, which could decimate the alf workforce. 2. obtaining testing for residents and staff who are symptomatic or with known exposure, including arranging for on-site testing to be available. 3. providing guidance on implementing advanced hygiene practices, including: a. increasing signage about the effectiveness of handwashing for at least 20 seconds with soap and hot water; physical distancing (also referred to as social distancing); and face covering. b. ensuring soap dispensers are full; providing easy access to alcohol-based hand sanitizer; and implementing routine surface cleaning protocols to high-touch surfaces where contamination risks are high, such as communal areas and areas around sinks and toilets. 12 4. communicating about, and supporting adherence to, the need for physical distancing, face covering, and enhanced hygiene practices, such as washing hands for 20 seconds. when providing care for those with cognitive impairments, staff will need to provide direct supervision, as much as possible, to improve adherence. 5. training all staff on infection control, the proper use of ppe, and recognition of covid-19 symptoms. 6. developing plans for caring for residents who are symptomatic, including criteria to guide collaborative decision making around transfer vs manage-in-place. for those residents who are managed in the alf, plans must address ensuring access to ppe, clinical staff, and telehealth for coordination with the residentʼs primary care clinician and family. 7. facilitating local collaborations among alfs, hospitals, and nhs with consideration for dedicated covid-19 facilities that have the expertise, ppe, and supplies to care safely for these patients. as recommended by the cdc, the first and best option is to discharge to home in isolation with any needed home care. because alfs are the individualʼs home, this will involve ensuring that enough home healthcare resources are available to patients who have remaining health needs. it will also involve the use of telemedicine for clinicians to monitor patients discharged to home. departments of public health should work with alfs to ensure they have access to clinical advisors who can assist with managing covid-19positive residents safely, including assisting with planning to isolate them from other residents and conducting contact tracing within the alf. at the same time, the federal government and states should build capacity to care for patients with covid-19 post-hospital discharge if they cannot return home. this will include working with the network of providers (hospitals, nhs, alfs, home health, long-term services, and support providers) to identify safe locations for those with wandering behaviors and highly complex care needs, and identifying housing for patients who are not stable enough for discharge to home but who still need support and close monitoring. 8. ensuring adequate and safe staffing ratios for all disciplines providing care to alf residents by working with state and local governments to ensure that alfs are included in emergency personnel deployment planning. 9. providing access to training and resources to promote advance care planning discussions by coordinating with primary care clinicians and other clinical staff. this entails eliciting goals of care and completing physician orders for life-sustaining treatment forms or other portable physician orders. we recognize that congress has taken steps to address access to paid family leave for all americans. however, more must be done to ensure that all health professionals and direct care workers on the frontlines of addressing this crisis have access to paid family, medical, and sick leave, including paid time when isolating due to exposures. ensuring access to paid leave is important for alf staff, including certified nursing assistants, personal care assistants, dietary staff, direct care workers, and environmental support staff, as well as home care workers who are paid hourly, often lack paid sick leave, and commonly have marginal financial resources at baseline. congress should ensure that tax relief is provided to those alfs that provide paid family leave to support nurses, therapists, and direct care workers caring for older adults and people with disabilities. while the recently passed families first coronavirus response act takes some important steps to support paid leave, it does not provide a way for most healthcare organizations to offset the costs of providing medical and family leave to employees. in addition to alfs, home care agencies, hospitals, nhs, and clinician practices should have immediate access to federal grants, interest-free loans, or tax relief to help offset these costs. as we continue to learn and grow from this emergency, we urge congress to provide educational and grant opportunities for direct care workers. the following actions would enhance the profession and strengthen the pipeline of individuals to work in aging service: (1) implement immediate recruitment campaigns, particularly targeting displaced workers; (2) provide funding for online training relevant to the alf population (including entry-level and covid-19 content) and competency evaluations; (3) increase funding to direct care training providers to enhance the training infrastructure; and (4) provide funding for in-person training following the public health emergency to increase and maintain direct care workforce capacity. faststats: residential care communities people who are at higher risk for severe illness long-term care providers and services users in the united states a profile of the assisted living direct care workforce in the united states long-term care providers and services users in the united states: data from the national study of long-term care providers covid-19 crisis threatens beleaguered assisted living industry. kaiser health news public health officials announce aurora assisted living facility with 49 cases, eight deaths from covid-19. colorado politics ags) policy brief: covid-19 and nursing homes what testing capacity do we need? kaiser family foundation website national coronavirus response: a road map to reopening simulating covid-19: part 2. paul romer professional website novel coronavirus (covid-19) pandemic: built environment considerations to reduce transmission. msystems sponsor's role: none. key: cord-332083-135iic7m authors: xia, wei; fu, lin; liao, haihan; yang, chan; guo, haipeng; bian, zhouyan title: the physical and psychological effects of personal protective equipment on health care workers in wuhan, china: a cross-sectional survey study date: 2020-09-29 journal: j emerg nurs doi: 10.1016/j.jen.2020.08.004 sha: doc_id: 332083 cord_uid: 135iic7m introduction: the purpose of this study was to rapidly quantify the safety measures regarding donning and doffing personal protective equipment, complaints of discomfort caused by wearing personal protective equipment, and the psychological perceptions of health care workers in hospitals in wuhan, china, responding to the outbreak. methods: a cross-sectional online questionnaire design was used data were collected from march 14, 2020, to march 16, 2020, in wuhan, china. descriptive statistics and χ square analyses testing were used. results: standard nosocomial infection training could significantly decrease the occurrence of infection (3.6% vs 13.0%, χ(2) = 4.47, p < 0.05). discomfort can be classified into 7 categories. female sex (66.0% vs 50.5%, χ(2) = 6.37), occupation (62.7% vs 30.8%, χ(2) = 5.33), working at designated hospitals (44.8% vs 26.7%, χ(2) = 5.17) or in intensive care units (70.4% vs 57.9%, χ(2) = 3.88), and working in personal protective equipment for > 4 hours (62.2% vs 39.2%, χ(2) = 9.17) led to more complaints about physical discomfort or increased occurrence of pressure sores (all p < 0.05). psychologically, health care workers at designated hospitals (60.0% vs 42.1%, χ(2) = 4.97) or intensive care units (55.9% vs 41.5%, χ(2) = 4.40) (all p < 0.05) expressed more pride. discussion: active training on infection and protective equipment could reduce the infection risk. working for long hours increased the occurrence of discomfort and skin erosion. reducing the working hours and having adequate protective products and proper psychological interventions may be beneficial to relieve discomfort. coronavirus disease , which is now known to be caused by the severe acute respiratory syndrome coronavirus 2, has become a worldwide pandemic. [1] [2] [3] [4] the virus has now spread to 6 continents, endangering more than 10 million people. 5 the cumulative number of diagnosed patients had reached 85,204 in china as of june 29, 2020. 6 controlling the spread of the disease and providing medical care to the infected patients has been an unprecedented challenge. despite wearing personal protective equipment (ppe), there is evidence of health care workers (hcws) becoming infected. [7] [8] [9] in addition, owing to the heavy workload at the forefront and discomfort from wearing ppe for long periods, hcws, especially nurses in highworkload departments such as the emergency department, are suffering from considerable physical and mental burdens. [10] [11] [12] [13] owing to its rapid spread and highly contagious nature, as of february 11, 2020, 1,716 hcws in china had been infected by covid-19 according to a report from the chinese center for disease control and prevention. 14 hcws' main complaints include difficulty seeing owing to the misting of eye protection and difficulty breathing through protective masks. a proper method of donning and doffing ppe is highly important to protect hcws from inadvertent exposure. the national health commission of the people's republic of china has issued standard protocols for putting on and removing ppe according to different protective grades. 15 there are 3 levels of protection in china depending on different departments and degrees of exposure risk. equipment and n95 masks are required, and certain procedures must be followed in donning and doffing level ii ppe and above. (level iii protection is for those who are performing operations such as tracheal intubation that may produce aerosols in patients suspected of having, or confirmed to have, covid-19.) level ii protection is required for hcws working in emergency departments with patients with fevers; those who enter observation rooms or isolation wards with suspected cases; those who transport patients suspected of having, or confirmed to have, covid-19; and those who dispose of the corpses of patients who died owing to covid-19. because level ii ppe is used under most circumstances, with the exception of invasive operations, our research focused mainly on the use of level ii ppe. detailed donning and doffing procedures are described in the supplementary figure the purpose of this study was to rapidly quantify the safety measures of donning and doffing ppe, complaints of discomfort caused by wearing ppe, and the psychological perceptions of hcws in hospitals in wuhan, china, responding to the covid-19 outbreak. furthermore, we aimed to explore group differences in safety measures by infection status; complaints of discomfort by sex, working time, occupation, department, age, and workplace; and psychological perceptions by demographic characteristics. we used a cross-sectional design. we conducted an anonymous questionnaire survey (supplementary table 2 table 2 ). the authors were actively involved in frontline clinical care in wuhan, china, and the survey was based on their expert experience with ppe in the early phases of the covid-19 pandemic. there were 25 multiple-choice questions-6 had multiple-response options-with 5 questions per page, 5 pages in total. we used the questionnaire star survey program (wise talent information technology co, ltd) to collect the information. a link to the questionnaire was published on the wechat platform (tencent), the most widely and frequently used social networking platform in china. 16 it was open to all hcws in wuhan and those hcws came to support them. the survey was voluntary, with no incentives offered, and completing the survey was considered implied informed consent. we also attached a completeness check to the questionnaire, and responding to all 25 questions was mandatory; therefore, the participants had to choose at least 1 answer for each question listed. participants were not permitted to review after submitting the questionnaire; therefore, the participants could not change their answers once they were submitted. because our participants were all hcws in wuhan hospitals, we divided their demographic information as follows: the demographic variables included sex (male or female); age (20-30 years, 30-40 years, 40-50 years, and >50 years); occupation (physician, nurse, pharmacist, medical technician, or other); workplace (a designated hospital for patients critically ill with severe covid-19; an undesignated hospital for patients uninfected with covid-19; and fangcang hospital for patients with mild symptoms of covid-19); and department (general isolation ward, intensive care unit [icu], emergency department for patients with fevers, and other). the evaluation questionnaire included (1) whether or not the hcw had standard nosocomial infection training before treating patients in the wards, (2) whether or not the hcw was well acquainted with the standard operating procedure (sop) of donning and doffing ppe, (3) the presence of a full-length dressing mirror, (4) measures that the hcw thought were necessary to standardize the donning procedure, and (5) the best length of the hcw's hair at work. the respondents were also asked if they had been infected by covid-19 owing to exposure at work. we asked questions on the specific time that the hcw spent in the ward wearing ppe, their discomfort owing to ppe, and possible solutions. the questions included: time. (1) the time it took for an hcw to put on ppe, (2) the maximum time an hcw had spent in ppe, and (3) the maximum tolerance time of an hcw in ppe. discomfort in ppe at work. (1) discomfort: dizziness or palpitation; chest distress or dyspnea; nausea or vomiting; micturition desire; retroauricular pain (mask pressurerelated); thirst or dry throat; inconvenience at work; other symptoms of discomfort, for example, how an hcw felt in ppe, which was formatted as a multiple-response option. questions considering several vulnerable areas according to our clinical observation were also included: (2) was there mist on the hcw's goggles? (3) what were the effective methods that the hcw used to prevent misting in practice? (this question allowed for multiple-response options.) (4) did the hcw have pressure sores on their face? (5) in which areas did the hcw have pressure sores? (6) did the hcw have skin injury owing to gloves? (7) what type of glove-related skin damage did the hcw have? (1) discomfort that the hcw felt after doffing ppe, which was also a multiple-response option. (2) the first thing on an hcw's mind after doffing ppe. we asked about the amount of time off that the hcw felt was necessary to recover from work between shifts. the hcw's state of mind after donning ppe was also assessed. in a multiple-response-option format, the hcw was asked about experiencing 1 or more of 6 emotions: proud, excited, anxious, afraid, uncomfortable, or other. first, among the demographic information and safety measures, continuous variables were divided into categorical variables and were shown as numbers and percentages. second, complaints owing to ppe were reported (also as numbers and percentages), and the chi-square test or fisher exact test was used for intergroup comparisons (sex, occupation, age, workplace, department, and time in ppe). third, the psychological states of the hcw was described in a table categorized into different groups: occupation, age, sex, workplace, department, and time in ppe. a post hoc power analysis was performed to recommend the sample size for a replication study. all data were analyzed using spss version 26.0 (ibm corp). p values less than 0.05 were considered statistically significant. a total of 299 individuals agreed to participate, with 297 valid and complete questionnaires for a completion rate of 99.33%. the demographic characteristics are shown in supplementary regarding the measures that the hcws believed were necessary for standardizing the donning procedure, 14 hcws thought that only a full-length mirror was necessary (4.7%), 33 believed in having a checking monitor (11.1%), 15 thought that checking with a partner was adequate (5.1%), and 234 hcws attached importance to all of these measures to standardize the donning procedure (78.8%). for the best length of hair at work, 14 hcws believed that "fully shaved" was the best (4.7%), 89 thought that their hair should be as short as possible (23.0%), 90 believed that just tying it up was adequate (30.3%), and 104 thought that the length did not matter as long as it was properly handled when donning ppe (35.0%). table 1 explores the relationship between standard nosocomial training, familiarity with the sop, the availability of a dressing mirror, and the incidence of infection among the respondents. standard training on nosocomial infection before treating patients in the wards could significantly decrease the infection rate compared with the no-training group (3.6% vs 13.0%, x 2 ¼ 4.47, p < 0.05), whereas the unavailability of dressing mirrors could lead to a higher rate of infection (3.6% vs 13.0%, p < 0.05). the time it took the hcws to don ppe varied. a total of 52 hcws claimed to be able to don ppe within 10 minutes (17.5%), 111 needed 10 minutes to 15 minutes (37.4%), 79 needed 15 minutes to 20 minutes (26.6%), and 55 spent more than 20 minutes donning ppe (18.5%). after donning ppe, most of the hcws spent a maximum time of 4 hours to 6 hours (48.2%) or 6 hours to 8 hours (28.0%) working in it. for the maximum ppe tolerance time, 179 hcws believed that 4 hours to 6 hours was their limit (60.3%), 66 thought that 2 hours to 4 hours should be the maximum (22.2%), whereas 46 hcws believed that they could endure 6 hours to 8 hours in ppe at most (15.5%). all the types of discomfort with multiple-response options demonstrated a comparatively high occurrence (more than 40%, figure) . retroauricular pain (mask pressure-related) was the most reported complaint (81.8%), chest distress or dyspnea was the second (78.5%), inconvenience at work (for auscultatory tests, blood sample collection, and punctures) was the third (61.3%), followed by thirst or dry throat (60.3%), dizziness or palpitation (58.9%), micturition desire (55.6%), nausea or vomiting (42.1%), and other symptoms (14.8%). overall, 240 hcws reported misting on their goggles (81.8%). to prevent misting, most hcws thought it was useful to apply cleaning agents (63.3%) or spray antimist agents on their goggles or glasses (47.1%). a total of 173 hcws reported having pressure sores on their faces (58.3%), mainly distributed on the nose (81.0%), cheek (66.5%), forehead (45.1%), and retroauricular areas (43.6%). overall, 154 hcws reported glove-related skin damage (51.9%): eczema (59.1%), dry skin (57.8%), and skin erosion (53.9%) were the main injuries. the symptoms reported after doffing ppe included dizziness or palpitation (27.3%), chest distress or dyspnea (33.0%), nausea or vomiting (16.8%), and other symptoms (6.1%), whereas 160 hcws reported none of these symptom (55.2%). after doffing ppe, 130 hcws reported that the first thing on their mind was to drink water (43.8%), whereas 104 wanted to clean themselves (35.0%), and 36 wanted to rest (12.1%). discomfort in ppe, misting on goggles, pressure sores, and skin injury stratified by sex, occupation, age, workplace, department, and working time discomfort in ppe, misting on goggles, pressure sores, and skin injury stratified by sex, occupation, age, workplace, department, and working time are shown, respectively, in bar chart of the discomfort caused by personal protective equipment in the study sample. the respondents reported a relatively high level of discomfort. month 2020 volume -issue -www.jenonline.org table 3) . more than half the participants believed that an hcw needed 24 hours off between shifts (53.5%), and 27.61% felt that they needed 12 hours off between shifts. a post hoc power analysis was conducted to recommend the sample size for a future replication study on the basis of our results. here, we calculated the sample size using the ratebased sample size estimation formula in cross-sectional studies: n ¼ (zs/d)2 3 p(1-p). estimating the incidence of the survey population with 95% confidence level (zs is taken as 1.96), the prevalence, p, of discomforts in ppe is approximately 80% (p takes a value of 80%), q ¼ 1-p, and the tolerance, d, takes a value of 5%. in this case, the required sample size is calculated to be 246. considering the 5% invalid response, a sample size of 258 may meet the requirements. here, we add uniquely to the published literature by rapidly quantifying the safety measures of donning and doffing ppe, complaints of discomfort owing to ppe, and the psychological perceptions of hcws at hospitals in wuhan, china, responding to the covid-19 outbreak in march 2020. according to our online questionnaire survey, there was a high prevalence of uncomfortable symptoms suffered by the hcws during their fight against the covid-19 epidemic, although active and timely training was helpful for the effective prevention of infection. more complaints of discomfort were reported by women, physicians, nurses, and those working at a designated hospital or in an icu. the hcws working at a designated hospital or in an icu were prouder than their comparable groups after doffing ppe. training on nosocomial infection before treating patients in the wards is of considerable significance for preventing hcws from contracting covid-19, which was also demonstrated in previous studies. 17, 18 adding a dressing mirror at all sites would support staff during donning and doffing ppe, and it is an easy improvement to implement. we strongly recommend strictly adhering to the correct procedure for donning and doffing ppe. 15 timely, interactive training on the prevention of nosocomial infection and on the sop for wearing ppe can considerably reduce the risk of hcws' exposure to covid-19. studies have shown that adding computer stimulations or video-based learning methods could increase compliance and performance scores. [19] [20] [21] taking help from an assistant or partner, sometimes coupled with a mirror, was often resorted to month 2020 volume -issue -www.jenonline.org while donning ppe, and a hygienist supervised doffing. 22 we recommend using a full-length dressing mirror, being checked by a partner before entering the wards, and assigning a "dofficer" (or donning/doffing officer) for both donning and doffing ppe. hair length may not influence working or create extra risks of infection, but short hair is definitely easier to cover with a surgical cap, and saves time when putting on and removing ppe. according to a consensus by chinese experts, 23 hair should be cleaned with running water once ppe is removed, hair should be cleaned before taking a shower, and the head should be lowered when cleaning hair to keep the contaminated water out of the eyes, nose, and mouth. female hcws are more likely to suffer uncomfortable symptoms such as chest distress or dyspnea, retroauricular pain (mask pressure-related), thirst or dry throat, and inconvenience at work (for auscultatory tests, blood sample collection, and punctures), which suggests that there might be gender differences. these gender differences may be due to a difference in the types of work male and female hcws are assigned, the design of ppe, the cultural and gendered norms of expressing and reporting discomfort, or in both physical strength and psychological reaction. previous studies have shown that male hcws are prone to a higher rate of skin erosion than female hcws. 24 physicians, nurses, or hcws in an icu were more likely to complain about the inconvenience of working while wearing ppe than those in other positions or departments. this may be due to the different tasks and work intensity because clinical practices such as auscultatory tests, blood sample collection, and venipuncture are usually performed by physicians or nurses, and hcws in an icu treat patients with the most severe or complicated conditions; therefore, their work intensity or duration of ppe wear is much higher than that of those working in other departments. among the hcws working at designated hospitals for patients critically ill with severe covid-19, the prevalence of nausea or vomiting and inconvenience at work and pressure sores were significantly higher, further suggesting that the discomfort the hcws felt was positively correlated with their workload. complaints about inconvenience at work and pressure sores were more frequently reported by the hcws who worked in ppe for more than 4 hours; the longer the duration of wearing ppe, the greater the rate of complaints about discomfort. the following measures should be considered to alleviate discomfort owing to ppe: apply moisturizer before putting on and after taking off gloves; and refer to dermatologists if necessary. [25] [26] [27] we recommend routinely supplying protective supplies such as hand moisturizer. as for maskrelated discomfort, we recommend wearing a properly fitted mask and applying moisturizer or gel beforehand for lubrication. 28 we recommend nonirritating products for handwashing, and applying adhesive bandages on the portions of the skin in contact with the mask to help reduce friction. because of the possibility of conjunctival transmission of covid-19-first reported by a chinese expert 29 and later confirmed by scientific studies 30 -we strongly recommend using face shields in conjunction with goggles. 31 in addition, applying cleaning or antimist agents on the goggles might also help prevent misting. according to the results of the intergroup comparison, the working time in ppe at designated hospitals and in an icu should be reduced to approximately 4 hours, whereas in other workplaces and departments, 6 hours could be considered the maximum duration. a 24-hour break between shifts is recommended for hcws to be refreshed from fatigue and work pressure, but a 12-hour break between shifts might be more feasible. maintaining hydration before and after wearing ppe is recommended. timely psychological interventions that build confidence and relieve stress are important considerations. 32 according to a survey on hcws' emotional problems and coping strategies, positive attitudes in the workplace, clinical improvement of infected colleagues, and halting disease transmission among hcws after adopting strict protective measures alleviated their fear and supported them through the pandemic. 33 thus, a rational focus on facts and timely psychological assistance such as offering coping strategies and measures to provide adequate medical equipment to treat patients and prevent hcw infection are beneficial. we were motivated to conduct this research to share our useful experience and help reduce the discomforts of hcws worldwide during the covid-19 pandemic. many of our recommendations here were adopted at our hospital site, which is designated as a special hospital for patients with covid-19. these adoptions include every hcw receiving training on nosocomial infection before treating patients, adding dressing mirrors to assist with both donning and doffing ppe, creating 4-hour shifts for nurses, and staffing the emergency and icu departments with more nurses. medical isolation pads were used to prevent pressure sores caused by wearing n95 masks, and hand creams were provided to every hcw. informally, we found that most of the hcws in our hospital thought that these recommendations were very helpful, and future study is needed to confirm the efficacy and effectiveness of these recommendations. this study has several limitations. first, we used a questionnaire designed for the purposes of this study; further work is needed to test the validity and reliability of the survey. second, nurses working at a designated hospital made up most of the survey participants. third, owing to the covid-19 pandemic, this survey was administered online; therefore, the sampling was voluntary and web-based, creating possible selection bias, and we could not confirm that the participants were who they reported they were. as a crosssectional survey, no causation can be inferred. we conducted multiple group testing without applying a p value correction, which may have resulted in spuriously significant results. as our results demonstrated, discomfort owing to ppe is widespread among hcws, especially among nurses fighting covid-19 on the front lines. female sex as well as working under relatively high pressure for long hours closely correlated with the occurrence of uncomfortable symptoms and skin erosion. active training on the ppe donning and doffing procedure as well as education on nosocomial infection significantly reduced the risk of exposure. most of our study participants were nurses at a designated hospital for patients critically ill with severe covid-19, and these nurses are under tremendous pressure, which differs from ordinary times. we believe that working long hours in ppe as well as the heavy workload is quite comparable to work patterns in emergency departments, and thus our evidence and practical suggestions will be beneficial for daily emergency nursing practice. only 10% of our participants worked in the emergency department setting, and a replication study is warranted in this unique population alone. hcws in isolation wards should receive standard training on the ppe donning and doffing protocol, along with proper psychological encouragement and timely support. fighting the covid-19 pandemic is an unprecedented global challenge, and hcws are shouldering considerable responsibility as well as pressure. in light of this highly infectious disease, ppe remains the first-line recommendation for effective prevention; however, ppe-related discomfort is widely experienced by hcws. this study revealed the main types of discomfort, analyzed the relationship between demographic information and the occurrence of different physical complaints and mental states, and offered practical strategies for improvement. supplemental outbreak of pneumonia of unknown etiology in wuhan, china: the mystery and the miracle coronavirus infections-more than just the common cold clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus infected pneumonia in wuhan a novel coronavirus from patients with pneumonia in china the continuing 2019 ncov epidemic threat of novel coronaviruses to global healththe latest 2019 novel coronavirus outbreak in wuhan world health organization (who) coronavirus disease (covid-19): situation report-161 french high council for public health; french society for hospital hygiene. putting on and removing personal protective equipment uncertainty, risk analysis and change for ebola personal protective equipment guidelines h1n1 influenza infection in korean healthcare personnel survey of stress reactions among health care workers involved with the sars outbreak how to train health personnel to protect themselves from sars-cov-2 (novel coronavirus) infection when caring for a patient or suspected case physiologic and other effects and compliance with long-term respirator use among medical intensive care unit nurses discomfort and exertion associated with prolonged wear of respiratory protection in a health care setting epidemiology working group for ncip epidemic response, chinese center for disease control and prevention. the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19) in china. article in chinese the national health commission of the people's republic of china. notice on issuing the technical guidelines for the prevention and control of novel coronavirus infection in medical institutions how the public uses social media wechat to obtain health information in china: a survey study evaluation of a pandemic preparedness training intervention of emergency medical services personnel the role of education in the prevention and control of infection: a review of the literature video based learning vs traditional lecture for instructing emergency medicine residents in disaster medicine principles of mass triage, decontamination, and personal protective equipment personal protective equipment in health care: can online infection control courses transfer knowledge and improve proper selection and use? using interactive computer simulation for teaching the proper use of personal protective equipment personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff consensus of chinese experts on protection of skin and mucous membrane barrier for health care workers fighting against coronavirus disease 2019. dermatol ther. 2020 the incidence, risk factors and characteristics of pressure ulcers in hospitalized patients in china protecting healthcare staff from severe acute respiratory syndrome: filtration capacity of multiple surgical masks hand hygiene and skin health facemasks for the prevention of infection in healthcare and community settings pressure induced skin and soft tissue injury in the emergency department wang guangfa of peking university hospital disclosed the treatment situation on weibo, suspected of causing infection without wearing goggles a missing link between sarscov-2 and the eye?: ace2 expression on the ocular surface safety guidelines for sterility of face shields during covid 19 pandemic psychosocial effects of sars on hospital staff: survey of a large tertiary care institution healthcare workers emotions, perceived stressors and coping strategies during a mers cov outbreak we acknowledge all the health care workers who are providing patient treatment and care. conflicts of interest: none to report. the procedure for donning and doffing the personal protective equipment donning procedure in the clean zone for donning: (1) clean your hands according to the hand hygiene rules for hcw;(2) put on the medical protective mask (n95, and perform a seal-check; medical isolation pad could be used beforehand to prevent pressure sores); (3) put on the surgical cap; (4) put on the goggle; (5) put on the first layer of shoe coverings; (6) put on the protective clothing; (7) put on the first pair of gloves (covering the sleeves of the protective clothing); (8) put on the medical surgical mask; (9) put on the surgical cap (covering the upper edge of the goggle) and face shield (if available); (10) put on the gown; (11) put on the second layer of gloves (covering the sleeves of the gown); (12) put on the second layer of shoe coverings; (13) put on the face shield. doffing procedure 1. in the contaminated area: hand hygiene 2. in the first buffer room for doffing: (1) hand hygiene, take off the face shield;(2) hand hygiene, take off the shoe coverings(the outer layer); (3) hand hygiene, take off the gown with the gloves (the outer layer) together (attention: roll the gown inside-out without touching the contaminated outer surface, as shown in the supplementary video 1); (4) hand hygiene, take off the surgical cap and medical surgical mask; (5) hand hygiene, enter the second buffer room for doffing. 3. in the second buffer room for doffing: (1) hand hygiene, take off the protective clothing and the gloves (the inner layer) together (attention: roll the protective clothing inside-out without touching the contaminated outer surface, as shown in the supplementary video 2); (2) hand hygiene, take off the goggle;(3) hand hygiene, take off the surgical cap; (4) hand hygiene, take off the shoe coverings (the inner layer); (5) hand hygiene, take off the medical protective mask; (6) nasal vestibule cleansing; (7) put on the medical surgical mask. 4. in the clean zone: (1) hand hygiene;(2) take a shower.hcw, health care worker. the designated hospital, which is for severe and critical covid-19 patients. à the undesignated hospital, which is for patients uninfected with covid-19. x fangcang hospitals which belong to field mobile medical system are a number of movable cabins with multiple medical functions and the ability of rushing to the scene during emergency, during the epidemic of covid-19, they're mainly used for the treatment of mild patients. key: cord-349740-xed4aybr authors: wang, yulong; zeng, lian; yao, sheng; zhu, fengzhao; liu, chaozong; di laura, anna; henckel, johann; shao, zengwu; hirschmann, michael t.; hart, alister; guo, xiaodong title: recommendations of protective measures for orthopedic surgeons during covid-19 pandemic date: 2020-06-10 journal: knee surg sports traumatol arthrosc doi: 10.1007/s00167-020-06092-4 sha: doc_id: 349740 cord_uid: xed4aybr purpose: it was the primary purpose of the present systematic review to identify the optimal protection measures during covid-19 pandemic and provide guidance of protective measures for orthopedic surgeons. the secondary purpose was to report the protection experience of an orthopedic trauma center in wuhan, china during the pandemic. methods: a systematic search of the pubmed, cochrane, web of science, google scholar was performed for studies about covid-19, fracture, trauma, orthopedic, healthcare workers, protection, telemedicine. the appropriate protective measures for orthopedic surgeons and patients were reviewed (on-site first aid, emergency room, operating room, isolation wards, general ward, etc.) during the entire diagnosis and treatment process of traumatic patients. results: eighteen studies were included, and most studies (13/18) emphasized that orthopedic surgeons should pay attention to prevent cross-infection. only four studies have reported in detail how orthopedic surgeons should be protected during surgery in the operating room. no detailed studies on multidisciplinary cooperation, strict protection, protection training, indications of emergency surgery, first aid on-site and protection in orthopedic wards were found. conclusion: strict protection at every step in the patient pathway is important to reduce the risk of cross-infection. lessons learnt from our experience provide some recommendations of protective measures during the entire diagnosis and treatment process of traumatic patients and help others to manage orthopedic patients with covid-19, to reduce the risk of cross-infection between patients and to protect healthcare workers during work. level of evidence: iv. in december 2019, the coronavirus disease 2019 (covid-19) caused by coronavirus (2019-ncov) was found in wuhan (hubei, china) [44] and then became a worldwide pandemic on 11th march 2020. compared with severe acute respiratory syndrome (sars) coronavirus, covid-19 has a lower mortality, but it is more infectious and pathogenic [4, 31, 36] . according to statistics from johns hopkins university [24] , a total of 4,136,056 cases of covid-19 have been confirmed globally until 11 may, 2020. due to the high infectivity of 2019-ncov, the source of infection can be covid-19 patients and asymptomatic infected people. the main routes of transmission of 2019-ncov are respiratory droplets, close contact and aerosol transmission [4, 17, 31-33, 36, 45] . furthermore, covid-19 has a latent period yulong wang and lian zeng have contributed equally to this paper, and considered as first co-authors. of 1-14 days, up to 24 days [17] . therefore, in the process of patient treatment and diagnosis, there is a high risk of cross-infection to healthcare workers [19] . the pandemic of covid-19 has brought great challenges at every step in the patient pathway, from pre-hospital, emergency diagnosis and treatment, emergency surgery, anesthesia, and perioperative management. in every step of treatment, the strategies for the treatment of trauma patients should be formulated and protective measures should be taken. what ppe should be worn, and what preventive steps should be undertaken by healthcare workers in different areas of the patient pathway? hence, we performed the present systematic review that aimed to identify the optimal protection measures during covid-19 pandemic and provide guidance of protective measures for orthopedic surgeons. the secondary purpose was to report the protection experience of an orthopedic trauma center in wuhan, china. as of march 26, 2020, a total of 23,187 cases with covid-19 including rescuing 1,134 cases of acute and critical illness and more than 400 patients with ventilators have been treated in our institution (hubei, china) located in the center of the epidemic; meanwhile, various surgeries are performed in more than 300 cases with covid-19. the orthopedic department has handled more than 260 emergency cases. recommendations of protective measures was developed in a learning by doing and consensus process [14, 17, 20, 26, 31-33, 37, 42, 45, 48] . this paper also describes what was done and how it was implemented. a systematic review of the available literature was performed for articles published up to april 27, 2020 using the keyword terms "covid-19", "fracture", "trauma", "orthopedic", "surgeon", "healthcare workers", "protection", "telemedicine" in several combinations. the following databases were assessed: pubmed, cochrane, web of science, google scholar, and all the publications were searched. the search was limited to english studies only. studies in other languages were not included in this review. all peer-reviewed articles were considered. randomized controlled trials (rcts), prospective trials and retrospective studies as well as reviews and case reports were included in this systematic review. two authors independently screened the titles and abstracts of all the articles were identified. if the abstract and the full-text was unavailable, the paper was excluded. in the event of disagreement, a consensus was reached by discussion, if needed with the intervention of the senior author. this systematic review was conducted in accordance with the established guidelines from preferred reporting items for systematic reviews and meta-analysis (prisma). however, due to the heterogeneity of available data, it was decided to present the review in a narrative manner. one author extracted data from all the selected original articles, which was repeated by two other authors. if there was no agreement between the three, the senior author was consulted. where required, the corresponding authors were contacted for additional information. this review focused on protective measures in the entire diagnosis and treatment process. at each stage of the literature search, a kappa value was calculated to determine inter-reviewer agreement on study selection. pertinent information extracted included author, date and journal of publication, study design (and level of evidence). descriptive statistics, such as the means, ranges, and measures of variance [e.g., standard deviations (sd)], are presented where applicable. the initial literature search found 176 articles. after removing 23 duplicates, 153 studies were screened. of the 153 studies, 126 were excluded after screening of the title and abstract. additional 9 studies were excluded after full-text review. thus, 18 articles were finally eligible for data extraction. agreement between the reviewers on study selection was substantial at the title review stage (k = 0.705; 95% ci 0.563-0.828), almost perfect at the abstract review stage (k = 0.871, 95% ci 0.475-0.999), and perfect at the full-text review stage (k = 1.0). based on the analysis of levels of evidence, one study was classified as level iii, fourteen studies were classified as level iv and the remaining three studies were classified as level v. due to study design heterogeneity it was not possible to pool results across studies and perform a meta-analysis. only one case series study reported 10 fracture patients (8 women and 2 men) with covid-19, for which the mean age was 68.4 ± 17.5 years old (range 34-87). eight (80%) with complications such as hypertension, diabetes, brain injury, etc., and 4 (40%) patients eventually died [29] . it indicated that enormous challenges to treat patients with traumatic fracture are given to orthopedic surgeons during covid-19 pandemic. many studies [1, 27, 28, 30, 39, 50] reported that using video or teleconference for morning rounds, electronic consultations, videoconferencing, digital outpatient and other telemedicine methods to provide medical guidance and follow-up instruction for patients can reduce unnecessary contact, limiting the spread of the virus and save protective materials. two surveys of surgeons found that the kind of protective measures should be taken and how to or not to screen patients with covid-19 are different in different countries or different departments [16, 30] . another survey of covid-19 disease among orthopedic surgeons from 8 hospitals in wuhan found a total of 26 surgeons were diagnosed with covid-19 [19], and the incidence varied from 1.5 to 20.7%. training on prevention measures and wearing of respirator masks was found to be protective. not wearing an n95 respirator was a risk factor for infection with covid-19 as well as severe fatigue due to work overload [19] . delaying and canceling elective surgery, and the exact definition of emergency surgery are still under debate [1, 11, 13, 14, 16, 27, 29, 37, 39, 42, 50] . emergency surgery in the context of the current crisis can be defined as urgent pathologies that could result in long-term disability and/or chronic pain if surgery is postponed [14, 35, 37] . trauma related fractures are the most common cause of emergency surgery [5, 6, 9, 12, 21, 23, 38, 47] . the who and evidencebased literature have not given any detailed recommendations for emergency orthopedic treatment during covid-19 pandemic. there was no study concerning the management of an outpatient clinic and surgical activities and the challenges in handling with a high-volume practice during epidemic. only one article offered important points and strategies to provide the highest level of safety to healthcare workers during the start-up phase [13] . most studies (13/18) emphasized that orthopedic surgeons should pay attention to personal protection when facing the covid-19 pandemic to prevent cross-infection [1, 11, 13, 14, 16, 19, 20, 27, 34, 35, 39, 42, 50] . four studies have reported in more detail on personal protection [1, 11, 20, 35] (table 1) . there are no studies about the level of protection should be recommended for orthopedic surgeon from on-site emergency to patient discharge. only hirschmann et al. [20] gave an evidence-based recommendation on which ppe should be used to avoid occupational transmission of covid-19 during surgery. during the covid-19 pandemic, orthopedic patients as well as medical staff may be infected with covid-19 when they are exposed to people infected with covid-19 during their work. transmission from medical staff to medical staff, patient to medical staff, as well as medical staff to patient, has been demonstrated. the most commonly suspected areas of exposure during the entire diagnosis and treatment process were general wards, followed by public places at the hospital, operating rooms, the intensive care unit, and the outpatient clinic [19] . to avoid occupational transmission of covid-19 to medical staff, appropriate protective measures taken by orthopedic surgeons during pandemic in different sites from pre-hospital, emergency diagnosis and treatment, emergency surgery, anesthesia, and perioperative management are of great importance. in principle, all patients with fractures which occurred in pandemic areas should be treated as suspected covid-19 cases [11, 35, 46] . the ambulance requires sufficient protective equipment and rescue equipment [32] . all medical personnel should be familiar with the symptoms of covid-19 and should have received professional training in levelthree personal protective equipment (ppe) [11, 19, 20, 29, 31, 34, 35, 45] (table 2 ). in addition, all should be educated well in wearing and taking off a disposable hat, disposable protective clothing, long shoe cover, n95/ffp2 mask, goggles, double-layer gloves and protective face screen. ppe is important to minimize the chance of contact with body fluids of the wounded. before arriving at the scene, all the healthcare workers and drivers involved in the pre-hospital emergency should take level-two ppe. for patients with contact with covid-19 patients or exhibiting the symptoms of fever and/or respiratory symptoms, the pre-hospital emergency healthcare workers and drivers in the non-pandemic area should take level-two ppe in advance. in principle, all the injured patients should be transported to the nearest hospital with proper isolation facilities, adequate levels of ppe and the ability to diagnose and treat covid-19 patients. the ambulance is exposed to high concentration of aerosol for a long time in a relatively closed environment, and must be cleaned and disinfected thoroughly [4, 17, [31] [32] [33] 45] . negative pressure ambulances are preferred. only patients with excluded infection of covid-19 can be sent to the general emergency department, the rest should be sent to the covid-19-designated hospital for treatment. all staff who receive patients with suspected or confirmed covid-19 need at least level-two ppe in the emergency room (er) [1, 11, 31, 35, 45] (table 2 ). if the patient is unconscious, or his/her family members cannot describe the epidemiological history, the suspected cases shall be treated as covid-19. during pandemic, all patients should be treated as suspected cases of covid-19 (table 3) . adequate ppe and disinfection of medical equipment is paramount [17, 32, 33, 45] . if possible, the hospital personnel should take sputum, nasopharynx swab or blood samples using real-time fluorescent rt-pcr to rapidly detect viral nucleic acid or gene sequencing to make the final diagnosis. according to the guidelines [33] , the physicians should make a suspected or confirmed diagnosis of covid-19. if the patients who are sent to the emergency room are preliminarily assessed as suspected covid-19, they might be transferred immediately to complete a chest ct scan [13, 31, 33] . all patients admitted should be screened for 2019-ncov (table 3 ) [13, 30, 31, 39] , and covid-19 needs to be differentiated from traumatic wet lung. in the pandemic area, the patients who do not need emergency surgery are admitted to the emergency buffer ward in single room isolation, and treated as suspected cases of covid-19. after screening for covid-19 (table 3) , covid-19 negative patients can be transferred to the general ward in a single room, minimizing the number of family caregivers (at most 1 member) and forbidding other family members to visit [30, 39] . caregivers should be screened for covid-19 [14, 39] (table 3) , and must be negative. confirmed cases can be admitted in the same negative-pressure isolation ward with multiple persons. severe or critical patients can be admitted to the intensive care unit as soon as possible [31, 46] . the criteria for emergency surgery is "threat to the patient's life if surgery or procedure is not performed, threat of permanent dysfunction of an extremity or organ system, risk of metastasis or progression of staging, risk of rapidly worsening to severe symptoms" [27, 35, 37, 42] . the main indications for emergency surgery at our center are: trauma seriously endangering life or limb [5, 14, 22] , such [15, 23, 40, 47] . patients with mild to moderate covid-19 are treated as above, whereas those with severe covid-19 are more likely to be treated non-operatively (table 4 ). in other words, severe covid-19 is a relative contraindication for emergency orthopedic surgery. patients with critical covid-19 or those who are intolerant to operation or anesthesia are an absolute contraindication [33, 35, 37, 46] . according to patient's condition, trauma, injury type, stability, neurological function, medical equipment and technical conditions, the purpose of operation should be completed in a single approach or minimally invasive surgery as far as possible [2, 6, 7, 9, 10, 18, 22] . the team should take measures to reduce the influence of time, trauma, hemorrhage and anesthesia on patients with covid-19. disposable surgical instruments should be used where possible and non-operative treatment should be strongly considered [26, 33] . the covid-19 testing is difficult to get quickly enough in an emergency setting. all emergency patients are protected according to suspected or confirmed patients [1, 31, 35] . all medical personnel should take level-two protective measures, using the special transfer vehicle with disposable sheets to lead patients to transfer to the negative pressure operation room through a special channel and a special lift [1, 25, 31, 32, 35, 41, 48] . the door of the operating room should be marked with a covid-19 sign. staff numbers should be minimized in the operating room [1, 11, 35] . visitors to the or should be restricted and medical personnel should not enter or leave the operating room to avoid interrupting the negative pressure. level-three ppe is required in the operating room for all staff [31, 48, 49] , except patrol nurses/runners who can use level-two ppe. the operating room must be in a state of negative pressure (− 5 pa) before the operation [11, 13, 41, 43, 48] . the buffer room should be closed, and equipment should be minimized in the operating room. staff wearing ppe in the operating room are forbidden to leave the operating room until the ppe has been removed and the operation has finished. patients with non-generalized anesthesia should wear surgical masks throughout the operation [11, 34, 43, 48] . for patients under general anesthesia, a breathing filter should be installed between the anesthetic mask and the respiration loop, and a breathing filter should be installed at the inhalation and exhalation end of the anesthesia machine, respectively [41, 43, 48] . the high-efficiency particulate air (hepa) filters must be in use and the room should have a negative pressure [35, 41, 43, 48] . after surgery, the room should be disinfected by spraying peracetic acid or hydrogen peroxide for more than two hours, and the laminar flow should be off and air supply closed. sampling of the surfaces and air in the operation room should be tested by the hospital infection control team after the disinfection process. the next operation can the clinical symptoms are mild and no pneumonia manifestations can be found in imaging no contra-indication due to covid-19 moderate patients have symptoms such as fever and respiratory tract symptoms, etc. and pneumonia manifestations can be seen in imaging no contra-indication due to covid-19 severe adults who meet any of the following criteria: respiratory rate ≥ 30 breaths/min; oxygen saturation ≤ 93% at a rest state; arterial partial pressure of oxygen (pao 2 )/oxygen concentration (fio 2 ) ≤ 300 mmhg. patients with > 50% lesions progression within 24-48 h in lung imaging should be treated as severe cases critical meeting any of the following criteria: occurrence of respiratory failure requiring mechanical ventilation; presence of shock; other organ failure that requires monitoring and treatment in the icu absolute contraindication be continued only after the monitoring results are qualified [33, 43, 48] . surgery using the electrocautery, ultrasonic bone knife, drill, pulsatile lavage and other powered equipment result in aerosolization of blood, bone, and tissue fluid [20] . covid-19 is present in all body fluids and so will be present in this aerosol. limitation of the use of these procedures will minimize the aerosol [20, 49] . hirschmann et al. reported that orthopedic surgery in particular to the lower limb produces vast amounts of aerosols when high-speed power tools are used, and orthopedic surgeons should use ffp2-3 or n95-99 respirator masks [20] . the ability for the aerosol to cause infection of the surgical team is unknown and dependent on the ppe worn by the surgical team. smoke generated should be removed by an aspirator (note that suction also generates an aerosol) [49] . during the operation, normal saline for flushing should be minimized, splashing of the patient's body fluids should be avoided, and the residue of the fluid should be reduced as much as possible to prevent the pollution of the surrounding environment [20, 49] . the surgical team need to cooperate closely to prevent smoke from electrocautery, splashing of the patient's body fluid, and sharp instrument injury [1, 11, 35, 48] . surgical instruments that have been directly exposed to the patient's body fluid should be immediately scrubbed with 1000-2000 mg/l chlorine-containing preparation, and then placed into double-layer yellow medical waste bags, labeled with 2019-ncov, and immediately inform the disinfection and supply center to take them away [32, 33] . medical staff are advised to take appropriate protective measures according to the patient with/without covid-19 and the environment which they are exposed in their work (table 5) . preoperative chest ct scan [13, 31, 46] is an important investigation for clinical diagnosis of covid-19, as well as diagnosing lung injury caused by high-energy trauma. nevertheless, nucleic acid testing for covid-19 or virus sequencing should be done as soon as possible after surgery. the body temperature of patients should be monitored at least three times a day after operation. for patients with covid-19, wound infection should not be judged only by the results of blood tests and body temperature [3] . consider whether fever is caused by a wound infection or covid-19 [46] . for patients undergoing a routine operation, if covid-19 has been excluded, the surgery should be arranged with the normal treatment procedure according to the patient's priority; healthcare workers should take level 1 protective measures at least during surgery. for patients with surgery contraindicated in the early stage or other reasons such as conservative treatment failure, fear of hospitalization during the pandemic, etc., surgery can be performed according to treatment experience for delayed union [10, 25] , referring to the aforementioned protective measures. during the transition period, it is necessary to strengthen the monitoring and protection of patients and family caregivers [13, 30, 39] . for patients without covid-19, discharge should be scheduled time after surgery to reduce cross-infection in the hospital [31, 34] . after being discharged from the hospital, an online outpatient clinic or telemedicine can be used to guide the patient's follow-up treatment [1, 27, 28, 30, 39, 50] . at the same time, it is necessary to continue to strengthen the monitoring and protection of patients and family caregivers, and pay attention to the possibility of positive viral etiology test results in patients recovered from covid-19 [14, 26, 31, 46] . strict protection at every step in the patient pathway is important to reduce the risk of cross-infection during pandemic. lessons learnt from our experience provide some recommendations of protective measures during the entire diagnosis and treatment process of traumatic patients and help others to manage orthopedic patients with covid-19, to reduce the risk of cross-infection between patients and to protect healthcare workers during work. peri-operative considerations in urgent surgical care of suspected and confirmed covid-19 orthopedic patients: operating rooms protocols and recommendations in the current covid-19 pandemic is it possible that most of the displaced acetabular fractures can be managed through a single ilioinguinal approach? 2-7 years experience results american college of surgeons and surgical infection society: surgical site infection guidelines, 2016 update indirect virus transmission in cluster of covid-19 cases clinical and radiological outcomes following arthroscopic-assisted management of tibial plateau fractures: a systematic review minimally invasive screw fixation of unstable pelvic fractures using the "blunt end application of computerassisted virtual surgical procedures and three-dimensional printing of patient-specific pre-contoured plates in bicolumnar acetabular fracture fixation biomechanical comparison of different fixation techniques for typical acetabular fractures in the elderly single modified ilioinguinal approach for the treatment of acetabular fractures involving both columns clinical and research approaches to treat non-union fracture surgery in covid-19 patients: operational directives preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift returning to orthopaedic business as usual after covid-19: strategies and options guidelines for ambulatory surgery centers for surgically necessary/time-sensitive the care of orthopaedic cases during the covid-19 pandemic triaging spine surgery in the covid-19 era covid-19: initial experience of an international group of hand surgeons notice of novel coronavirus infection office in the office of the national health and health commission for medical waste management are pelvic anatomical structures in danger during arthroscopic acetabular labral repair? definition of safe bone depth covid-19 coronavirus: recommended personal protective equipment for the orthopaedic and trauma surgeon yearbook of neurorestoratology management of lower limb amputations time is spine: a review of translational advances in spinal cord injury coronavirus covid-19 global cases by the arthroscopic reduction and internal fixation of acetabular fractures consensus on emergency surgery and infection prevention and control for severe trauma patients with 2019 novel coronavirus pneumonia surgical selection and inpatient paradigms during the coronavirus covid-19 pandemic lead the way or leave the way: leading a department of orthopedics through the covid-19 pandemic characteristics and early prognosis of covid-19 infection in fracture patients covid-19 and spinal cord injury and disease: results of an international survey national health commission of the people's republic of china, state administration of traditional chinese medicine. prevention and control protocols of novel coronavirus pneumonia national health commission of the people's republic of china national health commission of the people's republic of china. notice on printing novel coronavirus infection prevention and control technical guidelines (first edition) in medical institutions management of orthopaedic and traumatology patients during the coronavirus disease (covid-19) pandemic in northern italy preparing to perform trauma and orthopaedic surgery on patients with covid-19 transmission of 2019-ncov infection from an asymptomatic contact in germany a review of state guidelines for elective orthopaedic procedures during the covid-19 outbreak evaluation of strategies for the treatment of type b and c pelvic fractures the orthopaedic trauma service and covid-19-practice considerations to optimize outcomes and limit exposure method of decompression by durotomy and duroplasty for cervical spinal cord injury in patients without fracture or dislocation what we do when a covid-19 patient needs an operation: operating room preparation and guidance novel coronavirus covid-19 current evidence and evolving strategies practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-ncov) patients novel coronavirus (2019-ncov) situation report infection prevention and control during health care when covid-19 is suspected. interim guidance characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention epidemiology of worldwide spinal cord injury: a 307 literature review anesthetic management of patients with suspected or confirmed 2019 novel coronavirus infection during emergency procedures minimally invasive surgery and the novel coronavirus outbreak: lessons learned in china and italy advice on standardized diagnosis and treatment for spinal diseases during the coronavirus disease 2019 pandemic the authors wish to thank healthcare workers who key: cord-322871-cf4mn0pu authors: o'keeffe, dara ann; bradley, dorothy; evans, linda; bustamante, nirma; timmel, matthew; akkineni, roopa; mulloy, deborah; goralnick, eric; pozner, charles title: ebola emergency preparedness: simulation training for frontline health care professionals date: 2016-08-08 journal: mededportal : the journal of teaching and learning resources doi: 10.15766/mep_2374-8265.10433 sha: doc_id: 322871 cord_uid: cf4mn0pu introduction: at brigham and women's hospital, we identified the need for a comprehensive training program designed to prepare frontline staff to safely manage a patient with ebola viral disease (evd). the primary goal of this program was to ensure the safety of staff, patients, and the general public by training staff in the correct use of personal protective equipment (ppe) before, during, and after care of patients with evd. methods: we delivered a 4-hour experiential training program to frontline health care professionals who would be expected to care for a patient with evd. the program occurred in a simulation center with multiple flexible spaces and consisted of demonstration, multiple skills practice sessions, and a patient simulation case. we analyzed completed preand posttraining questionnaires. the questionnaire assessed their subjective level of confidence in three key areas: donning and doffing ppe, performing clinical skills while wearing ppe, and management of a contamination breach. results: this program was effectively deployed in the stratus center for medical simulation over a 4-month period, with 220 health care professionals participating in the training and 195 participants completing the pre-/posttraining questionnaires. our intervention significantly increased the confidence of participants on each primary objective (p = .001 for all three stations). discussion: this interprofessional simulation-based program has been shown to be a well-received method of training clinicians to manage patients collaboratively during an evd outbreak. our intent is that the skills taught in this training program would also be transferable to management of other infectious diseases in the clinical setting. training staff in the correct use of personal protective equipment (ppe). many hospital-wide drills and training sessions were implemented in response to the recent ebola epidemic. here, we describe a simulation laboratory-based program that was used as the foundation training for frontline staff in the correct use of ppe for clinical care activities. epidemics have challenged human existence for millennia. there is evidence of widespread infectious outbreaks as early as 400 bce in ancient greece. in recent history, severe acute respiratory syndrome in the early 2000s and h1n1 influenza in 2009 resulted in significant worldwide morbidity and mortality. the medical community is now confronting two recent epidemics, the current west african evd outbreak that began in 2014 and, since 2012, an outbreak of middle eastern respiratory syndrome in south korea and china for which the world health organization reports 1,595 laboratory-confirmed cases, including at least 571 related deaths. all of these events have stressed the need for greater investment in building resilient systems to prepare for, respond to, and recover from emerging infectious disease epidemics. for nearly 20 years, simulation-based education has proven to be an integral part of medical training. since the early work of small et al., numerous studies have shown simulation-based education's invaluable contribution to the refinement of team structure, communication, and procedural skills. due to its emphasis on patient and staff safety, it has become an invaluable adjunct to traditional methods of teaching and training, especially in residency programs. since the 1970s, simulation has been used in epidemic response training. programs now include disaster exercises, semester-long courses for professional students, web-based simulation exercises, and large-scale high-fidelity curricula that utilize human simulators and actors. preparing for a response to an emerging infectious disease includes not only the conventional factors that characterize other disasters but also the need to become efficient in using clinical and procedural skills while wearing protective gear that has the potential to hinder flexibility, dexterity, and communication. simulation education provides a seamless stage for this type of training. at the neil and elise wallace stratus center for medical simulation and the center for nursing excellence at bwh, we have extensive experience in the simulation of many clinical events and skills across multiple disciplines. we consistently conduct interprofessional team and skills training sessions and have a team that frequently creates curricula for these programs. the overall goal of this program is to teach and enable practice of the appropriate donning and doffing of ppe according to accepted protocols and to teach the management of biosafety level 4 waste. the skills practiced will enable participants to perform or assist in the performance of standard clinical skills while wearing appropriate ppe. due to the austere nature of the clinical environment, this program is intended to be interprofessional. it is intended to enable and encourage collaborative care by providers who will need to participate in activities not typically required of them in less restrictive environments. as the primary goal of this course is to facilitate familiarity with the use and functionality of specific equipment and implementation of specific step-by-step processes, the most suitable instructional format is deliberate practice in a simulated environment. this program requires space to meet the needs of at least 12 participants rotating through multiple stations, some of which run concurrently. the participants will actively don and doff ppe, learn and practice the management of biosafety level 4 hazardous waste, and be provided an opportunity to manage, in interprofessional groups, a variety of routine medical processes and procedures while wearing ppe. participants should be hospital clinicians who have the potential to be exposed to and care for patients with evd in an isolated environment. these would include physicians, nurses, physician assistants, respiratory therapists, phlebotomists, and other relevant health care workers. the curriculum described hereafter is a 4-hour fundamental interprofessional training course designed for potential evd caregivers. the course consists of a concise didactic session and observation of a demonstration of donning/doffing evd-required ppe, active participation in the donning/doffing of ppe, course outline a concise schedule outlining the time and basic requirements for each section of the course is contained in appendix a. introduction of donning and doffing ppe setup: arrange table and chairs conference-style to enhance introductions, observation, debriefing, and evaluation processes. assign seating prior to class by placing nameplates with roles and designated groups around the table to ensure learning groups are interdisciplinary and to enhance conversations from the beginning of class. have a computer with audiovisual capabilities on hand, as well as adequate space for the demonstration of donning and doffing of ppe using an observer and a separate narrator. give each participant a precourse survey prior to the start of the class. participants and faculty introduce themselves, providing their name, institutional role, and personal expectations for the program. center layout and amenities are introduced. full attention of participants is requested, and a request to turn off beepers and telephones is made. the expectation that participants will stay for the complete 4-hour training is stated as is a short description of ground rules for the course: the management of patients with evd is evolutionary in nature. protocols will therefore be iterative. the training session is not the only training that people will be receiving, and a description of subsequent opportunities should thus be presented. up-to-date protocols are being taught as recognized by the institution, and participants are asked to delay specific questions concerning the protocols until they are actively participating in the don/doff exercise or until the end of the program. clarification regarding the purpose of the program is reinforced: except for safe donning and doffing and waste-management skills, no new clinical skills will be taught today; this is an opportunity to practice a variety of already-known skills while wearing ppe. the environment in which the ppe is worn will necessitate enhanced teamwork. as there is little chance of getting extra help expeditiously, a willingness to participate in patient care skills outside the normal realm of practice will be required. however, at no time will caregivers be asked to perform any skill outside their scope of practice. the schedule is explained. psychological safety of the simulation learning environment is ensured by guidelines for active participation, engagement, respect for fellow participants, and confidentiality (as per the simulation center's usual practice). three faculty members are required: a narrator, a clinician, and a safety monitor (third-party trained observer). obtain all necessary ppe. introduce participants to the don/doff checklist and required processes. a narrator briefly shows and explains each piece of equipment (participants are asked to hold questions until they move to the practice station). the narrator reads the checklist sequentially as the safety monitor assists the clinician in the donning/doffing procedure. provide space(s) for three teams to don and doff ppe. all donning and doffing accessories (chlorine-based wipes, armless stationary stool, ppe equipment, and waste containers) should be available. two faculty members are assigned to each group: one to serve as the checklist narrator and one to serve in the role of evd safety monitor responsible for assisting clinicians with the safe donning/doffing of ppe. the narrator reads the checklist slowly and methodically. the safety monitor assists participants in the active exercise of donning/doffing ppe. appendix b contains detailed checklists for donning and doffing ppe. note that these checklists were developed based on the bwh protocol for ebola management. some variations may exist at different institutions. three individual spaces with supplies specific to each are needed. see appendix c for a more detailed description of the equipment required for each station. two faculty members are needed at each station to assist in learning activities. individual requirements of the three stations follow. station a station a covers airway management, dressing care, iv infusion management, and urinary catheter care (± additional basic skills as required). airway management substation: a mannequin should be placed on a table or in bed wearing a nonrebreathing mask and must be able to be ventilated with a bag-mask ventilator and intubated orally, as well as having an iv arm with a crystalloid infusion for drug administration. ideally, the mannequin is attached to a pulse oximeter and cardiac monitor that can be manipulated to represent a desaturating patient; however, this is not necessary. also present should be airway equipment and medications (vials, prefilled syringes, alcohol wipes, and needles/infusion systems) that are typically employed in airway management at the institutions in which the participants practice. there should also be appropriate waste-disposal equipment. dressing care and iv infusion management substation: the mannequin can be medium or low fidelity on a table or a bed and have a dressing taped to an area of the skin. it should have an iv arm with a primary iv set infusing saline through an infusion pump. a 2-mg infusion of magnesium sulphate with appropriate accessories for piggybacking the infusion should be available. a dressing and tape should be available as well. there should also be appropriate waste-disposal equipment. urinary catheter care substation: on a table or bed, there must be a mannequin or task trainer in which a urinary catheter can be placed. urine should be in the bladder. a urinary catheter, a catheterization start kit, and a drainage bag should be available. there should also be appropriate waste-disposal equipment. for each of the stations above, interprofessional groups of three to four learners will perform the routine clinical care tasks set up in the station. each participant should perform tasks appropriate to his/her discipline and training, but all will practice assisting each other, as mastering communication and dexterity while wearing the ppe is a core learning objective of station a. setup: this station should be equipped with mops, solutions, appliances, waste bins, and waste bags that will be employed in the management of biosafety level 4 waste within the institutions in which the participants practice content: see appendix d for detailed content. station c station c features human patient simulation. equipment/environment: a medium-to high-fidelity mannequin is dressed in hospital garb and is laying at 45° in a bed with a blanket covering it. the mannequin is not initially attached to the cardiac monitor or pulse oximeter. the mannequin will have a urinary catheter with a drainage bag that has 700 ml of fluid simulating urine hanging off the side of the bed. the mannequin will be placed on typical hospital linens with an absorbable underpad that has material simulating stool on the pad. equipment to initiate and secure a peripheral iv and an iv infusion pump with which to initiate the iv infusion must be present. the rest of the room should appear as a patient isolation room. personnel: the simulation specialist runs the mannequin. one faculty member is the patient's voice via microphone from a control room. as this is a low-acuity scenario, one faculty member should suffice to both perform as the patient and observe for later debriefing. however, if a second faculty member is available to be the observer/debriefer, that would be of additional benefit. no confederates are required in the room. assessment: the participants are observed for their communication with the patient and with their colleague in the room and for their performance of simple clinical tasks, such as attaching the patient to monitors, cleaning the soiled patient, and disposing of the soiled materials in the correct way. faculty may choose to add additional tasks to the scenario such as insertion of an iv line or managing a fluid spill on the ground. faculty may refer to the protocols for such tasks included in this publication or reference their own protocols or checklists for specific tasks from their institution. however, the principle learning objective is that participants are able to perform already-known tasks within the confines of the ppe and that all procedures for infection control are strictly adhered to. donning and doffing the ppe may also be included as part of the scenario or as a separate station depending on the time available. debriefing: the debriefing consists mostly of a facilitated discussion by participants on what the expected and unexpected consequences of having the ppe in place were on their ability to perform basic patient care tasks. faculty identify errors or lapses in protocol that they observed and ask participants to outline what they feel contributed to those incidents. patterns and difficulties with communication should also be debriefed, with an emphasis on how the team performed given the constraints of the environment and the ppe. we did not use video playback in our debriefing session as time was limited and not all of the interprofessional faculty were familiar with our video playback software. however, it should be considered a valuable addition to the debriefing session if available and if faculty are trained in its use. see appendix e for full details of the simulated patient scenario's setup, content, and debrief. final doffing at the conclusion of the final skills station for each participant, final doffing of ppe takes place. setup requires ample room marked by tape to mimic both a hot zone and a warm zone. appropriate doffing accessories (chlorine-based wipes, armless stationary stool, waste containers, and receptacle for ppe) should be available in the room. see appendix c for a more detailed description of the equipment required. appendix b contains the doffing checklist. this program was effectively deployed in the stratus center for medical simulation over a 4-month period in 2014-2015. participants in our 4-hour program included physicians, nurses, respiratory therapists, laboratory technicians, and ancillary staff. two-hundred and twenty health care professionals participated in the training. all were asked to complete the same three-question survey before and after participation in the training program. the survey assessed their subjective level of confidence in three key areas: management of a contamination breach, performing clinical skills while wearing ppe, and donning and doffing ppe. these questions were answered using a 5-point likert scale with the anchors not at all confident and extremely confident. replies were converted to their numerical value on the likert scale, and a one-way analysis of variance was performed to calculate the p value. we analyzed completed pre-and posttraining questionnaires from 195 participants. prior to participating in the program, 61%, 67%, and 66% of participants rated their confidence level as not at all confident or a little bit confident in management of a contamination breach, performance of clinical skills in ppe, and donning and doffing, respectively. after completing the course, 96%, 97%, and 98% of participants rated their confidence as to some extent, quite a bit, or extremely confident (figure 1 ). our intervention significantly increased the confidence of participants on each primary objective (p = .001 for all three stations). means and p values for confidence scores in each station are presented in table 1 . overall, 90% of participants rated the quality of the simulation on the program as good or outstanding, and 97% rated the faculty as good or outstanding. these results are outlined in figure 2 . this program was successfully deployed and well received by the health care professionals in our institution. as it was a newly designed program for our center, there were many lessons learned along the way. we concede that the design of the program is faculty intensive. however, it was important to have a high faculty-to-participant ratio in order to replicate the high level of supervision that occurs when monitors supervise donning and doffing techniques in the clinical setting. potentially, faculty requirements could be reduced by using core teaching faculty in the monitor role in the one-to-one donning and doffing sessions. participants could also perform this role, provided they were instructed in the monitoring process in advance. we utilized a high-fidelity simulation environment for our simulated patient experience station, but most of the course objectives could be achieved in a lower-resource setting by omitting this station if the facilities are not available. the 4-hour program length was necessary to allow for repeated practice of a very complex donning and doffing process with many specific steps to complete. one difficulty we encountered was the continuously evolving protocols for ppe. protocols were revised as newer equipment was received, limited by a challenged supply chain as demand outweighed supply from numerous vendors from october 2014 until february 2015. for example, based on drills and exercises, we converted from one respirator brand to another that provided clearer communication and improved cooling. these protocols may vary between institutions and may be revised and altered within single institutions over time. it is important that centers implementing this course establish what the local protocols for ppe use are and adhere to them in order for the training to be applicable to the health care professionals in that institution. at the same time, we also encourage institutions to follow nationally and internationally accepted protocols as closely as possible. while we have solicited and analyzed feedback from a large number of participants, one of the questions in our survey referred to a skill not directly covered in the training. when originally designing our program, we hoped to include full training on management of a breach. however, it was felt that this was a higherlevel training objective, more suited to the monitors (trained clinical observers), and therefore, this content was removed from the course. our participants were instructed that if a suspected breach occurred, they would be directed by their trained observer. we decided to leave this question in our feedback survey 16 and found that confidence was increased in this area. we feel this represented a level of confidence in the system of donning and doffing in pairs with an observer guiding. also, we have not evaluated durability of the training by assessing long-term retention of the skills we trained for. ideally, implementation of this program should include shorter sessions of follow-up training at regular intervals. no clear guidance for frequency and modality of training for health care workers in this intensive scheme exists, and our models are based on information garnered from national centers of excellence (emory university, the university of nebraska). nongovernmental organizations' national and international efforts should be directed toward outlining standards to define competency, training modalities (functional and tabletop exercises, simulation, web-based training, didactics, etc.), and frequency of those modalities. medicine can look to other industries, including aviation, as the gold standard for competency measurement and evaluation. our interprofessional simulation-based program has been shown to be a well-received method of training clinicians to manage patients collaboratively during an evd outbreak. our intent is that the skills taught in this training program would also be transferable to management of other infectious diseases in the clinical setting. this training should form part of a linear program with subsequent shorter courses at regular intervals aimed at ensuring retention of skills over time. dna examination of ancient dental pulp incriminates typhoid fever as a probable cause of the plague of athens summary of probable sars cases with onset of illness from 1 geographic dependence, surveillance, and origins of the 2009 influenza a (h1n1) virus demonstration of high-fidelity simulation team training for emergency medicine simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study enhancing patient safety during pediatric sedation: the impact of simulation-based training of nonanesthesiologists for the saem technology in medical education committee and the simulation interest group epidemic simulation for training in public health management investigating an epidemic: a seven-part simulation used in teaching epidemic investigation simulation immersive simulation education: a novel approach to pandemic preparedness and response high-fidelity multifactor emergency preparedness training for patient care providers using a web-based simulation as a problem-based learning experience: perceived and actual performance of undergraduate public health students improving emergency preparedness system readiness through simulation and interprofessional education what a disaster?! assessing utility of simulated disaster exercise and educational process for improving hospital preparedness centers for disease control and prevention web site emergency department processes for the evaluation and management of persons under investigation for ebola virus disease none to report. presented as a poster at the society for academic emergency medicine annual meeting, may 2015. reported as not applicable. key: cord-355827-e38itktq authors: adisesh, anil; durand-moreau, quentin; patry, louis; straube, sebastian title: covid-19 in canada and the use of personal protective equipment date: 2020-05-18 journal: occup med (lond) doi: 10.1093/occmed/kqaa094 sha: doc_id: 355827 cord_uid: e38itktq nan on 30 january 2020, the world health organization (who) declared the coronavirus disease 2019 (covid-19) outbreak a public health emergency of international concern and on 11 march 2020 it was declared a pandemic by the who director-general, dr tedros ghebreyesus. in his speeches dr ghebreyesus first called on countries to, 'review preparedness plans, identify gaps and evaluate the resources needed to identify, isolate and care for cases, and prevent transmission' [1] . when declaring the pandemic, he urged countries to, 'communicate with your people about the risks and how they can protect themselves -this is everybody's business; find, isolate, test and treat every case and trace every contact; ready your hospitals; protect and train your health workers. and let's all look out for each other, because we need each other' [2] . the protection of healthcare workers (hcws), readiness of hospitals and protection of the public were clearly emphasized early by the who. canada's experience with the severe acute respiratory syndrome (sars) outbreak in 2003 led to the creation of the public health agency of canada (phac) [3] . this organization monitors and responds to disease outbreaks that could endanger the health of canadians. the canadian government has contributed to international efforts to combat the covid-19 pandemic, supporting who efforts as well as implementing travel restrictions and issuing guidance to the canadian provinces and territories [4] . since 2013 phac has produced a federal guideline entitled, 'routine practices and additional precautions for preventing the transmission of infection in healthcare settings' which provides a framework for organizations in developing policies and procedures [5] . this document details the circumstances in which contact, droplet or airborne transmission precautions should be used. it lists specific micro-organisms including the virus responsible for sars, severe acute respiratory syndrome coronavirus (sars-cov), for which contact and droplet precautions are advised, except during aerosol-generating medical procedures, when airborne precautions are to be instituted. when respirators are used for airborne precautions (in the context of a full ensemble of appropriate personal protective equipment (ppe)), amongst instructions are, the importance of hcw being clean-shaven in the area of the face seal and that, in cohort settings, respirators may be used for successive patients. upon discharge of the patient or discontinuation of airborne precautions, the recommendation is that sufficient time should be allowed for the air to be free of aerosolized droplet nuclei before housekeeping staff perform terminal cleaning, or else the housekeepers should wear a respirator, again together with other appropriate ppe. there is also guidance on modification for long-term care, ambulatory care, home care and pre-hospital care settings. the routine practices and additional precautions lay out in some detail the ppe to be used together with descriptions of the different types of medical grade gloves, masks and respirators, and eye protection. contact precautions direct that in addition to the use of ppe as for 'routine practices', gloves should be used and long-sleeved gowns, where it is anticipated that clothing or forearms will be in direct contact with the patient or with potentially contaminated environmental surfaces or objects. these gowns should be cuffed and cover the front and back of the hcw from the neck to mid-thigh. the type of gown worn is based on the degree of contact with infectious material, potential for blood and body fluid penetration and the requirement for sterility. in the instructions for gown use it is mentioned that the cuffs of the gown should be covered by gloves. droplet precautions additionally specify facial protection (i.e. masks and eye protection, or face shields, or masks with visor attachment) should be worn: for the care of patients with symptoms of acute respiratory viral infection, or when within 2 m of a patient who is coughing at the time of interaction, or if performing procedures that may result in coughing. airborne precautions are additional to the routine practices, contact and droplet precautions. as well as federal guidance, there is national guidance in the form of technical standards issued by the canadian standards association (csa) who in september 2018 provided an update to the document csa z 94.4 'selection, use and care of respirators' [6] . the standard covers the choice of respiratory protection for bioaerosols and adopts a control banding approach. it is noteworthy that if this approach were followed for exposure to sars-cov-2, a biosafety risk group 3 organism [7], the choice of respiratory protection for any patient encounter for suspected or known covid-19 disease would be at least a filtering face-piece respirator. in north america, this would typically be an n95 respirator, european equivalent ffp2. during the covid-19 pandemic, to assist in the response, the csa group have made their standards available at no cost. phac guidance has been in keeping with who recommendations [8] with the consistent application of routine practices, and to follow contact and droplet precautions. when performing aerosol-generating medical procedures on a person under investigation (pui) for covid-19, the use of an n95 respirator is recommended. canada usually tends to align closely with us practices, but it is notable that the guidance from the us centers for disease control and prevention (cdc) is different in recommending an n95 respirator in all situations for a patient suspected or known to have covid-19 [9] . cdc only suggests use of a facemask if a respirator is not available. the availability of ppe has been a concern in canada, with notable differences across canadian jurisdictions. for example, alberta has been able to send supplies to others. in common with other countries, items stockpiled in canada have often been found to be many years past expiry, causing uncertainty about usability. consequently, a number of provincial efforts have been started to determine the functional performance of such ppe, including respirators. in tandem, efforts to explore the potential for reprocessing respirators and other ppe are also being undertaken. hcws have expressed concerns about the level of respiratory protection recommended when caring for pui and have used occupational health and safety legislation to challenge provincial standards [10] . it seems that, in common with other countries, the long-term care homes have not been as well provided for as the hospital system although their residents were tragically vulnerable. compensation for the health effects and any deaths from covid-19 adjudicated to be acquired at work will be available from the provincial and territorial workers' compensation boards. the canadian workers' compensation system is a no-fault system which precludes any litigation against the employer where for instance it may be alleged that there was inadequate provision of ppe. the ministry of labour inspectors of each province or territory would address any such failings based on complaints or evidence presented. it is also these inspectors who would judge whether a worker's right to refuse what was perceived as unsafe work was justified or not. whilst the provision and use of ppe has certainly been, and remains, an issue during the covid-19 pandemic, canada has been well-served by having comprehensive guidance describing not only the minimum ppe provisions but that states, 'although the use of ppe controls are the most visible in the hierarchy of controls, ppe controls are the weakest tier in the hierarchy of controls, and should not be relied on as a stand-alone primary prevention program' [5] . 2019-ncov) director-general's opening remarks at the media briefing on covid-19 government of canada takes action on covid-19 canada's role in strengthening global health security during the covid-19 pandemic routine practices and additional precautions for preventing the transmission of infection in healthcare settings. public health agency of canada use, and care of respirators (can/csa-z94.4-18) sars-cov-2 (severe acute respiratory syndrome-related coronavirus 2) infection-prevention-and-controlduring-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125 using personal protective equipment (ppe) canadian nurses treating covid-19 patients cite unsafe-work laws to demand n95 masks key: cord-310285-ua894psi authors: khatri, anadi; kharel, muna; chaurasiya, babu dhanendra; k.c., ashma; khatri, bal kumar title: covid-19 and ophthalmology: an underappreciated occupational hazard date: 2020-07-20 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.344 sha: doc_id: 310285 cord_uid: ua894psi nan letter to the editor-we read the article "covid-19 and ophthalmology: an underappreciated occupational hazard" by kuo and o'brien 1 with great interest. they have described the challenges faced by eye care personnel during this pandemic very well in a systematic manner. we would like to add few of our own experiences. personal protective equipment (ppe) has become the gold standard during the covid-19 pandemic for prevention of infection. although it has its advantages, many problems may arise in terms of comfort and ease in certain circumstances. currently, with much of the primary focus on infection prevention, these may often be overlooked. in the long term, these difficulties may hamper the performance of healthcare workers like ophthalmologists, whose work demands high precision. as lockdowns are easing and services are resuming, we present our report from a pilot study we conducted in nepal among ophthalmologists on this matter. we conducted a small survey among 24 ophthalmologists who had recently (<1 week) returned to work using ppe. they were asked to describe issues related to discomfort or difficulty in performing regular tasks when using ppe. they were also asked to grade on a likert scale of 1 to 5 (1 least likely to 5 most likely) the issues they considered were most troubling (table 1) . returning to work after weeks of furlough only to suddenly and be enshrouded in ppe is a new challenge for many of us. although it has become a norm, the evidence is already clear that many ophthalmologists and eye care professionals are having difficulties related to ppe use. 2 although the evidence is concrete on infection prevention with its use, 3 our results suggest that ppe may need to be redesigned and customized to best fit the activity or the demands of individual workers. problems like fogging, sweating, and difficulty focusing are unacceptable not only in ophthalmological but many other faculties related to high-precision procedures. with more evidence that covid-19 is here to stay, 4 these problems will continue to hinder efforts to restart or continue services. physical distancing often tops the list and is the most prioritized advise during this pandemic. however, due to the nature of examination, it is practically impossible for eye care professionals to adopt it. 1, 5 in addition to ppe, improvised, low-tech, "do it yourself" (diy) protective devices are also being widely used. 6 although this may be an advantage because much of the "design for the greatest ease of use" would have already been already improvised, many such diy efforts remain unproven in terms of the actual protection they provide. until tested for its "quantifiable" protection value, physicians may fall into the trap of "pseudo" protection and confidence in their use. collaboration of physicians with the manufacturers, laboratories, and testing facilities are of utmost importance to devise such protective devices. efforts focused on extensive testing of these materials and designs to make them more protective and comfortable are necessary immediately if we are to continue serving with confidence in this era of "the new normal." covid-19 and ophthalmology: an underappreciated occupational hazard survey of ophthalmology practitioners in a&e on current covid-19 guidance at three major uk eye hospitals personal protective equipment and covid-19 challenges of "return to work" in an ongoing pandemic covid-19: limiting the risks for eye care professionals safety testing improvised covid-19 personal protective equipment based on a modified full-face snorkel mask acknowledgments.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-330333-un8lvw5o authors: pieterse, pieternella; dickson, claire; ndyetabula, lilian; hardeman, megan; scanlan, patricia title: locally produced personal protective equipment can offer hospital staff protection against covid‐19 if combined with surgical masks and rigorous personal protective equipment cleaning routine date: 2020-09-30 journal: int j health plann manage doi: 10.1002/hpm.3080 sha: doc_id: 330333 cord_uid: un8lvw5o locally made, washable and reusable personal protective equipment (ppe), used in combination with n95 masks that were reused safely, has proven to be a viable alternative to disposable gowns and caps for hospital staff in low‐ and middle‐income countries. muhimbili university hospital's children's cancer ward in dar es salaam, tanzania, developed locally made ppe and created rigorous cleaning and disinfecting protocols, when the daily use of imported, disposable materials were not an option. these items continue to protect staff, children and parents. the novel ppe approach was able to prevent staff from becoming infected during the pandemic despite the fact that several parents, and subsequently their children, became infected with covid‐19 during cancer treatment at the facility. lmics had insufficient disposable protective equipment to keep health workers safe at all time, and had to come up with alternative innovative solutions. for the paediatric oncology ward 3 at muhimbili national hospital, the largest government hospital in dar es salaam, tanzania, it was no different. its solution was locally sourced reusable ppe, which has kept its staff safe and infection free. in early march, when there were mere rumours of the virus across the continent, the children's oncology ward management decided that everyone (including administrators, cleaners, patients and guardians, as well as nurses and doctors), would wear a mask at all times regardless of symptoms, and carry disinfectant gel to clean hands as frequently as possible. this decision was made at a time where no-one fully understood the patho-clinical nature of the virus. the muhimbili oncology team based its decision on their joint medical knowledge and prioritisation of patient safety, using the same 'fundamental principles of decision making in healthcare', which ferrinho et al. described as being so important to guide best public health practices when faced with an absence of robust scientific evidence. 4 muhimbili's oncology ward had a vital but limited supply of n95 and surgical masks. during this time, the type of masks offered (cloth, surgical or n95) depended on defined clinical situations. where medical grade masks were required, a sterilisation process to extend the life of n95 masks was instituted, guided by the medical literature. 5 surgical masks remained single use only. children for whom n95 masks were too large were fitted with double masks, a surgical and a cloth mask. cloth masks were frequently changed, cleaned, and sterilised. outpatients and staff were issued clean cloth masks to wear on their journey from the hospital and back again, providing them and their communities needed protection. cloth bags to store all types of masks were also produced, ensuring that every mask, clean or dirty, could be stored separately before it was cleaned, and that clean supplies could be taken home without fear of contamination before use. safety guidelines outlining safe use, laundering and disinfecting procedures were translated, printed and distributed. to help meet the need for cloth masks and full-body ppe, tumaini la maisha, the local ngo that supports the cancer ward, received masks donated by an international ngo, and saw a group of teachers, business owners and volunteers from the local community unite to work in partnership with tanzanian seamstresses, producing over 1500 cloth face masks in 2 months. the volunteers and fundraisers produced other reusable ppe items; gowns, scrubs and caps were adjusted to fit individual staff members, who ultimately received three sets, along with laundry bags to keep clean and dirty ppe separate. the reusable ppe stays at the hospital, where, at the end of a shift, it is steeped in a water and bleach solution, before being washed at 60 degrees celsius and ironed. the material used for the ppe is locally available kitenge, which is tightly woven cotton. the kitenge ppe brings colour to the wards and was well received by staff and patients, who explained that it added to a collective team spirit which has replaced the overwhelming sense of fear initially felt by all. the team has gained confidence in the protective measures and pride in overcoming this difficult time together. the seamstresses have spoken of feeling proud to support doctors and nurses carrying out important jobs for their community. while the paediatric oncology ward did experience a number of covid-19 cases among parents and patients, widespread outbreaks were prevented due to the well-rehearsed hygiene protocols and the reusable ppe. no staff is known to have contracted the virus. the ward management chose to go well beyond the original international advice on the wearing of masks, and emerging evidence and recent advice from the who now supports this decision. 6 reusable ppe offered the ward many economic benefits. at a cost of 1.30 us$ for masks, 5.40 us$ for medical gowns and 1.08 us$ for caps, compared to 0.69 us$ per disposable mask and 10.00-15.00 us$ per disposable gown, reusable products have greater value for money, and are more environmentally sustainable. for the seamstresses making products, this model provides important economic benefits. pieterse et al. critical supply shortages -the need for ventilators and personal protective equipment during the covid-19 pandemic covid-19 and fiscal space for health system in pakistan: it is time for a policy decision the paediatric oncology ward muhimbili university hospital is managed by a mix of charity funded and public hospital staff. the charity tumaini la maisha provides free cancer treatment and holistic care to all paediatric oncology patients at muhimbili and a network of 11 associated hospitals and healthcare facilities throughout tanzania principalism in public health decision making in the context of the covid-19 pandemic effectiveness of three decontamination treatments against influenza virus applied to filtering facepiece respirators advice on the use of masks in the context of covid-19 locally produced personal protective equipment can offer hospital staff protection against covid-19 if combined with surgical masks and rigorous personal protective equipment cleaning routine the authors declare no conflict of interest. 1. this material is the authors' own original work, which has not been previously published elsewhere.2. the paper is not currently being considered for publication elsewhere.3. the paper reflects the authors' own research and analysis in a truthful and complete manner.4. the paper properly credits the meaningful contributions of co-authors and co-researchers. 5 . the results are appropriately placed in the context of prior and existing research.6. all sources used are properly disclosed.7. all authors have been personally and actively involved in substantial work leading to the paper, and will take public responsibility for its content. https://orcid.org/0000-0001-7100-3514 key: cord-335648-lbmhprjn authors: estrich, cameron g.; mikkelsen, matthew; morrissey, rachel; geisinger, maria l.; ioannidou, effie; vujicic, marko; araujo, marcelo w.b. title: estimating covid-19 prevalence and infection control practices among us dentists date: 2020-10-15 journal: j am dent assoc doi: 10.1016/j.adaj.2020.09.005 sha: doc_id: 335648 cord_uid: lbmhprjn background: understanding the risks associated with severe acute respiratory syndrome coronavirus 2 (sars-cov-2) transmission during oral health care delivery and assessing mitigation strategies for dental offices are critical to improving patient safety and access to oral health care. methods: the authors invited licensed us dentists practicing primarily in private practice or public health to participate in a web-based survey in june 2020. dentists from every us state (n = 2,195) answered questions about covid-19–associated symptoms, sars-cov-2 infection, mental and physical health conditions, and infection control procedures used in their primary dental practices. results: most of the dentists (82.2%) were asymptomatic for 1 month before administration of the survey; 16.6% reported being tested for sars-cov-2; and 3.7%, 2.7%, and 0% tested positive via respiratory, blood, and salivary samples, respectively. among those not tested, 0.3% received a probable covid-19 diagnosis from a physician. in all, 20 of the 2,195 respondents had been infected with sars-cov-2; weighted according to age and location to approximate all us dentists, 0.9% (95% confidence interval, 0.5 to 1.5) had confirmed or probable covid-19. dentists reported symptoms of depression (8.6%) and anxiety (19.5%). enhanced infection control procedures were implemented in 99.7% of dentists’ primary practices, most commonly disinfection, covid-19 screening, social distancing, and wearing face masks. most practicing dentists (72.8%) used personal protective equipment according to interim guidance from the centers for disease control and prevention. conclusions: covid-19 prevalence and testing positivity rates were low among practicing us dentists. this indicates that the current infection control recommendations may be sufficient to prevent infection in dental settings. practical implications: dentists have enhanced their infection control practices in response to covid-19 and may benefit from greater availability of personal protective equipment. clinicaltrials.gov: nct04423770. as information about sars-cov-2 transmission emerged during the early stages of the pandemic, concern regarding the transmission of virus-containing airborne particles in the dental office was also brought to the forefront. it has been suggested that additional potential for sars-cov-2 transmission exists in dental settings during the delivery of aerosol-generating dental procedures (agdps). these agdps might be potential vectors for patient-to-practitioner and patient-to-patient transmission, as the aerosols and droplets produced during such procedures can contain infectious materials. 6 multiple dental professionals at the school and hospital of stomatology, wuhan university, wuhan, china, have contracted covid-19, but it is unclear whether these infections were due to community transmission or transmission associated with oral health care delivery. 7 developing a fuller understanding of the risks to patients and practitioners related to transmission during oral health care delivery and assessing mitigation strategies within the dental office are key components of improving patient safety and access to ongoing oral health care in this pandemic environment. with the emergence of this novel virus and the ensuing pandemic, dentists have worked to establish guidance for practices to ensure the safety of practitioners, staff members, and patients. as early as march 2020, journal of dental research published the infection control guidelines that dentists at wuhan university used, 7 and, in april and may 2020, the american dental association (ada) and the centers for disease control and prevention (cdc), respectively, released interim guidance on infection control protocols and changes to the practice and office environments. 8, 9 these guidelines and other local interim guidance documents broadly agree, but the degree to which the us dental profession is aware of and adheres to these recommendations remains unknown. furthermore, baseline data evaluating infection rates among dentists throughout the us are not widely known because cdc surveillance groups dental professionals with all other health care personnel. 10 as far as we are aware, this is the first longitudinal study designed to track infection control practices and infection rates among us dentists. in this article, we used the first month of study data to estimate the prevalence of covid-19 among us dentists and to determine the rate of compliance with cdc and ada infection prevention and control procedures. 8, 9 methods we administered a web-based survey using qualtrics survey software (qualtrics) from june 8 through june 12, 2020. us-based dentists were invited to participate in the survey if they held a license to practice dentistry in the united states, were in private practice or public health, and if, in a may 2020 ada survey, 11 they reported that they would be willing to participate in a study on symptoms, testing, or diagnosis of covid-19. in total, 5,479 dentists received an invitation to participate in the survey on june 8, 2020; a reminder invitation e-mail was sent june 11, 2020. participating dentists read and signed an electronic informed consent before participating in our study. the 18-question survey was constructed for this research. demographic survey questions included birth year, race and ethnicity, gender, primary practice location, and dental specialty. sars-cov-2 infection was ascertained via self-reported date, type, and positive result of a sars-cov-2 test (confirmed case) or, if not tested, the date a health care provider informed the respondent that they had a probable sar-cov-2 infection (probable case). on the basis of these questions, and excluding those awaiting test results or with inconclusive results, covid-19 prevalence was estimated. consistent with cdc surveillance, the test positivity rate was defined as the numbers of confirmed cases over the total number of tested cases. 12 the survey also asked respondents to identify symptoms experienced in the past month (defined as since may 8, 2020), health conditions associated with covid-19 severity, 13 and dental and nondental activities in the past month. because stressful events such as a pandemic can affect mental well-being, the validated patient health questionnaire-4 screened respondents for depression or anxiety. 14, 15 respondents who reported providing oral health care in the past month were asked about infection prevention or control procedures in their primary dental practice. respondents indicated which personal protective equipment (ppe) they used when treating patients in the past month and whether they used it sometimes or always. the cdc interim guidance document was used to categorize ppe use, 8 and respondents were categorized as following ppe guidance for agdp if, in addition to basic clinical ppe of gloves and protective clothing, they "always" wore an n95 or similarly protective respirator (also called an "n95 mask") with eye protection, or the highest level of surgical face mask available with a full-face shield. dentists who performed no agdp were categorized as following ppe guidance if they "always" wore gloves, protective clothing, a surgical mask, and eye protection. occupational safety and health administration guidance was used to categorize the risk of transmitting sars-cov-2 to dental providers or patients. 16 finally, respondents who reported wearing respirators or masks were asked how often they changed them. the ada institutional review board approved the research protocol and survey, which are registered at clinicaltrials.gov (nct04423770). all statistical analysis was conducted in stata software, version 14.0 (statacorp). for covid-19 prevalence, statistical weighting was performed using linearization variance estimation so that the sample appropriately represented licensed us dentists in private practice or public health according to age group and us census bureau division. the weights and information on age, race or ethnicity, gender, dental specialty, and us census bureau division for all licensed us dentists in private practice or public health came from the ada master file of all dentists (ada members and nonmembers) in the united states. dentist records are updated weekly through state licensure databases, death records, ada surveys of dentists, and other sources. the data used for weighting in our study were extracted from the ada master file on june 25, 2020. differences between continuous variables were tested using analysis of variance and between categorical variables using c 2 tests, with statistical significance set at .05. single and multivariable logistic regression models were used to test for associations between age category, race or ethnicity, gender, dental practice type, dental specialty, medical conditions, and confirmed or probable sars-cov-2 infection. due to complex survey question skip patterns and because respondents were able to skip any question or stop answering the survey at any time, not all respondents answered all questions. the percentage of missing answers ranged from 2.0% through 3.5% per question. a total of 2,195 us dentists representing all 50 states and puerto rico participated in the web-based survey june 8, 2020 through 12, 2020 (response rate, 40.1%). median age of responding dentists was 54 years (range, 27-84 years) (table 1) . overall, most respondents identified as male (59.9%), nonhispanic white (79.2%), in private practice (96.6%), and with a focus on general dentistry (83.6%). approximately one-fourth of the respondents (24.4%, n ¼ 536) had at least 1 medical condition associated with a higher risk of developing severe illness from covid-19. 13 the most common conditions were asthma (7.3%) and obesity (7.6%). compared with all dentists licensed in the united states in private practice or public health, higher proportions of survey respondents were aged 40 through 69 years, and fewer were 39 years or younger and 70 years or older (table 1) . compared with dentists nationally, survey respondents were more likely to come from certain us census bureau divisions, be non-hispanic white, female, or a general dentist. dentists were asked whether they experienced any symptoms in the month before the survey administration, regardless of whether they thought the symptoms were related to covid-19; 82.2% (n ¼ 1,805) had no symptoms in the past month. the most commonly experienced symptom was headache (9.0%, n ¼ 197) ( dentists were queried about their activities during the period of may 8 through june 12, 2020. most respondents (81.6%) met in person with someone outside their household in the past month (table 2) . however, few dentists reported gathering in groups, attending public events, or sharing transportation in the past month. few respondents (4.7%) stated that they believed they had been in contact with someone with suspected or confirmed covid-19 in the month before the survey. of the respondents who reported such contact, most (53.0% [n ¼ 53]) reported that the person with suspected or confirmed covid-19 was a dental patient, another 20.0% thought someone they worked with in the past month had covid-19. during the established period of our study, 91.1% of respondents (n ¼ 1,999) provided emergency oral health care and 80.1% (n ¼ 1,758) provided elective oral health care (table 2) . among the 2,042 dentists who had provided oral health care in the month before administration of the survey, 92.8% (n ¼ 1,892) performed agdps. enhanced infection prevention and control efforts were common; 99.7% of dentists reported practicing them in the past month (n ¼ 2,189). almost all practicing dentists reported disinfecting all equipment and surfaces that are commonly touched, checking staff members' and patients' temperatures, screening patients for covid-19, encouraging distance between patients while waiting, and providing face masks to staff members ( table 3 ). the most common additional infection control efforts were staff members' masking (99.1%) and disinfecting the operatory between patients (99.1%). the less frequently reported infection control efforts were making physical changes to the practice (85.2%) or providing face masks to patients (75.9%; however, write-in responses indicate this may be due to some practices requiring patients to bring their own masks). respondents could also describe the infection control efforts in their practices if not already listed. most of these write-in responses fit into existing categories, except for preprocedural mouthrinses for patients (12.0% [n ¼ 51]) and use of extraoral suction device during dental procedures (4.0% [n ¼ 17]). ppe use when treating patients was common; 99.6% of practicing dentists (n ¼ 2,034) reported its use. for dental procedures not expected to produce aerosols, the cdc interim guidance table 3 . self-reported infection prevention and control efforts by dentists who practiced in the month before survey administration. preprocedural mouthrinse 12.0 (51) extraoral suction device 4.0 (17) recommended surgical masks and basic clinical ppe, including eye protection. 8 of the 146 dentists who reported performing non-agdp in the past month, 82.9% (n ¼ 121) always wore masks, basic clinical ppe, and eye protection (figure) . during agdp with patients assumed to be noncontagious, interim guidance suggests use of a fitted n95 or equivalent mask and basic clinical ppe, including eye protection; 59.0% of dentists (n ¼ 1,117) who reported performing agdps in the past month always wore this combination of ppe, and 61.6% (n ¼ 90) dentists reported wearing this during non-agdp. if n95 or equivalent masks are not available, the cdc interim guidance recommends using both the highest-level surgical face mask available and a full-face shield during agdps 8 ; 12.9% of dentists (n ¼ 245) performing agdps used this combination of ppe, as did 12.3% (n ¼ 18) dentists during non-agdp. in all, 72.8% (n ¼ 1,486) of dentist respondents used ppe according to cdc interim guidance. 8 during the time evaluated with this survey, there were limited supplies of ppe, particularly n95 or equivalent masks. 18 some respondents (17.6%, n ¼ 355) reported changing masks in between patients. more commonly, dentists changed masks between multiple patients (20.2%; n ¼ 407), daily (34.2% , n ¼ 689), weekly (7.7%, n ¼ 155), or only if soiled or damaged (20.2%, n ¼ 407). respondents also wrote in to report that they used multiple masks simultaneously, with surgical masks worn over n95 or equivalent masks, and replaced the surgical masks more often. confirmed or probable covid-19 among dentists among respondents, 16.6% (n ¼ 355) reported that they had been tested for sars-cov-2 with at least 1 testing type. fifty-one respondents (2.3%) were tested with 2 testing typesd50 (2.3%) with both blood and nasal or throat swab tests and 1 (0.05%) with saliva and nasal or throat swab tests. a total of 244 respondents (11.1%) were tested with a nasal or throat swab, of which 9 (3.7%) tested positive. one hundred and fifty-six respondents (7.1%) were tested with a blood sample, and 4 (2.7%) had a positive result. six respondents (0.3%) were tested for sars-cov-2 using a saliva sample and 0 had a positive result. because testing was not widely available during this time, respondents were also asked whether they had received a diagnosis of probable covid-19 infection and 7 (0.3%) had. twenty dentists (0.9%) in this sample had either confirmed or probable covid-19 cases. weighted to approximate the age and location of licensed private practice and public health dentists nationally, the estimated prevalence of confirmed or probable covid-19 among dentists was 0.9% (95% confidence interval, 0.5 to 1.5). the likely source of sars-cov-2 transmission was identified via contact tracing through a health agency or clinic in only 5 cases, and in none of those cases was the source of transmission the dental practice. association between covid-19 and personal characteristics although respondents were tested for sars-cov-2 on dates ranging from march 6 through june 11, 2020, all but 1 positive test result came before the period the survey covered. the survey questions about symptoms, activities outside the household, dental procedures, and infection prevention or control efforts in their primary dental practice covered the past month only. this misalignment in timing precludes using these survey data to investigate modifiable and behavioral risk factors for covid-19 among dentists. when we compared those with and without confirmed or probable covid-19, there were no statistically significant differences in age, gender, race or ethnicity, underlying medical condition, dental practice type, dental specialty, or us census bureau division (all c 2 p > .2). given the limitations of antibody tests currently available in the united states, 19 a sensitivity analysis was conducted that excluded covid-19 cases confirmed with antibody tests only. this analysis similarly found no statistically significant associations with age, gender, race or ethnicity, dental practice type, dental specialty, or us census bureau division (all c 2 p > .2). however, there was a statistically significant association between antigen or viral confirmed or health care provideresuspected covid-19 cases and patient-reported immunocompromised status. specifically, 0.9% (n ¼ 17) of covid-19 negative dentists were immunocompromised compared with 6.3% (n ¼ 1) of covid-19 positive dentists (c 2 p ¼ .02). our study is the first to our knowledge to estimate sars-cov-2 infections in the us dental community and to assess the dental-related infection prevention and control efforts of dentists. in addition, this description of us dentists' dental practices and ppe use at 1 point can be useful to future understanding of the dental response to the pandemic and to assessing the results of future surveillance for covid-19 prevalence. we estimated the infection rate of sars-cov-2 in us dentists. as of june 2020, an estimated 0.9% (95% confidence interval, 0.5 to 1.5) of us dentists have or have had covid-19. this is similar to infection rates reported in health care workers in the netherlands (0.9%) 20 and china (1.1%), 21 but lower than the rate in seattle, washington (5.3%). 22 furthermore, in our sample, 3.7% of nasal or throat swabs tested positive, which is lower than the 10.3% positivity in respiratory specimens from the broader us population from march 1, 2020 through june 13, 2020. 23 this might reflect the higher socioeconomic status of many dentists and their subsequent ability to use social distancing and mitigate viral exposure. the responses to our survey indicated that 99.7% of dental offices were using enhanced infection protection and control practices and many had also adopted advanced ppe. the reports from dentists of mask reuse or combined use of surgical masks and respirators might reflect the current cdc guidance regarding optimization of ppe due to supply issues. 8 as of june 29, 2020, patient volume in dental practices nationwide was estimated to be 70% of preecovid-19 levels, and it has been increasing steadily. 11 use of disposable products for ppe and infection control might increase if patient volume increases, which could result in scarcity or alteration of practices within dental offices based on availability. in addition, changes in local and regional ordinances and infection rates might also alter practices within dental offices moving forward, particularly as covid-19 cases resurge in many states. 24 although there were no significant demographic differences between covid-19enegative and confirmed or probable cases, the covid-19epositive group included more immunocompromised people. this relationship might reflect greater susceptibility in those people, a higher level of surveillance due to concern about underlying immune dysfunction, or the underlying mechanisms of viral binding and entry into host cells via angiotensin-converting enzyme 2. 25 angiotensinconverting enzyme 2 is upregulated in the presence of certain systemic diseases. to our knowledge, this is the first large-scale report of data surveilling rates of covid-19 and concomitant infection protection and control practices among us dentists. the sample was generally representative of us dentists and large enough to allow for analysis of subgroups of interest. there are, however, limitations to these findings. the survey response rate of 40.1% was higher than the mean e-mail survey response rate of 24.0%, 26 but nonrespondents might differ from respondents, which can reduce the validity and generalizability of these results. the survey sample might also be subject to selection bias, leading to an underestimation of covid-19 prevalence or severity because dentists who have died or been hospitalized with covid-19, for example, cannot or might be less likely to participate. due to the limited availability of covid-19 tests in the united states, 27 it is possible respondents had limited access to covid-19 testing and might have had undiagnosed infections. furthermore, these findings are only as accurate as the covid-19 tests and diagnoses themselves, which can be subject to false-negative and false-positive results. 28 there might be recall bias in the questions that asked about activities and symptoms in the past month. it is likely that respondents reported higher levels of social distancing and infection prevention and control compliance due to social desirability bias and unrecognized lapses in ppe usage. these crosssectional data were also limited in that the timing of known sars-cov-2 infections in this survey sample precluded testing for associations with symptoms, activities, or infection prevention and control efforts. given that there is known community transmission of covid-19, dentists might acquire covid-19 in the community and outside of the delivery of oral health care. we attempted to use reports of contact tracing and infection timing to ascertain whether dentists were at increased infection risk owing to dental practice activities. the probable source of infection was not identified for most dentists in this sample (75.0% [n ¼ 15]); for the remainder, contact tracing indicated community transmission. it should also be noted that disease spread during nonclinical activities within the dental office is also a potential transmission route and should be probed. in response to the covid-19 pandemic, in march 2020 the cdc and ada recommended that dentists postpone elective procedures. 8, 29 subsequently, the number of dental patients seen and procedures conducted in the united states dropped. 11 in this survey sample, 75.0% (n ¼ 15) of dentists with presumed or confirmed covid-19 tested positive in march or april, when 95% of us dental practices were closed or provided only emergency oral health care. 11 subsequent surveys sent to the cohort described in our study will continue to collect covid-19 test results, symptoms, activities, and infection prevention and control efforts in dental practices. future research in this cohort might therefore be able to estimate covid-19 incidence, as well as associations with dental activities and infection prevention or control efforts. this survey was conducted to initiate surveillance of licensed, practicing dentists and public health dentists to determine the prevalence of covid-19 before june 12, 2020, as well as the behavioral and infection control and prevention practices of dentists from may 8, 2020 through june 12, 2020. to our knowledge, this is the first study to estimate the prevalence of covid-19 among us dentists. for this sample of dentists, the weighted prevalence of covid-19 was 0.9%. among the tested respiratory samples, 3.7% had positive results. these rates support that use of the cdc's currently recommended infection prevention and control procedures in dental offices will contribute to the reduced risk of developing infection during the delivery of oral health care, and risks associated with nonclinical activities and community spread might pose the most substantial risks for the exposure of dentists to covid-19. future investigations will assess ongoing rates of covid-19 for us dentists and can assess modifiable risk factors for sars-cov-2 transmission and development of covid-19 disease, in addition to defining incidence rates of disease. n supplemental data supplemental data related to this article can be found at https://doi.org/10.1016/j.adaj.2020.09.005. how covid-19 spreads projecting the transmission dynamics of sars-cov-2 through the postpandemic period reducing transmission of sars-cov-2 presymptomatic transmission of sars-cov-2: singapore transmission routes of respiratory viruses among humans aerosols and splatter in dentistry: a brief review of the literature and infection control implications coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine guidance for dental settings: interim infection prevention and control guidance for dental settings during the coronavirus disease (covid-19) pandemic ada interim guidance for minimizing risk of covid-19 transmission 13. centers for disease and prevention. coronavirus disease 2019 (covid-19): people at increased riskdand other people who need to take extra precautions, people at increased risk for severe illness a 4-item measure of depression and anxiety: validation and standardization of the patient health questionnaire-4 (phq-4) in the general population mental health, substance use, and suicidal ideation during the covid-19 pandemic: united states kluytmans-van den bergh mf, buiting ag, pas sd, et al. prevalence and clinical presentation of health care workers with symptoms of coronavirus disease 2019 in 2 dutch hospitals during an early phase of the pandemic coronavirus disease 2019 (covid-2019) infection among health care workers and implications for prevention measures in a tertiary hospital in wuhan, china prevalence of covid-19 infection and outcomes among symptomatic healthcare workers in centers for disease and prevention. covidview summary ending on coronavirus resource center: impact of opening and closing decisions by stateda look at how social distancing measures may have influenced trends in covid-19 cases and deaths are patients with hypertension and diabetes mellitus at increased risk for covid-19 infection? e-mail survey response rates: a review covid-19 testing problems started early, u.s. still playing from behind false negative tests for sars-cov-2 infection: challenges and implications ada recommending dentists postpone elective procedures dr. araujo is the chief science officer, american dental association; the chief executive officer, ada science and research institute, american dental association; and the chief executive officer, american dental association foundation, chicago, il.disclosure. none of the other authors reported any disclosures.the authors thank all of the dentists who participated in this survey and shared their time and expertise, and adriana menezes and dr. ruth lipman for their advice and insights. jada n(n) n http://jada.ada.org n november 2020 key: cord-337633-arivuags authors: perkins, douglas jay; villescas, steven; wu, terry h; muller, timothy b; bradfute, steven; foo-hurwitz, ivy; cheng, qiuying; wilcox, hannah; weiss, myissa; bartlett, chris; langsjoen, jens; seidenberg, phil title: covid-19 global pandemic planning: decontamination and reuse processes for n95 respirators date: 2020-04-14 journal: nan doi: 10.1101/2020.04.09.20060129 sha: doc_id: 337633 cord_uid: arivuags coronavirus disease 2019 (covid-19) is an illness caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (sars-cov-2). the disease was first identified as a cluster of respiratory illness in wuhan city, hubei province, china in december 2019, and has rapidly spread across the globe to greater than 200 countries. healthcare providers are at an increased risk for contracting the disease due to occupational exposure and require appropriate personal protective equipment (ppe), including n95 respirators. the rapid worldwide spread of high numbers of covid-19 cases has facilitated the need for a substantial supply of ppe that is largely unavailable in many settings, thereby creating critical shortages. creative solutions for the decontamination and safe reuse of ppe to protect our frontline healthcare personnel are essential. here, we describe the development of a process that began in late february 2020 for selecting and implementing the use of hydrogen peroxide vapor (hpv) as viable method to reprocess n95 respirators. since pre-existing hpv decontamination chambers were not available, we optimized the sterilization process in an operating room after experiencing initial challenges in other environments. details are provided about the prioritization and implementation of processes for collection and storage, pre-processing, hpv decontamination, and post-processing of filtering facepiece respirators (ffrs). important lessons learned from this experience include, developing an adequate reserve of ppe for effective reprocessing and distribution, and identifying a suitable location with optimal environmental controls (i.e., operating room). collectively, information presented here provides a framework for other institutions considering decontamination procedures for n95 respirators. rapid global dissemination of a novel coronavirus disease (covid-19) caused by an the enveloped nonsegmented positive-sense rna virus, sars-cov-2, has overwhelmed healthcare systems around the world. the rapid increase in clinical cases presenting at healthcare facilities when the disease propagates in a particular geographic region requires a rapid response by the healthcare system. the primary means of protecting frontline healthcare personnel (hcp) from contracting covid-19 is through the proper use of personal protective equipment (ppe), such as n95 filtering facepiece respirators (ffrs). based on the rapid spread of the virus around the globe, there is a high-volume demand for the continuous supply of ppe. the consequences of such a global demand has created a significant strain on the supply-chain of n95 respirators and other ppe. the shortage of ppe raises substantial concerns for healthcare facilities and hcp. the centers for disease control and prevention (cdc) has implemented an ongoing and continually updated release of information to optimize the supply of n95 respirators with most recent updates on 4 april 2020 1 . while it is without question that reuse of n95 respirators (and other ppe) would be obviated if an adequate supply were available, creative strategies are required when there is an imbalance in the supply and demand. given the current global shortage of ppe, creative solutions are immediately required to mitigate the risk of exposure of hcp to sars-cov-2. in anticipation of such a shortage, we began exploring the most viable and safe methods for sterilizing ppe for reuse in late february 2020 at the university of new mexico (unm). during this short period of time, we have quickly learned the importance of having concerted and coordinated efforts devoted to the overall workflow for the safe collection, storage, decontamination, and distribution of reprocessed ppe, along with requisite safety training of staff who perform the reprocessing. . cc-by-nc-nd 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . in preparation for a probable shortage of ppe at our study sites in kenya, and a possible shortage in the us (including unm), we began investigating methods for decontaminating of ffrs in late february 2020. at that time, it became apparent that several decontamination procedures had been investigated, and that some of the methods (importantly) did not substantially impact on the structural integrity (i.e., filter aerosol penetration, airflow resistance, and physical integrity) of the n95 respirators after multiple decontamination cycles. in considering the possible options, we used a data-driven approach based on the currently available peer-reviewed literature, publicly available information, and consultation with subject matter experts. the strategic planning also considered the availability of instruments commonly found in in healthcare systems that could be rapidly transitioned and implemented for decontamination of n95 respirators. . they discovered that all the methods for all six ffrs maintained the optimal levels of filter aerosol penetration (<5%), excect for hpgp which had >5% penetration levels for four of the six ffrs. neither of the two studies, however, examined organism killing as part of the experimental paradigm. one published report from an fda award to battelle memorial institute investigated decontamination of n95 ffrs (3m model 1860) using hydrogen peroxide vapor (up to 50 cycles) delivered from a bioquell clarus c hpv decontamination system 4 . the study found that aerosol collection efficiency and air flow resistance were not affected over the 50 cycles of reprocessing. although no visible degradation of the elastic straps was observed at up to 20 cycles, after 30 cycles the elastic straps showed signs of fragmentation upon stretching. the battelle study also measured decontamination properties using a biological indicator (bi), geobacillus stearothermophilus, since this spore-forming organism has resistance . cc-by-nc-nd 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . to hpv decontamination and heat, and therefore, represents a high stringency surrogate for pathogen inactivation. importantly, their work demonstrated biological aerosol exposure and hpv decontamination were effective for up to 50 cycles with a 6-log reduction in the bi. battelle recently received approval by the fda to incorporate the vhp method into a mobile critical care decontamination system tm (ccds) for large-scale decontamination of ppe for reuse, including n95 respirators for up to 20 cycles 5 . in line with the battelle findings, duke university and health system recently evaluated and implemented vhp methods for the decontamination and reuse of n95 respirators for up to 30 cycles 6 . the university of nebraska medical center recently developed a detailed workflow for decontamination of n95 respirators and opted to utilize a uvgi process 7 . deployment of reprocessed ffrs for some of their hcp has already been implemented. based on the available literature and consultation with subject matter experts throughout the planning phase, we prioritized vhp decontamination of ffrs as a top-choice by mid-february, and subsequently began developing our processes. additional influence for our choice included: 1) hpv technology is a widely used industry standard for decontamination/sterilization in research and medical facilities, and 2) improved hydrogen peroxide has the lowest epa acute toxicity category (i.e., category iv) meaning that it is essentially non-toxic and not an irritant for oral, inhalation, and dermal routes of administration 8,9 . for additional validation of our choice for hpv decontamination, the cdc recently released information about ffr decontamination and reuse as a "crisis capacity strategy to ensure continued availability", and hpv was listed as one of the most promising potential methods 10 . we employed a process in which the hcp removes the ffr following the appropriate institutional guidelines. inspection for visible soiling, saturation, or loss of structural integrity is performed, and ffrs that are structurally intact and not visibly soiled or saturated are placed in a designated foot-pedal receptacle containing a biohazard bag. those ffrs that do not meet the inspection standards are discarded in a separate receptacle using standard institutional procedures. this process is followed by safely doffing of the gloves and hand-hygiene. designated personnel retrieve the biohazard bags from the unit when the receptacles become half-full per communication (telephone call) from the originating unit. information communicated from the unit to the designated pick-up individual includes: unit name, location of bins (e.g., room numbers), and assigned contact person on the unit. the individual retrieving the material follows the designated . cc-by-nc-nd 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/10.1101/2020.04.09.20060129 doi: medrxiv preprint institutional guidelines for ensuring safety. the biohazard bag being retrieved is placed in another biohazard bag and closed using a zip tie. a sticker is placed on the outside of the bag designating date and unit of origin, followed by transport of material to a locked storage area. lakewood, co), with another bi placed immediately outside of the room to serve as a control. once the aeration phase is complete, a portasens iii hydrogen peroxide sensor is used to ensure that h2o2 vapor in the room is below 1.0 ppm prior to personnel entry into the room 11 . the cis were visually inspected immediately after the run and the bis placed in culture following manufactures instructions. each run using the conditions listed above has achieved 6-log reduction for the cis and negative cultures for the bis ( figure 3 ). ffrs are not removed from the racks until they reach 0.0 ppm. the personnel performing the post-processing wear a procedure mask and gloves. once the ffrs are removed from the rack, they are visibly inspected for any damage, and those with signs of physical damage (mask surfaces, staples, and elastic bands) are discarded. ffrs that pass the physical inspection are marked with a small indelible mark (using a sharpie pen). the marking pattern on the ffrs for up to 20 cycles, the maximum number of reprocessing runs, is shown in figure 4 . the reprocessed ffrs are then placed into individual bags marked with the processing date and batch run, followed by sorting into size and model for redistribution. all users of the reprocessed ffrs should perform a visual inspection of the n95 prior to donning to ensure overall structural integrity, followed by a fit test to ensure that an effective seal is achieved. those ffrs that do not meet this integrity check are discarded. . cc-by-nc-nd 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/10.1101/2020.04.09.20060129 doi: medrxiv preprint a short time ago, the decontamination of ffrs for reuse would have been considered (by most) to be either unnecessary or non-viable. however, strain on the global supply chain of ppe, in the context of providing a safe working environment for hcps, has fostered creative solutions that are now being considered and implemented at some institutions. the most critical steps in the process are: 1) to consider ppe as a limited commodity with a finite supply, and 2) to begin the safe collection and storage of ppe for potential reuse. without a reserve of supplies to reprocess, the ability to efficiently create a workflow for decontamination and deployment of reprocessed ffrs (or other ppe) becomes exceedingly limited. prior to deciding on the exact method for the future decontamination procedure that we may needed to implement, we created the workflow to safely collect and store the ffrs (and other ppe) to create sufficient reserves. this allowed us to focus our efforts on deciding which procedure(s) were viable in our environment, and once determined, the ability to rapidly implement the steps involved in the decontamination process. based on the available information at the time, we prioritized hpv decontamination as our first choice, and uvgi as a viable second option. however, since we did not have any pre-existing configurations that contained large chambers with external sources of hpv, we started testing in hpv generators in different environments. learning through trial and error, in an iterative process and with open minds, was critical to our eventual success. initially, we tested the process in a standard room (22' x 8' with 8' ceilings; 131 m 3 ) and were meet with challenges. for example, the room did not have adequate airflow to cool the environment to an optimal temperature between the hpv processing runs. this resulted in the bioquell instrument shutting down during the gassing phase due to overheating, thereby, reducing the desired levels of h2o2 (ppm). it became apparent that waiting for a protracted period to allow the room to reach the desired temperature for a subsequent run would not achieve desired efficiently. as such, we eliminated this environment as a viable option and set up the hpv decontamination process in one of four unused operating rooms. based on their intended use, such environments are constructed with optimized climate control, outside air exchanges, and finishes that are monolithic, scrubbable, and free of crevices and fissures. sterilization of operating rooms with portable hpv generators, such as the instrument we employed, is an industry standard for no-touch disinfection of the environment to prevent transmission of pathogens. during the hvp exposure application we further isolated the operating room by sealing off the heating, ventilation and air conditioning (hvac) supply / exhaust ducts and door with polyethylene sheeting and tape. upon setting up the hpv process in the operating room, we achieved immediate . cc-by-nc-nd 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/10.1101/2020.04.09.20060129 doi: medrxiv preprint success and moved forward in that setting. we have achieved similar efficacy in a second operating room with a different bioquell system (bq-50), indicating flexibility in the overall process. results presented in this manuscript are meant to serve as an information sharing tool for other institutions who may wish to set up such processes, particularly for those who do not already have specific hpv chambers already in place. the workflow described here is one of many different options to operationalize the overall process. it is realized that different institutions will have creative ways to find solutions for their own unique challenges with ppe shortages. the two most important lessons learned from our experience are: 1) develop an adequate reserve of ppe for efficiently implementing the reprocessing workflow, and 2) locate a suitable environment for the hpv decontamination procedure, such as an operating room, which has the pre-existing conditions required for conducing the hpv decontamination process. while it is certain that we face unique challenges with covid-19 that were not previously imagined, an efficient and safe workflow for reprocessing ffrs, and other ppe, can foster substantial improvements for protecting our hcp during this phase of critical shortages. an efficient and robust reprocessing workflow can also promote re-implementation of previous (more stringent) standards of ppe use that were commonly used before the current shortage. figure 1 . ffr placement and spacing on processing rack. . cc-by-nc-nd 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/10.1101/2020.04.09.20060129 doi: medrxiv preprint figure 2 . configuration for hpv decontamination process in an operating room. . cc-by-nc-nd 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/10.1101/2020.04.09.20060129 doi: medrxiv preprint figure 3 . culture results from biological indicators (geobacillus stearothermophilus spores) with control placed outside the room (left, yellow) and 10 bis placed in the processing room during the hpv decontamination (right 1-10, purple). . cc-by-nc-nd 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/10.1101/2020.04.09.20060129 doi: medrxiv preprint reprocessed 6x reprocessed 20x . cc-by-nc-nd 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/10.1101/2020.04.09.20060129 doi: medrxiv preprint strategies for optimizing the supply of n95 respirators evaluation of five decontamination methods for filtering facepiece respirators decontamination processing for filtering facepiece respirators final report for the bioquell hydrogen peroxide vapor (hpv) decontamination for reuse of n95 respirators battelle ccds critical care decontamination system decontamination and reuse of n95 respirators with hydrogen peroxide vapor to address worldwide personal protective equipment shortages during the sars-cov-2 (covid-19) pandemic. absa international n95 filtering facepiece respirator ultraviolet germicidal irradiation (uvgi) process for decontamination and reuse decontamination and reuse of filtering facepiece respirators key: cord-324654-nnojaupv authors: vordos, nick; gkika, despoina a.; maliaris, george; tilkeridis, konstantinos e.; antoniou, anastasia; bandekas, dimitrios v.; ch. mitropoulos, athanasios title: how 3d printing and social media tackles the ppe shortage during covid – 19 pandemic date: 2020-06-07 journal: saf sci doi: 10.1016/j.ssci.2020.104870 sha: doc_id: 324654 cord_uid: nnojaupv during the recent covid-19 pandemic, additive technology and social media were used to tackle the shortage of personal protective equipment. a literature review and a social media listening software were employed to explore the number of the users referring to specific keywords related to 3d printing and ppe. additionally, the qaly model was recruited to highlight the importance of the ppe usage. more than 7 billion users used the keyword covid or similar in the web while mainly twitter and facebook were used as a world platform for ppe designs distribution through individuals and more than 100 different 3d printable ppe designs were developed. the population is informed for health issues and communicate with health professionals through social media [13] . the best advantage of that form of contact is that it is a means of mass communication and offers the ability to facilitate disease surveillance [12] , [14] . at the same time, medical applications for 3d printing are expanding rapidly and are expected to revolutionize health care [15] . the first 3d printers were invented from hideo kodama and charles hulls in the early 1980s [16] . additive technology used in various sections such as the aerospace and automotive industry, military, sports field, architecture, toys industry and bioengineering with different benefits and disadvantages [17] . since then, different 3d printing methods have been used, based on extrusion, powder solidification and liquid solidification, with different types of materials as building materials [18] . the aim of the present article is to explore the relationship between social media and 3d printing, in the context of the recent covid-19 pandemic. we will analyze which types of personal protective equipment can be printed, and how the 3d printing users can be coordinated to achieve mass printing volumes. two independent searches have been conducted, in order to examine the degree that social media has affected the development and dissemination of ppe and medical equipment parts. they explore how 3d printed designs were utilized to address the covid-19 pandemic, as well how the qaly model can be applied in this case to measure the effects of the use of ppe. in the first in depth search, social media was studied using targeted keywords, while an official database was implemented and the qaly model was applied. since covid -19 appeared in the wuhan district in china, several drawings of ppe were shared between social media users, 3d community and individual citizens. a specialized social media software (awario) was recruited for gathering information about content which refers to covid-19, 3d printing and ppe. targeted queries were performed on popular social media such as facebook, twitter, instagram, youtube, reddit and also on news/blogs and the web in general. the searches were conducted between january 1, 2020 through april 14, 2020. the results were further examined for details on the representative designs of ppes. the search strategy consisted of using two generic lists of terms with one specific keyword. the first keyword set refers to the different names of the novel coronavirus and will be referred to as keywords set 1 (ks1), with the following syntax: the general keywords set 2 (ks2) comprised of terms which correlate to 3d printing technology and have the following boolean syntax: "design" or "3d" or "additive technology" or "3d printing" or "print" the specific keyword is related to the ppes and specific medical equipment, which for this study are "ppe", "personal protective equipment", "face shield", "goggles", "gloves", "boots", "surgical hood", "valves", "ventilator" and "respirator". the syntax of the queries that were submitted in the social media listening software has the following format: "ks1" and "ks2" and "x", where x is one of the specific keywords mentioned. for example, when looking into which social media post includes the keywords covid (or similar)" and 3d printing (or similar) and ppe, the following query syntax "ks1" and "ks2" and "ppe" was used. there are two major parameters that have been studied, the life expectancy of health professionals and the average life expectancy until the death of someone who became ill with covid -19 which suggests that hygiene rules or personal protective equipment have not been used or are being misused. data on life expectancy were obtained from who and oecd, while the calculation of the average lifespan was researched in the scientific databases pubmed and scopus with the keywords "symptoms" and "death" and "covid" and "days" [19] , [20] . the results of the search were analyzed and summarized in the next section. table 1 table 1 . goggles, gloves, boots and surgical hoods have the lowest resonance in social media and web, in contrast to respirators and face shields (9100 k and 3100k users respectively used combinations of keywords). ventilators and valves are also prominent in the results. fig 2 is a graphical representation of table 1 results where each combination of keywords is presented in relation to the percentage of appearances in the corresponding social media or web. in many cases, zero results were returned, while in most of the cases with high percentages, those were found through websites and blogs. table 2 shows which of the who proposed pp equipment are printable with personal or university laboratory 3d printers. the third column of the table shows whether they can be sterilized while the fourth column shows the number of the different designs appeared in social media. 109 different designs of face masks (similar in many cases) were proposed in order to help the health workers avoid exposure. more than 30 designs were proposed for respirators, two designs for goggles, while there were not any design for boot covers. fig. 3 . according to the world health organization, life expectancy on average in the world is 72 years. a more detailed study of the organization for economic co-operation and development (oecd) showed that life expectancy for men is 77.7 years while for women it is 83.1 years. by the time of this study, more than 200 healthcare professionals have died from the novel coronavirus disease [21] . 29% were physicians in the usa, with ages ranging between 56 -65 years old and 17% were over 66 years old, while in europe 38% of healthcare professionals were older than 55 years old [22] , [23] . the search in the scientific databases for the time interval between the onset of the symptoms and the death showed, as expected, different results. table 3 shows the results from the scopus bibliographic database, which procured 17 articles, as opposed to 12 from pubmed. the total number of those results that included the desired information was 6, whereas the time between symptoms and death appeared between 8 and 23.4 days. in this study, the relationship between the epidemic, the social media and the use of three-dimensional printing is presented. the ultimate goal of the article is to highlight the use of social media and additive technology in general from common users, to address the lack of basic personal protective equipment or even parts of machinery used by health professionals. the qaly model was employed to illustrate the necessity of ppe use. more than 5000 scientific articles, for the role of social media during different crisis types (terrorist attacks, hurricanes, tsunamis, earthquakes, etc.) appear in scientific databases (scopus, pubmed and google scholar). in many cases, social media can operate as a crisis platform to generate community crisis maps [24] , [25] . there are four types of connection between the users of social media during a crisis: i) the authorities communicate with citizens (statements, information, instructions, etc.), ii) authorities communicate with other authorities for an inter-organizational crisis management, iii) citizens to citizens (photographs, information, communities) and iv) the citizens communicate with authorities [26] . as was expected, social distancing due to covid -19 resulted in an increase in social media use. only in march 11, 2020, more than 19 million mentions related to the new coronavirus. in general, social media are used for communication between citizens or simply to kill time and to reduce distancing. on the other hand, healthcare organizations like who used social media to provide information and rules of hygiene to battle covid -19. almost all platforms set at the main page a joint statement for the fight of the pandemic [27] . the spread of covid -19 in the global community, in a short period of time, has resulted in the rapid depletion of ppe. risk to health or the danger of accident of professional health workers can be minimized with the use of ppe [28] . the choice of the appropriate ppe must be done according to the degree of exposure in gems, the material of ppe and the ergonomics of it [29] . many healthcare professionals, from different countries use social media to express the lack of respirators, gowns and face masks [30] [31] [32] . who also uses social media to ask from government and industry to increase the manufacturing process of ppe by 40% [33] . the interaction between authorities and other authorities, as well as authorities and citizens and vice versa was as expected. the reaction was impressive between the citizens, who used social media to tackle the shortage of ppe and to help the doctors and nurses during the pandemic. worldwide, social media groups exchanged ideas, drawings, schematics and technical instructions, in order to produce face shields, reusable respirators, ventilators and other ppe [34]. one of the most important actions of social media users is the use of 3d printing technology to produce specific ppe. social networks have the potential to combine both information from the official sources and popular information from citizens in a short period of time, making them a valuable tool in crisis management [35] . previous studies show that in times of crisis, citizens seem to be more cooperative and better able to respond to authorities' instructions via social media [36] . the main advantage of using these tools, is the dynamic capability they provide to disseminate the information [37] . unfortunately, the use of media has not only advantages, but also disadvantages, such as unreliability of the information, and inefficiency and dispersal of panic [13] , [38] . at the time of the covid -19 pandemic, the network platform use rose by at least 20%, communicating information for the virus spread and for the shortages of ppe [39] . this information has motivated the global community to look for possible solutions to these problems. the formulation of relevant groups was immediate, and designs for the possible solutions were placed in digital repositories, where the main technology used is 3d printing. it is not the first time that 3d printing and additive technology in general has been used to provide solutions in the field of medicine and biomechanics. various technologies and materials have been used to print surgical instruments, dentures, organ dummies, etc. [18] . only in the united stated of america, there is an estimated amount of 444.000 printers, then the united kingdom has more than 168.000 printers, while germany occupies the 3 rd place in the world [40] , [41] . it is the first time that the community of 3d printer home users has come together and mass-produced ppe. more than 180.000 users worldwide can produce up to 6 face shields in 10 hours each, depending on the capabilities of printers and the design. assuming that a country like greece has about 500 printers, then in one day more than 6.000 face shields can be produced, enough to equip doctors, nurses, rescuers, staff working with patients in general, in a short period of time. in our study, the queries that included the general terms ppe and personal protective equipment show the most results in user response, as expected, because they concern general fields and not individual ppe. in most cases, the largest percentage is due to the impact of social media users on news / blogs and web, due to the fact that social media groups display their products/results on news websites. proof that the teams were organized through social media is that in the ppes that can be printed (face shields, respirator but also valves and ventilators) show increased percentages on twitter, facebook and youtube, while in the rest they are zero. although several designs have been developed for 3d printing, the biggest concern is whether all of them can be used. some of these designs have been approved by nih and fda. particular attention should be paid to the materials used for their production, but also to the way they are used so as not to endanger human lives. the american society of anesthesiologists made a statement about the possibility of having multiple patients per ventilator. characteristically, they state a number of reasons why it is impossible to do so, for example, "volumes would go to the most compliant lung segments. positive endexpiratory pressure, which is of critical importance in these patients, would be impossible to manage." [42] . for such types of reasons, even after about three months from the beginning of the pandemic, licenses for the manufacture of respirators by individuals in the vast majority, have not been issued in figure 5 a proposed process used before 3d printing is illustrated. the need for ppe and medical supplies triggers the beginning of the process. individuals are usually searching for designs and solutions for the problems concerning the local community through social media. accordingly, they should verify whether the final product has been approved by the competent authorities. in case the proposed design lacks a license, a similar design that has the relevant license should be selected. following, the prototype is printed and inspected from the local healthcare professionals for micro adjustment, if necessary. finally, if all the previous steps are completed, the product can be printed in mass quantities. the qaly allows for the combined study of outcomes of any health-related actions and their effect on mortality into a single indicator, thus establishing a method that enables comparisons across multiple disease areas. throughout their life, people have different health states, which are weighted based on the preassigned utility ranks. the qaly model was applied as shown in figure 4 , taking into account that one of the main reasons of viral infection affecting the respiratory system is the non-usage or poor application of protective equipment as well as the fact that health professionals are more exposed and subsequently more likely to get infected. patients using ppe gained quality of life compared to health worker professionals from europe or us, without the usage of ppes. this study examined the way individual social media users and 3d printer owners tackle the ppe shortage during a pandemic. social media influences the problem in multiple levels: firstly, they highlight the problem, in this context the lack of ppes, secondly they encourage and promote the formation of task forces/teams from the general population with a relevant interest, thirdly they provide the means for exchanging information and technology and finally they can identify the number of required 3d printers in a local, national, or even international level needed to achieve the task. at the same time the role of ppe as necessary equipment for health professionals is fundamental. the qaly model was employed to show the importance and effect of using personal equipment on life quality and expectancy. during the recent coronavirus pandemic, the world faced a serious shortage of ppe. individuals and universities co-ordinated their action using web networking and social media in order to produce around 150 3d printable designs of ppe that got developed and distributed. social networking and 3d printing combined can be seen as a new tool for tackling pandemic emergency situations. no competing financial interests exist coronavirus covid-19 global cases by the demographic science aids in understanding the spread and fatality rates of covid-19 identification of coronavirus isolated from a patient in korea with covid-19 a novel coronavirus from patients with pneumonia in china epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study association of airborne virus infectivity and survivability with its carrier effectiveness and costeffectiveness of vaccination against pandemic influenza (h1n1) 2009 the future of social media in marketing the emerging use of social media for health-related purposes in low and middle-income countries: a scoping review patients' and health professionals' use of social media in health care: motives, barriers and expectations use of social media in health communication: findings from the health information national trends survey the digital incunabula: rock additive manufacturing (3d printing): a review of materials, methods, applications and challenges 3d printing in pharmaceutical and medical applications -recent achievements and challenges global health observatory (gho) data, world health observatory in memoriam: healthcare workers who have died of covid-19 social media as crisis platform: the future of community maps/crisis maps social media and crisis management: cerc, search strategies, and twitter content social media in crisis management: an evaluation and analysis of crisis informatics research how covid-19 is testing social media's ability to fight misinformation emarketer marking of personal protective equipment minimizing occupational hazards in endoscopy: personal protective equipment, radiation safety, and ergonomics attenuated total reflectance infrared spectroscopy as a screening tool for the urinary calculi characterization nhs staff 'gagged' over coronavirus shortages american college of surgeons statement on ppe shortages during the covid-19 pandemic american college of surgeons shortage of personal protective equipment endangering health workers worldwide shortage-of-personal-protective-equipment-endangering-health-workers-worldwide social media in disaster risk reduction and crisis management examining the role of social media in effective crisis management: the effects of crisis origin, information form, and source on publics' crisis responses the dynamic role of social media during hurricane #sandy: an introduction of the stremii model to weather the storm of the crisis lifecycle 40+ 3d printing industry stats you should know printing industry stats you should know dig deeper into 3d printing sentiment joint statement on multiple patients per ventilator  social networking and 3d printing combined can be seen as a new tool for tackling pandemic emergency situations. key: cord-314460-dbrp4vxc authors: gibbs, shawn g.; herstein, jocelyn j.; le, aurora b.; beam, elizabeth l.; cieslak, theodore j.; lawler, james v.; santarpia, joshua l.; stentz, terry l.; kopocis-herstein, kelli r.; achutan, chandran; carter, gary w.; lowe, john j. title: review of literature for air medical evacuation high-level containment transport date: 2019-10-31 journal: air medical journal doi: 10.1016/j.amj.2019.06.006 sha: doc_id: 314460 cord_uid: dbrp4vxc abstract introduction aeromedical evacuation (ae) is a challenging process, further complicated when a patient has a highly hazardous communicable disease (hhcd). we conducted a review of the literature to evaluate the processes and procedures utilized for safe ae high-level containment transport (ae-hlct) of patients with hhcds. methods a literature search was performed in pubmed/medline (from 1966 through january 2019). authors screened abstracts for inclusion criteria and full articles were reviewed if the abstract was deemed to contain information related to the aim. results our search criteria yielded 14 publications and were separated based upon publication dates, with the natural break point being the beginning of the 2013-2016 ebola virus disease epidemic. best practices and recommendations from identified articles are subdivided into pre-flight preparations, inflight operations, and post-flight procedures. conclusions limited peer-reviewed literature exists on ae-hlct, including important aspects related to healthcare worker fatigue, alertness, shift scheduling, and clinical care performance. this hinders the sharing of best practices to inform evacuations and equip teams for future outbreaks. despite the successful use of different aircraft and technologies, the unique nature of the mission opens the opportunity for greater coordination and development of consensus standards for ae-hlct operations. air medical evacuation (ae) is a challenging process, further complicated when a patient has a highly hazardous communicable disease (hhcd). the ease of air travel, tourism, and expansion of international commerce exposes all regions of the world to these diseases. 1 the preference is to treat patients with hhcds on-site, rather than transport from the outbreak area 2 ; however, high-level containment transport (hlct) evacuations may be preferred when 1) there is an incapacity of the local infrastructure to provide care, 2) there is a potential detrimental effect to local health care workers (hcws) (ie, the patient is a colleague), 3 3) the outbreak is in an active war or conflict zone, 4) it is a policy decision (to increase volunteerism), or 5) there are local or national political concerns. regardless, successful ae hclts of patients with hhcds requires a discussion on risks, benefits, planning, training, and resources. the 2013 to 2016 ebola virus disease (evd) epidemic prompted multiple ae hlcts; at least 10 nations conducted ae hlcts for at least 33 patients with evd within the country and internationally. [4] [5] [6] [7] the ae-hlcts were conducted by single-patient isolation transports. since that epidemic, multiple groups have developed ae hlct systems enabling simultaneous isolation and care of multiple patients; these include the us department of state containerized bio-containment system and the us department of defense (dod) transport isolation system. the us centers for disease control and prevention issued ae guidance for evd in 2015. 8 although portions of the guidance were broadly applicable, it was evd specific, lacked discussion of logistical challenges, and did not include experiences from recently conducted ae hlcts. 2 no ae hlcts during the epidemic had secondary transmissions although they were conducted differently by each organization. some evacuation procedures were preestablished and drilled, whereas others were based on situational needs. ae hlct has increased since it was introduced in the 1970s, but no literature review comparing approaches has been published. a 2000 literature review 9 queried the intersection of key words "biological warfare" and "aeromedical evacuation" or "transportation of patients" and yielded a single citation; today, that same search yields 4 results. [10] [11] [12] [13] this study's purpose is to provide a more comprehensive evaluation of the processes and procedures used for safe ae hlcts of patients with hhcds in preflight, in-flight, and postflight environments. a literature search was performed in pubmed/medline (from 1966 through january 2019) with the following terms: 1) "aeromedical isolation," 2) "aeromedical evacuation" or "transportation of patients" or "air ambulance" or "hems" or "helicopter" and "ebola" or "lassa" or "viral hemorrhagic" or "highly infectious" or "highly hazardous" or "contagious" or "communicable" or "middle east respiratory syndrome (mers)" or "sars" or "smallpox", and 3) "mobile" or "transport" and "high-level isolation" or "high containment". authors screened abstracts for the following inclusion criteria: peer-reviewed literature, written in english, and described ae hlct of persons with an hhcd. diseases considered highly hazardous were identified based on the following definition by the european network for highly infectious diseases: "an infection that is easily transmissible from person to person; life-threatening; presents a serious hazard in the health-care setting and the community; and requires specific control measures (e.g., high-level isolation)." 14 this definition is understood to include various viral hemorrhagic fevers, severe acute respiratory syndrome (sars), and other easily transmissible emerging infectious diseases. articles were reviewed if the abstract contained information related to the aim, with those focused exclusively on ground transport or ae of non-hhcd patients excluded. the search terms yielded 101 publications; 14 met the inclusion criteria and were included in the study (tables 1 and 2). the articles were separated based on publication dates, with the natural break point being the 2013 to 2016 evd epidemic. thoms et al 2 discussed drawing on the operational experience from phoenix air corporation, a private organization that began ae hlcts in 2007 when it developed the aeromedical biological containment system. the us department of state, united nations, and other governments used that single-patient transport system for ae hlcts of patients with evd in 2013 to 2016. 15 although phoenix air corporation's ae hlct experience is widely known, details of their procedures and policies were not published in peer-reviewed literature and were not available. planning for and executing ae hlcts must account for multiple variables; our review is organized around "preflight, in-flight, and postflight" environments. a broad spectrum of diseases was covered in the reviewed articles, including airborne diseases, 16 biological warfare agents, 9, 10, 17 and viral hemorrhagic fevers. articles published before 2014 targeted many diseases (table 1) , whereas articles published after 2014 (table 2) focused almost exclusively on evd. pre-2014 articles included considerations for airborne isolation, whereas post-2014 articles stressed contact isolation associated with evd. the reviewed articles understated the considerable collaborations involved in ae hlct decision making because most only vaguely mentioned frequent discussions and multiagency requests must occur before transport. [17] [18] [19] nicol et al 19 did indicate that the decision to evacuate patients is a "complex process that considers the clinical, public health, and political contexts." although no article identified a decision-making rubric for deploying ae hlct assets, several discussed factors involved in the decision-making process (eg, recommendations by domestic and international agencies). lotz and raffin 20 indicated their transport met recommendations set by the world health organization for medical evacuation of patients with high infectious risk (36-48 hours). thoms et al 2 noted that ". . . u.s. military policy is to treat highly infectious patients 'in place', and avoid unnecessary evacuation to the u.s." but acknowledged instances in which transport would occur, such as index cases or for political considerations. given the current emphasis on military participation in nation-building efforts, it is unlikely that adequate resources for "treatment in place" will be present during future outbreaks. as such, the military may become increasingly reliant on ae hlcts. patient stability and survivability were noted as principal factors in the decision to conduct an ae hlct; a patient moved before the onset of severe disease manifestations is preferable and, at times, a requirement for transport because of limited isolation units. 5, 6, 17, [19] [20] [21] ae hlct places additional stressors associated with altitude on the patient that impact their physical condition (eg, hypoxia and claustrophobia). 2, 6, 19, 21, 22 articles identified a lack of local facilities with resources and capabilities as a reason for domestic or international evacuation. 2, 6, 22 volunteers supporting humanitarian endeavors overseas are often assured that they will be repatriated should they become ill, as was the case during the 2013 to 2016 evd epidemic when at least 24 evd-infected hcws/volunteers were evacuated to their home countries. 7 no reviewed articles detailed the types, duration, requirements, or frequency of training. biselli et al 22 noted training includes personal protective equipment (ppe), patient management on ground and inflight, and equipment decontamination, whereas christopher and eitzen, 17 24 which detailed a 2006 royal air force mission, remarked on the benefit of in-flight, just-in-time training that occurred on the flight to the patient, while also stating that the mission resulted in routine air transport isolator exercises. as with many fields, it is difficult to determine applicable training and exercise needs for ae hlct. organizations work internally (considering equipment, mission, and personnel) to determine the appropriate training and delivery to maintain competency. the regulations and legal limitations associated with the ae hlct were not fully explored in any reviewed article. two articles mentioned the need to adhere to organizational policies, 2,6 1 noted a requirement to obtain consent from governments for transports 5 and one stated ae hlct teams routinely seek diplomatic clearance when flying over other nations, 19 but none discussed applicable federal or international regulations. withers and christopher 9,10 discussed the need for regulations to address the unpredictable reaction of the international community in a hhcd event but primarily focused on the biological weapons and toxin convention protocol. schilling et al 21 discussed the need for flight certification to ensure materials are deemed safe to fly. withers 9 and adams et al 11 detailed preference for long-range capable aircrafts to limit refueling stops. all us military aircraft used in ae hlct missions are capable of midair refueling and are able to eliminate stops for fuel and/or extend flights to avoid the airspace of hostile or reluctant nations. four studies mentioned the importance of effective communication and coordination among partners, but none discussed details of communication plans. 5, 6, 17, 20 seven articles did identify organizations that would be contacted to initiate a transport, albeit at a high level. 5, 10, 16, 17, 19, 20, 22 thoms et al 2 detailed crew predeparture briefings. the article by christopher and eitzen 17 was the only one to detail communication plans with the patient in-flight, namely, 2-way radios between team members and patients. ewington et al 6 and thoms et al 2 detailed the space layout within the c17 aircraft that both evacuations used, including placement and securing of the isolation unit. thoms et al 2 detailed "aircraft containment zones" for patient areas within the aircraft where hcws and crew could move within the aircraft and procedures and level of ppe that hcws and crew would need for each zone. nicol et al 19 also demarcated clean and dirty zones for confirmed patients and established a corridor for access to toilets and eating spaces for exposed, asymptomatic cases. zone designation lends the ability to transport multiple patients at different stages of disease progression for the same disease or, more likely, to transport both suspected and confirmed patients. in the 1974 air medical transportation of a lassa fever patient from nigeria to germany, the following zones were established: a containment zone where the patient was located, a crew zone where ppe was not worn, and a neutral zone between the 2 that was also available for plane-related emergency procedures. 25 withers and christopher 9,10 stated that military "flight nurses know that cabin airflow is 'top to bottom, front to back' on the c-9a nightingale; therefore, contagious patients are placed as far aft and as low as possible." withers and christopher 9,10 also noted particular considerations (eg, high-efficiency particulate air systems, air exchanges/hour, and negative pressure zones) are made on the ventilation systems within each aircraft for potential dispersion of aerosolized microbes from a contagious patient that is either uncontained in an isolation unit or may have been unknowingly contagious. the professional training level of ae hlct personnel varied ( table 3 ). the articles by thoms et al 2 and nicol et al 19 were the only ones that explicitly noted the care team could be augmented with additional support to ensure adequate staff levels for the full flight dependent on the number of patients transported and, in the case of thoms et al, 2 for flight duration; however, no details were provided on the targeted staffing-to-patient ratio or the flight duration that would demand augmented staff. although a critical issue, the time personnel spent in ppe is not extensively discussed. schilling et al 21 noted a portable anteroom is used for ppe donning and doffing when flights exceeded 4 hours. lamb 24 noted the ae hlct team worked shifts consisting of 1 nurse and 1 paramedic, enabling the rest of the team to eat, sleep, and rest. other articles lacked analysis and recommendations for hcw fatigue x indicates the subject was included in the article. and shift rotation during longer transports. ppe can be cumbersome and trigger hcw physiological and psychological distress-even in environmentally controlled biocontainment facilities 26 -and may be exacerbated at altitude. appropriate work-rest cycles; considerations to time in ppe; and fatigue, alertness, and clinical performance monitoring are important during ae hlct. the objective analysis of these factors is necessary to maximize performance and safety. every article mentioned the importance of proper ppe use, but few detailed ppe ensembles, and none described donning and doffing procedures. ewington et al 6 noted that decontamination procedures were overseen by a designated and trained ppe monitor but lacked details on the ppe level or type. dindart et al 5 stated their personnel used "full ppe" with no details provided; however, based on article images, it appears they used the world health organization−recommended ppe (goggles, procedure masks, fluid-resistant hood, fluidresistant coveralls, gloves, and boots). 27 thoms et al 2 described their use of "coveralls, multiple pairs of surgical gloves, rubber outer boots and a powered air purifying respirator (papr) system to prevent skin exposure"; christopher and eitzen 17 and withers and christopher 10 described similar configurations. schilling et al 21 discussed the physical stress of working in a respirator but did not specify type; however, images indicate a ppe configuration similar to thoms et al. 2 nicol et al 19 repeatedly noted that once sealed, patient care during transport with the trexlar air transport isolator (t-ati) does not require staff to wear ppe. although lamb 24 did not specify in-flight use, ppe similar to that described in the article by dindart et al 5 was used for personnel that helped transport the patient onto the aircraft. most articles indicated that a portable isolation unit, such as the air transport isolators used by the italian air force and british military (previously used by usamriid), the t-ati currently used by the british military, the vickers aircraft transport isolator (previously used by usamriid), or the human stretcher transit isolator-total containment (oxford) limited (hsti-tcol) used domestically in guinea, were operated in-flight. 1,5,16,19,21,22,24 the hsti-tcol was described in detail with significant limitations, including the inability to restrain the patient during turbulence or place items (eg, medicine, devices) into the unit once the patient is enclosed. 5 although these portable units were described in varying levels of detail, each offered complete enclosure for a single patient, barrier protection for the hcws, and high-efficiency particulate air−filtered negative pressure air. 17, 18, 20 most depended on batteries with a 6hour life, 5 whereas others had the ability to use the aircraft's electrical system. 2, 6 experiments showed that portable isolation chambers may leak or rupture when exposed to an explosive decompression 28 ; therefore, contingency procedures should be in place. sweden and italy use a combined ground and air transport whereby a specially designed and equipped ambulance is driven inside of a c-130. 21 the patient remains in the ambulance in-flight; essentially, the ambulance becomes an isolation unit. this combination reduces loading time and the likelihood of aircraft contamination. the british military uses a dedicated road transport vehicle for the t-ati positioned at the receiving air base for seamless transport to the destination facility. 19 a major limitation of transport systems was the inability to house multiple patients. newer systems currently in validation seek to alleviate this limitation. the transport isolation system is a dod containment modality designed and approved for loading onto c-17 and c-130 military aircraft; each system (aluminum frame with clear plastic liner that maintains a negative pressure isolation environment) is capable of moving multiple patients simultaneously, and 2 such systems can be accommodated on the larger c-17 platform. the containerized bio-containment system is a us state department−sponsored platform similar to a hard-sided shipping container with viewing ports and a negative-pressure isolation environment. it has the capability to transport 4 patients simultaneously with space for multiple caregivers and is designed to be loaded onto the c-17 (not yet approved by the us air force) or the boeing 747 airframe. 29, 30 procedures/capabilities in-flight care provided during ae hlcts will not be equivalent to that available at a dedicated health care facility. however, several articles detailed the ability to provide a wide range of medical procedures in-flight (eg, endotracheal incubation and defibrillation) 2, 6, 18, 19 ; other articles implied in-flight procedures were limited to monitoring. 5 the type of isolation unit limits capabilities in-flight; for example, the hsti-tcol detailed in the study by dindart et al 5 is a sealed pod and enables only limited interventions (eg, intravenous rehydration and antiemetics). in reviewing articles and operational experiences for evd, 31 we found a lack of consideration and planning for liquid and solid waste. there is a general underestimation of the volumes of both produced in-flight and an unclear understanding of the rules and regulations that govern waste during each transport phase. lotz and raffin 20 and ewington et al 6 indicated waste generated by the patient in-flight were kept within the isolation unit but segregated from the patient. upon transport completion, the isolation unit was enveloped, and all associated waste destroyed 6, 20 ; however, methods for packaging, transporting, and subsequent waste destruction were not described. thoms et al 2 stated a transportable lavatory would be included on the aircraft and used to capture liquid waste but did not discuss the handling and storage of solid wastes generated in-flight (eg, ppe). nicol et al 19 noted waste can be minimized in-flight by using containers with absorbent powder or solidifying agents but did not detail the process. lamb 24 discussed the process of double bagging ppe used for patient receival with the intention to dispose with waste generated in-flight but did not elaborate. dindart et al 5 indicated that waste generated in-flight would be collected and incinerated postflight; however, no details were provided. withers and christopher 9,10 discussed criteria for a decontaminating compound (eg, effective within a short time, in low concentrations with low human toxicity, stable shelf life, and compatible with aircraft materials). this stressed the importance of the compound compatibility with aircraft materials. only nicol et al 19 mentioned the existence of a mortuary protocol if the patient were to pass away in-flight, stating only that a death inflight is "managed with standard procedures, which vary depending on the jurisdiction of the flight." in the case of a death in-flight, a decision would have to be made to either continue to the destination or return to the departure origin based on factors such as distance traveled, available fuel, political considerations, and other patients awaiting transport. although such a decision would be made in communication with decision makers on the ground, preliminary discussions of this contingency would be beneficial. several potential in-flight emergency scenarios were discussed. ewington et al 6 acknowledged the potential of an isolation unit breach and noted the medical engineer would conduct repairs immediately. in discussing emergency evacuation procedures, thoms et al 2 noted crew would don patients in ppe to reduce exposure and minimize contact with rescuers or nonmission personnel. postflight details were limited in most reviewed articles. dindart et al 5 stated "the plane is decontaminated using a chlorine solution at every point of contact between the pod and the plane, which take about 15 min." thoms et al 2 indicated that a dilution of disinfectant solution calla 1452 (zip-chem products, morgan hill, ca) and sani-wipes (disposables international, incorporated, orangeburg, ny) were available during the transport. it also stated that postflight "medical crewmembers and/or equipment will be decontaminated per current policy"; however, there were no policy details. 2 lotz and raffin 20 indicated that "disinfection of the cabin of the aircraft and medical equipment with nocolyse (oxy'pharm; champigny-sur-marne, france) spray (hydrogen peroxide, catalyst, biosurfactant)" is conducted after mission conclusion. schilling et al 21 detailed the use of formaldehyde fumigation as the final decontamination posttransport and indicated that sweden used a nonflammable peracetic acid for decontamination of the staff. nicol et al 19 stated the t-ati system was fumigated with vaporized hydrogen peroxide and the frame decontaminated and returned for reuse after 7 days. tsai et al 16 detailed the use of bleach solution spray on the isolation unit and ppe before air transport of patients with sars, and the use of water spray and desiccation on the isolation unit upon transport completion. wilson and driscoll 1 also reported the use of bleach for surface decontamination before boarding the aircraft. posttransport decontamination of aircraft differed. efficacy is the primary intention; however, decontamination agents must also comply with aircraft material compatibility. the viability and stability of pathogens differ; therefore, decontamination methods may be adapted based on the hhcd. lufthansa technik, a german laboratory, found 3 disinfectant components effective against hhcds while also aircraft compatible (alcohol, formaldehyde, and hydrogen peroxide) and detailed standard operating procedures for aircraft disinfection. 32 more research and information on regulations are needed to support safe aircraft decontamination. waste disposal details were lacking. two articles indicated waste was incinerated 5,20 but did not specify how it was packaged or transported before incineration. likewise, nicol et al 19 noted the isolator envelope is autoclaved on-site and disposed of as regulated clinical waste after decontamination but did not provide additional details. in the united states, the terminal disposal of category a waste (of which evd and many other hhcds are classified) is costly and requires specific packaging and a vendor with a department of transportation special permit to move and process the waste. all transporting organizations should have written protocols and procedures for the terminal disposal of category a waste and, when necessary, preidentify a certified vendor if the waste is not able to be autoclaved, incinerated, or deactivated on-site to downgrade the hazardous materials classification. thoms et al 2 mentioned only that an infectious disease physician might screen medical personnel postflight. tsai et al 16 indicated that personnel performed twice daily temperature monitoring for 10 days after a sars transport. lamb 24 noted that personnel were monitored for only 48 hours after returning to the united kingdom because the transported patient later tested negative for lassa fever and positive for malaria. as with monitoring of hcws providing care in high-level containment facilities, postmission monitoring of crew and hcws should be included in written protocols to minimize the opportunity for further transmission. there are limitations to this review. ae of trauma patients and cases of other communicable diseases that are not highly hazardous may offer important considerations for operating procedures that were not included in this review. there also exists an inherent bias in the exclusion of non−english language documents, as well as the lack of access to publicly available non−peer-reviewed resources produced by various organizations. additionally, our review was conducted specifically searching for "highly hazardous" and "highly infectious" diseases. other terms are also used, but these were not included in the literature because we were aware that european high-level containment facilities and the majority of federal documents used the terms "highly infectious" or "highly hazardous communicable" diseases before and during the evd epidemic. moreover, this review focuses specifically on ae of patients with hhcds; clearly, the ground transportation facet is a critical component of the safe movement of such patients and has its own challenges and risks. since the evd epidemic, the us state department and dod have developed systems for ae hlcts of multiple patients of varying levels of hhcd acuity during the same operation. although ae hclt during the evd epidemic was managed within phoenix air corporation's capabilities, a larger global epidemic may demand scalability. ae hlct systems advancement with increased space and ability to perform care within the unit enables more advanced patient care procedures than available in single-patient isolation. however, with the improved capability for in-flight care, discussions are needed on what medical procedures should be conducted in-flight, focusing on minimizing aerosol generation. additionally, post-2014 reviewed articles (table 2 ) reflect the increasing staffing demands for patients with evd; the transport of multiple patients with hhcds will only enhance the resource-intensive nature of these missions. ae hlct poses significant risks to crews. high hhcd mortality rates 7 and the unstable environment inherent in aes require policies and procedures to decrease transmission risks and maximize patient management. the designation of high-level isolation facilities in the united states and europe narrows the list of potential receiving facilities; procedures should be well discussed and thoroughly exercised between transporting organizations and their respective receiving facilities. a future outbreak of a hhcd is likely; advancing the field of ae hlct is critical. there is limited peer-reviewed literature available on ae hlct, including important aspects related to hcw fatigue, alertness, shift scheduling, and clinical care performance. few experienced teams have published details on their processes, experience, and operations, and this limited breadth of literature hinders the sharing of best practices to inform evacuations and equip teams for future outbreaks. 33 despite the successful use of different aircraft and technologies, the unique nature of the mission opens the opportunity for greater coordination and the development of consensus standards for ae hlct operations. supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.amj.2019.06.006. mobile high-containment isolation: a unique patient care modality long-range transportation of ebolaexposed patients: an evidence-based protocol the immediate psychological and occupational impact of the 2003 sars outbreak in a teaching hospital pre-hospital transportation in western countries for ebola patients, comparison of guidelines aerial medical evacuation of health workers with suspected ebola virus disease in guinea conakry-interest of a negative pressure isolation pod-a case series transferring patients with ebola by land and air: the british military experience clinical management of ebola virus disease in the united states and europe guidance on air medical transport (amt) for patients with ebola virus disease (evd) aeromedical evacuation: management of acute and stabilized patient aeromedical evacuation of biological warfare casualties: a treatise on infectious diseases on aircraft new scenarios in major accidents−use and adaption of current concepts to ward off damage jubail−an aeromedical staging facility during the gulf conflict: discussion paper association for professionals in infection control and epidemiology inc. and centers for disease control and prevention framework for the design and operation of high-level isolation units: consensus of the european network of infectious diseases how phoenix air entered the ebola business transporting patient with suspected sars air evacuation under high-level biosafety containment: the aeromedical isolation team transporting patients with lethal contagious infections aeromedical transfer of patients with viral hemorrhagic fever aeromedical evacuation using an aircraft transit isolator of a patient with lassa fever european concepts for the domestic transport of highly infectious patients the added value of preparedness for aeromedical evacuation of a patient with ebola containment aircraft transit isolator evaluation of infection control practices during an ae neuilly sur seine, france: advisory group for aerospace research and development ebola virus disease: preparedness and infection control lessons learned from two biocontainment units world health organization. personal protective equipment in the context of filovrius disease outbreak response airplane transport isolators may lose leak tightness after rapid cabin decompression ready for the challenge: dobbins selected as home for new biocontainment system mil/desktopmodules/articlecs/print.aspx?portalid=1&moduleid=850&ar-ticle=562739 nebraska biocontainment unit perspective on disposal of ebola medical waste disinfection of aircraft: appropriate disinfectants and standard operating procedures for highly infectious diseases need for aeromedical evacuation high-level containment transport guidelines key: cord-339614-28s205p8 authors: dover, jeffrey s.; moran, mary lynn; figueroa, jose f.; furnas, heather; vyas, jatin m.; wiviott, lory d.; karchmer, adolf w. title: a path to resume aesthetic care: executive summary of project aescert guidance supplement—practical considerations for aesthetic medicine professionals supporting clinic preparedness in response to the sars-cov-2 outbreak date: 2020-05-01 journal: facial plast surg aesthet med doi: 10.1089/fpsam.2020.0239 sha: doc_id: 339614 cord_uid: 28s205p8 nan extremis with severe respiratory and renal failure, stroke, pericarditis, neurologic deficits, and other suddenly lifethreatening complications, in addition to its pernicious effects on those with pre-existing morbidities and advanced age. accordingly, the guidance supplement seeks to establish an elevated safety profile for providing patient care while reducing, to the greatest extent reasonably possible, the risk of infectious processes to both patients and providers. while the guidance supplement cannot foreclose the risk of infection or serve to establish or modify any standards of care, it does offer actionable risk-mitigation considerations for general office comportment and for certain nonsurgical procedures typically performed in aesthetic medical settings. it is axiomatic that all such considerations are necessarily subject to the ultimate judgment of each individual health-care professional based on patient situation, procedure details, office environment, staffing constraints, equipment and testing availability, and local legal status and public-health conditions. federal, state, and local government legal pronouncements and public-health conditions will inform the gating decisions of when permissible and prudent to reopen practices and re-engage with patients, and whether to limit certain procedures that may present greater contagion risk. while such gating decisions are not the focus of this guidance supplement, it is advisable that practices should consider, at a minimum, whether in their local communities: (1) new covid-19 cases are declining sequentially to eliminate or at least substantially control community spread; (2) testing is available at a meaningful scale to validate perceived prevalence reductions; and (3) adequate protocols and resources are in place in conjunction with local health departments to conduct effective contact tracing where necessary in response to covid-19 incidents. without robust testing, the ability to identify individuals with covid-19, do appropriate contact tracing, and isolate and treat the infected is substantially reduced. therefore, in the absence of these enumerated local conditions, practices must factor cautiously the attendant increased risk of transmission into their reopening calculus. significantly, the principal variables within the control of the practicing aesthetic medicine physician are office and staff preparation, and communication and transparency with patients. the guidance supplement is focused heavily on these subjects, offering consensus guidance from authors representing relevant scientific and clinical disciplines. the project aescert guidance supplement provides specific recommendations and considerations for preparing to reopen a medical aesthetic office and begin to deliver aesthetic patient care in a covid-19 environment, including: patient communication-establishing appropriate expectations for office visits and attendant risks; clinic schedule management-considerations for schedule modification to convert non-treatment interactions to telehealth consultations, separate patients from one another in the office and avoid unnecessary staff contact; facility management-physical modification of office common areas and treatment rooms, as well as check-in and check-out procedures, to promote safe practices and physical distancing; cleaning procedures-discussion of disinfection methods and practices in each office area, ranging from medical instruments and treatment rooms to administrative items and reception areas; personal protective equipment (ppe) for providers, staff and patients-recommendations for ppe types and use depending upon procedure-based risk assessment, and recognizing current global equipment shortages; employee health screening and training-procedures and methods for identifying staff members who may be unwell before, during, and after work, and training of staff to identify potential covid-19 presentation in coworkers, patients, and other office visitors; risks associated with exposure to known or suspected covid-19-positive individuals are also discussed; patient health and screening-procedures and methods for symptom recognition in patients before, during, and after office visits, with follow-up monitoring where appropriate; remedial measures following onsite symptom presentation-a framework for addressing isolation of symptomatic individuals, office containment and disinfection, and contact tracing; treatment room setup-preparing and securing treatment rooms for patient entry to contain office contamination and reduce overall potential covid-19 exposure; and aesthetic treatment considerations-pretreatment preparation and precautions, and other suggestions for minimizing risk of transmission in performing the most common types of office-based aesthetic procedures, such as neurotoxin and dermal filler injections, noninvasive body contouring, lasers and other similar energy-emitting devices, and a range of medical skin care treatments. the project aescert guidance supplement also contains summary charts and checklists designed in collaboration by both infectious disease and aesthetic experts, which can be utilized immediately to assist office staff in understanding and modeling sound safety practices. aesthetic medicine practices must navigate a daunting series of medical and business challenges occasioned by the covid-19 pandemic. most offices have been closed by operation of both common sense and legal requirement, as the public health community labors to comprehend both the magnitude and complexity of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) and its sequelae. this crisis has created significant safety concerns and occasioned severe financial hardship for aesthetic physicians, staff, and patients alike. however, the authors posit that application of sound safety measures identified and considered in the guidance supplement will serve to assist aesthetic medicine specialties in returning to the delivery of patient care with reasonable risk-minimization strategies. it is critical that all disciplines of medicine, aesthetic and otherwise, share available information and work together to evolve effective approaches to practicing in a dramatically changed environment. this project aescert guidance manuscript (''guidance'') was developed in partnership with a multidisciplinary panel of board-certified physician and doctoral experts in the fields of infectious disease, immunology, public health policy, dermatology, plastic surgery and facial plastic surgery. this guidance is intended to provide aesthetic medicine physicians and their staffs with a practical guide to safety considerations to support clinic preparedness for patients seeking non-surgical aesthetic treatments and procedures following the return-towork phase of the covid-19 pandemic arising out of the novel coronavirus sars-cov-2, once such activity is permitted by applicable law. many federal, state and local governmental authorities, public health agencies and professional medical societies have promulgated covid-19 orders and advisories applicable to health care practitioners, largely focused on the threshold determination of whether and when to reopen for business. these standards should be seriously considered, and where required by law or otherwise applicable or prudent, followed thoughtfully. this guidance is not intended to contravene any such other mandates, which supersede this guidance in the event of any conflict, but rather, to provide aesthetic physicians and their staffs with an additional set of practical considerations for delivering aesthetics care safely and generally conducting business responsibly in the new world of covid-19. aesthetic physicians and their staff will face new and unique challenges as government stay-at-home orders and related commercial limitations are eased, and the u.s. economy reopens and healthcare systems transition from providing only urgent and other essential care to resuming routine care, elective procedures and services. debate will continue about the wisdom, pace and scope of such reopening, but in the meantime patient demand for aesthetic treatments will return. the medical aesthetics specialties will therefore wish to resume practice in order to ensure high quality, expert care is available, and importantly to help promote patients' positive selfimage and sense of well-being following a lengthy and stressful period of quarantine. in reopening aesthetic practices during the ongoing pendency of the covid-19 outbreak, delivery of care must be accompanied by necessary precautions to safeguard the health and welfare of not only the patients and providers within the context of the office environment, but also the community at large with whom they interact immediately beyond the office walls. there is widespread perception that, while aesthetic procedures are self-esteem and self-image enhancing, they are generally considered elective, with notable exceptions that may be deemed medically necessary (e.g., cases of congenital anomaly or traumatic injury). because of their elective nature, extraordinary care must be taken to protect patients and healthcare professionals from covid-19. while physician practice guidance is available from many sources, the aescert guidance has been developed specifically for aesthetic medicine settings. in a number of areas, this guidance exceeds traditional aesthetic office safety precautions, recognizing reduced tolerance in an elective treatment environment for any risk associated with covid-19's highly variable presentation and unpredictable course. the disease has placed a disturbing number of young, otherwise healthy patients in extremis with severe respiratory and renal failure, stroke, pericarditis, neurologic deficits and other suddenly life-threatening complications, in addition to its pernicious effects on those with pre-existing morbidities and advanced age. accordingly, the guidance seeks to establish an elevated safety profile for providing patient care while reducing, to the greatest extent reasonably possible, the risk of infectious processes to both patients and providers. while the guidance categorically cannot foreclose the risk of infection, nor serve to establish or modify any standards of care, it does offer actionable risk-mitigation considerations for general office comportment and for certain non-surgical procedures typically performed in aesthetic medical settings. this guidance is purely advisory in nature and should be regarded as a set of baseline precautions that should be considered; however, it is not an exhaustive list of everything required to operate safely. it is axiomatic that all such considerations are necessarily subject to the ultimate judgment of each individual healthcare professional based on patient situation, procedure details, office environment, staffing constraints, equipment and testing availability, and local legal status and public health conditions. importantly, this guidance is also subject to present limitations on medical and scientific understanding of covid-19, and any future changes in such understanding will need to be evaluated by providers in determining its continuing utility. additionally, this guidance has been prepared in a nationwide environment marked by limited diagnostic resources for both active disease and possible immune response, and an absence of validated pharmaceutical treatments or vaccines. as point of care testing becomes more widely available, affordable and reliable, and once therapeutic or preventive protocols are in place, such developments may permit certain modulation of the guidance. in the interim, federal, state and local government legal pronouncements and public health conditions will inform the gating decisions of when it is permissible and prudent to reopen practices and re-engage with patients, and whether to limit certain procedures which may present greater contagion risk. given the multiplicity of such circumstances across the country, these are necessarily highly localized and indeed individualized assessments. while such gating decisions are not the focus of this guidance, it seems clear that practices should consider, at a minimum, whether in their local communities: (1) new covid-19 cases are declining sequentially to eliminate or at least substantially control community spread, (2) testing is available at meaningful scale to validate perceived prevalence reductions, and (3) adequate protocols and resources are in place in conjunction with local health departments to conduct effective contact tracing where necessary in response to covid-19 incidents. without robust testing, the ability to effectively identify individuals with covid-19, do appropriate tracing, and isolate and treat the infected is substantially reduced. therefore, in the absence of these enumerated local conditions, practices must cautiously factor the attendant increased risk of transmission into their reopening calculus. further, subsequent to the threshold decision to reopen, it is possible that future covid-19 prevalence in a particular community, along with limits on testing and treatment availability, could periodically require limitations in scope of practice or even temporary office closure to reduce risk of harm. again, this guidance takes no position on these contingencies, and seeks only to provide information and best practices for operational implementation where it is otherwise legally permissible and medically responsible to interact with patients in the office setting for delivery of medical aesthetics care. more broadly, in this highly dynamic pandemic environment, this guidance is necessarily based on, and its applicability confined to, the public health environment and related government pronouncements in effect as of the date of publication. subsequent evolution in transmission prevalence, testing and tracing capacity, and treatment as well as vaccine availability could warrant either further restriction or expansion of aesthetic practice from this guidance, depending on the direction of such evolution. in the meantime, based on the current public health landscape and the medical and scientific information now available, the guidance next proceeds to outline a series of practical considerations associated with practice reopening, ranging from preparing the medical office environment, staff training, and patient and staff health screening, to treatment room set-up, selection of personal protective equipment (ppe), and precautions for common office aesthetic procedures, such as neurotoxin and dermal filler injections, energy-emitting devices, body contouring and medical skin care treatments. while effective patient communication and transparency are always a hallmark of any well-functioning medical practice, they are particularly critical during the returnto-work phase of this covid-19 outbreak. accordingly, it is important for practices not only to implement and follow high safety standards as a substantive matter of public health, but also to clearly convey these steps to their patients to foster a sense of awareness and confidence. therefore, as an overarching theme to this entire guidance, measures and changes undertaken by practice in response to the covid-19 outbreak should be proactively signaled to patients to heighten confidence. utilizing established means to communicate to patients, such as the practice's website and notifying patients via digital and direct personal communication, is an important first step in conveying the practice's commitment to the health and safety of patients and the public, while maintaining high-quality patient care. communicating new policies and protocols throughout the clinic with visible reminders such as display posters and other signage will assist staff in remaining vigilant, in addition to conveying a practice's emphasis on safety for patients and others. it is advisable to display such materials throughout the clinic, including common areas, reception areas, waiting room, treatment rooms and bathrooms, reminding patients and staff of symptoms related to covid-19, healthy hygiene and prevention etiquette. examples of display posters are provided in the following links, although it should be noted with respect to the symptoms poster that this is not an exhaustive list, and additional symptoms are increasingly recognized, such as severe fatigue, nausea and diarrhea, chills, repeated shaking with chills, myalgia, headache, sore throat, new loss of taste or smell, and unexplained anorexia: symptoms of covid-19 -sample poster/flyer, preventing the spread of covid-19 -sample poster/flyer, and handwashing and respiratory hygiene -sample poster/flyer. additionally, in the same spirit of patient transparency and disclosure, given that there remains inherent, ineliminable risk of an infectious process or other complication arising from any sort of medical procedure during an ongoing global pandemic, even after respecting the considerations set forth in this guidance and elsewhere, practices may wish to append a covid-19 disclosure to their standard patient consent form. an example consent form developed by the american society of plastic surgeons (asps) may be found using the provided link. 16 further, in the case of patients at higher risk of covid-19 complications, such as those who are of advanced age, immunocompromised, or otherwise afflicted with cardiac or respiratory conditions or other comorbidities such as diabetes, hypertension or obesity, consideration should be given to possibly delaying aesthetics intervention, if patient risk factors are deemed too high. 19 managing the office environmentgeneral guidance it is clear that during this pandemic, social distancing (hereinafter referred to as ''physical distancing'' in order to emphasize the intended minimum physical separation of six-feet between individuals, and limits on congregating in large groups) is as important to the safe operation of a medical aesthetics practice as to any other business, household or community. and it will remain so for the foreseeable future. accordingly, as a second overarching theme running through this guidance, physical distancing principles should be incorporated throughout the practice, from the moment of initial patient scheduling through post-procedure check-out, and all office workflows from staff's arrival in the morning until the doors are locked at night. put simply, limiting the number of individuals in a particular setting and space at a given time is fundamental to minimizing transmission. utilizing telemedicine and leveraging remote videoconferencing technology for patient consultations and non-procedure visits will aid in minimizing office traffic while allowing for the development of a treatment plan (both short-and long-term), building rapport with patients and reducing in-office contact time. 2, 16, 17, 20 the efficiency and value of this approach can be enhanced by sending patients a pre-consultation form in advance of a scheduled telehealth interaction to learn more about patient's primary concerns and the type of information or treatment they are seeking. capturing this information in a more formal manner will help facilitate and guide discussion between the patient and clinician in a manner that timely surfaces various opportunities to divert in-person visits to safer, more efficient interactions. various enabling developments have occurred in this regard, ranging from the proliferation of telehealth and other video technology platforms, to certain applicable standards surrounding the privacy and reimbursement of distance versus in-person provider interactions (n.b. -legal requirements vary by jurisdiction). 20 with respect to treatment-related visits or other necessary in-person office visits, consider spacing or staggering appointments to reduce the number of patients in the office at one time and to allow for proper disinfection between patients. mindful of office size and staffing constraints, consider limiting overall patient volume per day, or extending office hours to spread patients out over a longer time horizon throughout the day. remind patients of the need to arrive to their appointment promptly and alone, and that individuals accompanying patients will be required to wait in their vehicle or outside of the office for the duration of the appointment. 2, 16 special arrangements may be made in advance for minors, elderly patients or persons with disabilities. visitors spending any time in the office should be screened in the same manner as patients. and remember for any staff, patients or other visitors in the office, it is important to observe and model safe physical distancing by limiting greetings to a smile, wave and other noncontact gestures. for treatment interactions, endeavor to limit the number of staff members in the treatment room during procedures. for example, where possible, consider whether a sole provider is able to appropriately perform a particular procedure without the need for other staff in the treatment room. if not, consider allowing the provider to be accompanied in the treatment room by no more than one medical assistant, with such staff person observing safe physical distancing across the room as circumstances permit. develop and adopt policies regarding fellows, residents, medical students, and visitors to reduce to an absolute minimum the number of individuals in any given treatment room and the office as a whole. training opportunities for staff and residents should be subordinated to the requirements of physical distancing, and this safety measure may be worth expressly messaging to patients, who may appreciate understanding that the practice has taken measures to prioritize their health. keep treatment room doors closed and utilize place card signage on treatment room beds or chairs to inform patients that rooms, beds, chairs, surfaces and instruments have been disinfected. remove unnecessary blankets, pillows, robes or headbands from treatment rooms, and limit items on countertops. reorganize waiting rooms by either removing chairs and spacing the remaining chairs at least six feet apart, or by designating certain chairs to be used and others not to be occupied. consider limiting the size of the waiting room or common areas to create ''natural'' barriers (e.g. potted plants, tables) to prevent individuals from congregating in one area. remove magazines, promotional or other collateral reading materials from the waiting room, treatment room and reception areas. patient reception coffee, beverage and snack bar service should be discontinued. for the occasional patient who might require food or drink for a medical condition, such as a diabetic who develops hypoglycemia, especially when instructed to be npo pre-procedure, items can be provided as needed from storage. and importantly, place alcohol-based hand sanitizer, hand wipes and tissues, with no-touch trash cans, liberally throughout the clinic, accessible to both patients and staff. 2, 16 in managing the movement of patients and others through the office, consider limiting points of entry and exit, strive for one-way traffic in hallways where possible, and try to designate separate areas for patient screening and check-in, as well as check-out. care should be taken to ensure any such special ingress/egress restrictions do not violate applicable building codes and can be overridden to permit safe evacuation in case of emergency. if possible, take patients upon arrival directly to treatment rooms for screening and check-in, in order to limit or entirely eliminate people congregating in the waiting room. ideally, check-out could be handled the same way, and for all patient administrative paperwork at check-in and check-out, clean and disinfect clipboards between each use, and consider providing single-use disposable pens to avoid multiple individuals handling the same writing instrument. for the same reason, if possible, encourage the use of remote payment systems instead of credit cards and cash, in order to minimize touching of credit card machines and office tablets. staff seating and work-stations should be reconfigured to respect physical distancing. for internal collaboration, staff should employ one-on-one or small meetings (depending on space availability) to allow for appropriate safe interpersonal distancing or arrange for virtual meetings. alert all vendors and contractors regarding new office policies limiting the number of visitors to those that are integral to either clinical practice or the business functions of the office. additionally, insist that vendors and contractors be aware of and follow the clinic's ''stay home if sick'' policy. direct all delivery personnel to a designated area for drop-off of packages and proper package disinfecting. in additional to proper physical distancing, the cleaning and disinfecting practices that are part of any medical aesthetics practice in ordinary times should be elevated and sustained during this period. first, prior to reopening a practice to patients, a qualified professional cleaning service should conduct an initial, comprehensive deep cleaning and disinfecting of the entire facility. a professional service should similarly perform a thorough cleaning and disinfecting process following the close of business each workday. on a regular basis throughout each workday, the entire staff should be trained on and committed to ongoing cleaning and disinfecting roles. based on the transferrable nature of covid-19, enhanced frequency of disinfecting surfaces throughout the day and between patients is critical in protecting the health of patients and staff members. 5 developing a protocol and crosstraining individuals responsible for managing and monitoring cleaning may be helpful in the adoption and consistent execution of these new processes. creating a checklist and schedule and displaying it on treatment room doors can serve as a reminder for staff and demonstrates to patients that treatment rooms are being consistently supervised and disinfected before their particular treatment (appendix figures a1 and a2) . with the aforementioned frequency, cleaning should also include disinfecting all common, high-touch areas such as the waiting room, reception areas, check-in and check-out areas, kitchen and break rooms, labs, offices and workstations, computer keyboards, tablets, credit card machines, pens and bathrooms (table 1) . and again, at the end of each workday, a thorough, supervised professional cleaning service is an essential daily practice. when disinfecting surfaces, staff should wear disposable gloves and any additional protection based on the cleaning products being used and the potential risk of exposure. use of 70% ethyl alcohol is recommended in disinfecting small areas, or discrete items between repeated use such as reusable dedicated equipment (e.g. thermometers). environmental protection agency (epa) registered disinfectants include the use of sodium hypochlorite at 0.5% (equivalent to 5000 ppm) for disinfecting surfaces, as well as a range of other common cleaners such as clorox disinfectants containing either sodium hypochlorite or quaternary ammonium; lysol products containing sodium hypochlorite, quaternary ammonium, hydrochloric acid, or citric acid; and purell ethanol-based products. 2, 13, 16, 21 the list of disinfectants that meet epa criteria for use against sars-cov-2 may be found in the link provided here. 21 steps to properly disinfect surfaces include first cleaning an area or item with soap and water or another detergent prior to using a proper disinfectant. in addition to recommended use of epa-registered disinfectants, make sure rooms are adequately ventilated and follow label instructions, as some products recommend keeping surfaces and items wet for a period of time to enhance antimicrobial activity. it is recommended before donning and immediately after doffing gloves to wash hands thoroughly or use an alcohol degerming solution (hand hygiene solution). cdc steps for cleaning and disinfection may be found here. 13 personal protective equipment and medical supplies adequate ppe (principally, face masks, gloves, gowns, and goggles, shields or other eye protection) are necessary to protect providers and serve to protect patients alike, and therefore should be viewed as indispensable for reopening, and continuing to operate, any medical aesthetic office. this guidance recognizes the lamentable reality that severe ppe shortages on a global scale continue to pose significant challenges to the entire u.s. healthcare system at the time of guidance publication, and in some cases the impact of this shortage on particular practices has been exacerbated by those practices' decisions during the last several months to contribute ppe inventory to hospitals, emergency rooms and first responders in their respective communities. notwithstanding such supply chain challenges, however, adequate access to and deployment of ppe within a practice, both initially and on an ongoing basis, should be viewed as a precondition to medical office and patient care activity. it is imperative that practices proactively develop a plan to optimize their supply of ppe, both for current needs and in the event of future shortages, and to identify mechanisms to procure additional supplies when needed. continually assessing quantities and replenishing supplies throughout the day, as well as monitoring public health agency recommendations regarding the use of ppe for healthcare professionals, are critical as the covid-19 outbreak evolves and public health guidance shifts. the type of face mask and other ppe recommended for use by healthcare professionals is based upon anticipated risk of exposure to covid-19 while performing specific procedures. 4 more broadly, occupational safety and health administration (osha) recommendations regarding the type of ppe used by a healthcare professional or individuals working in a healthcare setting are based upon anticipated risk of exposure while performing specific tasks or procedures (table 2 ). 2, 3, 4 starting from this framework and given the current state of the covid-19 crisis, this guidance recommends that practices should consider a strategy of having every employee in the office, irrespective of function, wear a three-ply surgical mask. given existing supply chain limitations, if it is impossible to source such three-ply surgical masks for an office's clerical or administrative employees who have no or minimal patient interaction, a professionally-manufactured cloth mask with full mouth and nose coverage is preferable to no protection; however, this guidance deems a three-ply surgical mask to be the recommended practice for all staff in the current environment. 16 for reasons of both substantive protection and patient confidence, handkerchiefs, scarves and other homemade masks should not be utilized by any staff, and if inventory constraints require that these are the only option, practices should seriously consider the wisdom of having such employees on-site at all. it is recommended that surgical masks used by clerical or administrative staff be discarded and replaced on at least a daily basis. to the extent such employees are permitted by an office to utilize cloth masks, they should generally be deployed for no longer than one day without being professionally laundered prior to next use. providers or staff who are involved in administering treatment or are otherwise in the treatment room for any patient assessment or general treatment or care should wear, at a minimum, a three-ply surgical mask, eye protection in the minimum form of safety glasses, and gloves. inventory permitting, use of a gown is also recommended for all such individuals associated with the treatment room. masks, gloves and gowns involved in treatment should generally be considered single-use and safely disposed after each patient procedure, and eye protection should be cleaned and disinfected with the same regularity. for those providers or staff performing, assisting with, or otherwise in the treatment room for any aerosol-generating procedures (agps) as described more fully later in the clinical and non-surgical treatment section of this guidance, the use of an n95 filtering face piece respirator (n95 mask), or its equivalent, is the minimum nose and mouth protection required, providing respiratory protection and protection from blood and body fluids. 17 for such agps, in the absence of n95 availability, osha indicates other types of acceptable respirators with similar or greater protection may be used, such as r/p95, kn95, n/r/p99, and n/r/p100. these respirators are often more comfortable for the wearer when fitted with a valve exhalation feature, but this feature has the effect of elevating wearer safety over that of patients and others in the vicinity, and therefore is generally discouraged. single-use gloves and gowns should also be used for all providers and staff in the treatment room for agps, and providers administering treatment should consider use of a single-use surgeon's cap. further, providers administering agps should consider using heightened eye protection beyond standard safety glasses, such as full goggles or face shields, which should be thoroughly cleaned and disinfected after each use. notwithstanding any inventory challenges, n95 masks used in agps should generally be considered single-use only, unless used in conjunction with a face shield and proper disinfection procedures are utilized ( table 3 ). the cdc generally recommends use of a cleanable face shield over an n95 when feasible. non-agp procedures performed above the clavicle generally pose greater risk than lower body procedures, and therefore practices should consider whether higher level ppe items should be utilized. 16 for non-agp procedures involving the head and neck region, particularly where detailed work requires the provider to remain in close face-to-face proximity with a patient's airways, use of an n95 mask and more substantial eye protection is preferable. irrespective of job function or procedure type, ppe training should be provided to all providers and staff throughout the office and across job function, including proper hand hygiene practices, correct fit, donning and doffing to avoid cross-contamination, and considerations for contemplated extended use or reuse of ppe. 4, 22 in particular, users of n95s or other respirators should be fittested prior to first use, thereafter on an annual basis, or more frequently in the event of significant weight loss or change in facial hair. the cdc fact sheet on use of ppe and proper donning and doffing may be found here. 22 due to ppe shortages, certain medical societies and other public health authorities have advised that healthcare professionals who typically wear a mask for procedures may consider wearing the same mask throughout the day in an effort to conserve ppe. 2 for example, the cdc has provided guidance on practices allowing the extended use and limited reuse of n95 masks when supplies are depleted. extended use (leaving the mask on for multiple patient encounters, without removal) is generally favored over reuse (using the same mask for multiple encounters and removing it between encounters), as there is less risk of repeat handling-related contact transmission. in addition to strict adherence to proper hand hygiene practices before and after touching or adjusting the mask, proper fit and function are paramount to safe extended use or reuse. 15 manufacturers may have specific guidance regarding reuse. however, variables such as contamination over time make it difficult determine the maximum number of reuses. ultimately, single use of a mask is lower risk than extended use or reuse, and therefore reflects the general consensus of this guidance, particularly for agps, unless, as stated above, a mask is used underneath a face shield and proper disinfection of the face shield occurs after each procedure. the other variable here involves the highly dynamic state of ppe decontamination technology. for example, certain hospitals have been developing vaporized hydrogen peroxide systems for decontaminating n95 masks, and studies are beginning to validate various other modalities and protocols as well. 23 accordingly, it is impossible for the guidance to anticipate and adjudicate every permutation of ppe deployment duration and decontamination, for example, the possible single use of a surgical mask over an extended use n95 for a non-agp procedure. such decisions are necessarily subject to the best professional judgment of the provider on a case-by-case basis, based on the specific combination of patient and procedure risk factors and the overall ppe availability and decontamination landscape. if extended use or reuse of face protection is necessary, take care to avoid touching the mask or respirator itself, touching only the fasteners when donning and doffing. if reuse across multiple days is unavoidable, it is incumbent upon providers to ensure thorough decontamination and safe storage. such contingencies are beyond the scope of the position taken by this guidance, but it is observed that thoughtful procedures have been articulated elsewhere, ranging from a study on a proposed n95 decontamination protocol, 23 to a proposal for cycling five masks over a five-day period, using one mask per day and then storing each individually until the same day the following week to allow for a seven-day period of non-use of each mask. if attempted, any such storage should be in a sealed, breathable container between uses to reduce damage, labeled to identify user, date and duration of prior use, and with thorough disinfecting or disposal of containers on a regular basis. 15 beyond mouth and nose protection, wearing protective eyewear in conjunction with a mask when treating patients reduces exposure and inadvertent touching of facial mucous membranes. with respect to eye protection, prescription eyeglasses do not afford adequate protection in the covid-19 treatment environment, without wearing a wraparound style of secondary eyewear. for agps in particular, full wraparound goggles are recommended, again with a face shield advisable as well. special attention should be paid throughout the office, and not just the treatment room, to those wearing prescription eyeglasses or non-prescription readers, as plastic or metal surfaces have the potential to become a fomite for covid-19 given the propensity of frequent touching of one's eyeglasses throughout the day. as with staff cell phones, eyeglasses should be cleaned and disinfected throughout the day, and staff should avoid touching or handling such objects between hand washings. as a corollary to the need for consistent use of ppe, there are emerging reports of skin complications resulting from repeated ppe exposure and excessive hand hygiene, especially among healthcare workers. these complications variously include skin breakdown, erythema, papules, scaling, burning, itching and stinging. providers may wish to consider proactive and therapeutic use of emollients, barrier repair creams and other skin calming and hydration preparations to mitigate such conditions. 24 in addition to ppe, other medical supplies of particular import to managing the covid-19 environment include alcohol-based hand sanitizer and hand wipes, which should be placed at entry and exit points and throughout the office including in the waiting area, reception area(s), treatment rooms, and bathrooms. ensure the availability of liquid soap at sink areas, and facial tissues and notouch wastebaskets with disposable liners and lids throughout the office. non-contact thermometers (infrared or thermal scanner models) are recommended in lieu of forehead, oral or tympanic (auditory canal) thermometers. 10, 11 iv. employee and patient health employee health and training in order to offer safe care in a safe environment to their patients, practices must first ensure that providers and staff are healthy and do not constitute a transmission vector. this starts with clearly and proactively communicating to all employees the clear mandate to stay home if sick or experiencing any early suggestion of symptoms, and reviewing applicable benefits and provisions related to sick leave, caring for sick family members and children, and flexible scheduling. questions and concerns regarding employee health, safety, compensation and benefits may arise, and are heightened during these uncertain times. information should be provided about available employee assistance services and steps employees can take to protect themselves at home. with respect to covid-19 in particular, practices should develop an infectious disease preparedness plan that addresses the level of risk associated with various jobs and tasks to help guide actions and reduce the risk of employee exposure to covid-19. assessments should be undertaken of potential sources of employee exposure to covid-19, including coworkers, patients, the general public, individuals that are symptomatic or who have recently been symptomatic for covid-19 or a febrile respiratory tract infection, and those at high risk (e.g., other healthcare workers, travelers who have visited locations with widespread covid-19 transmission, including domestic locations with significant community spread, etc.). attention should be given to nonoccupational risk factors at home, including family and immediate or close contacts, and community settings (e.g., attendance at recent large gatherings or events) and individual risk factors (e.g., immunocompromised status and various chronic conditions). 4 as part of this larger process, an employee health screening should be completed every day before staff enters the office or beyond a designated assessment area. models vary, but at a minimum this could be accomplished with a short form, or even an email to a designated responsible person in the office, constituting a quick self-attestation that an employee is asymptomatic and otherwise unaware of any exposure to a confirmed or suspected covid-19-positive individual, with such records being maintained by the practice in either paper or preferably digital form. even better, if feasible, a daily employee wellness check should be performed in addition to the symptoms self-report, comprised of a temperature check using a non-contact thermometer, and any necessary follow-up. any employee who reports feeling sick, senses any early hint of symptoms, or exhibits elevated temperature or other symptoms is required to refrain from entering, or immediately leave the office and follow up with their primary care physician or other appropriate offsite care facility for evaluation and, as indicated, viral testing. depending on the nature and extent of any positive findings and follow-up testing, office policy should dictate a protocol for minimum time off work and appropriate timing of return based on symptom progression, cessation, and all test results. it is advisable to select one or two individuals (''workplace coordinators'') in the practice to serve as point persons in this regard, and more generally for all covid-19-related issues in the practice, including oversight of clinic infection prevention measures. establish this communication plan early, clearly communicate and share it with all employees. beyond this initial screening and preparedness plan, as a general matter, all employees should model physical distancing and good hygiene practices in all office activities, whether related to patient interactions or otherwise. this includes minimizing use of shared workspaces, office supplies and medical instruments, such as sharing other employees' phones, desks, offices, computers and other equipment. 5 staff should minimize handling of personal cell phones throughout the workday, and refrain from any cell phone handling between their last hand washing and any patient contact. lunch rooms and staff lounges should be closed or restricted to limited size and spaced groups and alternating schedules. with respect to hygiene, all employees should engage in frequent, thorough handwashing (for at least 20 seconds) and cough and sneeze etiquette. 18 the world health organization (who) counsels healthcare professionals to follow ''my five moments for hand washing,'' using alcohol-based hand sanitizer or soap and water: (1) before touching a patient, (2) before engaging in clean or aseptic procedures, (3) after potential exposure to body fluids, (4) after touching a patient, and (5) after touching patient surroundings. 7 to keep employees safe, as previously discussed, it is advisable to consider use of surgical masks by all staff regardless of job function; a minimum of surgical masks, protective eyewear, gowns and gloves for all staff involved in any procedures; and the addition of n95 or equivalent masks, more fulsome eye protection and/or a face shield, and possibly a surgical cap for all staff involved in agps. again, effectiveness of ppe is highly dependent on proper handling, fit, and correct and consistent use; therefore, employee training on these topics is critical. and in addition to the aforementioned who handwashing moments, handwashing is also required before putting on, after taking off, and whenever touching or adjusting ppe, always careful to handle face protection only by the fasteners without touching the mask itself. 18 more generally, employees should avoid touching their eyes, nose or mouth with gloves or bare hands, both in connection with ppe use and otherwise around the office and throughout the workday. in addition to ppe, staff clothing decisions bear on office safety and patient confidence. to avoid the risk of clothing as a transmission vector into or out of the office, it is recommended that surgical scrubs or other dedicated office uniforms be worn by all providers and staff, even those who are not in immediate proximity to patients. when practicable, these should be worn only in the office, not commuting to and from work, changed daily, and thoroughly laundered by a professional service that collects soiled garments from the office to avoid employees bringing dirty laundry home and risking crosscontamination. it is vital that all providers and staff, including those who serve in non-clinical patient contact roles such as receptionists and other administrative personnel involved in patient scheduling, check-in or check-out procedures, be able to identify and report the symptoms associated with covid-19. symptoms may range from mild to severe and appear anywhere from approximately 2-14 days following exposure. symptoms of covid-19 to be on alert for include flu-like symptoms, fever ( ‡100.4°f or 38°c), cough or shortness of breath, new nasal congestion or runny nose, loss of taste or smell, as well as non-specific symptoms such as sore throat, myalgia, fatigue, nausea and diarrhea. additional symptoms reported include chills, repeated shaking with chills, muscle pain, and headache. 9 all employees should also be trained to identify emergency warning signs that require immediate medical attention, such as trouble breathing, persistent pain or pressure in the chest, new confusion, inability to arouse a patient, and bluish lips or face. 6 employees should be vigilant for all these symptoms, not only in themselves and coworkers in the office, but also patients, vendors, contractors and other visitors to the office. at any sign or suspicion of covid-19 symptoms, the affected individual should be required to refrain from entering, or immediately leave, the office, and a workplace coordinator should be promptly notified, in a hipaa-compliant manner in the case of patients. with respect to prospective patient visits, appointment scheduling processes should be modified to include prescreening patients before their office visit in conjunction with appointment reminder calls to help identify potential infection and recent risk of exposure. 3 a phone screening tool may be developed for use as a wellness checklist in this regard to aid in surfacing any areas of concern (appendix figure a3 ). if through such telephonic pre-screening efforts patients report symptoms potentially associated with covid-19 or have indicated potential sources of exposure by other means based on recent contacts or travel, explain to patients that out of an abundance of caution, they will need to reschedule their appointment for a later time. in the event of symptoms, also recommend they promptly follow up with their primary care physician or other appropriate offsite care facility for evaluation and, as indicated, viral testing. the minimum timeframe for rescheduling any such patients is a riskbased assessment depending on symptom presentation and testing results and should be governed by applicable cdc guidelines. in addition to patient pre-screening, offices must implement a protocol for health screening patients immediately upon arrival on the date of appointment, ideally in a contained area designated for this purpose to minimize other interactions prior to clearance (appendix figure a3 ). as with employee health screening, this process should include both a form of questionnaire for eliciting disclosure of symptoms or other exposures, and a staffadministered temperature check using a no-touch thermometer. if on the appointment date a patient presents and reports symptoms or exposure to known or suspected covid-19-positive individuals, or if temperature check or other assessment by staff reveals that a patient is symptomatic or at high risk upon arrival, immediately isolate the patient in an unoccupied room, provide a surgical mask for the patient to apply, irrespective of whether the patient arrived uncovered or over whatever mask with which the patient arrived, minimize contact with others in the clinic, and quickly and discretely remove the patient from the office. if the patient is well enough to drive home, send the patient home immediately. recommend that patients isolate themselves at home, practice careful infection prevention measures, and follow up immediately upon returning home with their primary care physician or other appropriate offsite care facility for evaluation and, as indicated, viral testing. patients may be alarmed and anxious to discover that they may have symptoms or are otherwise at risk of prior exposure related to covid-19. remain calm and supportive of the patient and continue to adhere to predefined infection prevention protocols. depending on the nature and extent of the patient's positive follow-up findings and testing, office policy should dictate a protocol for minimum time away from the office before a rescheduled office visit may be permissible, based upon the patient's symptom progression, cessation, and all test results. this same isolation-and-exit protocol applies equally to employees, who despite having presumably observed the practice's stay-home-if-sick policy, may first become symptomatic at work, or otherwise stimulate a positive finding during the previously described employee arrival screening process. the procedure would similarly apply to any vendors, contractors or other visitors to the office, all of whom should be notified to stay away if sick or at risk, and then subjected to a similar screen-on-arrival protocol. in the event of a positive visitor screen, the same isolation-and-exit protocol obtains. following execution of the isolation-and-exit protocol, in the event of any on-site presence, however brief, by any patient, employee, vendor, contractor or other visitor who is either suspected or confirmed to have covid-19, it is imperative to immediately switch focus to minimizing risk to the office premises. in this regard, care should be taken to follow applicable infection control guidelines, and thoroughly clean and disinfect all area(s) the individual had accessed or moved through. 12 the cdc recommends closing off all areas accessed by that individual to reduce intra-office contamination, opening external doors and windows to that contained area to increase air circulation from the outside, and (if feasible) waiting 24 hours before cleaning and disinfecting to minimize potential exposure of others to respiratory droplets. 12, 14 ideally a professional service should be utilized for this reactive cleaning, and any staff involvement should require use of adequate ppe. depending on the nature, duration and overall extent of the individual's activity in the office, including interactions with other patients, employees and others, the practice may need to consider further prophylactic measures up to and including temporary office closure, in order to minimize further exposure, ensure adequate site remediation, and assess the risk of further transmission. finally, it is advisable to notify all patients, employees and others who may have been exposed to any such known or suspected covid-19-positive individual in the office. 17 state and local laws and public health regulations, as well as other canons of professional responsibility, are likely to govern or otherwise inform these disclosure obligations, and accordingly such contact tracing ought to be undertaken in coordination with local health departments and other authorities. pre-screening patients much of the physical distancing-related protections that a medical aesthetics practice can leverage to enhance covid-19 safety are a function of decisions made before a patient ever arrives at the office. thoughtful prescreening procedures and advance communications serve to limit the need for office visits and minimize the duration of and unnecessary contacts during those that do occur. patients should be educated on how these new measures have been implemented to enhance their safety, and what they should expect when they arrive. as discussed previously, consultations and other nontreatment appointments may be arranged through patient portals, telemedicine or other technology-enabled communications. 2, 16 billing and other administrative matters, treatment plans and other preparatory items can be addressed over the phone or by video-conference, thereby shortening office stays. office arrival, check-in and check-out patients should be encouraged to arrive to their appointments alone, and notified that individuals accompanying them will be required to wait in their vehicle or outside the office for the duration of the appointment. 2,16 special arrangements can be made for the elderly, minors and persons with disabilities. from their vehicle, an arriving patient may call or text the contact number for a designated hippa-trained staff member and wait until the staff member indicates the patient may enter the office. staff should greet each patient at the entrance to guide them through the intake process and to an appropriate location. a patient screening flow chart may assist staff in mapping this and subsequent steps in a patient arrival process designed to combine heightened safety protocols with efficient and responsive customer service (appendix figure a4 ). patients should be advised to bring a face mask or similar covering with them to their appointment, and informed that they will be required to wear it for the duration of their appointment, to be removed only if and to the extent they are undergoing facial procedures. 16 in the event patients forget or are unable to bring a face mask, they should be provided one for use throughout their appointment. while a three-ply surgical mask is ideal and will inspire elevated patient confidence, limitations on ppe availability would alternatively justify providing another form of commercially-manufactured cloth mask instead. staff should remind patients not to adjust their face mask or touch their eyes, nose or mouth, and that if they must do so they will need to wash or sanitize their hands before and after such contact. 8 similarly, patients should be counseled to minimize handling their cell phones during the appointment, and to rewash or re-sanitize their hands following any such use. for those practices located in multi-story buildings serviced by elevator access, patients should be counseled on best practices for elevator use in this environment, beginning with the need to arrive early to allow extra time to wait for a less crowded elevator that permits physical distancing. once inside, maximum spacing from other riders should be sought, facing forward, and ideally as close to the front of the elevator, and hence the doors, as possible for access to outside air during any intervening stops. patients should wear their mask at all times, and avoid touching elevator buttons with bare hands, instead using a clean tissue, elbow or other similar approach. alternatively, if elevator circumstances appear to defy safe usage and stairs are a viable option given the office's floor location and the patient's physical capacity, it may be useful to provide the location of applicable stairwells. upon arrival in the office suite, consider having designated staff take the patient directly to an exam room for check-in, in order to avoid congregating in the waiting room or the common area around the reception desk. confirm the patient has already donned a mask, request the patient wash or sanitize their hands, and then proceed to conduct a wellness assessment to confirm the absence of a fever, other covid-19 symptoms or related highrisk exposures. a similar form of the wellness screening checklist used at the prior time of telephonic appointment confirmation may be repurposed at the time of office arrival (appendix figure a3) . following the wellness screening, it is advisable to endeavor to complete the patient's ensuing aesthetic services with minimal relocation throughout the office, preferably in the same treatment room in which checkin occurred if possible, or alternatively in such other manner as reduces the patient's geographic footprint and multiplicity of interactions within the office. further, it is recommended that, if possible, patient check-outs be conducted within the treatment room, or an otherwise designated, separate check-out area to avoid re-exposure to reception or other common areas. finally, the office should conduct a post-visit followup video-conference or telephone call to the patient several days after the appointment, both to monitor progress post-procedure and also to ascertain whether any covid-19 symptoms have recently developed despite the patient having been asymptomatic at the time of the appointment. here again, a wellness screening checklist may be a useful tool for staff (appendix figure a5 ). any positive report during this follow-up may trigger contact tracing considerations and other remedial measures by the practice. further, even if patients report being asymptomatic at this follow-up, they should be asked to notify the office in the event they subsequently develop any covid-19 symptoms within the balance of the remaining 14-day period of their recent appointment, again in order to permit appropriate contact tracing. treatment room set-up due to the duration and proximity of patient and other interpersonal contact, as well as the possibility for various procedure-specific activities to elevate the risk of viral shedding, the treatment room requires particularized attention to safety concerns and practices. for containment purposes, doors to treatment rooms should remain closed during and in-between use. office-wide air handling systems should be evaluated to understand the path and extent of circulation of air from the treatment room vents into other rooms and common areas throughout the office, and where possible, to minimize such flow. where available, external windows may be opened during inter-procedure treatment room cleaning to provide maximum ventilation. thorough cleaning and disinfecting of treatment rooms and all exposed surfaces and equipment, whether or not utilized in the prior procedure, must be performed after each patient. patient visits often involve more than one type of procedure during a scheduled appointment (e.g., neuromodulator injections and dermal fillers). where possible in view of device and other equipment (including digital photography or camera systems) deployment throughout the office, consider consolidating multiple patient treatments into a single treatment room to minimize multiple points of exposure. further, it may be advisable to consider limiting the number of procedures or grouping the type of procedures per patient visit in order to reduce multiple patient exposures, contact time and overall appointment duration. in advance of a patient procedure, it is advisable to take all steps necessary to prepare equipment, supplies and other positioning of assets prior to bringing the patient into the treatment room, in order to minimize exposure time between the staff and patient. examples of advance planning in this regard includes preparing all trays, instruments, supplies, drugs, and injectables. in the case of energy-based devices, this might include turning the equipment on and pre-performing setup tasks, including calibration to the treatment parameters if known for the specific upcoming case. sterile items should be left in packaging to be opened in the patient's presence, both for safety reasons and to instill patient confidence. it is important to train staff on, consistently follow, and consider visibly displaying confirmation of, a treatment room cleaning and disinfecting protocol and schedule in each room, again both to ensure substantive office compliance and to promote patient confidence (appendix figure a1) . additionally, as previously reported elsewhere in sections iii and iv of this guidance, it bears reemphasis that ppe is of particularly critical import within the treatment room during this time, for reasons of safety, patient perception and the overall risk minimization required to justify elective aesthetic procedures during the current phase of the covid-19 outbreak. accordingly, this will result in recommended use of masks, gowns and protective eyewear in certain procedures where many healthcare professionals previously may have justifiably used none, and heightened ppe protocols across a number of other procedures beyond what was previously the norm. when topical anesthetic agents are used for office-based aesthetic procedures, it is common for application time to range from approximately 30-60 minutes. for reasons identified above, ideally such application would occur within the same room as the ensuing treatment to minimize movement; however, if office capacity precludes that option, an alternative is to use another dedicated room for this purpose, during which a thorough cleaning and disinfecting process can be completed of the treatment room between each patient. following application, patients should be encouraged to continue wearing their masks for the duration of the waiting time until they are ready for the actual procedure. other pain management options include topically applied cooling gel or ice packs, which typically have a plastic cover that can serve to retain the virus or other contaminants. wherever possible, consider disposing of these items entirely after each use. if not, care should be taken when reusing these packs to thoroughly cleanse and disinfect before returning to a common freezer unit, perhaps after being placed within a new, single use plastic bag to be used for storage only. also, be aware patients may lay these items down during treatment and check-out, which also creates a potential risk for reuse. if disposing of otherwise reusable cold packs is impractical within a particular office, an effective alternative could simply be the single use of double-bagged ice, which in many cases is colder and longer lasting. nitrous oxide inhalational analgesia is occasionally used in aesthetic practices and creates an exhaled gas that is directional in nature. for the reasons set forth below, the use of this pain management modality should be reduced to a minimum given the current covid-19 environment. patients receiving this analgesic treatment may inhale on a regular basis throughout the procedure. while some clinics deliver this gas mixture using a traditional facial mask (similar to mask oxygen delivery in hospital settings), the most common method of delivery is a disposable plastic mouthpiece. these mouthpieces will become contaminated with the patient's saliva after the first use, and the mouthpiece is then stored with the device, and this process occurs repeatedly during the course of the treatment, after which the entire breathing mouthpiece and hoses are disposed of. review of existing procedures and protocols for protection from saliva on the mouthpiece should be performed and adapted as needed for covid-19 risks. additionally, the patient is typically encouraged to inhale (and thus exhale) deeply for several times at each use of this gas. this policy should be cautiously reviewed in light of covid-19 risk data on aerosolized droplets resulting from deep breathing, and any necessary use of this pain management modality should be construed as an agp and subject to the corresponding highest levels of ppe requirements for agps recommended throughout this guidance, including use of an n95 mask and a face shield. dermal fillers, botulinum toxins, and other similar minimally-invasive facial injectables and other injectable procedures are among the most common treatments performed in many aesthetic offices and are likely to be in great demand by patients who have had their regular treatment cycles interrupted by covid-19 stay-athome orders. these procedures usually take only several minutes of actual injection time but may take longer depending on the type of treatment being performed and the number of treatment areas being injected. despite the short duration of treatment, anatomic location of injections, largely in the face and neck area, combined with the extremely close proximity to the patient's airways necessary for the high-detail work, create exposure risk. irrespective of prior practice, post-covid-19 it is important to deploy adequate ppe for these procedures, at a minimum including the use of a three-ply surgical mask, wraparound safety glasses, gown and gloves for the provider administering the injections, as well as all staff in the treatment room. wherever possible, it is advisable to consider elevating the ppe set-up for these procedures to include the use of an n95 mask and full goggles and face shields. in all cases, intra-procedure discussion by both provider and patient should be kept to an absolute minimum to reduce the risk of airborne transmission through speaking. 26 as a general practice, vials and syringes should be laid out and prepared prior to patient entrance into the treatment room to minimize exposure time. proper hand washing and infection control procedures should also be followed when handling vials and syringes, and when applying ice and topical anesthetic agents. patients should reapply their masks post-procedure. injectable procedures below the clavicle, for example such as sclerotherapy and fda-pending treatments for cellulite reduction, allow some additional distance from the patient's respiratory pathways; however, they still require close physical contact and risk of disease transmission through airborne droplets in shared airspace due to normal breathing and talking, and further exposure may occur through sneezing and coughing. therefore, this guidance recommends the same minimum baseline ppe protocol for all injectable procedures irrespective of anatomical region. non-invasive body contouring because they are largely focused on anatomical regions other than the face, the category of cryolipolysis, radiofrequency, electromagnetic and other similar body contouring and body sculpting procedures often do not involve the same face-to-face proximity between provider and patient during treatment. this is also true because certain body contouring procedures require limited in-room contact with the patient once the device has been applied and the procedure has commenced. that said, all such procedures nonetheless require a provider or staff to interact closely with the patient during set-up and application of the device to the selected treatment areas, and during that time the risk of transmission through breathing, talking, coughing and sneezing is omnipresent. further, some of these body contouring procedures do involve treatment in the neck area to address submental fat. accordingly, for all body contouring procedures, this guidance recommends the same minimum ppe level required as a baseline for any form of office treatment, namely a three-ply surgical mask, wraparound eye protection, gown and gloves for all providers and staff in the treatment room. this consistent approach to ppe prioritizes patient and employee safety, minimizes the risk of errors by attempting to parse ppe levels too finely, and fosters maximum patient confidence in the practice. when contouring procedures are performed above the clavicle, consider heightened ppe including an n95 mask, goggles, and possibly a face shield. for body contouring procedures below the clavicle, it is advisable for patients to remain masked throughout the treatment, and particularly when a provider or staff is in the treatment room. as mentioned above, following commencement of certain of these procedures, the patient is often in a separate room from the provider while the treatment takes place, which may take 15 to 60 minutes depending on the device and the treatment area. in such scenarios, ppe may be removed upon exiting the treatment room and reapplied on reentry; however, in so doing, it is critical to scrupulously observe proper donning and doffing protocols and associated handwashing requirements, in order to avoid cross-contamination. with some body contouring devices, it is possible to position a disposable pad between the treatment area and device, a practice that should be followed wherever possible. often a measuring tape is used in conjunction with these procedures for initial patient assessment, and if so, it is advisable to utilize a single-use measuring tape in this regard, when measurement is needed. to the extent support pillows are used during the procedure, consider using disposable pillows or pillows that have a waterproof, plastic or vinyl covering capable of being thoroughly disinfected. following each procedure, the entire body contouring device, not simply the contact points, should be comprehensively cleaned and disinfected, using approved disinfecting agents, and in conformance with any manufacturer instructions. energy-based procedures of the face and neck depending on the type of device used, setting and depth of treatment, the various laser, light, heat and other similar energy-based procedures of the face and neck performed in a medical aesthetic office are often mechanically disruptive and thus need to be deployed with a high degree of safety protocols. in addition to the inherent risks associated with the fact that they involve extended contact time at close proximity with patient airways, a number of these treatments may be categorized as non-respiratory agps based upon emission of airborne debris particles or other contaminants. for example, certain laser and other energy-emitting device procedures may produce a plume of vaporized and ejected tissue that, even when evacuated by suction, has the potential to exit into the treatment room. 25 evacuator suction systems should have adequate and regularly monitored twostage filtration type, and require frequent inspection and replacement of the filters. further, it is common for cooling positive air pressure to be used for pain management during a number of laser and other energy-emitting device procedures, often engineered into the operation of the devices themselves. these devices typically have a control for air speed/velocity. such positive air pressure increases the risk of transmission; therefore, for those procedures where use of cooling air is a function of patient comfort and not required device safety, consider substituting other forms of pain management where possible to achieve adequate pain control with other modalities. where such pain control is not possible, and/or if cooling air is required for device safety, consider modulating air speed, duration of use, and vector of flow to reduce usage to a minimum level required for safety and/or comfort. for all these reasons, consider limiting all such agps to one or more designated treatment rooms with appropriate air handling, containment and evacuation systems, in order to avoid exposing other treatment rooms or office areas. review air filter replacement policies and consider accelerated replacement schedules in consultation with device manufacturers. in the event an office has any treatment rooms equipped with negative air pressure capacity, agps should be concentrated in these facilities to the maximum extent possible. similarly, the maximum available level of ppe should be deployed for all these energy-based procedures of the face. minimum required ppe for providers and staff either administering, or otherwise in the treatment room for, these agps should include an n95 or equivalent mask, wraparound safety glasses or full goggles, gloves and a gown, and if available a surgical cap. use of a face shield is also strongly advised. gloves, gowns and caps used in agps should be considered single use only, and eye protection should be thoroughly cleaned and disinfected with an approved disinfectant after each use. it is strongly advised that masks should similarly be disposed after each procedure, unless used under a face shield in conjunction with thorough disinfecting protocols. in all cases, despite ppe utilization, intraprocedure discussion by both provider and patient should be kept to an absolute minimum to reduce risk of airborne transmission through speaking. and other than the provider administering the procedure and the patient, nobody else should be in the treatment room, unless a staff member is required to be present, and then only with full ppe consistent with the provider's set-up. special consideration should be given to integrating various ppe elements for safe use in practice during performance of these agps. while it is true that all procedures involving use of a mask in combination with protective eyewear carry the risk of a gap or slip midprocedure that creates an exposure to contaminants, such risk is amplified with these agps given the possible presence of plumes and positive air pressure, as well as the contingency of laser energy being misdirected and impairing a provider's vision. it is important that employees are not just educated on proper use of ppe, but also practice integrating kits to ensure comfort, fit, coverage, stability and visibility. across all energy-based procedures, comprehensive cleaning and disinfection should occur after each treatment, using approved disinfecting agents and pursuant to manufacturer instructions. this should include both the tip of the handpiece and other patient and operator contact points, as well as the entirety of the device and all surfaces in the treatment room that may have been subject to plume or other positive air pressure displacement effect. it is also critical to establish a protocol for appropriate frequency of sterilization procedures for, and inspection and replacement of, all device filters and cartridges. as an additional final step, disinfect the tip of the handpiece again in front of the next patient prior to the next procedure. as a result of disruption to the skin barrier following all these treatments, skin may be more susceptible to infection. it is advisable to provide patients with a new, clean face mask following all such procedures. patients should not reuse the mask they wore into the office, if at all possible. with respect to patient masks, it also bears noting that, to the extent certain laser, light and other similar energybased procedures are sometimes performed below the clavicle, patients should wear a mask for the entirety of such procedures. irrespective of the anatomical area of treatment, however, providers and staff should remain at the highest level of ppe protection described above, as these particular procedures remain properly regarded as agps, even when focused on the body. skin care treatments encompass a wide range of procedures from those that are non-invasive (e.g., medical facials, water-based facials, chemical peels, and nonablative fractional resurfacing), to those that are moderately invasive (e.g., microneedling) and may result in a nominal amount of localized (pinpoint) bleeding. given the positioning of such treatments within a busy aesthetics practice and the designation of staff often responsible for administering them, there may be some tendency to default to a lower level of safety vigilance for such procedures; however, any such impulse should be categorically resisted. these treatments are labor-and timeintensive and may require anywhere from 30-60 minutes of time spent in close proximity to the patient, often with staff hands directly in contact with a patient's face. accordingly, in addition to consistent use of proper baseline ppe as with any office aesthetic treatment discussed in this guidance, it is advisable to limit the number and duration of treatments provided per patient visit, provide pain management through modalities other than cooling fans or handheld cooling devices wherever possible, and minimize intra-procedure discussion by both staff and patient. additionally, preference should be given to utilizing devices with disposable tips, cartridges, blades, and applicators and mixing bowls. within the broader category of skin care treatments, some procedures require additional consideration in the current covid-19 climate. for example, deeper microneedling may produce bloodborne pathogen risk, and certain micro-and hydra-dermabrasion procedures may actually be properly regarded as non-respiratory agps due to risk of emission of airborne particles or contaminants as a result of device features such as positive pressure water jets, closed loop vacuum or other vortex type treatments. in such cases, it is advisable to approach this subset of skin care treatments with the same heightened safety protocols as other energy-based procedures of the face, as outlined above. thus, in addition to complying with device-specific and room-wide infection control and cleaning protocols, consider limiting use of these procedures to a specific treatment room with appropriate air evacuation systems, and enhancing the type of ppe for all staff in the room (e.g., single-use n95 or equivalent mask, single-use gown, gloves and wraparound glasses or goggles, possibly even in conjunction with a face shield). also, it is prudent to provide patients with a new, clean disposable face mask following all these procedures. in sum, across the various categories of common office aesthetic procedures discussed throughout this guidance, the key considerations for enhanced covid-19 vigilance through ppe selection and disinfection protocols are summarized below (table 3) . this aescert guidance is intended to supplement other advice offered by professional societies and governmental agencies. it has been deliberated and prepared on a multi-disciplinary basis so as to consider many relevant factors involved in operating an aesthetic practice in a covid-19 environment, as we today understand the virus and its contagious properties. progress will be made in the months ahead in testing capability, both for active disease and antibody production. similarly, progress is likely in clinical evaluation of drug therapies and, ultimately, development of a vaccine. it is incumbent upon every practitioner to stay abreast of these developments as they will affect the practice of aesthetic medicine and patient care and safety in important ways. outpatient and ambulatory care settings: responding to community transmission of covid-19 in the united states everyday health and preparedness steps in clinic get your clinic ready for coronavirus disease 2019 (covid-19) guidance on preparing workplaces for covid-19. occupational safety and health administration website getting your workplace ready for covid-19. world health organization the covid-19 risk communication package for healthcare facilities. world health organization interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease healthcare infection prevention and control faqs for covid-19 thermometer for detecting fever: a review of clinical effectiveness. ottawa (on): canadian agency for drugs and technologies in health website comparison of non-contact infrared skin thermometers prepare your small business and employees for the effects of covid-19 disinfecting your facility html#suspected-or-confirmed-cases-of-covid-19-in-the-workplace recommended guidance for extended use and limited reuse of n95 filtering facepiece respirators in healthcare settings covid-19 resources for plastic surgeons and their practices. american society of plastic surgeons website opening up america again. centers for medicare & medicaid services (cms) recommendations. re-opening facilities to provide nonemergent non-covid-19 healthcare: phase i cms website skin experts covid-19 groups at higher risk for severe illness dermatologists can use telemedicine during covid-19 outbreak. american academy of dermatology association website list n: disinfectants for use against sars-cov-2. united states environmental protection agency website using personal protective equipment (ppe) assessment of n95 respirator decontamination and resue for sars-cov-2. medrxiv preprint covid-19 pandemic and the skin -what should dermatologists know? published online ahead of print american society for laser medicine and surgery (aslms) laser and energy device plume position statement visualizing speech-generated oral fluid droplets with laser light scattering the authors wish to acknowledge the scientific and clinical staff of the skinbetter science instituteô for its key: cord-309521-2cb992u1 authors: iqbal, muhammad rafaih; chaudhuri, arindam title: “covid-19: results of a national survey of united kingdom healthcare professionals’ perceptions of current management strategy – a cross-sectional questionnaire study” date: 2020-05-21 journal: int j surg doi: 10.1016/j.ijsu.2020.05.042 sha: doc_id: 309521 cord_uid: 2cb992u1 objective: covid-19 has caused a global healthcare crisis with increasing number of people getting infected and dying each day. different countries have tried to control its spread by applying the basic principles of social distancing and testing. healthcare professionals have been the frontline workers globally with different opinions regarding the preparation and management of this pandemic. we aim to get the opinion of healthcare professionals in united kingdom regarding their perceptions of preparedness in their workplace and general views of current pandemic management strategy. method: a questionnaire survey, drafted using google forms, was distributed among healthcare professionals working in the national health service (nhs) across the united kingdom. the study was kept open for the first 2 weeks of april 2020. results: a total of 1007 responses were obtained with majority of the responses from england (n=850, 84.40 %). there were 670 (66.53%) responses from doctors and 204 (20.26%) from nurses. most of the respondents (95.23%) had direct patient contact in day to day activity. only one third of the respondents agreed that they felt supported at their trust and half of the respondents reported that adequate training was provided to the frontline staff. two-thirds of the respondents were of the view that there was not enough personal protective equipment available while 80% thought that this pandemic has improved their hand washing practice. most of the respondents were in the favour of an earlier lockdown (90%) and testing all the nhs frontline staff (94%). conclusion: despite current efforts, it would seem this is not translating to a sense of security amongst the uk nhs workforce in terms of how they feel trained and protected. it is vital that healthcare professionals have adequate support and protection at their workplace and that these aspects be actively monitored. the novel coronavirus, sars-cov-2 (covid19) , since its outbreak in wuhan (1) , has sent shockwaves across the globe. world health organization (who) announced a public health emergency of international concern on 30 january 2020 (2) followed by declaring it as a 'pandemic' on 11 march 2020 (3) . at present no treatment or vaccine is available for covid-19, with only recent proposals emerging for vaccine development (4) . the number of people getting infected and those dying are increasing day by day. as of 12 may 2020 4,193,302 people have been infected and 286,613 have died in 187 countries across the globe (5) while in united kingdom(uk) 223,060 have been infected with 32,065 deaths (6) . as this pandemic accelerates across the globe, healthcare systems have been put under tremendous strain. for the same reason the strategy adopted globally has been to 'flatten the curve' in order to avoid the overburdening of the healthcare system and preventing its collapse (7) . this has been implemented in the form of social distancing and lockdowns. in such dire situations the key is not only to treat the infected but equally essential is to ensure healthcare professionals (hcps) involved in the care of the patients have a safe working environment. protection of hcps is of prime importance because of the risk of infecting other members of the team, patients (8) , and indeed family members. currently 5.7% of the nhs workforce is off sick or in self-isolation (9) with resultant workforce depletion; of more concern is the number hcps deaths (10) , with ethnicity recently questioned as a risk factor. preventing the spread of infection among the medical personals and then to the patients depends upon the appropriate training and use of the personal protective equipment (ppe) -facemasks, respirators, goggles, face shields, gowns and aprons. due to the imbalance between the demand and supply, a critical shortage of ppe is expected even in the most developed countries. opinions in the uk regarding the shortage of ppe for hcps, timing of lockdown and testing for covid-19 have been divided (11, 12) . we aimed to get the opinion of hcps regarding the situation in their respective hospitals along with their opinion on the timings of the lockdown and testing for covid-19 in uk. a 13-item questionnaire was drafted using the google forms electronic survey. a combination of forced choice (yes/no) and multiple-choice selections (strongly agree, agree, neither agree nor disagree, disagree, strongly disagree) was used. all questions were mandatory. the questionnaire collected data regarding region of work, role and direct patient contact. respondents were asked five questions regarding their trust preparation for the pandemic: whether they felt supported at their trust, availability of adequate facilities (specialist beds, specified isolated areas) to treat covid-19 patients, availability of enough ppe, whether there was enough local guidance regarding the pandemic and if sufficient local training was provided. further two questions were related to their daily source of information regarding this pandemic and if it has improved their hand washing practice. three general questions regarding their views of the pandemic included britain's preparedness for this pandemic, timing of the lockdown and testing of the frontline nhs staff were asked. a full list of survey questionnaire is available in the supplementary information. the questionnaire was distributed across the uk to the hcps working in the nhs through nhs emails, local hospital whatsapp groups and social media (facebook and twitter). in order to reduce bias of the result at a specific point, the survey was kept open for 2 weeks from 01 april 2020 to ascertain the results over the whole period. nhs research ethics committee approval was not required as this was a study of hcps who agreed to participate in the online questionnaire. all participants were informed that the information they provide would be confidential and would not be used in a manner to allow identification of the individual responses. the study has been reported in line with the strocss criteria (13) . there were a total of 1007 responses. majority of them (n=850, 84.40%) were from england followed by scotland (n=74, 7.34%), wales (n=70, 6.95%) and northern ireland (n=13, 1.29 %) (figure 1 ). 66.53% (n=670) of the respondents were doctors, 20.26% (n=204) nurses and 5.56% (n=56) healthcare assistants (figure 2 ). 95.23% (n=959) of the respondents had direct patient contact in daily routine. a total of 40.21% (n=405) respondents "felt supported at their trust" and 27.80% (n=280) did not while 31.98% (n=322) remained neutral (neither agreed nor disagreed). with regards to the "availability of adequate facilities (specialist beds, specified isolated areas) in their trust", 34.55% (n=348) were of the view that such facilities were not available while only 28% (n=282) were in agreement regarding their availability. two-third of the respondents (n=665, 66.03%) did not think that "adequate ppe were available to the frontline staff". nearly half of the respondents (n=557, 55.31%) were of the view that there was "enough local guidance available at their trust" while approximately the same (n=525, 52.13%) responded that "sufficient local training was not provided to the frontline staff" (figure 3) . a comparison of the responses based on geographical location (table 1) , indicated respondents from england felt least supported at their trust (30.00%) whilst a larger percentage from scotland felt maximally supported (56.75%). 39.18% of the respondents from scotland thought adequate specialist facilities were available at their trust as compared to 28.57% from wales and 27.17% from england. a third of the respondents from scotland (32.43%) thought adequate ppe was not available while in other regions nearly two-third of the respondents were not happy with the availability of ppe (northern ireland: 61.53%, england: 68.11%, wales: 77.14%). scotland had the highest percentage of the respondents who were happy with the local guidance available (74.32%). responses regarding the hospital situation between different hcps were comparable ( table 2) . for "daily source of information regarding the covid-19 pandemic", nearly half of the respondents (n=558, 55.41%) used multiple sources (daily hospital emails, news, social media, gov.uk, friends and family and other health professionals) while a quarter (n=249, 24.73%) relied on daily hospital emails (table 3) . 80.73% (n=813) of the respondents thought that this "outbreak has improved their hand washing practice" (table 4) . when asked if "britain was well prepared for this pandemic", majority (n=890, 88.38%) of the respondents were not in agreement with it. similarly, most of the respondents (n=906, 89.97%) thought that an "earlier lockdown would have helped much better". with regards to "testing the frontline staff for covid-19", 94.14% (n=948) recommended in favour for it ( figure 4 ). the survey gives a broad overview of hcps' views regarding the covid-19 pandemic in the uk. a key point to highlight is that 95% of the respondents are those who have direct patient contact in day to day activities and so are key frontline staff. they are the ones who are at constant risk. it is vitally important that hcps feel supported and protected at their workplace in this crisis and they have a safe working environment. a number of hcps have lost their lives in the current covid-19 crisis. as of 20 april 2020, government figures stand at 49 deaths for hcps while 102 deaths had been reported in news (10, 14) which according to the latest figures have increased to 201 (15) . this may have bearing on their mental health and morale of the hcps as well (16) . our survey showed that only 40% of the respondents felt supported at their trust in the current crisis. the causation of this can be multifactorial which were beyond the scope of this survey. uk ppe guidelines published on 02 april (17) recommends use of gowns instead of aprons, mandatory eye protection and guidance on the use of ffp3 masks with further updates on 09 april 2020 (18). the daily media briefing emphasises that millions of pieces of ppe are being made available to health workers in the uk. this is in line with the health & safety executive's directive on ppe, including the employer's duty in the provision and use of these (19) . the emphasis here is of course on the risk of contamination from air-borne pathogens (20). currently this consists of guidelines stratified according to the level of exposure with the maximal protection level consisting of full body coverage and wearing of n95 respirator (e.g. ffp3) masks. the key regulations (personal protective equipment at work regulations 1992) (21) surrounding the use of ppe in this crisis hinge on (i) proper assessment to assess fitness for purpose (ii) provision of instructions on safe use (iii) ensuring correct usage by employees. there has been a lot of concern regarding the availability of adequate ppe for the frontline staff (12). guidance in itself offers no protection till the resources are available for implementation of such guidelines and adequate training provided. two-third of the respondents in our survey did not think that adequate ppe was available while approximately 50% did not receive adequate local training. a survey (snapshot over 24 hrs) carried out by the royal college of physicians (22) in the first week of april revealed 78% respondents could access ppe. a similar survey by the royal college of surgeons (23) in the second week of april demonstrated that a third of the surgeons and trainees did not believe that they have adequate ppe supply and about 57% thought that there have been shortages of ppe in the last 30 days preceding the survey. the general medical council's (gmc) guidance on safety revolves primary around patient safety. from a generic standpoint, the area relating to doctors' health alludes to suspecting oneself of having a communicable condition and responding to it appropriately. trainees have been asked to not undertake activities beyond their competence, with an overview maintained by the relevant postgraduate dean (24), though there is a recognition that there will be an increasing need for trainees to support local healthcare systems. it would not be unreasonable to consider that it is not within the gmc's remit to advise on ppe, but they are engaged with the national directives, having produced an advisory webpage in this respect, dealing with doctors' wellbeing, protection in both the inpatient and outpatient setting, and maintaining standards of practice during the pandemic (25). similar to the gmc, the nursing medical council (nmc) clearly recognises the concerns around the availability and usage of appropriate ppe and have outlined key principles in their code and standards statement (26). the royal college of nursing have also recognised ongoing concerns regarding ppe shortage in line with the responses in this survey (27). recommendations from the who (28) were "to use every possible tool to suppress the transmission of the virus" meaning isolating cases, contact tracing and testing. in the early phase of this pandemic in uk, initial contact tracing was started but on 12 march it was decided to stop community case-finding and contact tracing (11) despite a report published on 9 march 2020 (29) had suggested that biggest impact on cases and deaths would be from social distancing and protection of vulnerable groups. another report published on 16 march 2020 had suggested that in worst case scenario 250,000 people would die in uk (30). a lockdown was finally imposed on the 23 march 2020. was it already too late? in our survey a staggering 88.38% (890/1007) of the respondents were not happy with britain's preparation and 89.97% (906/1007) were in the favour of an earlier lockdown. another issue which has been the highlighted is testing nhs frontline staff for covid-19 (31). this is essential not only from health and safety point of view but also from the workforce point of view because the last thing one would want in such a situation is the key workers being off sick. a survey by the royal college of physicians (22) reported around 18% of the respondents off work either due to sickness or isolation. government figures suggested 5.7% of the hospital doctors were off sick or absent because of covid-19 (9). many of them may have been isolating due to contact rather than actual symptoms so would not qualify for testing. in our survey 94.14% (948/1007) were in favour of testing the frontline staff. this was a large scale national study of hcps who gave a broad overview of the covid-19 situation during the study period. most of the findings of the study are parallel to what has been reported in news. limitations of the study include that reasoning of the respondents' reply was not asked and bias may have been present depending upon the geographical region. even with these limitations, we believe the findings of our study provide a meaningful insight into the concerns of the hcps. despite current national efforts, it would seem this is not translating to a sense a security amongst the uk nhs workforce in terms of how they feel trained and protected. it is vital that hcps have adequate support and protection at their workplace. employers have a legal responsibility to provide these. importance of increasing the access to ppe and testing needs to be highlighted. nursing medical council: nmc statement on personal protective equipment during the covid-19 pandemic available from: https://www.nmc.org.uk/news/news-andupdates/nmc-statement-on-personal-protective-equipment-during-the-covid-19-pandemic/. 27. royal college of nursing: personal protective equipment: use and availability during the covid-19 pandemic available from: https://www.rcn.org.uk/news-andevents/news/half-of-nursing-staff-under-pressure-to-work-without-ppe-reveals-rcn. 28. world health organization: who-china joint mission on coronavirus disease 2019 (covid-19) available from: https://www.who.int/news-room/feature-stories/detail/whochina-joint-mission-on-coronavirus-disease-2019-(covid-19). 29. gov.uk. potential impact of behavioural and social interventions on a covid-19 pandemic in the uk available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data /file/874290/05-potential-impact-of-behavioural-social-interventions-on-an-epidemic-ofcovid-19-in-uk-1.pdf. 30. ferguson n, et al. report 9: impact of non-pharmaceutical interventions (npis) to reduce covid-19 mortality and healthcare demand. imperial college covid-19 response team; 2020. 31. gov.uk. government to extend testing for coronavirus to more frontline workers available from: https://www.gov.uk/government/organisations/department-of-health-andsocial-care. outbreak of pneumonia of unknown etiology in wuhan, china: the mystery and the miracle world health organization declares global emergency: a review of the world health organization. who director-general's opening remarks at the media briefing on covid-19 -11 oxford covid-19 vaccine programme opens for clinical trial recruitment 27 number of coronavirus (covid-19) cases and risk in the uk available challenges to the system of reserve medical supplies for public health emergencies: reflections on the outbreak of the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) epidemic in china practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-ncov) patients number of nhs doctors off sick 'may be nearly triple the official estimate' the guardian exclusive: deaths of nhs staff from covid-19 analysed doctors still facing potentially 'fatal' consequences of treating patients without adequate covid-19 protection guideline: strengthening the reporting of cohort studies in surgery doctors, nurses, porters, volunteers: the uk health workers who have died from covid-19. the guardian coronavirus crisis: health worker heroes death toll passes 200 managing mental health challenges faced by healthcare workers during covid-19 pandemic we are grateful to all the healthcare professionals who participated in the survey. the following additional information is required for submission. please note that failure to respond to these questions/statements will mean your submission will be returned. if you have nothing to declare in any of these categories, then this should be stated. please enter the name of the registry, the hyperlink to the registration and the unique identifying number of the study. you can register your research at http://www.researchregistry.com to obtain your uin if you have not already registered your study. this is mandatory for human studies only. research registry 2. unique identifying number or registration id: researchregistry5570 3. hyperlink to your specific registration (must be publicly accessible and will be checked): https://www.researchregistry.com/browse-the-registry#home/registrationdetails/5eb063278ebf30001609bdd8/ please specify the contribution of each author to the paper, e.g. study design, data collections, data analysis, writing. others, who have contributed in other ways should be listed as contributors.muhammad rafaih iqbal : study design, data collection, data analysis, writing arindam chaudhuri : writing the guarantor is the one or more people who accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish. please note that providing a guarantor is compulsory. key: cord-297863-ou432md0 authors: ye, lei; yang, shulan; liu, caixia title: infection prevention and control in nursing severe coronavirus disease (covid-19) patients during the pandemic date: 2020-06-12 journal: crit care doi: 10.1186/s13054-020-03076-1 sha: doc_id: 297863 cord_uid: ou432md0 nan with covid-19 patients in health care, household, and community settings were all detected [7] . covid-19 infections among health workers are common and fatal to the health system. infection among health workers may cause widespread transmission within the system and even lead to the collapse of the whole services. and this was what exactly happened in harbin in the past weeks; a persisting cluster centered on an 87-year-old inpatient infected more than eighty people, including 8 health workers. the affected hospital urgently suspended routine medical services as a result. based on wuhan's experience, it is critical to develop tailored infection prevention and control (ipc) protocols for both workplace and non-occupational settings and to conduct effective ipc training. thus, the following suggestions were summarized based on the first-hand experience of a national medical team from zhejiang, to facilitate the development of ipc protocols in critical care settings. generally, all health workers should implement appropriate personal protective equipment (ppe) regarding contact and droplet precautions based on recommendations by who [8] . for health workers in icu, advanced protections are required during routine intensive care and airborne precautions are considered as airborne transmission may happen during aerosol-generating procedures. the implementation of ppe may be different by option in certain practices. in our experience, the most protective choices were made and the "zero" medical infection rate was treated as the top priority that all staff were equipped from head to toe. compared to official recommendations, we selected some additional ppe during intensive care, such as an extra medical face mask outside the respirator, and both face shield and goggles (see fig. 1 ). additional ppe may increase the risk of sharp injuries and increase the difficulty of donning and doffing. to lower the incidence of adverse events, sequences of donning and doffing ppe were carefully developed based on the above selections through thorough group discussions and agreement was reached among the team. donning and doffing ppe under the three-zone double-channel structure the ward was reconfigured into a three-zone doublechannel structure before accepting covid-19 patients. in this design, the ward was divided into several working areas according to cleanliness and the moving lines of patients and medical staff were fixed (see fig. 2 ). the patient care area was identified as contaminated, and all staff were fully equipped with ppe before entering the buffer area. when doing doffing, all staff took off the additional ppe during intensive care (such as the fluidresistant gown and face shield) in the first buffer area that was near the patient care area. in the second buffer area, staff doffed the coverall and goggles. finally, in the clean area, all staff removed the remaining ppe and conducted personal hygiene. we also developed reasonable shift rotations determined by the most tolerable shift lengths to prolong the use of ppe. in a 4-6 h shift, health care workers avoided eating, watering, and toileting. to strengthen ipc, an inspector was set to facilitate the routine ipc management by on-site monitoring. basically, the inspector was responsible for supervising the adherence of donning and doffing procedures of each health worker and real-time surveillance. in this way, some highrisk intensive interventions were identified and improvement measures were implemented promptly. covid-19specific precautions were drawn among the team consequently, such as waste management. according to recent reports, not only respiratory specimens but also serum, urine, and stool specimens might be positive for covid-19. even though no further ipc advice was provided, advanced procedures for waste managing were necessary, such as collecting respiratory and non-respiratory wastes in covered containers filled with chlorinated disinfectants and discarding in fastened double-layered medical waste garbage bags. timely after arriving wuhan, we established the icp team and developed our own practical icp procedures in non-occupational settings as well. we strictly ruled our behaviors during traffic routes and in the residential region and facilitated the whole team with a remote communication and collaboration platform using cellphone applications to strengthen communication. same as what we do in the ward, we established the three-area double-channel structure and fixed our moving line. besides, we developed behavior codes among the team, such as limiting gatherings and personnel contacts, routine disinfection of contact surfaces (handphone, doorknob, handle, etc.), and frequent hand hygiene on certain occasions. all information provided in this paper is to strengthen the clinical practice in critical care settings and to better protect front-line health workers in nursing severe covid-19 patients. the "zero" medical infection rate in our experience was hard won but worth fighting for. clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective, observational study clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan coronavirus disease 2019 (covid-19) in italy covid-19) in italy: analysis of risk factors and proposed remedial measures characteristics and outcomes of 21 critically ill patients with covid-19 in washington state tribute to health workers in china: a group of respectable population during the outbreak of the covid-19 characteristics of health vare personnel with covid-19 -united states infection prevention and control during health care when covid-19 is suspected: interim guidance publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations not applicable.authors' contributions shulan yang and lei ye were the major contributors in writing and revising the manuscript. all authors read and approved the final manuscript. not applicable. availability of data and materials data sharing not applicable to this article as no datasets were generated or analyzed during the current study.ethics approval and consent to participate not applicable. not applicable. the authors declare that they have no competing interests.author details key: cord-341531-w788qwya authors: montero feijoo, a.; maseda, e.; adalia bartolomé, r.; aguilar, g.; gonzález de castro, r.; gómez-herreras, j. i.; garcía palenciano, c.; pereira, j.; ramasco rueda, f.; samso, e.; suárez de la rica, a.; tamayo medel, g.; varela durán, m. title: practical recommendations for the perioperative management of patients with suspicion or serious infection by coronavirus sars-cov date: 2020-05-04 journal: nan doi: 10.1016/j.redare.2020.03.002 sha: doc_id: 341531 cord_uid: w788qwya abstract in december 2019, the wuhan municipal health and health commission (hubei province, china) reported a series of cases of pneumonia of unknown aetiology. on january 7, 2020, the chinese authorities identified as a causative agent of the outbreak a new type of virus of the coronaviridiae family, called sars-cov-2. since then, thounsands of cases have been reported with global dissemination. infections in humans cause a broad clinical spectrum ranging from mild upper respiratory tract infection, to severe acute respiratory distress syndrome and sepsis. there is not specific treatment for sars-cov-2, which is why the fundamental aspects are to establish adequate prevention measures and support treatment and management of complications. in december 2019, the wuhan municipal health commission (hubei province, china) reported a series of cases of pneumonia of unknown aetiology, all with a history of exposure to a wholesale seafood, fish and live animal market in wuhan. 1 on 7 january 2020, chinese authorities identified a new type of virus from the coronaviridae family called sars-cov-2 as the causative agent. since then, thousands of cases have been reported worldwide. as of 11 march 2020, more than 118,000 cases of covid-19 (the disease caused by sars-cov-2) have been documented in 114 countries, with more than 4200 deaths, of which approximately 95% of cases and 97% of deaths have occurred in china. community transmission is now believed to exist in mainland china, singapore, hong kong, japan, south korea, iran and italy (lombardy, veneto, emilia-romagna and piedmont regions). in spain, more than 2000 cases have been confirmed so far, some of them with no epidemiological criteria. coronaviruses belong to the subfamily orthocoronavirinae of the coronaviridae family, and 7 coronaviruses that affect humans have so far been described (hcov-229e, hcov-nl63, hcov-oc43, hcov-hku1, sars-cov, mers-cov and sars-cov-2). sars cov-2 appears to have been introduced into humans through an as yet undetermined animal reservoir, and has since spread from person to person. the vast majority of these viruses cause mild upper respiratory tract infections in immunocompetent adults, and can cause more severe symptoms in patients with risk factors. on 30 january 2020, the director-general of the world health organisation declared the outbreak of the new 2019 coronavirus in the people's republic of china a public health emergency of international concern. epidemiology the largest case series published so far by the chinese centre for disease control includes a total of 44,672 confirmed cases as of february 11. 2 of these, 87% were between 30 and 79 years old, 2% were under 20 years old, and 3% were over 80 years old; 81% of cases were reported as mild, while 14% were severe and 5% critical, with a total of 1023 deaths (case fatality rate 2.3%). the mortality rate was higher in patients with comorbidities: cardiovascular disease (10.5%), diabetes (7.3%), chronic respiratory disease (6.3%), high blood pressure (6%), oncological disease (5.6%). a quarter (26%) of patients requiring hospitalisation were admitted to the icu, of which 47% required mechanical ventilation and 11% required extracorporeal membrane oxygenation (ecmo). the mortality rate was far higher among critically ill patients. 2,3 confirmed cases included 1716 healthcare workers, of which 14.8% were in serious or critical condition, and 5 died. infections in humans cause a broad clinical spectrum ranging from mild upper respiratory tract infection to severe acute respiratory distress syndrome (ards) and sepsis. four case series of hospitalized patients have been published in wuhan, china, with 5, 41, 99 and 138 cases, respectively. 4---8 the most frequent symptoms in hospitalised patients were fever, shortness of breath, and dry cough. digestive symptoms (diarrhoea and nausea) were less common. common lab findings include: lymphopaenia, prolonged prothrombin time, increased lactate dehydrogenase and crp. the most common radiological findings were bilateral pulmonary infiltrates. based on studies published in wuhan, china, the 28-day mortality rate of critically ill icu patients with sars-cov-2 pneumonia was estimated at 61.5%. 3 the average incubation period was between 5.2 and 12.5 days, 4 although cases with incubation periods of 24 days have been documented. based on current evidence, person to person transmission 5 mainly occurs via respiratory droplets (up to 2 m) and by mucosal contact with contaminated material (oral, ocular and nasal). it can also be transmitted by aerosols during aerosol-generating therapeutic procedures. faecal-oral transmission is another hypothesis for which there is no evidence to date. the virus has been detected in stool samples in some infected patients, but the significance of this with regard to transmission is uncertain. one case of disease transmission by an asymptomatic carrier has so far been documented. 9 the average number of secondary cases produced from one infected individual has been estimated at between 2 and 3. diagnostic tests are currently performed in all patients who meet any of the following criteria: 1. clinical picture compatible with acute respiratory infection of any severity and any of the following exposures in the 14 days prior to onset of symptoms: a. history of travel to areas with evidence of community transmission. b. history of close contact with a probable or confirmed case. 2. severe acute respiratory infection (fever and at least one sign or symptom of respiratory illness [cough, fever, or tachypnoea]) requiring hospitalisation after ruling out other possible infectious aetiologies that may justify the clinical picture. diagnostic confirmation of coronavirus is performed using molecular techniques (rt-pcr) and by comparing genomic sequencing with sars-cov-2. the recommended samples are: 1. respiratory tract: a. upper, nasopharyngeal/oropharyngeal exudate in patients with mild disease. b. lower, preferably bronchoalveolar lavage, sputum and/or tracheal aspirate, particularly in patients with severe respiratory disease. if initial tests are negative in a patient with high clinical and epidemiological suspicion of sars-cov-2 (particularly when only upper respiratory tract samples have been collected), diagnostic testing should be repeated with new respiratory tract samples. once cases have been confirmed, the following samples should also be sent for testing: 1. blood: blood tests are useful for confirming the immune response to coronavirus infection. in this case, the first sample should be collected in the first week of illness (acute phase) and the second sample 14---30 days later. 2. faeces and urine: to confirm or rule out virus excretion via alternative routes. there is no specific treatment for sars-cov-2; instead, treatment is based on supportive care and management of complications. 10---12 1. early start of supportive care in patients with respiratory involvement (tachypnoea, hypoxaemia) or shock. 2. advanced respiratory support. some patients can develop severe respiratory failure, which will usually appear around the eighth day after the onset of symptoms. high flow nasal oxygen or non-invasive mechanical ventilation, being aerosol-generating procedures, should be reserved for very specific patients who must be closely monitored; intubation should never be delayed unnecessarily. patients who require invasive mechanical ventilation should receive lung protection ventilation in accordance with current clinical guidelines. patients with severe ards may need to be ventilated in the prone position, with neuromuscular blockade during the first 24 h and elevated peep. if ventilatory difficulties persist despite these measures, the use of ecmo is recommended, since this can improve survival, according to the scant information available. 13, 14 patient-ventilator disconnection should be minimised by using closed-loop systems, and active humidification must be avoided by using heat and moisture exchangers. 3. management of septic shock. generally speaking, the recommendations of the surviving sepsis campaign are applicable to the management of septic shock in patients with sars-cov-2. 4. antimicrobial treatment. administration of antimicrobials should be avoided unless there is suspicion of associated sepsis or bacterial superinfection. in this case, empirical antibiotic treatment for community-acquired pneumonia should be started early in accordance with clinical guidelines and the patient's specific characteristics. in patients with ards, superinfection is frequently associated with septic shock and multi-organ failure. superinfection with pathogens such as acinetobacter baumanii and apergillus fumigatus have been described. 5 . systemic steroid treatment. systemic steroids should not be routinely administered to treat ards or viral pneumonia, unless indicated for another reason. 15 a systematic review of observational studies in which corticosteroids were used in patients with sars found no significant survival benefit, while their use was associated with adverse effects such as an increased incidence of infection and delayed viral clearance. 6. treatment with specific antiviral agents. there is no conclusive evidence that antivirals are effective in patients with sars-cov-2. results are still pending from several ongoing clinical trials: ---neuraminidase inhibitors: there are no data available on their effectiveness in the treatment of sars cov-2, so routine use is not recommended unless there is a risk of concomitant infection with influenza viruses. ---nucleoside analogues: remdesivir is believed to have potential as a treatment for sars cov-2. in clinical trials in animals infected with mers-cov, both viraemia and lung damage were significantly reduced compared to controls a randomised controlled clinical trial is currently underway to evaluate its efficacy and safety in these patients. ---protease inhibitors: inhaled interferon-␣ (broad antiviral spectrum) and the combination of lopinavir/ritonavir (in vitro activity against sars cov-2) are currently being administered as antiviral therapy, but there is still no evidence that these are clinically effective. ---monoclonal antibodies: these could be useful in sars cov-2 infection based on their good results in patients with ebola (regn-eb3, mab114 ). off-label use of these drugs is only permitted in ethically approved clinical trials or in the context of monitored emergency use of unregistered and investigational interventions. (table 1) the patient should preferably be placed in a negative pressure isolation room that meets established standards (12 air changes/hour, hepa filter and airlock). the number of people caring for the patient and the time spent in the room must be reduced to the absolute minimum. 16 every effort should be made to avoid intra-hospital transfers by performing all exploratory studies at the beside using portable equipment. if unavoidable, patient must wear a face mask during transfer ( table 1) . the protection of medical personnel is a priority, and they must be given adequate personal protective equipment (ppe) and be trained in donning and doffing techniques. medical staff must perform hand hygiene before and after contact with the patient, particularly before donning and after doffing ppe. the minimum recommended ppe required in patients that are not scheduled for aerosol-generating procedures consists of a fluid resistant gown, ffp2 mask, gloves, splash-proof eye protection and head cover. protective measures should be maximised when caring for patients with confirmed infection, in critically ill patients with a high viral load, and in patients that require invasive aerosol-generating procedures and manoeuvres such as aerosol therapy and nebulisation, aspiration of respiratory secretions, bag-mask ventilation, non-invasive ventilation, intubation, respiratory sampling, bronchoalveolar lavage, tracheostomy or cardiopulmonary resuscitation. 17, 18 hospitals must: ---plan procedures in advance to make sure all barrier precautions are in place and to prepare the material needed. it is important to avoid unnecessary delays in invasive ventilation. ---minimise the number of exposed staff. ---ppe: the aim is to protect staff from inhalation and contact with aerosols and droplets that can be generated during the procedure. ppe elements that can achieve this level of protection include: n95 or preferably ffp3 respirator, close-fitting goggles or full face shield, fluid resistant gown, gloves, fluid resistant head and shoe place patients preferably in a negative pressure isolation room that meets established standards. limit the number of people caring for the patient and the time spent in the room to the absolute minimum. the protection of medical personnel is a priority, and they must be given adequate personal protective equipment and be trained in donning and doffing techniques. use ppes that protect staff from inhalation and contact with aerosols and droplets that can be generated during therapeutic procedures. ppes must consist of: n95 respirator or preferably ffp3 mask, close-fitting goggles or full face shield, fluid resistant gown, double gloves, waterproof head and shoe covers. perform hand hygiene before and after contact with the patient, particularly before donning and after doffing ppe. minimise the need for aerosol-generating procedures, and if unavoidable, always use the recommended protective measures. if tracheal intubation is needed, it should be performed by the most experienced clinician available. perform rapid sequence induction, avoid bag-mask ventilation, use a video laryngoscope and preferably a subglottic secretion drainage endotracheal tube. start supportive treatment as soon as possible in patients with respiratory involvement (tachypnoea, hypoxaemia) or septic shock. avoid high-flow nasal oxygen and non-invasive mechanical ventilation as far as possible ---they are aerosol-generating devices and should only be used in certain patients. avoid administering antimicrobials unless there is suspicion of associated sepsis or bacterial superinfection. superinfection with pathogens such as acinetobacter baumanii and apergillus fumigatus have been described. do not routinely administer systemic steroids. ppe: personal protective equipment. covers. two aspects of ppe use are particularly important: ensuring the mask is correctly sealed and double-gloving, using a clean inner glove to reduce the possibility of touching contaminated material by hand when removing the ppe. correct hand hygiene should always be performed before donning and after doffing the ppe. ---if tracheal intubation is required, it must be performed by the clinician with most experience in airway management (fig. 1) . unless specifically indicated, awake intubation under fibreoptic vision and nebulised airway anaesthesia must be avoided. make sure a high efficiency heat and moisture exchanging filter is placed between the face mask and the ventilation circuit before starting pre-oxygenation. perform rapid sequence induction with adequate cricoid pressure. avoid bag-mask ventilation before intubation as far as possible; if required, ensure the mask is correctly sealed to prevent leakage and administer small tidal volumes. it is advisable to perform if a patient with suspected or confirmed covid-19 requires surgery, transfer to the operating room will be carried out following all the precautionary measures previously described for the health personnel in charge of the transfer (ppe with ffp2 and preferably ffp3 mask if the distance between the patient and the staff is less than 2 m). dedicated transfer routes should be used or the number of staff present should be minimised. patients must wear a surgical mask. ideally, the operating room must be equipped with absolute or hepa filtration (table 2) . general or regional anaesthesia? no clear recommendation can be given in this regard. the choice of technique will depend on the patient's respiratory symptoms, such as coughing and expectoration, and the type of surgery required. if surgery is performed using regional anaesthesia without intubation, intraoperative oxygen therapy should be used, placing a surgical mask over the ventimask ® or the nasal cannulas. the personnel safety and protective measures described should be followed during both intubation and extubation, using an appropriate ppe with a n95 respirator or ffp3 mask, bearing in mind that these procedures involve a high risk of aerosolization. high efficiency heat and moisture exchanging filters should be placed on the inspiratory and expiratory branches of the ventilator. during the intervention, the operating room doors should remain hermetically sealed and only essential personnel should be allowed inside, wearing full ppe and preferably masks without an expiration valve, since these are unsuitable for sterile environments. ventilator disconnections should be minimised, and closed suction systems should be used. after surgery, once the patient has left the operating room, the ventilator tubing and filters should be discarded, and the operating room cleaned following the recommendations of the hospitals' preventive medicine service, paying particular attention to any surfaces that might be contaminated. patients should be woken in the operating room (avoid transferring them to other units). they should remain in the operating room until it is safe to transfer them to their room, and until any early postoperative complications (such as respiratory depression, vomiting, pain) have been treated. if post-anaesthesia surveillance is required, it should be performed in an isolation room (preferably negative pressure) or in other adequately monitored units that have been set aside specifically for covid-19 patients. healthcare personnel caring for these patients should wear full ppe with ffp2 or ffp3 masks at all times, depending on the type of care that is performed, as discussed above. in patients requiring postoperative oxygen therapy, the use of aerosols, high-flow nasal oxygen or noninvasive ventilation should be avoided as far as possible. patients that have been extubated in the operating room must wear a surgical mask over the ventimask ® or nasal oxygen cannulas used for the administration of oxygen therapy during transfer from the operating room to the hospital unit set aside for postoperative surveillance. prior to the intervention, note the patient's history, allergies, and other routine information in their progress notes; this will serve as a preoperative report. do not perform an airway assessment (explain why). depending on their isolation status, either the patient or a family member must sign an informed consent form transfer the patient to the operating room following all the precautionary measures previously described for healthcare personnel (ppe with ffp2 protective masks and preferably ffp3 if the distance between the patient and the staff is less than 2 m). use dedicated transfer routes or minimise personnel. patients must wear a surgical mask during transfer the operating room should be equipped with absolute filtration or hepa the same recommendations on limiting staff numbers and using protective measures are applicable to patient care in other hospital areas the protection of medical personnel is a priority, and they must be given adequate personal protective equipment and be trained in donning and doffing techniques. perform hand hygiene before and after contact with the patient, particularly before donning and after doffing ppe the type of anaesthesia will depend on the patient's respiratory status and the type of surgery. use regional anaesthesia (nerve block, spinal anaesthesia) whenever feasible. the patient must wear a surgical mask throughout the procedure. there is no evidence to show the superiority of any particular anaesthesia technique prepare all the material (face masks, video laryngoscopes, tracheal tubes, guedel airway, etc.) and fluids with and without delivery systems in advance, before the patient arrives in the operating room, to avoid opening and manipulating trolleys. use disposable material whenever possible prepare in advance any drugs that might be needed, placing them on a large tray. avoid manipulating drug trolleys as far as possible. likewise, made sure that everything that may be needed during surgery is already in the operating room in order to avoid opening the doors once the patient has arrived start monitoring in accordance with asa and sedar recommendations (continuous ekg, non-invasive blood pressure, sato2). do not use other monitoring devices (srto2, bis) unless absolutely essential, and do not place arterial or central lines unless unavoidable due to the patient's status if regional anaesthesia is administered without intubation, deliver oxygen under the surgical mask during the intervention, keep the operating room doors hermetically sealed and only allow the entry of essential personnel wearing full ppe and preferably masks without an expiration valve follow safe airway management procedures during both intubation and extubation. only use laryngeal masks when unavoidable ventilator settings must be entered by a clinician who has not been in contact with the patient place high efficiency heat and moisture exchanging filters on both branches of the ventilator minimise ventilator disconnections and use closed suction systems after surgery, dispose of all material (tubing, filters and endotracheal tube) as hazardous medical waste (group 3 biological agents) and clean the environment in accordance with the recommendations of the preventive medicine service patients should be woken in the operating room (avoid transferring them to other units). they should remain in the operating room until it is safe to transfer them to their room, and until any early postoperative complications (such as respiratory depression, vomiting, pain) have been treated. if postoperative surveillance is necessary, it will be carried out in adequately monitored isolation units, preferably with negative pressure avoid using aerosols, high-flow nasal oxygen or non-invasive ventilation as far as possible in patients requiring postoperative oxygen therapy healthcare personnel who care for patients during postoperative surveillance must wear appropriate personal protective equipment at all times and must be taught donning and doffing techniques the same recommendations for transferring patients to the operating room apply to postoperative transfer a novel coronavirus outbreak of global health concern characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72,314 cases from the chinese center for disease control and prevention clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective, observational study clinical features of patients infected with 2019 novel coronavirus in wuhan a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china epidemiologic and clinical characteristics of novel coronavirus infections involving 13 patients outside wuhan, china presumed asymptomatic carrier transmission of covid-19 critical care management of adults with communityacquired severe respiratory viral infection severe acute respiratory syndrome: historical epidemiologic, and clinical features intensive care during the coronavirus epidemic preparing for the most critically ill patients with covid-19: the potential role of extracorporeal membrane oxygenation coronavirus epidemic: preparing for extracorporeal organ support in intensive care clinical evidence does not support corticosteroid treatment for 2019-ncov lung injury novel coronavirus infection during the 2019---2020 epidemic: preparing intensive care units-the experience in sichuan province practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-ncov) patients severe sars-cov-2 infections: practical considerations and management strategy for intensivists key: cord-331533-0toegbv8 authors: leiker, brenna; wise, katherine title: covid – 19 case study in emergency medicine preparedness and response; from personal protective equipment to delivergy of care date: 2020-07-27 journal: dis mon doi: 10.1016/j.disamonth.2020.101060 sha: doc_id: 331533 cord_uid: 0toegbv8 nan events and all group gatherings to try to "flatten the curve." most lockdowns began between late march and early april. california was the first state to issue lockdown orders on march 19th, following the lead of san francisco three days prior (nature, 2020 april 22) . restrictions on international travel were put in place, and a no sail order from the director of the cdc was issued on march 14th, suspending travel on us waters (schuchat, 2020) . on march 26th, the united states became the country hardest hit in the world by coronavirus with 81,321 confirmed infections (mcneil, 2020) . that trend continues today. spread of coronavirus and the challenges inherent in pandemic circumstances were similar in the state of illinois. its index case was the second detected case in the united states: a woman traveling from wuhan, china in mid-january who returned home to illinois and was hospitalized a week later with pneumonia (cdc, 2020 january 24). her spouse tested positive as well the following week which was the first recorded case of local transmission in the united states . early screening and positive cases in illinois were connected to travel histories such as recent travel to high risk areas as with illinois' first case or recent travel on a cruise ship (idph, 2020 march 6). nationally, retrospective analysis of surveillance data from this time period suggests that limited community transmission likely began by early february after initial importation from travelers from china and europe (jorden et al., 2020) . this could not be tracked until late february to early march via emergency department syndromic surveillance data as evidenced by an increase in emergency department visits for covid-like illness demonstrated increased incidence (see figure) . this data represents a critical indicator, given limitations in widespread testing at that time. by march 10th, the first cases of coronavirus were being reported not only outside cook county but also in individuals with no identifiable risk factors such as recent travel or known sick contacts (idph, 2020, march 10). retrospective analyses have confirmed the deadly nature of community transmission like the above case in albany, georgia: chicago department of public health (cdph) investigated a large, multi-family cluster of covid positives and presumed positive cases. this cluster investigation and tracing demonstrated transmission to non-household contacts and family gatherings after one index patient attended funeral events that triggered a chain of transmission that included 15 other confirmed and probable cases of covid and ultimately three deaths (ginai et al., 2020) . long term care facilities (ltcf) became a particular area of focus and monitoring. the first resident of an illinois long term care facility that tested positive during this time spurred testing of the entire facility and resulted in 21 positive cases including 17 residents and 4 staff members, confirming the fears of public health officials both of the inherent risky nature of congregate living and the vulnerability of congregate living residents (idph, 2020, march 17) . increased guidance from idph for nursing homes included restrictions on all visitors, volunteers, and non-essential health care personnel (e.g., barbers), cancellation of group activities and communal dining, and active symptom monitoring for both residents and staff. as one congregate living resident summarized during his emergency room visit at the time: "i haven't been allowed to leave my room and they bring all my meals to my door and leave it there. my family can't visit me." by the time that illinois governor pritzker issued stay-at-home orders on march 21st, illinois had 585 confirmed cases across 25 counties, including 163 recently diagnosed new cases and a death toll of five (idph, 2020 march 20) . the directive prohibited socializing in-person with people outside your household and gatherings larger than 10 people. playgrounds were closed and selective green spaces were used with 6 feet of social distancing. only essential travel was permitted and essential services continued. at the time, illinois was joining california, new york and connecticut, states with three of the largest cities in the country, to enforce strict sheltering measures. illinois remains one the states with stricter sheltering measures in the country and subsequent reopening guidelines currently. the approach to the coronavirus pandemic in the emergency department focused on identification and isolation of infected individuals, adequate protection of staff, reporting of positive cases to the health department, effective treatment, and education of patients and families. protocols for triaging, use of ppe (personal protective equipment), environmental services and cleaning, even the types of tests we ordered were adjusted to maximize protection. use of telemedicine technologies helped mitigate risk and exposure. care for these patients was pared down to the most essential personnel to minimize staff exposure, especially given a worst case scenario that predicted temporary loss of staff due to illness and quarantining. staff was re-allocated to essential areas such as the ed, icu, home health, and nursing homes to help test and care for covid patients. other staff were recruited from outpatient areas with less volume to assist in the ed in anticipation of higher volumes and unanticipated staff absences due to illness. the physical space of the emergency room was re-evaluated to best triage and isolate covid patients. protocols for cleaning and sanitizing rooms and common diagnostic areas (radiology, ct scanners) were formulated to balance the need to turnover spaces efficiently but safely. a trauma or stroke patient cannot be imaged in a ct scanner that just minutes before accommodated a confirmed covid positive patient, so protocol for use and cleaning had to be developed. these were but a few of the many challenges that pandemic conditions present to an emergency room and to a hospital. the northshore university healthsystem (northshore) had to be dynamic, informed, and innovative in its approach in order to provide effective care with minimal risk of exposure to both patients and staff. northshore is headquartered in evanston, il and includes 5 hospitals--evanston, skokie, glenbrook, highland park and swedish--on the north side of chicago and its suburbs. these ed's are busy--seeing a combined total of over 170,000 visits annually (idph, n.d.) . the integrated nature of the hospital system means that northshore can be dynamic and responsive to the needs of the community while also having the resources to be effective. advanced practice practitioner (apps) is a term used to represent physician assistants and nurse practitioners. app's have traditionally been widely used in the northshore system and are utilized in a variety of clinical areas from outpatient to inpatient roles. app's are used in nearly every service area, evaluating patients, ordering tests, formulating treatment plans, and educating and advising patients and families. the northshore ed app group consists of 31 full-time, part-time, and resource team app's. we work all the ed sites in both fast track and in main room areas. app's assist by seeing patients alongside and in addition to the physicians, dispersing responsibilities and providing more complete care as the physician juggles multiple patients at once. with the advent of covid, we have worked to adjust our role along with the rest of the er team. app's within northshore have had to alter their usual role to adapt to covid, many temporarily relocating to the ed, immediate care, inpatient floor, icu, and as part of the nursing home testing outreach team. app's who participated in these roles were able to alleviate the demand placed on these departments and provide access to on-site testing. app's in the immediate cares have played a crucial part in caring for covid patients and providing access to testing within their clinical sites. app's in the icu have been critical in helping fill the gaps where additional staff where needed to care for covid patients, make calls to update family members, and provide input for treatment protocols we, the authors of this article, work as app's within the northshore emergency department. the following is a detailed description of our perspective on how northshore, one hospital system in the us, adapted to respond to the demands of the covid pandemic. in writing this paper, we interviewed people across the system to help capture some of the changes our hospital system underwent to respond to covid. communication throughout the covid response faced many challenges and growing pains. the landscape of understanding and response to the virus changed so radically over this year that clear and constant communication was vital for healthcare workers. challenges arose with social distancing and sheltering at home guidelines restricting large meetings that posed a threat of transmission. yet it was essential to maintain a clear understanding of clinical and operational guidelines to ensure safe and effective care. these efforts occurred on many levels. early on, northshore set up an online covid resource center to update staff. the site was divided into protocols, updates, and specific service line guidelines (such as surgery, vascular lab, or psychiatry admissions). also included in updates and education were common procedures performed in caring for covid patients such as intubation, donning and doffing protocols, updated testing guidelines, and proper nasopharyngeal swabbing technique. northshore's internal covid website also included the most recent recording of the weekly physician update for the hospital system. these meetings were conducted by covid response team leaders in the northshore system who drew on their expertise in their clinical areas to update and educate physicians and other northshore employees on particular aspects of covid and northshore's response to the pandemic. representatives included northshore's leaders including dr. mahalakshmi halasyamani, chief quality and transformation officer, dr. tom hensing, chief quality officer, and dr. kamaljit singh, director of microbiology and infectious diseases research. each offered updates including testing and laboratory data, hospital protocols, and clinical research trials. the weekly meeting also offered a forum for addressing meeting attendees' questions, some of which were particular to their own area of work but also arose from general curiosity about northshore's covid response. northshore's cart (covid analytics research team) maintained a real time data resource accessible through epic, northshore's electronic medical record system. this page included current operational covid census within the hospital system as well as total testing outcomes. through the hard work of this team, data was analyzed by age, end outcome, and other markers. more recently, cart has begun analyzing and presenting early data from northshore's covid antibody testing. within the ed, our division chief dr. ernest wang hosted bi-weekly call-in meetings open to physicians, app's, nurses and ed staff. those meetings focused on ed workflow and covered a variety of topics. he also invited feedback and discussion as well as contributions from directors of each of the individual er locations. given the information deluge that has characterized covid, physicians in our group worked hard to stay up-to-date themselves and shared important information within the ed group using group chat platforms. it seemed like nearly daily there were important new understandings of covid and our team worked hard to share, interpret, and discuss this information. our ed app manager, sue bednar, apn, also held call-in meetings to field questions and concerns as well as sent out regular email updates. all these efforts were appreciated by staff because shared knowledge is important not only for personal safety but also for efficient and effective patient care. with our group trying to stay informed on ed workflows in several different ed pavilions, it was important that we received guidance and information from one central source. sue bednar, dr. wang, and all the other physician leaders in our group worked tirelessly to keep us safe and informed. their work ensured that we felt calm and prepared for challenging shifts, that we understood ppe use and rationale and ed testing and treatment protocols, and that we had knowledge of current areas of stress in the system and measures to address these challenges and bottlenecks in daily workflow. all this reinforced the message that we were valued members of the organization. as the first case of covid was confirmed in the united states in january, hospitals, clinics, and essential businesses across america started to think about how they were going to protect their employees. there was scarcity of equipment like standard surgical masks, n95 masks, and gloves for not only essential businesses but the general public as many rushed to protect themselves and their loved ones. in addition, hospitals needed to ensure that they had sufficient gowns, face shields, shoe coverings, and hair coverings so healthcare workers could safely do their jobs, not just in the days but also the weeks and months to come. having adequate ppe and training proved to be the most important means of enforcing workplace safety and preventing viral transmission to healthcare workers. reports of high healthcare worker infection rates out of countries badly hit by covid like china and italy, worried healthcare workers in the us (zhou et al., 2020) . hospital employees everywhere were questioning if their employers had the resources to protect them as the number of covid cases grew and if the ppe would be effective. surrounding communities stepped up to help by donating any extra ppe they had. despite shortages elsewhere, northshore has been fortunate to be able to provide adequate ppe for all employees that came in contact with covid patients. prior to the covid pandemic, most employees hadn't worn n95 masks often and most hadn't been recently fit tested for proper n95 mask size. at each northshore hospital, fit testing was offered as hundreds of employees lined up to be refitted for appropriate sizing of n95 masks. as the months progressed, employees were retested for appropriate fit as the hospital ran out of certain sizes of n95 masks and alternatives were provided. in addition to the need for n95 mask fit testing, northshore had to also reeducate employees on proper use of ppe. on march 11th, northshore released their first statement regarding ppe use, drawing from who (world health organization) and cdc (center for disease control) guidelines. northshore recommended full ppe when caring for confirmed covid or puis in immediate care, ed, and hospitalized settings. northshore also had to address concerns of improper ppe donning and doffing procedures that could inadvertently expose staff: kang et al. (2017) demonstrated that healthcare personnel contaminated themselves in almost 80 percent of videotaped ppe simulations. this was especially apparent during the ebola virus outbreaks from 2014 to 2016 (kwon et al., 2017; fischer, weber, & wohl, 2015) . in early march 2020, there were concerns about ppe shortages that created a tension between appropriate use and unnecessary waste. cdc guidelines at the time did not recommend wearing masks when not around covid patients, nor did they recommend masks for people without symptoms. it goes without saying that we all felt confused about ppe usage and what resulted were inconsistent practices within hospitals and also between hospitals. by mid-april every employee and visitor was required to be screened by taking temperatures and answering questions about symptoms or exposure prior to entering any northshore facility. with a negative screen, everyone entering the hospital was given a mask to wear throughout their visit. distribution of masks was limited initially in efforts to preserve supply, but as the hospital recognized the difficulty of socially distancing at work to prevent spread of infection, universal masking became standard. as of early june, northshore's positivity rate among employees is 13 percent, an improvement since enforcing universal masking and eye protection. it's unclear how many of these positive employees contracted covid at work or at home, but the decrease in positivity rate is a testament to the effectiveness of proper implementation of ppe. as northshore was able to increase covid testing, ppe protocols became more regulated. full ppe was required when interacting with patients with confirmed or suspected covid including n95 mask, goggles or face shield, hair covering, plastic or cloth gown, and gloves. northshore and ed management worked hard to disseminate instructions on when and how to properly use ppe via handouts, emails, and videos. this was especially important for employees that needed to review how to use a papr and proper decontamination after performing an aerosolizing procedure like intubations (see figure below for papr use). patients considered puis were flagged by the triage nurse and placed in a room with both contact and airborne precaution signs on the door, indicating need for full ppe. patients that were not flagged as puis were not placed on covid precautions, and providers interacting with these patients were only required to use standard precautions and a surgical mask. other ways in which northshore worked to protect its staff working directly with covid patients was offering the opportunity to shower at work post-shift and providing hospital-issued scrubs for shift use rather than wearing personal scrubs that must be laundered at home. although robust literature about the use of hospital-issued scrubs to minimize exposure is lacking, most experts don't believe laundering scrubs at home poses an infection control problem. regardless, neysa p. ernst, rn, msn, a nurse manager in the biocontainment unit at johns hopkins school of nursing notes "covid-19 is so novel that 'psychological safety' is extremely important… for many frontline providers, changing in and out, and wearing hospital-laundered scrubs reduces concerns about bringing covid home" (eldred, 2020) . although hospital scrub use was put up as optional to use at first, quickly all ed employees took advantage of this opportunity to prevent the spread of covid to home. in addition to what was provided by northshore, ed employees also shared amongst themselves strategies for mask storage and eye protection, shoe changing/storage, and social distancing precautions. when n95 mask resources were limited, it became routine to wear a surgical mask over the n95 to further prevent contamination of valuable n95 masks. a few physicians and app's referred to evidence published online regarding use of uv light or moist oven heat to decontaminate materials, some even buying personal portable uv lights to use on masks between patients (cdc, april 2020). items that were once kept at desks in the ed were now confined to a locker, phones were kept in plastic bags, and hair kept in scrub caps to prevent exposure. providers also referenced online resources that discussed strategies to prevent contamination at work and home through foam (free open access meducation) online resources like emcrit, emrap, and emergency medicine cases. from the beginning, northshore collaborated with employees to align with cdc recommendations, preserve resources, and create an environment in which employees felt safe and supported. each hospital employee also had to take into account their own level of comfort, some going so far as to isolate themselves from their family completely, sleeping in separate houses or hotel rooms at the height of the pandemic. when it came down to it, covid presented many new challenges that hospitals across the nation will continue to navigate as we move through the pandemic. as we learned more about the nature of the virus and the reality of an imminent pandemic set in, america scrambled to find a widely available means of diagnosing covid. in mid-february, illinois became the first state in the united states to use a nasopharyngeal swab to test for covid (idph, 2020, february 11). according to the fda, the sensitivity of the covid rt-pcr test is 95% with a specificity of 100%, but illinois was only producing about 12 swabs a day for the entire state (hinton, 2020; leventis-lourgos, dardick, & brinson, 2020, may 13) . at that time, testing was extremely restricted and controlled entirely by the state which posed difficulties in both meeting the community's testing needs as well as incorporating testing into hospital protocols. the rapidly changing recommendations for covid testing in illinois were reflected at northshore as we struggled to keep up with the daily changes in testing supplies, requirements and best use. on january 21st, northshore released their first statement regarding screening of patients under investigation (puis) including symptoms of cough, shortness of breath, and/or fever with either recent travel in china or contact with a covid positive patient within the past 14 days. this was in accordance with cdc guidelines. initially, tests were only available by request from the idph, leaving northshore dependent on state guidelines and resources for testing. when caring for a pui patient, providers were advised to isolate the patient in a negative pressure room, wear ppe, and contact northshore infection control for further guidance. additionally, the guidelines for pui's identification continually expanded to match viral spread throughout the world and our local community. by early march, pui's were considered to be those with cough, shortness of breath, and fever and had recently returned from italy, korea, iran, or china, or patients who had come in contact with a known positive person in the past 14 days. while there were many cases already confirmed in california and washington state and the first few covid cases emerging within chicago, puis at this time continued to be limited. recognizing the danger of limited testing, in late february the fda relaxed policies regulating development of covid testing kits to help achieve more rapid testing capacity nationally (fda, 2020) . this was in response to the cdc's failure to develop a test under the emergency use authorization granted by the fda that prohibited other laboratories from having the same freedom to fast track testing products. the cdc's initial test was distributed among states but problems with state testing sites and reagents yielded equivocal and unreliable test results (sharfstein, becker, and mello, 2020) . at a time when the government was unable to provide adequate tests with prompt results, hospital systems across the nation were faced with the task of developing their own test as quickly as possible. by march 12th, northshore became the first local community hospital in the chicago area to develop their own test for covid with the capacity to run 400 tests daily. northshore's 24 to 48-hour test turnaround time was impressive, given this was during a time when much of the rest of the country's covid testing took almost two weeks to result. covid also emerged in the midst of the influenza season, further complicating the approach to a diagnosis. testing protocols early on mandated ruling out flu/rsv prior to initiating a covid test and halting further viral testing with a positive influenza/rsv swab. at that time, the possibility of coinfection of covid with other respiratory viruses was thought to be unlikely. to simplify testing protocol, ed providers were given a flowsheet on how to approach patients with respiratory symptoms (see figure ***). by late march, the decision was made to remove flu/rsv testing. the flu/rsv test was set up with a reflex to test for covid if negative. by late march, the majority of the flu-rsv tests had resulted as negative, while many were reflexively resulting positive for covid. it was determined that continuing to test for flu/rsv was a misuse of resources, and it would be best if the step was eliminated from the protocol. by mid-march the screening criteria for covid was expanded to include patients with recent travel to japan and anywhere in western europe, domestic travel to the cities of seattle, boston, san francisco, los angeles, new york city and the surrounding suburbs, or patients that had attended large gatherings such as conferences or sporting events in the past 14 days. this came at a time when the virus continued to spread within the community. in an article published in the daily northwestern "there were 55 confirmed cases in evanston. 1,865 illinois residents have tested positive for the virus, and 26 have died as of thursday (03/26) at 2:30 p.m., according to the state's coronavirus (covid-19) response webpage." (herscowitz, 2020) despite the virus's rapid spread, northshore and idph worked to match the testing protocol with the demand within the community. by early april, covid had spread widely within the northshore population, significantly impacting surrounding nursing homes, independent living facilities, and other congregate living arrangements. eventually, community spread was so prominent and recent national or international travel rarer that history of travel became less emphasized in testing criteria. as northshore further increased their ability to perform in-house testing and we learned more about the virus, the threshold for covid testing continued to be lowered. the testing criteria as of april 11th is listed below: although the screening criteria is much the same as of time of writing in early june, it continues to expand as more discoveries are made and findings disseminated across the globe. there seems to be a clear relation between covid and vascular findings, with a study published on may 21st showing that alveolar capillary microthrombi were 9 times as prevalent in patients with covid as in patients with influenza (ackerman et. al., 2020) . a covid patient's initial presentation may be a catastrophic vascular event such as a stroke, mandating changes to stroke care that included early covid screening to protect staff (dafer, osteraas, and biller, 2020) . another example lies in pediatric populations frequently seen in the ed: the last few months, there have been minimal findings in the young otherwise healthy population, with a death rate of essentially 0% in those ages 0-17 in the chicago area (cdph, june 2020) (rcpch, 2020). however, as of late may, northshore pediatricians have alerted providers of covid-induced kawasaki syndrome as well as multisystem inflammatory syndrome in children (ncbi, 2020). along with covid toes, limb ischemia, and covid-induced hepatitis, clinicians are still in the process of discovering the full effects of this virus and the symptoms that align with it. management of covid patients from the ed requires complex decision-making and coordination. northshore's protocols took advantage of its unique systems-based and multi-hospital set up in its management of covid patients. patients that were stable enough to go home were notified of their results via phone call or online medical record portal. their discharge instructions included strict selfquarantining while waiting the 24 to 48 hours for test results but this was only a small inconvenience compared to test turnaround times of up to two weeks in other parts of the united states. for patients who required inpatient admission, several factors in their presentation were taken into consideration. need for admission mostly weighed on the patient's vital signs, specifically tachypnea and spo2 on room air as well as the need for supplemental oxygen. providers also took into account radiographic findings, medical history, living situation, and other significant test findings. biomarkers for covid were included in the work up and were used to help predict a positive test or severity of illness including crp, ldh, hepatic enzymes, and the presence of leukopenia or lymphopenia. for example, a patient with a crp of greater than 200, a chest x-ray with infiltrates consistent with covid, and a marginal oxygen saturation were much more likely to be admitted to the hospital than someone without these findings. in addition, these inflammatory biomarkers were helpful while waiting for the results of a covid pcr test to assist in inpatient placement. determining the disposition of a covid patient or pui required a reevaluation of the admission process. aside from patients that were considered stable enough to be discharged to quarantine at home, northshore had to create a protocol for patients too sick to be discharged that utilized the unique systems-based approach to covid. two of the four northshore hospitals offered a covid floor and icu: evanston and glenbrook hospitals. anyone who was swabbed for covid was then admitted to a covid floor or icu as they awaited the results of their test. skokie hospital was no longer admitting patients as pre-pandemic, during its transition to becoming primarily an orthopedic facility. the fourth northshore pavilion, highland park, was designated as covid-free and would admit only patients non-concerning for covid. all covid rule out cases were transferred to either glenbrook or evanston hospital. with a negative test result, these patients were immediately transferred to a non covid floor. while initially glenbrook admitted both covid and non covid patients, eventually the hospital was chosen as the covid only hospital and all other patients were transferred to one of the two other admitting hospitals. glenbrook's choice to be the main covid hospital was logical, given the layout of the newer emergency room as it was built with the potential to become completely negative pressure. this made it easier for the icu to overflow into the ed rooms at glenbrook as they reached capacity in the inpatient areas. therefore, the majority of the icu patients were transferred to glenbrook for admission. by the end of march an inpatient covid hospitalist team was formed to determine which patients being admitted required testing and to manage the covid rule-out and known positive patients on the inpatient side. with this new team, the ed physician or app discussed the patient with the covid hospitalist first and the need for testing. once the hospitalist agreed to admit the patient, the ed provider could place the order for the covid test and the patient would be admitted to the covid team either at evanston or glenbrook. the covid hospitalist served an important role when placing patients in the appropriate setting was more important than ever. ed providers worked in collaboration with the hospitalist to determine which patients needed to be tested for covid. it was the physician's responsibility to protect both the inpatient population and the patient to be admitted from unnecessary exposure in the interim before the results of the covid test were known. ultimately, they were the ones who made the testing and admission decisions. for example, consider the admission of an elderly patient with a history of copd, lung cancer and new respiratory symptoms. admission to a unit with covid positive patients puts that patient at risk for infection but admission to a general med surg floor can risk exposure of other patients if he does have covid. it was important to have a team in charge of determining what was best for the patient under review, other patients in the hospital, and the staff caring for them. as the rapid antigen test becomes more accessible the admission process will continue to change. on may 8th, the food and drug administration granted emergency use authorization to the nation's first antigen test, the sofia sars antigen fia (fda, may 2020). northshore's utilization of the cepheid xpert xpress rapid antigen test, made it possible to know if a patient is covid positive in a matter of 30 minutes as opposed to the 8 to 24 hours it would take with the regular covid pcr test (cepheid, 2020) . the addition of the antigen rapid covid swab changed the admission process further by making it easier to rule out covid in patients where the diagnosis was unclear or wasn't the primary admission diagnosis. this was for patients that had not had a known positive covid exposure, had a history of living at a congregate living facility with positive cases, or didn't have lab markers or chest x-ray or ct findings consistent with covid. for patients who had symptoms consistent with possible covid but the diagnosis was in question, the rapid test was able to provide a direction for admission within an hour. by late may, hospitals struggled to maintain an adequate supply of the antigen tests. this meant covid hospitalists and ed providers had to work together to determine which cases would benefit the most by using a rapid test. the admission protocol continues to change as northshore works to obtain a consistent supply of rapid antigen tests. the covid pandemic forced the ed to face a troubling dilemma: how to deliver oxygen and respiratory support to a covid-positive patient or pui in respiratory distress without placing unnecessary risk to the patient or placing staff at increased risk of exposure. decisions to intubate are never taken lightly but factors like the high patient mortality rates of covid patients once intubated and the potential staff exposure during intubation also were now being taken into consideration. additionally, conventional means of oxygen delivery and treatments for respiratory distress such as noninvasive positive pressure ventilation (nppv) modalities like bipap, high flow oxygen devices, and nebulized albuterol treatments became questionably dangerous tactics in a world where transmission was measured by aerosolization, degree of exposure and distance from source. reports out of china and italy, other countries hard hit by coronavirus, were also alarming in the high proportions of health care workers testing positive for coronavirus, presumably due to occupational exposure (chirico, nucera and magnavita, 2020; zhou et al., 2020) . the rationale behind early intubation was perceived to be giving the patient necessary ventilator support and also protecting staff from unnecessary airborne and droplet exposure due to the closed nature of the ventilator system. there has been an evolving understanding of the precise mechanism by which covid is spread such that we lacked consensus as to whether covid is a droplet or airborne spread disease (ong et al., 2020) . this is where the term "aerosol generating procedure" gained new weight due to the increased risk of exposure to health care workers within the vicinity of the patient during these events, especially with prior evidence of increased viral particle spread with other viruses like influenza (tellier, 2006) . these events include: coughing, sneezing, nppv with poorly fitting masks, nebulized medications via simple mask, bag mask ventilation, cpr prior to intubation, and tracheal suctioning. all of these events could be part of treatment for a severely hypoxic covid patient. early in the pandemic in the us, providers approached the problem of respiratory support based on experiences of other countries hit hard by the pandemic. experiences from italy advised early intubation to provide support for the hypoxic patient in ways that avoided the typical aerosol generating strategies like high flow oxygen and nppv and to prevent a chaotic emergency intubation that can unnecessarily expose staff (brewster, 2020) . early on, we treated covid like acute respiratory distress syndrome (ards) and mechanical ventilation was one of the mainstays of treatment. this approach was supported by reports from china expressing concern that delayed intubation led to worse outcomes (meng et al., 2020) . even transfer to another area of the hospital with the potential exposure to staff during transport and the safety of patient and staff during inter-hospital transport become important when considering intubation: can a patient safely be transported to the proper intensive care unit without being intubated first? meng et al. (2020) emphasizes "timely, but not premature, intubation" but, early on, we lacked the evidence and experience with covid to make these decisions. at times, the decision to intubate was clear: hypoxemia, tachypnea, work of breathing, increased fatigue, radiographic findings of severe illness, agitation and altered mental status and rate of clinical deterioration made intubation a necessary intervention. yet the knowledge that once a covid patient is placed on a ventilator, their mortality rate rises significantly also weighed heavily on the decision: many studies quote mortality rates of 50 to 90% after intubation for covid-related respiratory distress (yang et al., 2020; richardson et al., 2020; bhatraju et al., 2020) . as one er/icu doctor stated in an april interview with the new york times: "you have a disease that you don't understand, that is very deadly... with patients that are scared and staff that are scared… and on top of that, it does not appear that we have a good treatment strategy other than a ventilator. we are not sure when to put a breathing tube in … the crux of it is we don't want to put a breathing tube in to someone who doesn't need it knowing there's a 70% chance they will die and we don't want to not put it in to someone too late" (dr. cameron kyle-sidell, nyt video news, 2020 april 14). over the months of the epidemic, experience has given medicine a different, if still small-cohort and case-based, understanding of covid's effects on the lungs and body. despite continued debate and more updated contributions to the discussion, understanding that covid affects lungs differently has grown. the phenomenon of the "happy hypoxemic" puzzled many: many covid patients were presenting with hypoxia without other markers of respiratory distress such as shortness of breath, tachypnea and fatigue. after intubation, these hypoxic patients weren't displaying the decreased lung compliance of ards and instead showed a pure hypoxemia without stiffness or evidence of end organ damage (marini and gattinoni, 2020) . clinicians began to consider other strategies than intubation such as high flow oxygen delivery devices and awake or self proning. many providers noted that these hypoxic patients actually did not "tire out" and require dangerous "crash intubations" and instead slowly improved over time. others noted these patients became more hypoxic without signs of distress but then noted worsening bradycardia and cardiac arrest (resaie, 2020). another physician noted a story of "a patient satting 61% room air with a heart rate of 135, and tachypneic. he was talking and sitting up, signing consent to let us take pictures. we proned him and started high-flow. 2 hours later, his sats were in the 90s" (rezaie, 2020) . all these stories are anecdotes, stories of a single or small number of patients; medicine is based on large volume, evidence-based strategies. as one icu doctor summarized for the new york times in april: "within the last two weeks, what has been unacceptable has become very acceptable. some of these patients don't need to be intubated. you watch them carefully, you make sure their oxygenation is adequate and they can recover" (dr. richart harper, nyt video news, 2020 april 14). as another contributor stated about his experience with covid in an emergency medicine blog post: "the patient will teach us about the disease, but we have to really listen and watch to see how he responds to treatments" (rezaie, 2020) . this is the predicament of changing knowledge and treatment recommendations for intubation and oxygen support over the covid pandemic. as a potentially highly transmissible aerosol generating procedure (agp), the intubation process was reevaluated and standardized in the ed. close proximity to the patient's airway, necessity of removing the patient's mask to intubate, coughing and vomiting, and patient agitation from hypoxia and respiratory distress are but a few of many potential modes of transmission (brewster, 2020) . in addition, physicians had to become comfortable with intubating adeptly while wearing bulky papr devices and using intubation equipment and barriers that often changed glottic views and required different techniques. in a situation where swift action means limited exposure for the intubator and the staff in the room, it was important that physicians felt comfortable with the new protocols. dr. joanna davidson organized several in-situ simulation training sessions to help staff get comfortable with new covid protocols. at each northshore ed pavilion, she created simulation scenarios involving both intubation and cardiac arrest of a mannequin substitute for a covid patient that increased physician, nurse, respiratory therapy, and other ed staff familiarity and comfort. her work allowed staff to practice unfamiliar tasks, gain muscle memory and facilitate experiential learning and teamwork. topics included ppe donning and doffing, intubation protocols, communication barriers, and equipment organization. she also sought to standardize protocols across the four ed pavilions as well as identify and remedy knowledge gaps to ensure staff and patient safety. intubation protocols were standardized and reviewed for safety of both staff and patient. intubations were performed in negative pressure rooms with doors closed. all staff in the room wore ppe advised for agp's: undergloves, papr devices covering head and shoulders, gown or bunny suit, overgloves (alhazzani et al., 2020) . the donning and doffing of ppe dictated proper layering to maximize protection. roles were pared down to essential personnel only in the room to minimize exposure: one intubator, one respiratory therapist to assist and manage the ventilator, and one nurse to administer medications and monitor vital signs during the procedure (see figure to the left). early on, it was recommended that the most experienced physician intubate to minimize attempts and exposure (alhazzani et al., 2020) . supply lists were standardized including a specialized covid intubation tray with equipment and a disposable medication bag with rapid sequence intubation medications (see figure) . equipment had to be readily available and in a convenient location in the er. the intubation tray was equipped for both video laryngoscopy and also alternative scenarios such as direct laryngoscopy and airway intubate to minimize attempts and exposure (alhazzani et al., 2020) . supply lists were standardized including a specialized covid intubation tray with equipment and a disposable medication bag with rapid sequence intubation medications (see figure) . equipment had to be readily available and in a convenient location in the er. the intubation tray was equipped for both video laryngoscopy and also alternative scenarios such as direct laryngoscopy and airway adjuncts like laryngeal mask airways. as well, the medication bag was securely stored and contained the most commonly used medications for intubation such as sedation for example propofol and etomidate, paralytic agents including succinylcholine and rocuronium and vasopressors. by having all agents in one bag, you can ensure that medications are quickly available in a high stress, time sensitive situation. communication during these procedures inside a closed, negative airflow room was critical not only between staff in the room wearing ppe but also between those in the room and staff outside the room. over the months that we cared for patients, staff utilized many resources including hands free phones on speaker settings as well as secure chat messaging within our emr. even simple communication like hand signals and writing on glass doors with markers helped overcome some barriers and allowed staff to quickly communicate a need for additional supplies or assistance. the intubation process itself also became more standardized to minimize or eliminate minor aerosolizing steps such as ventilating the patient using a bag valve mask (bvm) or the patient coughing without a surgical mask in place with the intubator or other staff nearby. these recommendations came both from guiding societies' general recommendations and also from shared knowledge in emergency medicine practice during this time (alhazzani, 2020; safe airway society, 2020) . use of viral filters in line with bvm minimized exposure if bagging was done peri-intubation. often bagging was not done in favor of passive oxygenation. disconnection of oxygen delivery circuits was done with knowledge of where the viral filter was in the system and using the filter as a protective layer. even the traditional -c-e‖ technique of bag valve mask use in bls training was re-evaluated to emphasize improved mask seal and prevent aerosolization (see figure) . certain groups recommended an alternative vice (v-e) grip to maximize face mask seal and minimize gas leak after induction (brewster, 2020) . in other cases, preoxygenation was done by passive strategies only such as nasal cannula. rapid sequence intubation was preferred using therapeutic doses of longer acting paralytic agents such as rocuronium to prevent coughing and vomiting during intubation as well as prolonged time to start sedative medications to minimize vent intolerance and optimize patient comfort. even wait times from administration of paralytic medication to intubation pass were advised to be a 60 second window to maximize paralytic medication effects. videolaryngoscope intubations with indirect visualization using a video screen view (such as cmac or glidescope) were preferred over direct visualization to increase the intubator distance from the patient's face. after placement, inflation of the cuff of the endotracheal tube prior to administering the first ventilated breath via bvm provided a seal to further prevent aerosolization (cheung et al., 2020) . viral filters were also applied to ventilator tubing prior to initiating mechanical ventilation. other potential situations were considered as part of intubation protocols. increased oral secretions could be managed by administering atropine prior to intubation due to the risk of aerosolization by oral suctioning. some physicians elected to use an -aerosol box,‖ a clear hard plastic box placed around the patient's face to protect the intubator from aerosolized particles (canelli et al., 2020) . every step of an already detailed intubation process was examined for risk. this careful preparation ensured that both patients and staff were kept safe during this life-saving procedure. as our experience and understanding of covid patients increased, our treatment strategies evolved as well. with less early intubation, we pursued oxygen delivery strategies with minimal risk of transmission and staff exposure. ed physician dr. ben feinzimer researched aerosolization risk and alternative oxygenation strategies and formulated new algorithms for respiratory distress for all 4 ed pavilions. we learned that some previously prohibited strategies were not as risky as previously implied. simple nasal cannula at 1-6 liters per minute with a surgical mask in place supported many patients. when this was not enough support, northshore algorithms suggested a nonrebreather (nrb) mask at 15l be placed over the nasal cannula, also with surgical mask cover over the nrb mask (see figure: -covid-19 respiratory distress algorithm‖). when greater support than a nasal cannula at 6l was required, we initially were turning to intubation as the next intervention given the need to avoid aerosolizing forces of nppv such as bipap. over time and learning lessons from the pandemic over the past few months, we began utilizing other forms of oxygen delivery such as the heated high flow nasal cannula (hhfnc). if not already in a negative pressure room, these patients were moved and hhfnc therapy was initiated. this device has larger bore nasal prongs and tubing that delivers high-velocity nasal insufflation that flushes the anatomical dead space of the upper airway, thereby creating a fresh, oxygenated, co2-depleted gas reservoir that facilitates both oxygenation and ventilation (vapotherm, n.d.) . titrations of the device involve both liter flow rate (40 to 60 liters per minute) and fraction of inspired oxygen (fi02) management. by flushing the upper airway of carbon dioxide-filled expiratory gases and replacing it with warmed, humidified, highly concentrated oxygen, the hhfnc can noninvasively support a hypoxic and hypercarbic patient. the device can also assist with work of breathing by providing positive end expiratory pressure to maintain alveolar and airway opening. a patient who continues to have tachypnea and increased work of breathing despite conventional nasal cannula or nrb oxygen delivery often experienced decreased work of breathing after transitioning to hhfnc. small studies using hhfnc showed decreased mortality and intubation rates . the device also protects against mucosal damage to the upper nasopharyngeal space by warming and humidifying gas even at high oxygen concentrations. the combination of positive pressure and high concentration of inspired oxygen means that it offers more support than the conventional nasal cannula. studies have found that it is noninferior to (doshi et al., 2018) . in addition, hhfnc is often better tolerated than nppv by the patient as they can talk, drink and eat while wearing the cannula which cannot be done easily with nppv. this becomes especially important when you're anticipating days to weeks of oxygen support while the patient recovers. lastly, early expert opinion that questioned the aerosolization of these modalities such as hhfnc and nppv and associated exposure of staff has been found to not be as significant as initially thought. modifications were made to nppv devices like bipap to ensure good interface fitting and tubing that does not create widespread dispersion of exhaled air (whittle et al., 2020) . several studies show that droplet dispersion rates are actually much lower than initially feared and the addition of a surgical mask over the oxygen device also minimizes viral spread (hui et al., 2020; leonard et al., n.d.) . concern about co2 trapping behind the mask worn on the patient's face can be significantly offset by increasing the amount of gas liter flow of the hhfnc to increase co2 washout as well as continuous co2 monitoring. nppv like bipap has gained greater acceptance in treatment of hypoxia in covid patients. oxygen saturation goals have also been debated over the last few months. with the goal of end organ damage in mind, many -happy hypoxemic‖ patients confounded typical measures of end organ perfusion. new strategies of targeting sp02 goals of >80% with careful monitoring of other measures of respiratory distress such as work of breathing, fatigue, and altered mental status have been successfully utilized both in the emergency room and in the inpatient setting. clinical trajectory was also an important measure of level of intervention: a patient with a rapidly increasing oxygen requirement over the hours they were monitored in the ed often required more interventions including intubation over a patient with a stable oxygen requirement. tobin (2020) points out the complexity of assessing respiratory status, noting that an increased respiratory rate does not in itself indicate distress; instead, respiratory muscle use, sensation of air hunger, or fatigue can be more accurate measures (p. 1319). he also points out that hypoxia does not equate to end organ damage: evidence of endorgan damage is difficult to demonstrate in patients with pao2 above 40 mm hg (equivalent to oxygen saturation of 75%) in patients with adequate oxygen carrying capacity and cardiac output (p. 1320). this more detailed understanding allows emergency medicine clinicians to avoid knee jerk responses to hypoxia without taking into consideration other measures of respiratory status. another strategy to improve oxygenation in these patients included use of prone positioning to improve oxygenation. previous studies have shown prone positioning in severe ards intubated patients improved oxygenation but had not been recommended in mild to moderate disease and in non-intubated patients (munshi et al., 2017) . one small study of early prone positioning combined with hhfnc or nppv in ards (not covid positive) patients showed improvement in oxygenation which was hypothesized to help avoid intubation (ding, wang, ma, and he, 2020) . prone positioning decreases lung compression by displacing the weight of the heart and mediastinum off the lungs, allowing for greater aeration. it also supports more homogenous ventilation as evidenced by more homogenous distribution of transpulmonary pressures in the ventral-to-dorsal axis (guerin et al., 2013) . this theoretically can improve vq mismatch and alveolar recruitment. contrary to prone positioning in an intubated patient, self or awake proning of a nonintubated patient requires less staff and less risk as long as the patient is cooperative, protecting their airway, and keeping the surgical mask in place. this may also mobilize secretions and allow for greater airway clearance. some expert opinion even notes shifting of position from side to side rather than proning can make a difference in oxygenation, yet all of these suggestions are purely anecdotal (farkas, 2020) . when we are practicing at the bleeding edge of a viral pandemic that didn't exist 6 months ago, practitioners are often forced to work with less than robust data sets. infection prevention and control are cornerstones to a pandemic response. covid dramatically changed the nature of infection prevention and control both within the hospital setting as well as in the community. testing delays meant pui-related care required precious and at times scarce ppe just as much as confirmed positive patient care. as well, room turnover and equipment use related to covid had to be carefully considered in order to balance urgent need with safety and minimal exposure. this was important not only to support staff trust and feelings of safety but also to guarantee safety to our patients as well. efficient treatment room turnover in the ed even during non-covid times is paramount to smooth ed throughput. with covid, many questions arose regarding this workflow and how to protect not only direct care staff and the next patient using the room but also the environmental services staff tasked with cleaning the room. cdc guidance about when to enter a room after the patient has vacated takes into account ventilated air exchanges to remove potentially infectious particles, also known as air changes per hour (achs) (cdc, 2020 may 18). northshore was in line with these national recommendations as increased inpatient volume has stressed workflows in areas with direct covid patient care. achs and room type (standard versus negative airflow room) were evaluated and environmental services protocols followed the time recommendation for the number of ach's required to ensure 99.9% removal of potentially infectious particles in that room. in a standard ed patient room, this was 70 minutes; in an airborne isolation room with negative airflow, this wait time to enter and clean was reduced to 35 minutes due to the increased rate of achs. while this slowed room turnover, it assured that patients and staff were protected from viral transmission. as well, these protocols were applied to common areas such as radiology. these protocols became particularly important when considering areas like ct scanners which must be available at a moment's notice for trauma or stroke patients. a ct scanner goes -out of commission‖ for several hours after scanning a covid positive patient due to the cleaning process of equipment and room. this can be disastrous for a critically ill patient presenting with massive trauma or stroke. our radiology technologists worked tirelessly to ensure adherence to these infection control guidelines while also preserving as efficient workflow as possible. measures to limit movement of patients through the hospital were also adopted. two view pa and lateral chest x-rays were deferred in favor of portable ap chest x-rays that could be done in the patients' rooms (jacobi, chung, bernheim, and eber, 2020) . in addition, northshore's radiology technologists utilized innovative techniques to limit ppe use and staff exposure: the portable x-ray unit was placed outside the patient room with the tube directed through the glass of the isolation room window. the ap chest x-ray that is shot through the glass is of diagnostic quality. as part of modifications to workflows developed during the 2014 ebola outbreak, the university of washington showed that this can be done through wire-reinforced glass, through opened metal venetian-style blinds, and even 10 to 15 feet away from the patient across an isolation antechamber room into an isolation room (moss-basha, 2020). the patient is placed upright in the bed or in a wheelchair and a staff member (often a ppe-clad nurse) in the room places the double-bagged x-ray cassette behind the patient just prior to the x-ray. after the x-ray is done, the only equipment decontamination required is the cassette. using this technique, ppe is reduced, less equipment decontamination is required and staff exposure is reduced. physicians and staff in the ed sought to minimize exposure without compromising patient care. providers used cell phones and ipads to update patients and clarify treatment plans and also minimize the number of times the provider entered the room. in return, patients appreciated the ease of communication. by early march, northshore anticipated that many areas of its healthcare system would be stressed by the pandemic. northshore worked both with state and national authorities to analyze data and trends to best anticipate needs of the community. it was anticipated early on that screening and testing would be an integral part of the services we could provide the community. this could include any patient from a -walking well‖ who had mild symptoms or a history of exposure or travel to a critically ill and hypoxic patient. northshore had to be prepared to handle extremely high volume and variety, triaging effectively and moving patients through spaces that kept them safe but also served their needs. early on, discussions on how to convert spaces to isolate, evaluate, and test -walking well‖ populations centered on providing excellent care isolated from other patients in the department. two hospitals, evanston and northbrook, began building out areas in the ambulance bay to create a space distant from the main ed rooms but convenient for staff to operate. while the space was being built, well-appearing patients with stable vital signs were evaluated by staff in a tent adjacent to the evanston ed to best isolate potential covid positive patients. within weeks, this quickly expanded to a physical space encompassing the entire ambulance bay at evanston hospital that could manage dozens of patients at once. patients were socially distanced in both triage and evaluation areas of this part of the covid bay. the area included computers, phone lines, portable bathrooms, even an area for chest x-rays. data analytics was crucial at this time, often working to analyze how well these patients appeared and what level of care required: testing, interventions, hospital admission versus discharge home from ed, etc. using this data, northshore was able to see that most of the patients tested were well enough to go home with strict isolation protocols and that only a small percentage required further evaluation or hospital admission. app's were extremely helpful in the triage of these patients in this covid tent space. adequate staffing of these areas often required additional staff and many app's from other areas of the hospital system stepped in to help. the decrease in surgeries and outpatient visits allowed northshore to increase resources in areas stressed by the pandemic such as the ed. these app's were quickly trained to work in areas directly treating covid patients including triage, evaluation, and testing. an app could evaluate a patient presenting to the covid bay for covid testing and help determine whether further evaluation was needed: for example, a patient complaining of shortness of breath and fevers but also reporting leg swelling would need more resources than the test space could provide. for those patients requiring further evaluation in the ed, transfer into a negative airflow room in the main area using proper ppe and isolation protocols was done. despite the constant possibility of a patient needing more testing and intervention than the covid bay could provide, the majority of the patients seen in this area were well served by the dedicated resources and testing done there. these patients were triaged, tested and educated on self-quarantine measures and symptoms to seek medical care prior to discharge from the ed. so much so that the decision has been made at this time to keep these areas open and prepared for other potential surges in cases later this year. the immediate cares (ic) of northshore were integral to northshore's covid response and one of the most heavily utilized resources for covid testing in the community. the immediate cares were re-designed to accommodate large volumes of mildly ill patients with symptoms of covid. a combination of a online covid portal for triaging patient complaints, nurse phone lines, telehealth visits, drive thru testing, and designated immediate care testing sites enabled the northshore system to meet the needs of the community while also ensuring that other areas of the system, such as the emergency department or primary care offices were not overwhelmed. their efforts were an incredible success at triaging and addressing these populations who were able to manage their covid illness in an outpatient setting or at home. early on, certain ic's were chosen to be dedicated covid testing centers. these sites were chosen both for their location in the community as well as their physical separation from clinical areas seeing non infected patients such as primary care offices. many of these sites took over adjoining family and internal medicine offices to increase the quantity of treatment rooms given the necessary time it took to turn over rooms related to ventilation and cleaning protocols similar to inpatient environmental services protocols. through these modifications, a 4-room immediate care setting very quickly became a 25-room covid-focused testing center. with these modifications, one ic location saw and tested up to 200 patients daily in its busiest weeks. by dedicating staff and space to covid testing, ic staff quickly became proficient in ppe protocols and testing. fewer ic staff across the system were exposed to covid given the efforts to triage patients and direct them to designated testing centers. this contributed to their extremely low covid testing positivity rates among staff. with less staffing hours lost to illness and greater staff comfort and confidence in covid management, patients also received the best quality care. of course, the occasional walk-in patient with covid-like symptoms was seen in an ic outside these four dedicated ic's, but even these scenarios were tightly protocolized. these scenarios included instructions to patients directing them to one of the designated ic testing sites or immediate rooming of patients to minimize time the patient is in a common waiting area, use of telephones in room to complete registration by staff outside the room, and use of proper ppe to protect staff at that site. one of the many striking aspects of ic triage algorithms is the acknowledgement of the early period of covid illness when pcr testing was more likely to yield false negative results. these algorithms advise a -watch and wait‖ approach if a patient is in the first three days of symptoms and managing their symptoms safely. similar approaches were also applied to patients presenting without symptoms but with positive exposures. studies have shown a high false negative rate if a patient is tested too early due to a variety of factors (kucirka et al., 2020) . this results in missed diagnosis, false reassurance given to patients, in appropriate discontinuation of self-isolation protocols, and waste of valuable covid testing swabs. similarly, clinically severe or worsening conditions were addressed effectively. red flag symptoms such as fevers combined with shortness of breath, resting or ambulatory hypoxia or chest pain had much different workflows than an asymptomatic patient with concern for exposure. the good working relationship between the ic's and ed's of northshore facilitated seamless communication about the patient's condition and work up thus far: patients forwarded to the ed could be addressed promptly. the goal of medical workflows is to get the patient the most appropriate care by the most expeditious route possible: the ic was an excellent example of this effort. based on the presence or absence of symptoms, duration of symptoms, and history of comorbidity or pregnancy, a patient could be adeptly directed to monitor symptoms at home with close follow up, towards drive thru testing with minimal exposure of all parties, or to an ic visit, an ob visit if pregnant, or the ed. as of early june, there are over 7 million documented cases of covid worldwide. approximately 2 million of those were diagnosed within the united states, which far outweighs the amount of cases in any other country in the world. illinois continues to rank high among all states for covid cases, with nearly 130,000 positive cases so far. daily positive cases continue to oscillate in frequency over the past few weeks but the general trend has been a decline since early may. illinois has begun the process of ‗phase three' of reopening chicago and the state, which includes the opening of non-essential businesses like restaurants (outdoor dining only), personal services (barbershops and salons), and retail (cdph, june 3, 2020). throughout this process, health officials continue to stress the importance of hand hygiene, mask use, and social distancing to prevent the occurrence of a surge in cases. the number of positive cases within the northshore system nears 8,720 patients with nearly a 24% positive rate of the total 36,347 tested (northshore, 2020). as part of the reopening plan, northshore has begun to reinstate certain outpatient/nonemergent services. emerg ency department visits within illinois for shortness of breath, covid-like illness, and pneumonia continue to decline daily (idph, june 2020). this figure has been compiled from illinois' syndromic surveillance system and shows a decreasing percentage of visits to the emergency department for a chief complaint of pneumonia, covid-like illness, or shortness of breath (see figure) . northshore's own ed census decreased over the early months of the pandemic, mirroring national trends in emergency rooms. as the state has started reopening, emergency department volumes for non-covid complaints as a whole have begun to steadily climb as tensions abate. immediate care clinics continue to be a vital component of the ongoing battle with covid, with nearly 25,500 covid supersite icc visits and 6,900 drive thru visits to date. they continue to utilize their apps to triage patients, complete telehealth visits, and see patients source: https://www.dph.illinois.gov/covid19/syndromic-surveillance on june 21, 2020 in the clinic. as we move further into the summer, iccs will reevaluate the distribution of resources and continue to adjust to demand. northshore is processing thousands of rt-pcr tests a day, accommodating testing for several other non-northshore affiliated clinics and hospitals. northshore continues to follow a similar testing criteria as what was established in april, but have begun to expand testing to asymptomatic individuals with positive exposure, pre-surgical candidates, and labor and delivery. the hospital system continues to struggle with achieving reliable supply of rapid antigen tests. as northshore is able to secure a steady supply, the admission protocol is likely to evolve once again. ppe supply continues to remain adequate in most areas of the country as many companies have ramped up ppe production. ed personnel continue to wear full ppe for every pui and confirmed positive, although the number of these encounters have steadily decreased in frequency. we continue to use hospital-provided scrubs every day, wear a surgical mask through our entire shift, and pass through temperature and symptom screening every day. we continue to participate in bi-weekly ed covid conferences and weekly northshore covid physician updates. although the number of patients requiring this isolation has significantly decreased, the tents remain open in anticipation of another possible surge. as chicago moves into subsequent phases of reopening, it's impossible to know if cases will spike. in the meantime, the tents stay open to accept stable patients that present for testing. in addition, northshore services like snf covid swab teams continue to operate in congregate living facilities to evaluate and test symptomatic patients. as well, outpatient areas like primary care offices continue to do what they can to support their patients and keep them out of the emergency room and the hospital. physicians, app's, nurses, and office staff have triaged countless phone calls, telemedicine messages, and in person visits to keep patients as healthy and able as possible. northshore continues to adjust screening criteria, admission protocols, and staffing as we learn more about the virus and attempt to prepare. however, changes are happening at a rapid rate and it's difficult to predict what the future will bring. as we move into the summer months, there are many factors that will affect transmission with the possibility of warmer weather making a difference. a study out of mount auburn hospital found that, "while the rate of virus transmission may slow down as the maximum daily temperature rises to around 50 degrees (f), the effects of temperature rise beyond that don't seem to be significant." this indicates that it is unlikely that disease transmission will slow dramatically in the summer months from the increase in temperature alone (sehra, 2020). the study also found that the transmission rate is highest in months where the temperature is below thirty degrees fahrenheit, meaning the rate of positive covid cases will most likely increase as we move back into fall and winter. this will coincide with increased rates of several other respiratory viruses, including influenza and rsv. this challenge will allow us to reconsider how we approach triage and testing for respiratory complaints. in the meantime, northshore has started to provide ‗covid kits' to positive patients that are able to remain at home or those that have been discharged after admission. this kit includes masks, hand sanitizer, gloves, and most importantly--a pulse oximeter. patients are given the ability to monitor their oxygen levels at home. this will help catch the -happy hypoxic‖ patients who have low oxygen saturation but don't feel short of breath enough to present to the ed themselves. catching these patients early would theoretically prevent patients from presenting to the ed when their pulse oximeter is dangerously low with significant respiratory distress. the positive patients are followed by a designated outpatient team until their infection has cleared. this is an indispensable resource to those that don't have a primary care doctor to turn to when questions arise. with resources like antibody testing coming into play, we question when we will be able to achieve herd immunity to covid. as of late may, only a small portion of the population has built up antibodies to the virus. antibody testing has given us the ability to detect a history of the virus in those that may have been asymptomatic. in the area hit hardest by the pandemic within the united states, new york city, only 19.9% of the population has positive antibody status. in order to achieve herd immunity, it is necessary that 70 percent of the population show positive antibody status. -this implies that over 200 million americans would have to get infected to reach this threshold. even if the current pace of the covid pandemic continues in the united stateswith over 25,000 confirmed cases a dayit will be well into 2021 before we reach herd immunity. if current daily death rates continue, over half a million americans would be dead from covid by that time‖ (dowdy & d'souza, 2020) . attaining significant herd immunity would play a huge role in slowing down transmission rates. the majority of the chicago area population remains susceptible to the virus, but according to the data collected by northshore's team, around 5.17% of the northshore population has positive antibody status. this is a far cry from the 70% necessary for herd immunity, but immunity status can perhaps be improved with the availability of an effective vaccination. we continue to learn more about the virus as we search for ways to slow its spread and effectively treat its complications. many of the changes already made are likely here to stay, but the circumstances will almost certainly evolve as we navigate 2020 and another respiratory virus season. this article sought to describe one ed's response to the pandemic, given changing understanding of both the disease, its spread, and its complications. we understand that our experience is different from other ed's nationally and internationally in staffing, utilization of app's, social demographics, and resources. we believe that knowledge sharing is key to effective action and hope that this article is both informative and interesting. as we move forward, we approach reopening with caution and reiterate the importance of safe social distancing and mask usage. northshore's ed team remains vigilant and prepared to take on whatever the future may bring. abbott receives fda emergency use authorization for covid-19 antibody blood test on alinity™ i system pulmonary vascular endothelialitis, thrombosis, and angiogenesis in covid-19 surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (covid-19) covid-19 in critically ill patients in the seattle region-case series consensus airway society principles of airway management and tracheal intubation of covid-19 adult patients group barrier enclosure during endotracheal intubation second travel-related case of 2019 novel coronavirus detected in united states decontamination and reuse of filtering facepiece respirators interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings using personal protective equipment (ppe) xpert ® xpress sars-cov-2 product resources staff safety during emergency airway management for covid-19 in hong kong covid-19: protecting healthcare workers is a priority latest data. retrieved on phase iii cautiously reopen industry guidelines for reopening acute stroke care in the coronavirus disease efficacy and safety of early prone positioning combined with hfnc or niv in moderate to severe ards: a multi-center prospective cohort study high-velocity nasal insufflation in the treatment of respiratory failure: a randomized clinical trial early herd immunity against covid-19: a dangerous misconception risk for transportation of coronavirus disease from wuhan to other cities in china nurses disciplined, fired for wearing hospital-issued scrubs covid-19. the internet book of critical care personal protective equipment: protecting health care providers in an ebola outbreak coronavirus (covid-19) update: fda issues new policy to help expedite availability of diagnostics first known person-to-person transmission of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) in the usa community transmission of sars-cov-2 at two family gatherings prone positioning in severe acute respiratory distress syndrome covid-19 associated multisystem inflammatory syndrome in children (mis-c) guidelines; a western new york approach here's what you need to know about coronavirus in evanston. the daily northwestern letter from u.s. fda to quidel corporation regarding device sofia 2 sars antigen fia first case of 2019 novel coronavirus in the united states europe confronts coronavirus as italy battles an eruption of cases exhaled air dispersion during high-flow nasal cannula therapy versus cpap via different masks illinois hospital report card. retrieved on illinois first state to test for novel coronavirus mayor lightfoot, governor pritzker, public health and chicago public schools officials announce new presumptive positive case of coronavirus disease public health officials announce first coronavirus disease cases outside chicago and cook county [press release public health officials announce first illinois coronavirus disease death public health officials announce 163 new cases of coronavirus disease portable chest x-ray in coronavirus disease-19 (covid-19): a pictorial review update: public health response to the coronavirus disease 2019 outbreak-united states evidence for limited early spread of covid-19 within the united states use of personal protective equipment among health care personnel: results of clinical observations and simulations variation in false-negative rate of reverse transcriptase polymerase chain reaction-based sars-cov-2 tests by time since exposure assessment of healthcare worker protocol deviations and self-contamination during personal protective equipment donning and doffing covid-19 transmission assessment report. high velocity nasal insufflation (hvni) therapy application in management of covid-19 breaking down the different types of covid-19 tests -and why illinois and the nation have struggled with mass testing amid the pandemic china coronavirus: what do we know so far? management of covid-19 respiratory distress the us now leads the world in confirmed coronavirus cases intubation and ventilation amid the covid-19 outbreak: wuhan's experience public health responses to covid-19 outbreaks on cruise shipsworldwide policies and guidelines for covid-19 preparedness: experiences from the university of washington warmer temperatures slow covid-19 transmission, but not by much prone position for acute respiratory distress syndrome. a systematic review and metaanalysis doctors face troubling question: are they treating coronavirus correctly coronavirus: the first three months as it happened air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) from a symptomatic patient rebel cast ep79: covid-19 -trying not to intubate early & why ardsnet may be the wrong ventilator paradigm presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with covid-19 in the new york city area guidance: paediatric multisystem inflammatory syndrome temporally associated with covid-19 covid-19 airway management diagnostic testing for the novel coronavirus public health response to the initiation and spread of pandemic covid-19 in the united states coroner: first us covid-19 death occurred in early february. center for infectious disease research and policy news review of aerosol transmission of influenza a virus basing respiratory management of coronavirus on physiological principles who director-general's remarks at the media briefing on 2019-ncov on 11 clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective, observational study. the lancet respiratory medicine high velocity nasal insufflation and humidification: a summary of mechanisms of action the experience of high-flow nasal cannula in hospitalized patients with 2019 novel coronavirus-infected pneumonia in two hospitals of chongqing respiratory support for adult patients with covid-19 co-infection with sars-cov-2 and influenza a virus in patient with pneumonia, china protecting chinese healthcare workers while combating the 2019 novel coronavirus we'd like to thank all the people who participated in interviews and contributed to the writing of this article including sue bednar, apn, ali ruiz, pa-c, pam walsh, pa-c, kurt ortwig, apn, olga amusina, dnp, acnp, mary lavin, rn, jessica folk, md, joanna davidson, md, ben feinzimer, md, gulia labellarte, apn-cnp, mia donoghue, apn-cnp, and jeffery graff, md key: cord-284274-9uu7yflt authors: russi, christopher s.; heaton, heather a.; demaerschalk, bart m. title: emergency medicine telehealth for covid-19: minimize front-line provider exposure and conserve personal protective equipment (ppe) date: 2020-08-13 journal: mayo clinic proceedings doi: 10.1016/j.mayocp.2020.07.025 sha: doc_id: 284274 cord_uid: 9uu7yflt nan novel coronavirus continues to spread across the globe. 1,2 united states (us) hospitals in densely populated urban locales are overwhelmed with new cases that exceed their ability to provide safe efficient care to everyone while simultaneously conserving personal protective equipment (ppe) for their workforce. [3] [4] [5] [6] [7] sadly, our colleagues and friends on the frontlines of the covid-19 fight are sharing lessons with others as we prepare for the continued viral spread. 4, [8] [9] [10] [11] [12] hospitals across the nation have scrambled emergency preparedness and incident command teams to redistribute limited resources, retool workflows, and develop safe care practices for patients, families and healthcare teams. telehealth activities and tools are being rapidly deployed across the nation to help limit disease spread, reduce healthcare workforce (hcw) exposure and conserve valuable ppe. [13] [14] [15] [16] [17] [18] [19] [20] [21] telehealth is a more broadly encompassing term for all digital activities used for healthcare, whereas telemedicine can be loosely defined as direct virtual medical care from a health care professional to the patient. it is important to make the distinction between both synchronous and asynchronous telehealth activities; the former occurring real-time. in response to the pandemic and national emergency declaration, the federal government has eased restrictions on what were once significant administrative, regulatory, and legislative barriers to telehealth deployment: state licensure, hospital privileging and credentialing, range of providers, types of services and originating sites, government and commercial health insurance reimbursement, parity with regular in-person visits, and allowable digital technologies. this has opened a time-sensitive opportunity for novel, digital approaches to acute emergency and intensive patient care that should reduce healthcare risk by mitigating exposure and save highly valuable ppe. further, the accelerated adoption of existing digital tools by health consumers, payers and providers, coupled with analytics will help drive future healthcare strategic planning. mayo clinic contracts with intouch health for both software and hardware solutions for synchronous acute care telehealth programs. however, there are a myriad of hardware and software solutions that exist that could be stood up in a relatively short time frame in healthcare organizations that currently do not utilize telehealth (i.e. zoom, san jose, ca). the future of telehealth and healthcare will be debated following this crisis. we predict a profound change to current state health care operations. our purpose is to outline current mayo clinic strategies harnessing telehealth solutions for covid-19 emergency preparedness and acute emergency care . the mayo clinic emergency medicine telehealth (teleem) program is an ongoing network serving rural emergency departments across our large midwest practice, using both synchronous video and telephonic tools for complex or critically ill patients. however, given the current crisis, the department of emergency medicine has expanded this role internally by adopting telehealth to support its own academic campus. what makes mayo clinic unique is our large integrated multispecialty practice and our multidisciplinary approach to patient care. telehealth can amplify that work via the intouch health software platform via a feature called "multi-presence" allowing for multiple participants to engage a patient simultaneously (image 1.) after a primary synchronous video connection is established, other teams can join the video session as "guests" allowing for the multidisciplinary team approach to complex, high-acuity critical care. currently, the teleem team can bring in cardiology, critical care, neurologic critical care, pediatric intensive care (picu), telestroke, teleneonatology, teleobstetrics, as well as em telepharmacy primary benefits to utilizing telehealth internally and mission aims are to conserve ppe and reduce the hcw exposure when safely possible. telehealth opens the door to new models of acute emergency care. multiple workflows were identified as amendable to augmentation with telehealth technology. first, a variation in the provider in triage model: hemodynamically stable patients arriving to the ed suspect for covid-19 without respiratory distress and mild symptoms, do not require a full ed exam room. it is unlikely they require hospitalization but may require covid-19 testing and may be seen by a teleem physician via video. following an appropriate synchronous video exam during nurse triage and testing if necessary, patients may be discharged from an intake or triage area. this will keep open critical ed rooms for the more acutely ill patients arriving. a significant risk to the health care team comes from our desire to check on patients; in our ed, we deployed microsoft surface pro devices to reside in our patient care rooms. attending physicians and other members of the provider care team, nursing and consulting services, as well as ancillary teams like registration and social work are able to remote into each room and see patients virtually. consider how often hcws re-enter rooms to re-examine or communicate with patients; without a telehealth mechanism, this approach would consume massive and unsustainable amounts of ppe. starting mid-march through may, we observed 3508 uses with a median time of 1.5 minutes. we suspect the majority of uses are for patient reassessments for pain or therapeutics. however, it can be argued that this is 3508 ppe saved or potentially 3508 less hcw exposures for patients with covid symptoms. for more high risk situations, devices were deployed to our resuscitation and negative air flow rooms to facilitate lean teams and observe for ppe breaches. these are rooms where high risk procedures, like intubation, and aerosol generating activities, like nebulizers, occur. through these devices, we are able to locate our recording nurse outside the care room and facilitate more clear communication between the team in the room and the supply runners to ensure expeditious care of these often times critically ill patients. in addition, the mayo clinic center for connected care is liberally deploying microsoft surface pro devices across the rural mayo clinic health system (mchs) eds allowing for any quarantined, well ed physicians to see low acuity patients and off load clinical surge. deployment of telehealth internally on the academic campus ed creates new conceptual utilization that will drive the conversation on future care delivery. the future of telehealth and healthcare will be debated following this crisis. we predict a profound change to current state health care operations. . emergency medical services (ems) is also at the forefront of this pandemic. urgent efforts are underway to modify guidelines and protocols for ems teams to care for covid-19 known or suspected patients while simultaneously protecting teams and conserving ppe resources. mayo clinic ambulance (mca) has been developing and testing a community paramedic program, in partnership with the teleem program, and recently completed a feasibility study on field telehealth. the feasibility and early clinical results were promising. now, building on that work our ems system spanning minnesota and western wisconsin is well positioned to be the community pandemic response supported by the teleem team. mca is actively deploying telehealth solutions to all of the ambulance teams across the network. using a toughbook (panasonic, inc.) and the intouch health software, teams will be able to audio-video link to on-duty teleem or ems physicians in out-of-hospital locales for guidance and triage. paramedic crews will face unique challenges in the coming weeks and months. non-pandemic, normal operations are typically transporting patients for evaluation in an emergency department. however, during a pandemic with surge, with limited ppe and resources in short supply, ems teams will conceivably need to make challenging decisions during field resuscitations and whether or not patients should be transported for care. teleem and ems physicians can support decision making using synchronous advice to frontline paramedic teams delivering care. whether in symptomatic patients' homes for remote monitoring, ambulances in the field for transport, tents outside healthcare facilities for screening and testing, eds for diagnosis and treatment, or in the hands of all acute care providers for consultation, telehealth tools are being deployed across the continuum of ems and emergency medicine to help limit disease spread, reduce hcw exposure and conserve valuable ppe. j o u r n a l p r e -p r o o f coronavirus (covid-19) coronavirus covid-19 global cases by the supporting the health care workforce during the covid-19 global epidemic hospital surge capacity in a tertiary emergency referral centre during the covid-19 outbreak in italy personal protective equipment during the covid-19 pandemic -a narrative review covid-19: the crisis of personal protective equipment in the us waste not, want not: the re-usability of n95 masks protecting healthcare personnel from 2019-ncov infection risks: lessons and suggestions covid-19 containment: china provides important lessons for global response is africa prepared for tackling the covid-19 (sars-cov-2) epidemic. lessons from past outbreaks, ongoing pan-african public health efforts, and implications for the future a rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-ncov) infected pneumonia (standard version) clinical features of cases and a cluster of coronavirus disease 2019 (covid-19) in bolivia imported from italy and spain telemedicine in the time of coronavirus whatsapp messenger as a teledermatology tool during coronavirus disease (covid-19): from bedside to phone-side proposed protocol to keep covid-19 out of hospitals video consultations for covid-19 virtually perfect? telemedicine for covid-19 covid-19 and health care's digital revolution rapid scale-up of telehealth during the covid-19 pandemic and implications for subspecialty care in rural areas global telemedicine implementation and integration within health systems to fight the covid-19 pandemic: a call to action electronic personal protective equipment: a strategy to protect emergency department providers in the age of covid-19 key: cord-330737-6khv4kbj authors: cohen, jennifer; van der meulen rodgers, yana title: contributing factors to personal protective equipment shortages during the covid-19 pandemic date: 2020-10-02 journal: prev med doi: 10.1016/j.ypmed.2020.106263 sha: doc_id: 330737 cord_uid: 6khv4kbj this study investigates the forces that contributed to severe shortages in personal protective equipment in the us during the covid-19 crisis. problems from a dysfunctional costing model in hospital operating systems were magnified by a very large demand shock triggered by acute need in healthcare and panicked marketplace behavior that depleted domestic ppe inventories. the lack of appropriate action on the part of the federal government to maintain and distribute domestic inventories, as well as severe disruptions to the ppe global supply chain, amplified the problem. analysis of trade data shows that the us is the world's largest importer of face masks, eye protection, and medical gloves, making it highly vulnerable to disruptions in exports of medical supplies. we conclude that market prices are not appropriate mechanisms for rationing inputs to health because health is a public good. removing the profit motive for purchasing ppe in hospital costing models and pursuing strategic industrial policy to reduce the us dependence on imported ppe will both help to better protect healthcare workers with adequate supplies of ppe. since early 2020 the us has experienced a severe shortage of personal protective equipment (ppe) needed by healthcare workers fighting the covid-19 pandemic (emanuel et al., 2020; livingston, desai, & berkwits, 2020) . in protests covered by the news media, healthcare workers compared themselves to firefighters putting out fires without water and soldiers going into combat with cardboard body armor. medical professionals have called for federal government action to mobilize and distribute adequate supplies of protective equipment, especially gloves, medical masks, goggles or face shields, gowns, and n95 respirators. n95 respirators, which have demonstrated efficacy in reducing respiratory infections among healthcare workers, have been in particularly short supply (macintyre et al., 2014) . without proper ppe, healthcare workers are more likely to become ill. a decline in the supply of healthcare due to worker illness combines with intensified demand for care, causing healthcare infrastructure to become unstable, thus reducing the quality and quantity of care. sick healthcare workers also contribute to viral transmission. hence ill practitioners increase the demand for care while simultaneously reducing health system capacity. this endogeneity makes a ppe shortage a systemwide public health problem, rather than solely a worker's rights or occupational health issue. ppe for healthcare workers is a key component of infection prevention and control; ensuring that healthcare workers are protected means more effective containment for all. we investigate the four main contributing factors behind the us shortage of ppe in 2020 and their interaction. first, a dysfunctional budgeting model in hospital operating systems incentivizes hospitals to minimize costs rather than maintain adequate inventories of ppe. second, a major demand shock triggered by healthcare system needs as well as panicked j o u r n a l p r e -p r o o f journal pre-proof marketplace behavior depleted ppe inventories. third, the federal government failed to maintain and distribute domestic inventories. finally, major disruptions to the ppe global supply chain caused a sharp reduction in ppe exported to the us, which was already highly dependent on globally-sourced ppe. market and government failures thus led ppe procurement by hospitals, healthcare providers, businesses, individuals, and governments to become competitive and costly in terms of time and money. the remainder of this article provides detailed support for the argument that the enormous ppe shortages arose from the compounding effects of these four factors. we conclude that because health is a public good, markets are not a suitable mechanism for rationing the resources necessary for health, and transformative changes are necessary to better protect healthcare practitioners. the 2020 shortage of ppe was an eventuality that nonetheless came as a surprise. the us experienced heightened demand for ppe in the mid-to late-1980s following the identification of the human immunodeficiency virus and the release of centers for disease control (cdc) guidelines for protecting health personnel (segal, 2016 (hersi et al., 2015) . although various stakeholders (governments, multilateral agencies, health organizations, universities) warned of the possibility of a major infectious disease outbreak, particularly pandemic influenza, most governments were underprepared. the world economic forum's annual global risks report even showed a decline in the likelihood and impact of a spread of infectious diseases as a predicted risk factor between 2015 and 2020 (wef, 2015 (wef, , 2020 . the problems created by lack of preparation were exacerbated by the high transmissibility of covid-19 and the severity of symptoms. contributing to the inadequate stockpiles of ppe were the trump administration's policies -which included public health budget cuts, "streamlining" the pandemic response team, and a trade war with the country's major supplier of ppeweakening the cdc's capacity to prepare for a crisis of this magnitude (devi, 2020) . the ppe shortage is reflected in survey data on ppe usage and in data on covid-19 morbidity and mortality. as of may 2020, 87% of nurses reported having to reuse a single-use disposable mask or n95 respirator, and 27% of nurses reported they had been exposed to confirmed covid-19 patients without wearing appropriate ppe (nnu, 2020). as of july 28, 2020, at least 1,842 nurses, doctors, physicians assistants, medical technicians, and other healthcare workers globally, and 342 in the us, have died due to the virus, and many more have become sick (medscape, 2020) . the cdc aggregate national data of 114,529 cases among healthcare personnel and 574 deaths (cdc, 2020b). healthcare workers have died from covidhealthcare worker deaths by state recorded in medscape (2020) are correlated with cdc (2020b) covid-19 cases by state (pearson's r of 0.552, p<0.00) and even more strongly correlated with cdc-confirmed covid deaths in the general population (pearson's r of 0.953, p<0.00). these correlation coefficients are indicative of healthcare worker exposure to the virus, and of the critical role of ppe and healthcare systems for population health. in other words, population health is a function of the healthcare system and wellbeing of healthcare workers, and the wellbeing of healthcare workers is a function of the healthcare system and ppe. we now turn to our analysis of ppe shortages, which identifies on four contributing factors: the way that hospitals budget for ppe, domestic demand shocks, federal government failures, and disruptions to the global supply chain (figure 2 ). these four factors arose from a number of processes and worked concurrently to generate severe shortages. the first factor the budgeting model used by hospitals is a structural weakness in the healthcare system. the occupational safety and health administration (osha) requires employers to provide healthcare workers with ppe free of charge (barniv, danvers, & healy, 2000; osha, 2007) . from the perspective of employers, ppe is an expenditurea cost. ppe is unique compared to all of the other items used to treat patients (such as catheters, bed pans, and medications) which operate on a cost-passing model, meaning they are billed to the patient/insurer. an ideal model for budgeting ppe would align the interests of employers, healthcare workers, and patients and facilitate effective, efficient care that is safe for all. instead, the existing structure puts employers who prioritize minimizing costs and healthcare workers who prioritize protecting their safety and the health of their patients in opposition, leaving governmental bodies to regulate these competing priorities (moses et al., 2013) . employers, be they privately-owned enterprises, private healthcare clinics, or public hospitals, seek to minimize costs. in economic theory, cost-minimization is compelled through market competition with other suppliers. in practice, cost-minimization is a strategy for maintaining profitability or revenue. therefore, hospital managers adopt cost-effective behaviors by reducing expenditures in the short term to lower costs (mclellan, 2017) . despite some hospitals' tax-exempt status, hospitals function like other businesses: they pursue efficiency and cost minimization (bai & anderson, 2016; rosenbaum, kindig, bao, byrnes, & o'laughlin, 2015) . the pursuit of efficiency means hospitals tend to rely on just-in-time production so that they do not need to maintain ppe inventories. the osha requirement effectively acts as an unfunded mandate, imposing responsibility for the provision of ppe, and the costs of provision, on employers. when it is difficult to pass along the costs of unfunded mandates to workers (in the form of lower wages) or customers (in the form of higher prices), employers resist such cost-raising legal requirements. the tension between healthcare workers and employers over ppe is evident in the way nurses' unions push federal and state agencies to establish protective standards. it is demonstrated by the testimony of the co-president of national nurses united to the committee on oversight and government reform in the us house of representatives in october 2014. she advocated for mandated standards for ppe during the ebola virus while employers were pushing for voluntary guidelines: [o]ur long experience with us hospitals is that they will not act on their own to secure the highest standards of protection without a specific directive from our federal authorities in the form of an act of congress or an executive order from the white house…the lack of mandates in favor of shifting guidelines from multiple agencies, and reliance on voluntary compliance, has left nurses and other caregivers uncertain, severely unprepared and vulnerable to infection (govinfo, 2014). employer resistance is short-sighted but unsurprising in the existing costing structure. the costing structure for other items, like catheters, allows employers to pass costs on to patients and insurers. the implication is that if employers (hospitals) cannot pass along the cost of the osha mandate to insurance companies, then employers do not have an economic incentive to encourage employees to use ppe, replace it frequently, or keep much of it in stock, at least until any gains from cost-minimization are lost due to illness among employees. the budgeting model is especially problematic when demand increases sharply, such as during the ebola virus in 2014 and the h1n1 influenza pandemic in 2009. as the site where new pathogens may be introduced unexpectedly, hospitals are uniquely challenged compared to other employers to provide protection (yarbrough et al., 2016) . but even during predictable fluctuations in demand, the existing model does not ensure that adequate quantities of ppe are available. however, previous studies have framed these problems as consequences of noncompliance among healthcare workers rather than noncompliance among employers (ganczak & szych, 2007; gershon et al., 2000; nichol et al., 2013; sax et al., 2005) . hospitals might be incentivized to avoid shortages by passing ppe costs on to patients and insurers, like other items used in care, but that approach is not the norm. this alternative cost-passing model also leaves much to be desired. where the current model induces tension between workers and employers, a cost-passing model would effectively situate practitioners against patients (cerminara, 2001) . if patients pay the costs of ppe, they might prefer that practitioners are less safe to defray costs. such a model is detrimental to both healthcare workers and patients. introducing tension to a relationship built on care and trust is precisely why the employer, not the patient, should be required to provide ppe to healthcare workers at no cost to j o u r n a l p r e -p r o o f journal pre-proof the worker. practitioners and patients should be allowed to share the common goal of improving patients' well-being. some labor economists argue that employers could (or do) pay compensating wage differentials to compensate healthcare workers for working in unsafe conditions (hall & jones, 2007; rosen, 1986; viscusi, 1993) . they believe that workers subject to hazardous conditions command a higher wage from employers compared to workers in less dangerous employment. higher wages for healthcare workers would then be embedded in the costs of care, which include pay for practitioners, that are passed along to insurance companies. however, this counterargument does not apply to healthcare practitioners because its necessary conditions are not met. workers would need perfect foresight that a crisis would require more protective equipment, knowledge of their employers' stockpile of ppe, perfect information about the hazards of the disease, and how much higher a wage they would need as compensation for these risks. this information is not available for workers who may be exposed to entirely novel pathogens that have unknowable impacts. neither the existing budgeting model nor the cost-passing model align the interests of the employer, healthcare worker, and patient. yet these three agents have a shared interest in practitioners' use of ppe. ppe, like catheters, are inputs to health. but unlike catheters, the primary beneficiary of ppe use is less easily identifiable than that of other inputs. while healthcare practitioners may appear to be the primary beneficiaries of ppe, the benefits are more diffuse. patients benefit from having healthy nurses who are not spreading infections, nurses benefit from their own health, and hospitals benefit from have a healthy workforce. nurses' health is an input to patient health, to the functioning of the hospital, and to the healthcare system. in other words, every beneficiary depends on nurses' health, which depends on ppe. still, employers' short-term profit motive dominates the interests of healthcare workers and patients, which suggests that alternative models that are not motivated by profit-seeking should be explored. the second contributing factor to the us shortage of ppe during the covid-19 outbreak was the rapid increase in demand by the healthcare system and the general public. in a national survey of hospital professionals in late march 2020 close to one-third of hospitals had almost no more face masks and 13% had run out of plastic face shields, with hospitals using a number of strategies to try to meet their demand including purchasing in the market and soliciting donations (kamerow, 2020) . american consumers also bought large supplies of ppe as the sheer scale of the crisis and the severity of the disease prompted a surge in panic buying, hoarding, and resales of masks and gloves. as an indicator of scale, in march 2020 amazon cancelled more than half a million offers to sell masks at inflated prices and closed 4,000 accounts for violating fair pricing policies (cabral & xu, 2020) . panicked buying contributed to a sudden and sharp reduction in american ppe inventories, which were already inadequate to meet demand from the healthcare system. there were two different kinds of non-healthcare buyers of ppe. a subset sought profits and bought and hoarded ppe items such as n95 respirators with the intent of reselling them at inflated prices (cohen, forthcoming) . it is likely that the majority, however, were worried consumers. while it may be tempting to blame consumers for seemingly irrational consumption, their decisions are more complex. panic buyers are consumers in the moment of buying ppe, but they are workers as well; people buy ppe because they are afraid of losing the ability to work j o u r n a l p r e -p r o o f and support themselves and their families. put simply, the dependence of workers on wages to pay for basic necessities contributes to panic when their incomes are threatened. this is rational behavior in the short term given existing conditions and economic structures. still, ppe belongs in the hands of those whose health has many beneficiaries: practitioners. eventually both the profiteer and the average, panicked worker/consumer will require healthcare, and contributing to the decimation of the healthcare work force is in no one's interest. underlying consumption behavior was intense fear of not only the disease but also fear of shortages. this panic reverberated throughout the supply chain as manufacturers tried to increase their production capacity to meet the demand for ppe (mason & friese, 2020) . one can conceptualize this mismatch between ppe demand and supply in an ability-topay framework. in much of economic theory, markets match supply and demand to determine the price of a good or service, and the price operates as a rationing mechanism. market actors choose to buy or sell at that given price. but there are problems with this framework. on the demand side, some people cannot "choose" to buy a product because they cannot afford it; they lack the ability to pay, so the decision is made for them. an example is a potential trip to the doctor for the uninsured. for many americans, whether to go to the doctor, or whether to have insurance, is not a choice; the choice is made for them because they are unable to pay. on the supply side, the ability-to-pay framework remains, except the product in question is an input. in healthcare, the practitioner is the proximate supplier of care and inputs to health are intermediate goods. the supplier's -or their employer'sability (and willingness) to pay for inputs to care, including ppe, determines the quality and quantity of care the practitioner is able to supply. when healthcare workers do not have ppe (e.g. because others bought it and resold it at extortionary prices), they are unable to provide the care patients need. but reselling behavior is j o u r n a l p r e -p r o o f also economically rational, if unethical, at least in the short term. indeed, ability-to-pay works well for the hoarder/reseller, who both contributes to and profits from the shortage. it is in the pursuit of profitsof monetary gainthat the mismatch between ppe demand and supply resides. on the demand side there is a person in need of care who is constrained by their inability to pay, while on the supply side there is a practitioner who is constrained by their inability to access the resources required to provide high quality care safely. the ability-to-pay framework is incompatible with the optimal allocation of resources when the ultimate aim is something other than monetary gain. hence market prices are not a good mechanism for rationing vital inputs to health such as ppe, and the profit motive is ineffective in resolving this mismatch between demand and supply. given the large-scale failure of the market to ensure sufficient supplies of ppe for practitioners, the government could have taken a number of corrective actions: it could have coordinated domestic production and distribution, deployed supplies from the strategic national stockpile, or procured ppe directly from international suppliers (hhs, 2020; maloney, 2020). the us government has anticipated ppe shortages since at least 2006 when the national institute for occupational safety and health commissioned a report examining the lack of preparedness of the healthcare system for supplying workers with adequate ppe in the event of pandemic influenza (liverman & goldfrank, 2007) . in a scenario in which 30% of the us population becomes ill in pandemic influenza, the estimated need for n95 respirators is 3.5 billion (carias et al., 2015) . however, the actual supply in the us stockpile was far smaller at 30 j o u r n a l p r e -p r o o f million, thus serving as a strong rationale to invoke the defense production act to manufacture n95 respirators and other ppe (azar, 2020; friese et al., 2020; kamerow, 2020) . further, the ppe in the national stockpile was not maintained on a timely basis to prevent product expiration, forcing the cdc to recommend use of expired n95s (cdc, 2020a). adding to the problems of cdc budget cuts before and during the pandemic and their failure to stockpile ppe was the unwillingness of the federal government to invoke the defense production act to require private companies to manufacture ppe, ventilators, and other critical items needed to treat patients (devi, 2020) . by july 2020, at which time the us already had more covid-19 cases than any other country in the world, there were still calls from top congressional leaders and healthcare professionals, including the speaker of the house of representatives and the president of the american medical association, for the trump administration to use the defense production act to boost domestic production of ppe (madara, 2020; pelosi, 2020; j. rosen, 2020) . researchers had also begun to publish studies on how to safely re-use ppe as it became clear that shortages would continue (rowan & laffey, 2020) . hence even five months into the crisis, the profit motive was still inadequate to attract new producers, which indicates that markets do not work to solve production and distribution problems in the case of inputs to health. not only did the government poorly maintain already-inadequate supplies and fail to raise production directly, it also failed to provide guidance requested by private sector medical equipment distributors and the health industry distributors association (hida), a trade group of member companies (maloney, 2020) . the private sector sought guidance about accessing government inventories, expediting ppe imports, and how to prioritize distribution, as indicated in this communication from hida's president: specifically, distributors need fema and the federal government to designate specific localities, jurisdictions or care settings as priorities for ppe and other medical supplies. the private sector is not in a position to make these judgments. only the federal government has the data and the authority to provide this strategic direction to the supply chain and the healthcare system (m. . moreover, it was not until early april 2020 that the trump administration issued an executive order for 3m, one of the largest american producers and exporters of n95 respirators, to stop exporting masks and to redirect them to the us market (whitehouse.gov, 2020) . looking up the supply chain, at least one distributor proposed bringing efforts to procure ppe internationally under a federal umbrella to the trump administration (maloney, 2020, p. 11 ). states-as-buyers confront the same market-incentivized structural issues that individual buyers face. a single federal purchaser would reduce state-level competition for buying ppe abroad, and mitigate the resulting inflated prices and price gouging by brokers acting as intermediaries between states-as-buyers and suppliers. the federal government chose not to take on this role. the profound government failures related to producing, procuring, and distributing ppe effectively, in ways not achievable through markets, are likely to have long-term impacts. the same distribution companies characterized, "the economics of supplying ppe in these circumstances" as "not sustainable" (maloney, 2020, p. 3) . they also expressed concern about the ongoing availability of raw materials required to manufacture ppe in the future. hida member companies expressed these concerns about supply chain issues in calls with federal agencies between january and march 2020, specifically with respect to long-term supply chain issues impacting the upcoming 2020-21 flu season (maloney, 2020, p. 5) . in mid-june, fema officials acknowledged that, "the supply chain is still not stable" (maloney, 2020, p. 9 ). a smoothly functioning supply chain has immediate impacts on the ability of governments and health personnel to contain an epidemic. the infectiousness and virulence of the disease affects the demand for ppe, just as the supply chain's functionality impacts the spread of the disease by improving practitioners' ability to treat their patients while remaining safe themselves (gooding, 2016) . the us domestic supply chain of ppe has been unable to sufficiently increase production to meet the enormous surge in demand. a large portion of the ppe in the us is produced in other countries. excessive reliance on off-shore producers for ppe proved problematic in earlier public health emergencies (especially the 2009 h1n1 influenza pandemic and the 2014 ebola virus epidemic), and this lesson appears to be repeating itself during the covid-19 pandemic (patel et al., 2017) . the incentive for hospitals and care providers to keep costs down has kept inventories low and driven sourcing to low-cost producers, especially in china. china's low production costs combined with high quality have made it the global leader in producing a vast range of manufactured goods, including protective face masks, gloves, and gowns. even with the emergence of other low-cost exporters, china dominates the global market for ppe exports. meanwhile, the us is the world's largest importer of ppe. yet although the us is extremely dependent on the global supply chain, us manufacturers of ppe are also major exporters given the profits available in world markets. the trade data in table 1 show the world's four top exporters of face masks, eye protection, and medical gloves. the data is drawn from the un comtrade database, using trade classifications from the who's world customs organization for covid-19 medical supplies j o u r n a l p r e -p r o o f (who, 2020) . in these data, the category "face masks" includes textile face masks with and without a replaceable filter or mechanical parts (surgical masks, disposable face-masks, and n95 respirators); "eye protection" includes protective spectacles and goggles as well as plastic face shields; and "medical gloves" includes gloves of different materials such as rubber, cloth, and plastic (who, 2020). we collected data for the 2015-2019 period. because patterns in 2015-2017 were very similar to those of 2018, the china is the world's largest exporter of medical face masks and eye protection, followed not far behind by the us. the fact that the us recently exported such large amounts of a commodity that in early 2020 was marked by extreme shortages is indicative of the lack of public health planning and political will. unlike the case of masks and eye protection, the us is not a top exporter of medical gloves. the three largest exporters of medical gloves are all in asia and are well endowed with natural rubber. table 1 also shows that the us is by far the largest importer of face masks, eye equipment, and medical gloves in the world market, followed by japan, germany, france, and the uk. overall, this analysis points to the high vulnerability of the us to disruptions in the global supply chain of face masks, eye protection, and medical gloves, and especially to disruptions in exports from china. the covid-19 outbreak in china in late 2019 led to a surge in demand within china for ppe, especially for disposable surgical masks as the government required anyone leaving their home to wear a mask. in response to demand, china's government not only restricted its ppe exports, it also purchased a substantial portion of the global supply (burki, 2020) . these shocks contributed to an enormous disruption to the global supply chain of ppe. as the virus spread to other countries, their demand for ppe also increased and resulted in additional pressure on dwindling supplies. in response, other global producers of ppe, including india, taiwan, germany, and france, also restricted exports. by march 2020, numerous governments around the world had placed export restrictions on ppe, which in turn contributed to higher costs. the price of surgical masks rose by a factor of six, n95 respirators by three, and surgical gowns by two (burki, 2020 overall then, with respect to imports, the us is the biggest importer and so is highly dependent on the global supply chain, and with respect to exports, the us failed to prioritize the country's public health needs. after the covid-19 outbreak, the us was late to restrict ppe exports as other countries did, and the government failed to take the opportunity to order millions of masks in the years leading up to covid-19 crisis, including the two-month period between when the virus was recognized in china and when local transmission was detected in the us. impacts. hence the seemingly gender-neutral costing model described in our analysis does not have gender-neutral outcomes. by implication, a meaningful change in the way healthcare is funded that incentivizes hospitals to invest in adequate inventories of ppe will disproportionately benefit women workers. the gender differential is even more striking in the case of home-health aides. more research is needed on the extent to which men and women are impacted differently by ppe shortages. another important question is the extent to which gender issuessuch as women's relative lack of bargaining power in hospital administrationcontributed to shortages to begin with. our analysis points to the need for transformative changes and corrective actions to better protect healthcare practitioners. we must consider a full range of tools that not only create incentives for hospitals to protect their care providers with ppe, but also generate effective institutional capacity to ensure that health providers can mobilize quickly to handle pandemics. we have several recommendations: (1) prepare hospitals to better protect practitioners by removing the profit motive from consideration in the purchasing and maintenance of ppe inventories; (2) strengthen the capacity of local, state, and federal government to maintain and distribute stockpiles; (3) improve enforcement of osha's current regulations around ppe, including requirements to source the proper size for each employee; (4) develop new regulations to reduce practitioner stress and fatigue (cohen & venter, 2020; fairfax, 2020) ; (5) improve the federal government's ability to coordinate supply and distribution across hospitals and local and state governments (patel et al., 2017) ; (6) consider strategic industrial policy to increase us production of medical supplies and to reduce the dependence on the global supply chain for ppe; (7) consider industrial policy to incentivize ppe production using existing technology while encouraging development, testing, and production of higher-quality, reusable ppe. these changes will address the costing-model issue, the demand problem, the federal government failures, and supply chain vulnerability, but they will not be politically palatable. creating the institutional capacity for building and maintaining a viable stockpile of ppe will j o u r n a l p r e -p r o o f contribute to all of these policy options. such shifts will help set the stage for what global health should look like moving forward. covid-19 was not the first pandemic nor will it be the last, especially given the likely impacts of climate change. congressional testimony: health and human services fiscal year 2021 budget request. c-span a more detailed understanding of factors associated with hospital profitability the impact of medicare capital prospective payment regulation on hospital capital expenditures global shortage of personal protective equipment. the lancet infectious diseases seller reputation and price gouging: evidence from the covid-19 pandemic potential demand for respirators and surgical masks during a hypothetical influenza pandemic in the united states considerations for release of stockpiled n95s beyond the manufacturer-designated shelf life contextualizing adr in managed care: a proposal aimed at easing tensions and resolving conflict covid-19 capitalism: the profit motive versus public health the integration of occupational-and household-based chronic stress among south african women employed as public hospital nurses invisible women: data bias in a world designed for men u.s.-china tariff actions by the numbers us public health budget cuts in the face of covid-19 fair allocation of scarce medical resources in the time of covid-19 the occupational safety and health administration's impact on employers: what worked and where to go from here respiratory protection considerations for healthcare workers during the covid-19 pandemic surgical nurses and compliance with personal protective equipment hospital safety climate and its relationship with safe work practices and workplace exposure incidents a mixed methods approach to modeling personal protective equipment supply chains for infectious disease outbreak response the value of life and the rise in health spending* effectiveness of personal protective equipment for healthcare workers caring for patients with filovirus disease: a rapid review strategic national stockpile. public health emergency covid-19: the crisis of personal protective equipment in the us preparing for an influenza pandemic: personal protective equipment for healthcare workers sourcing personal protective equipment during the covid-19 pandemic efficacy of face masks and respirators in preventing upper respiratory tract bacterial colonization and co-infection in hospital healthcare workers letter from american medical association to vice president michael pence memorandum: information provided by medical distribution companies on challenges with white house supply chain task force and project airbridge protecting health care workers against covid-19-and being prepared for future pandemics work, health, and worker well-being: roles and opportunities for employers in memoriam: healthcare workers who have died of covid-19 the anatomy of health care in the united states behind the mask: determinants of nurse's adherence to facial protective equipment new survey of nurses provides frontline proof of widespread employer, government disregard for nurse and patient safety, mainly through lack of optimal ppe employer payment for personal protective equipment; final rule personal protective equipment supply chain: lessons learned from recent public health emergency responses transcript of pelosi interview on cnbc's mad money with jim cramer/interviewer rosen, homeland security committee colleagues demand answers from administration on strategic national stockpile letter from health industry distributors association the theory of equalizing differences. handbook of labor economics the value of the nonprofit hospital tax exemption was $24.6 billion in challenges and solutions for addressing critical shortage of supply chain for personal and protective equipment (ppe) arising from coronavirus disease (covid19) pandemic -case study from the republic of ireland knowledge of standard and isolation precautions in a large teaching hospital the role of personal protective equipment in infection prevention history the value of risks to life and health global risks report global risks report 2020 memorandum on order under the defense production act regarding 3m company respirator use in a hospital setting: establishing surveillance metrics acknowledgements: the authors thank jacquelyn baugher, rn, bsn, ocn, for providing insight that aided our understanding of occupational relations internal to hospitals. key: cord-337499-jzpgtkai authors: yong choi, sung; shin, joongbo; park, woori; choi, nayeon; sei kim, jong; i choi, chan; ko, jae-hoon; ryang chung, chi; son, young-ik; jeong, han-sin title: safe surgical tracheostomy during the covid-19 pandemic: a protocol based on experiences with middle east respiratory syndrome and covid-19 outbreaks in south korea date: 2020-06-17 journal: oral oncol doi: 10.1016/j.oraloncology.2020.104861 sha: doc_id: 337499 cord_uid: jzpgtkai background: a subset of patients with covid-19 require intensive respiratory care and tracheostomy. several guidelines on tracheostomy procedures and care of tracheostomized patients have been introduced. in addition to these guidelines, further details of the procedure and perioperative care would be helpful. the purpose of this study is to describe our experience and tracheostomy protocol for patients with mers or covid-19. materials and methods: thirteen patients with mers were admitted to the icu, 9 (69.2%) of whom underwent surgical tracheostomy. during the covid-19 outbreak, surgical tracheostomy was performed in one of seven patients with covid-19. we reviewed related documents and collected information through interviews with healthcare workers who had participated in designing a tracheostomy protocol. results: compared with previous guidelines, our protocol consisted of enhanced ppe, simplified procedures (no limitation in the use of electrocautery and wound suction, no stay suture, and delayed cannula change) and a validated screening strategy for healthcare workers. our protocol allowed for all associated healthcare workers to continue their routine clinical work and daily life. it guaranteed safe return to general patient care without any related complications or nosocomial transmission during the mers and covid-19 outbreaks. conclusion: our protocol and experience with tracheostomies for mers and covid-19 may be helpful to other healthcare workers in building an institutional protocol optimized for their own covid-19 situation. in december 2019, a local outbreak of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) occurred in wuhan (hubei, china). the coronavirus disease 2019 (covid19) was highly infectious from the early stage and rapidly spread to several countries. as of may 16, 2020, covid-19 has been reported in 185 countries, with more than 4,486,990 cases and more than 306,306 deaths. [1] since south korea recorded its first case of covid-19 on january 20, 2020, the total number of confirmed cases stands at 11,037, which is concentrated mainly in daegu and gyeongsangbuk-do (74.6% of all confirmed cases) and the number of the virus-associated deaths has reached 262 people. [2] most patients are projected to have mild symptoms (81%) and the mortality rate in covid-19 is relatively low (2.3%). [3] compared with mortality rates of 10% for severe acute respiratory syndrome (sars) [4] and 37% for middle east respiratory syndrome coronavirus (mers) [5] . however, some infected patients are classified as severe or critical cases, and often require intubation and mechanical ventilation (9.8%-15.2%). [3, 6] critically ill patients with prolonged intubation ultimately need tracheostomy for proper airway management and lung care. tracheostomy is a routine surgical procedure, and there has been a debate on the optimal time for tracheostomy in critically ill patients requiring intensive respiratory care. [7] in general, a timely tracheostomy within seven to ten days after intubation is preferred in terms of minimizing mechanical ventilation time, length of stay in the intensive care unit (icu) and mortality. [8] however, in this epidemic situation, the risks of exposure and transmission from patients to healthcare workers should be carefully considered when the tracheostomy is planned. it is essential that surgeons and icu staff stay current on the protocols and guidelines for infection prevention during the tracheostomy, and these should be based on real experience and the best available evidence on this topic. in 2015, we experienced the largest in-hospital mers outbreak with 92 laboratory-confirmed mers cases. [9] although all surgical procedures for mers patients were delayed as long as possible according to our institutional policy, nine cases inevitably required surgical tracheostomy. thus, we developed our own institutional protocol for safe tracheostomy in patients with mers. five years later, as the covid-19 pandemic rapidly spread, we revised and modified our tracheostomy protocol to prepare for the covid-19 situation. we applied and tested this protocol in a patient with covid-19 patient for whom tracheostomy was indicated in march 2020. here we describe our experience and protocol for surgical tracheostomy in patients with covid-19 in our hospital. this study was a retrospective analysis using clinical and pathological data from patients with mers and covid-19 who underwent surgical tracheostomy. the study protocol was approved by our institutional review board (no. 2020-04-178) and the electronic medical records and interviews of medical staff who cared for patients with mers and covid-19 who underwent surgical tracheostomy were used for the study. all data were de-identified. the study population included nine patients with mers who had undergone surgical tracheostomy at our institution from may to july 2015 (mers outbreak). on the basis of hospital closing date (june 13), we defined the early phase of the outbreak (before june 13) as phase 1 (two tracheostomies) and the middle phase of the outbreak (after june 13) as phase 2 (seven tracheostomies). [10, 11] one covid-19 patient who had undergone surgical tracheostomy at our institution was also included in this study. for mers-cov and sars-cov-2 pcr tests, either sputum or nasopharyngeal swab samples were collected using a sterile, leak-proof, screw-capped sputum collection container and nasopharyngeal swabs were collected with an eswab (482 c, copan diagnostics inc., murrieta, ca, usa). mers samples were tested by rrt-pcr with amplification targeting the upstream e region (upe) and confirmed by subsequent amplification of the open reading frame (orf)1a using powercheck™ mers real-time pcr kits (kogene biotech, seoul, korea). [9] covid-19 samples were screened by rrt-pcr with amplification targeting the envelope gene (e) and confirmed by subsequent amplification of the rna-dependent rna polymerase gene (rdrp) using powercheck™ sars-cov-2 real-time pcr kits (kogene biotech, seoul, korea). for serologic surveillance, we used commercial anti-mers-cov enzyme-linked immunosorbent assay (elisa) igg kits (euroimmun, lübeck, germany) to detect antibody response. we used automated fluorescent immunoassay system (afias) covid-19 ab assay kit for sars-cov-2 antibody detection (bodi-tech med inc., chuncheon, korea). the perioperative tracheostomy protocol for mers and covid-19 patients was developed and revised through multidisciplinary discussions led by our in-hospital infection control team during the mers and covid-19 outbreaks. a multidisciplinary discussion among icu, ent and infection control departments is essential in the decision to perform tracheostomy in an infected patient. when a tracheostomy was planned for a patient with mers, an open surgical tracheostomy was preferred to a percutaneous dilatational tracheostomy (pdt) due to decreased potential for aerosolization. thirteen patients with mers were admitted to the icu, and nine (69.2%) of them required surgical tracheostomy. tracheostomy was necessary is one of the seven patients with covid-19 in our hospital. surgical tracheostomy was also performed in this case not only because the open surgical tracheostomy is considered lower risk in terms of aerosol-generation compared to pdt, but also because a high-riding brachiocephalic (innominate) artery was noted on preoperative computed tomography (ct). thus, preoperative evaluation of neck anatomy is also important to determine the optimal procedure and reduce surgical complications. level of personal protective equipment (ppe) during tracheostomy during phase 1 of the mers outbreak (before june 13), two surgical tracheostomies were performed and standard personal protective equipment (ppe) comprising surgical gloves, surgical gowns, eye shields, and n95 respirators was used by health care workers on the tracheostomy teams. there was no tracheostomy-related mers transmission with this level of ppe, suggesting that standard ppe without papr could be appropriate depending on the situation. however, there were four cases of mers in healthcare workers involved in other procedures in patients with high viral loads (sputum pcr cycle threshold value <16) despite use of this level of ppe. as a result, the infection control department at our institution increased the level of recommended protection, and all members of the tracheostomy team used enhanced ppe, which included coverall clothes including a head cover, shoe covers, two pairs of surgical gloves, powered air purifying respirators (paprs) and n95 respirators. in addition to enhanced ppe, primary surgeons and surgical assistants used an outer surgical gown and gloves, resulting in double gowning and triple gloving. all members of the tracheostomy team remained free of disease, during and after performing a total of nine tracheostomies for patients with mers, suggesting these protections were successful and safe. thus, enhanced ppe including papr was also used with the patient with covid-19 (cycle thresholds 30.5 for e gene and 30.44 for rdrp gene from trans-tracheal aspirates) (supplementary figure 1) and there was no perioperative covid-19 transmission ( table 1) . as strict donning and doffing procedures are crucial to prevent operator contamination, institutional training, and education on the proper use of ppe was provided to the surgical teams before they cared for covid-19 patients ( figure 2 ). on the day of tracheostomy, surgical teams were carefully assisted and closely supervised by skilled nurses in the designated donning and doffing location in the icu ( figures 3a and 3b ). during the mers outbreak, we had no permanent negative-pressure icu rooms, and two patients inevitably underwent surgical tracheostomy in an isolated icu created for mers patients. because a negative pressure icu is ideal for surgical procedures to minimize airborne viral spread, isolated icus were temporarily converted to comprise negative-pressure icu rooms to facilitate performing surgical procedures in mers patients. [11] we performed seven surgical tracheostomies on patients with mers after this icu conversion was completed. based on lessons learned from the 2015 mers outbreak, two negative pressure icus with anterooms and 15 negative pressure isolation wards were separately constructed outside the main hospital in 2016. during the covid-19 pandemic, at the request of the government, a critically ill covid-19 patient with prolonged intubation was transferred directly to the negative-pressure icu at our hospital in march 2020. one week later, surgical tracheostomy was performed at the bedside in the icu in a negative-pressure room. our institution could not limit the number of team members involved in the tracheostomy procedure and post-operative management at the time of the mers outbreak. two surgeons comprising a primary surgeon and surgical assistant took turns with the icu specialist assisted by a standby nurse in performing tracheostomies. in contrast, the surgical tracheostomy for the covid-19 patient was performed by one dedicated head and neck surgeon and icu medical staff (two intensivists and one senior nurse), who worked only in the negative pressure room for covid-19, and assisted with all procedures (supplementary figure 1) . general principles for minimizing aerosolization and surgery time were applied during the tracheostomies. these included complete paralysis to prevent cough and movement, lower positioning, and hyper-inflation of the endotracheal tube cuff, holding ventilation before tracheal incision, and prompt cannula insertion and cuff inflation while withdrawing the endotracheal tube to just above the window. [12] [13] [14] [15] [16] performing a tracheostomy with enhanced ppe was not easy. enhanced ppe limited manual tactile sensation (multiple gloves), free surgical motion (double gowns), illumination and visualization. thus, we typically made a relatively wide incision (4-5 cm) to ensure a clear surgical field and visualization even if additional skin sutures were needed at the end of the procedure. a surgical light was also required for optimal visualization during the procedure. a wearable headlight or headlamp was used in all cases. however, the headlight did not fit a surgeon's head because of the enhanced ppe head cover. instead, surgical assistants (first and second) wore the headlamp and were in charge of illuminating the surgical field ( figure 3e ). different from many recommendations for avoiding diathermy and suction, we generally used electrical devices including bipolar and monopolar diathermy for hemostasis and to save time and we did not limit suctioning throughout the surgical tracheostomy procedure ( figure 3d ). nevertheless, there was no transmission caused by using diathermy and suction, suggesting that the possibility of transmission through diathermy producing vapor plumes or suction-related aerosolization is extremely low in the setting of enhanced ppe in a negative pressure room. we did not place stay sutures or a björk flap for any of the mers or covid-19 patients. instead, we made an oval-shaped tracheal window by removing the tracheal cartilage, which prevented forceful insertion and avoided tracheal damage or false passage. we prepared various sized non-fenestrated cuffed tubes and adjustable tubes on the surgical table to reduce the possibility of a poorly fitted cannula. portex ® "vocalaid" cuffed blue line ® tracheostomy tubes (id 7.5) were used in six mers patients and vocal aid cuffed mera ® sofit clear tubes (id 7.5) were used in two mers patients. a portex ® "vocalaid" cuffed blue line® tracheostomy tube (id 7.0) was used in the covid-19 patient. these were no accidental decannulation events. after tracheostomy and the associated procedures (e.g., tube insertion, balloon inflation, circuit connection, ventilation resumption and endotracheal removal), peristomal dressing and skin suture using 4-0 vicryl (absorbable) performed to minimize the need for tube and dressing changes ( figure 3e ). during the mers outbreak, the tracheostomy wound was dressed daily by trained icu nurses with enhanced ppe. a tracheostomy tube change was performed three days after the operation, and a subsequent change was performed ten days postoperatively by ent surgeons wearing enhanced ppe. there were no cannula-related complications, including stomal infection and cannula occlusion with a mucous plug (table 1) . we subsequently revised the tube management protocols based on other guidelines and experience in our icu system. these revisions included no dressing changes unless there were signs of infection and delaying the first tube change until covid-19 patients tested negative for viral rna. the first cannula change for the covid-19 patient was performed by the same surgeon with enhanced ppe at 13 days because that patient had three consecutive negative sars-cov-2 pcr tests 11 days after tracheostomy. the stoma site and tube lumen were noted to be clean despite the delay. the patients stayed in the negative-pressure icu for an additional three weeks to minimize the risk of nosocomial transmission, and was then transferred to an isolated icu, where decannulation without down-sizing and corking were performed four days after transfer. the patient was transferred to the general ward seven days after decannulation. during the mers outbreak, health care workers involved in tracheostomy and related procedures continued to work with monitoring and were removed immediately from duty if symptoms developed. however, at the end of the mers outbreak in our hospital, all healthcare workers who participated in procedures for the last mers patient were placed in home quarantine for 14 days from the last day of exposure and their sputum was tested by rrt-pcr as a screening test before they returned to general patient care. the pcr results for all associated staff were negative and serologic testing for mers-cov antibody was also negative. [17] during the covid-19 pandemic, all members of the team who participated in tracheostomy for the covid-19 patient were put under active monitoring (checking temperature and symptoms twice a day) while working (table 1) . at the end of patient care, icu staff were also placed on seven days of home quarantine and underwent screening by sputum rrt-pcr, and additional pcr screening was performed before they returned to work. the pcr results were all negative. although there was no pcr screening and no quarantine for the primary surgeon, serologic testing was negative for the anti-sars-cov-2 antibody. several studies related to guidelines or recommendations on surgical tracheostomy for covid-19 patients have been published. however, the detailed context of the procedure seems inconsistent and varies by the developing group, specialty, hospital and national health care systems. there is a limited number of protocols or recommendations based on real experience on this topic. fortunately, we have clinical experience with tracheostomies for both mers and covid-19 patients, and we thought it would be helpful to share our experience and protocol with readers. there has been a debate on whether pdt spreads more virus-containing aerosols than surgical tracheostomy. surgical tracheostomy is usually recommended over pdt in most guidelines. [14] [15] [16] 18] preoperative evaluation of individual anatomy and patient functional status is critical. this includes particular attention to anatomical variations (a high-riding major artery in our case), obesity, un-extended or short neck, bleeding tendency, or ventilator dependency. in addition to the possibility of aerosol dissemination, surgeons should consider these factors in determining the most appropriate tracheostomy procedure and to reduce surgical complications. some guidelines recommend a double-lumen cannula comprising a non-fenestrated cuffed outer with a disposable inner cannula. [16] however, the interface between the inner and outer cannulas can vary by manufacturer and ventilation setting, thereby increasing the chance of air leakage. [19] furthermore, double lumen cannulas tend to be rigid, which can cause mucosal irritation or injury. thus, we prefer to use single lumen non-fenestrated cuffed tubes with or without an adjustable function. this minimizes the risk of viral transmission through air leakage, particularly for infected patients receiving positive pressure ventilation. b virus (hbv) have reported that the plume originating from diathermy contains viable infectious particles that can be transmitted to the upper respiratory tract through inhalation of surgical smoke. [20, 21] in this context, some guidelines recommend avoiding or limiting the use of electrocautery to reduce exposure to the surgical plume. [14] [15] [16] however, although the possibility of disease transmission through electrocautery-induced surgical plumes has been recognized, only hpv transmission has been reported in rare cases [22] ; no prior study has demonstrated that brief exposure to electrosurgical smoke alone causes viral infection. there has been no evidence to indicate that covid-19 is transmissible through surgical plumes. [23] additionally, one study reported that none of the blood samples from covid-19 patients tested positive for rna from sars-cov-2, suggesting that the virus may not be present within the smoke produced by electrocautery. [24] consistent with our study, 10 surgical tracheostomies for covid-19 patients were preformed using an electrocautery device without any cases of transmission in a recent study. [25] therefore, we consider the clinical benefits of electrocautery, including reduced operation time, surgical view, and easy bleeding control, to exceed the risk of potential viral transmission. aerosol-generating procedures have highlighted the risk of nosocomial transmission of emerging viruses such as sars-cov. [26] many medical procedures including bronchoscopy, cardiopulmonary resuscitation (cpr), ventilation, surgery, nebulizers, and suction have been considered potential aerosol-generating procedures. based on these findings, use of suction during tracheostomy is not recommended in recent guidelines. during the sars-cov outbreak, only direct airway-stimulating procedures such as bronchoscopy, cpr, ventilation, and intubation have been reported to be potentially associated with sars-cov transmission. [27] [28] [29] during surgical tracheostomy, exposure of the tracheal lumen is very short and suction can be used to evacuate the diathermy-producing plume. furthermore, enhanced ppe in a negative pressure room minimizes exposure to aerosols and electrocautery-inducing smoke. therefore, we did not limit suction or diathermy in our institutional tracheostomy protocol for mers and covid-19 patients. complete hemostasis achieved by electrocautery and suction of blood or sputum in surgical fields could contribute to rapid and safe tracheostomy with fewer complications. a stay suture technique, suturing the anterior tracheal wall to the skin after making a tracheal window, facilitates insertion and prevents false passage in accidental decannulation. placing stay sutures or making a björk flap may lead to direct exposure to tracheal secretions through an opened tracheal window in infected patients, thereby increasing the chance of viral particle transmission. thus, we did not use a stay suture or björk flap during surgical tracheostomy in mers and covid-19 patients. instead, we made a round opening on the tracheal cartilage directly beneath the skin wound. fortunately, our patients did not suffer from false lumen formation or accidental decannulation, even without the stay sutures. one of the major modifications in the covid-19 tracheostomy protocol at our institution was postoperative management including dressing and cannula changes. during the mers outbreak, there was no difference in cannula dressing and change intervals between infected and non-infected cases. in preparing the covid-19 tracheostomy protocol, we agreed that daily cannula dressing seems unnecessary and the first cannula change can be delayed until the patient no longer tests positive. additionally, delaying the tube change allows maturation of the skin-to-trachea tract to avoid false passage without a suture or björk flap. our data and recent reports revealed that the rate of negative conversion within 21 days was 91.2% [30] and the median time from onset of symptoms to mechanical ventilation was 10.5 days in covid-19 patients. [6] thus, the modified time to cannula change should be within 14 days after tracheostomy. in our patient, the first tracheostomy cannula change was on postoperative day 13, which was two days after the patient had three negative tests. ultimately, decannulation was possible on day 28 after the first cannula change without any complications. decannulation is a critical process for weaning patients from the tracheostomy. [31] however, the process includes many aerosol-generating procedures, such as down-sizing, cannula type changes, balloon deflation, airway evaluation, active coughing to prevent aspiration, and repeated capping/uncapping. thus, we chose the abrupt tube removal method for covid-19 patients to decrease the potential risk of exposures. in response to reports of multiple cases testing positive for sars-cov-2 after having recovered, the patient stayed for an additional seven days in an isolated icu for close monitoring and to allow the stoma to seal, but this later proved unnecessary as no evidence has suggested that re-positive cases are infective. another stark difference in our revised protocol is the creation of a designated covid tracheostomy team comprised of one highly experienced head and neck surgeon, two attending icu specialist (one to manage ventilator/endotracheal tube, one to assist with the procedures) and a senior icu nurse. during the mers outbreak in 2015, we had to perform eight mersrelated tracheostomies in a short period between june 15 and june 29 without a dedicated team because of limited resources at our institution. as our institution is a tertiary referral center, we are prepared to care for severe cases of covid-19 requiring intensive medical support. thus, we were able to focus on critically ill covid-19 patients by preparing medical resources and creating a dedicated team in advance, without any limitations to accessibility or safety for non-covid-19 patients (figure 2 ). however, if team members in the icu need to be kept to the minimum critical number, an additional icu nurse could be omitted from the tracheostomy team. therefore, the optimal number and composition of covid-19 tracheostomy teams could vary depending on the medical resources available for each center, region, and country. in addition, we prepared a highly organized infection control system including a negative pressure icu with double anterooms and a validated screening strategy for healthcare workers. as shown in figure 3a , designated space in a negative pressure icu was created for procedures to minimize potential risk of exposures. it consisted of space for donning ppe and material equipment, one anteroom for entering, a second anteroom for doffing ppe, and a fitting and shower room for personnel protection. every step was guided and supervised by a senior icu nurse ( figure 3a-e) . we also confirmed the appropriateness of our screening and monitoring strategy (active monitoring and quarantine followed by sputum rrt-pcr) for involved healthcare workers by serologic investigation after the end of the mers outbreak, in which none of the tested sera were positive for mers-cov antibody. [17] these screening protocols were applied to assigned icu staff (icu specialists and nurses) in the covid-19 pandemic. however, pcr screening and quarantine for the primary surgeon was omitted as they wear enhanced ppe and are exposed only for a short period of time during the tracheostomy procedure and first cannula change. we had no transmission among healthcare workers who used enhanced ppe during the mers outbreak. [10] serum collected from the primary surgeon was negative for anti-sars-cov-2 antibody at the end of our hospital's care of covid-19 patients, implying that our screening protocol based on clinical situation is effective and practical. these facilities and screening systems for covid-19 allowed for all associated medical staff to continue their routine clinical work and daily life. to date, we have no cases of transmission from covid-19 patients to healthcare workers. here we presented our experience with tracheostomy in patients with mers and covid-19. the covid-19 pandemic has escalated and poses a global threat, therefore most hospitals should prepare for performing tracheostomy and perioperative management in patients with covid-19. our modified protocol and experience from the mers outbreak and covid-19 pandemic could serve as one reference to inform the design of protocols unique to other institutions' own covid-19 situation. there are no conflicts of interest. figures figure 1 . cross-sectional ct image of a covid-19 patient with tracheostomy. ct scans showed a high-riding innominate artery to the right of the trachea just below the thyroid. supplementary figure 1 . dedicated team for covid-19 tracheostomy. tracheostomy was performed by one experienced head and neck surgeon and two attending intensivists (one to the manage the ventilator/endotracheal tube, one to assist with the procedure). one icu nurse assisted with the procedure outside the surgical field. all team members used powered air purifying respirators (paprs). table 1 . details of tracheostomies for mers and covid-19 patients. phase 1 # phase 2 # no. of tracheostomies performing tracheostomy and perioperative management in patients with covid-19 should be based on real experience and the best available evidence on this topic. our protocol allowed for all associated healthcare workers to continue their routine clinical work and daily life. our protocol guaranteed safe return to general patient care without any related complications or nosocomial transmission during the mers and covid-19 outbreaks. coronavirus disease (covid-19) pandemic korean center for disease control and prevention. coronavirus disease-19 characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72314 cases from the chinese center for disease control and prevention summary of probable sars cases with onset of illness from 1 middle east respiratory syndrome coronavirus (mers-cov) clinical features of patients infected with 2019 novel coronavirus in wuhan early versus late tracheostomy for critically ill patients timing of tracheostomy in patients with prolonged endotracheal intubation: a systematic review mers-cov outbreak following a single patient exposure in an emergency room in south korea: an epidemiological outbreak study control of an outbreak of middle east respiratory syndrome in a tertiary hospital in korea infection prevention measures for surgical procedures during a middle east respiratory syndrome outbreak in a tertiary care hospital in south korea safe tracheostomy for patients with severe acute respiratory syndrome elective and emergency surgery in patients with severe acute respiratory syndrome (sars) corona-steps for tracheotomy in covid-19 patients: a staff-safe method for airway management surgical considerations for tracheostomy during the covid-19 pandemic: lessons learned from the severe acute respiratory syndrome outbreak a framework for open tracheostomy in covid-19 patients serologic evaluation of mers screening strategy for healthcare personnel during a hospital-associated outbreak elective tracheostomy in mechanically ventilated patients affected by covid-19: preliminary case-series from lombardy leakage characteristics of dual-cannula fenestrated tracheostomy tubes during positive pressure ventilation: a bench study surgical plume and its implications: a review of the risk and barriers to a safe work place the dangers of electrosurgical smoke to operating room personnel: a review surgical smoke exposure in operating room personnel: a review safe management of surgical smoke in the age of covid-19 virological assessment of hospitalized patients with covid-2019 safety and prognosis in percutaneous vs surgical tracheostomy in 27 patients with covid-19 nosocomial transmission of emerging viruses via aerosol-generating medical procedures aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review transmission of severe acute respiratory syndrome during intubation and mechanical ventilation possible sars coronavirus transmission during cardiopulmonary resuscitation factors associated with negative conversion of viral rna in patients hospitalized with covid-19 the practice of tracheostomy decannulation-a systematic review none sung yong choi a , joongbo shin a , woori park a , nayeon choi a , jong sei kim a , chan i choi key: cord-355431-efwuy8p9 authors: ambrosio, luca; vadalà, gianluca; russo, fabrizio; papalia, rocco; denaro, vincenzo title: the role of the orthopaedic surgeon in the covid-19 era: cautions and perspectives date: 2020-05-27 journal: j exp orthop doi: 10.1186/s40634-020-00255-5 sha: doc_id: 355431 cord_uid: efwuy8p9 the current coronavirus disease 2019 (covid-19) pandemic has revolutionized global healthcare in an unprecedented way and with unimaginable repercussions. resource reallocation, socioeconomic confinement and reorganization of production activities are current challenges being faced both at the national and international levels, in a frame of uncertainty and fear. hospitals have been restructured to provide the best care to covid-19 patients while adopting preventive strategies not to spread the infection among healthcare providers and patients affected by other diseases. as a consequence, the concept of urgency and indications for elective treatments have been profoundly reshaped. in addition, several providers have been recruited in covid-19 departments despite their original occupation, resulting in a profound rearrangement of both inpatient and outpatient care. orthopaedic daily practice has been significantly affected by the pandemic. surgical indications have been reformulated, with elective cases being promptly postponed and urgent interventions requiring exceptional attention, especially in suspected or covid-19(+) patients. this has made a strong impact on inpatient management, with the need of a dedicated staff, patient isolation and restrictive visiting hour policies. on the other hand, outpatient visits have been limited to reduce contacts between patients and the hospital personnel, with considerable consequences on post-operative quality of care and the human side of medical practice. in this review, we aim to analyze the effect of the covid-19 pandemic on the orthopaedic practice. particular attention will be dedicated to opportune surgical indication, perioperative care and safe management of both inpatients and outpatients, also considering repercussions of the pandemic on resident education and ethical implications. in december 2019, severe acute respiratory syndrome coronavirus 2 (sars-cov-2) broke out in wuhan, china, causing clusters of severe respiratory illness and rapidly spreading across the country [26] . in a matter of weeks, several outbreaks were recognized in italy, spain, france and the usa until on march 11, 2020 the world health organization (who) declared the coronavirus disease 2019 (covid-19) a global pandemic, with > 100,000 cases and 100 countries infected [53] . at the time of this writing, patients affected by covid-19 exceeded 4 million globally, with approximately 280,000 deaths [52] , becoming an unprecedented worldwide health issue. the need to control the spread of covid-19 has forced national and international governments to implement socioeconomic measures including confinement, arrest of non-essential production activities and financial resources reallocation. healthcare services have been reorganized to handle the covid-19 crisis while continuing to safely guarantee urgent care to the general population. orthopaedic daily practice has been profoundly revolutionized by the pandemic. most elective surgeries, accounting for a substantial part of orthopaedic activity, have been deferred ensuring that personal protective equipment (ppe), intensive care unit (icu) beds and additional workforce would be redistributed to tackle the covid-19 emergency. on the other hand, conditions including severe trauma, musculoskeletal tumors and infections, still necessitate urgent care and cannot be delayed. as surgery requires working in a confined space in close contact with the patient, the risk of infection transmission during the procedure and generally in the context of patient care, is reasonably high [7] . therefore, orthopaedic routine must be reshaped in light of an appropriate surgical indication and covid-19 index of suspicion, with considerable effects of inpatient management and outpatient visit rescheduling. in this review, we aim to analyze the complex and continuously evolving effect of the covid-19 pandemic on orthopaedic surgery. surgical indications will be discussed based on patients' underlying condition, comorbidities and covid-19 index of suspicion. particular attention will be dedicated to ppe protocols and nasopharyngeal swab indications to be adopted before, during and after surgery. inpatient care, physical therapy, containment and early discharge strategies will be also addressed. outpatient follow-up will be examined in light of a risk-benefit ratio, also considering the novel opportunities offered by telemedicine. furthermore, repercussions on resident education and ethical perspectives will be debated. perioperative management of the orthopaedic patient in the covid-19 era sars-cov-2 transmission and relevant protective measures the major routes of sars-cov-2 transmission are through respiratory droplets and contact with contaminated surfaces [6] . in addition, exhalation of respiratory secretions during aerosol-generating procedures (agps: tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation and bronchoscopy) may produce highly virulent airborne particles [55] . although symptomatic patients are the primary source of infection, asymptomatic subjects may also spread the disease and should not be neglected [8] . therefore, maintaining an interpersonal distance ≥1 m is essential to minimize viral particle dissemination during social and clinical encounters [57] . sars-cov-2 may persist up to 3 h in aerosols, 24 h on cardboard and 2-3 days on plastic [50] . thence, aeration of closed environments, appropriate use of ppe, frequent hand hygiene and surface decontamination are mandatory. according to the who, standard precautions should be universally applied and all patients should wear a medical mask in public areas [55] . to date, several types of face masks are available and are distinguished by different filter efficiencies. surgical masks are designed to prevent intraoperative contamination and have not proven to protect from droplet spread in laboratory conditions [50] . however, the use of surgical masks has demonstrated to reduce the risk of influenza [38] and sars-cov [60] transmission, probably by arresting the diffusion of larger droplets. in a report from ng, 85% of the providers in close contact with a covid-19 patient was wearing a surgical mask and none was infected [34] . despite the low evidence, a recent metanalysis attested that surgical masks and n95 respirators may provide a similar protection against viral respiratory infections during non-agps [9] . therefore, the use of surgical masks during low-risk patient interactions may be encouraged in case of respirator shortages. respirators are designed to protect against droplets and aerosols and are classified upon the percentage of filtered particles ≥300 nm. in europe, respirators are distinguished in filtering facepiece-1 (ffp1), ffp2 and ffp3 when filtering capacity is ≥80%, ≥94% and ≥ 99%, respectively. similarly, the centers for disease control and prevention (cdc) defines filter efficiency indicating the percentage of filtered particles in the device nomenclature (i.e. a n95 mask filters 95% of ≥300 nm particles) [50] . due to the higher protective potential, the who recommends that all healthcare workers should wear a respirator (≥ffp2/n95) when performing agps. in all other situations, wearing a surgical mask is reasonably safe when providing direct care to covid-19 patients, especially in case of respirator scarcity [51, 58] . according to the guidelines proposed by local institutions and international societies, including the american academy of orthopaedic surgeons (aaos) [1, 23] and the american college of surgeons (acs) [5] , elective surgeries should be judiciously postponed depending on the local prevalence of covid-19 and resource availability (ppe, icu beds, respirators and personnel). conducting "business as usual" is firmly discouraged as it may result in hazardous shortages of ppe and healthcare workforce in case of unexpectedly evolving conditions. by definition, a procedure is considered elective when no short-term or long-term negative impact may be expected if surgical treatment is delayed. however, such denotation is subjective in nature, as reported pain and disability may significantly vary among orthopaedic patients, thus influencing the decisional process. therefore, determining which procedures are strictly elective and which ones should be performed remains challenging. the centers for medicare & medicaid services (cms) have proposed a 3-tiered system considering both the acuity of the surgical procedure and the underlying patient condition [11] . tiers 1, 2 and 3 define low, intermediate and high acuity treatments which, if not provided, may result in a null, partial or significant increase in patient morbidity or mortality, respectively. patients are further designated as "a" if healthy or "b" when unhealthy. the cms recommends postponing tier 1a operations (i.e. carpal tunnel release), considering deferral of tier 2a procedures (i.e. joint replacement and spine surgery) and continuing to operate tier 3a conditions (i.e. cancers, severe trauma and "highly symptomatic patients"). however, symptom severity is subjective and may generate unwanted ambiguity when formulating a surgical indication. to prevent any equivocacy, the ohio hospital association imposed to cancel operations that did not match with the following criteria: "threat to the patient's life if surgery or procedure is not performed, threat of permanent dysfunction of an extremity or organ system, risk of metastasis or progression of staging, risk of rapidly worsening to severe symptoms" [40] . such principles may be useful when planning the restriction of surgical indications in case of paucity of resources during the peak of the pandemic. apart from treating trauma and tumors, chang liang et al. also allowed to operate on day surgical cases, including arthroscopies, implant removals and soft-tissue procedures. this early discharge policy may effectively reduce patients' risk of nosocomial covid-19 infection while not excessively weighing on healthcare resources. conversely, elective procedures requiring > 23 h of hospitalization have been postponed and temporarily tackled with pain-relieving strategies [10] . according to different surgical indications and socioeconomic measures adopted during the pandemic, an overall diversification of orthopaedic cases compared to normal surgical routine should be expected. quarantine, remote working and restriction of recreative activities will likely result in a reduction of vehicle accidents and work-related trauma, while school closure may increase the rate of pediatric injuries [29] . on the other hand, as elderly people will be more likely at home without the aid of caregivers, an increment of fractures due to domestic falls should be foreseen as well. fractures in the elderly population, especially at the lower limbs, are associated with increased susceptibility to pulmonary infections and a considerable risk of mortality. in a retrospective study of 10 patients affected by covid-19 and hospitalized for bone fractures, mi et al. reported increased clinical severity and mortality after open reduction and internal fixation surgery. hence, authors conclude that nonoperative treatment for fractures in the elderly should be considered in the first place when appropriate [33] . based on the guidelines provided by the aaos [23] , acs [4, 5] and cms [11] , together with additional expert opinions [16, 19, 36, 42, 44, 62] , we herein propose a decisional algorithm to assist the formulation of surgical indications in orthopaedic patients during the pandemic (fig. 1 ). conditions needing urgent care are listed in table 1 . it is advisable that the ultimate decision whether proceed or not to surgery is made by a multidisciplinary committee composed of surgery, nursing, anesthesia and administration representatives cautiously considering local covid-19 prevalence, ppe supply, availability of workforce, ventilators and beds (including icu) as well as patient age and comorbidities [37] . immediately after patient admission, covid-19 risk profile and history of exposure should be thoroughly assessed [1] . in order to minimize the chance of nosocomial infections, same-day admission should be encouraged. patients should be contacted the day before surgery and investigated for covid-19 risk factors, including flu-like symptoms, travel history and harmful exposures in the previous 14 days [10] . upon arrival, temperature should be checked and a surgical mask provided to all patients [37] . in accordance with local resources, all patients undergoing elective surgery should be preoperatively tested for covid-19 [55] . in emergent cases where surgical treatment cannot be delayed, the test should be readily performed and processed as soon as reasonably possible [31] . covid-19 testing requires an upper respiratory specimen obtained with a nasopharyngeal swab. the standard reference analysis detects viral rna using real-time polymerase chain reaction (rt-pcr), a highly sensitive test providing results in 2-6 h. in areas with no known sars-cov-2 circulation, at least two different genome targets should be assessed. in case of discordance, the patient should be resampled. conversely, in areas with a high sars-cov-2 circulation, a negative result in presence of a high index of suspicion does not exclude the diagnosis and requires additional analysis [56] . while waiting for the results, contact and droplet precautions should be adopted in addition to standard measures [55] . suspected or confirmed covid-19 cases should be treated in a dedicated space, away from busy zones and deprived of non-essential materials [47] . operative personnel should be reduced to the minimum and unnecessary traffic in and out the or should be discouraged. sales representatives should be present only if strictly necessary [45] . surgery should be performed in negative-pressure ors to avoid the dissemination of the virus outside the theatre. however, ors are usually equipped with positive-pressure systems to reduce the risk of surgical contamination. therefore, as conversion to negative pressure may require or maintenance, this should be planned with reasonable notice. if negative pressure cannot be obtained, positive pressure should be turned off and a portable high-efficiency particulate air (e.g. saw, drill) utilized during orthopaedic surgery are known to generate aerosols [59] , limited data is currently available regarding the risk of virus spread. therefore, electrocautery use should be minimized and power set at the lowest possible. suction devices should always be employed to reduce surgical smoke and aerosols generated during motorized procedures [61] . using absorbable sutures is advisable to diminish the need of additional post-operative visits. for the same reason, the use of a splint rather than a plaster to immobilize a limb is preferred [45] . in addition, transparent film dressings are useful when planning remote wound evaluation [37] . 4. exit room. before leaving the or, the surgeon should remove sterile gown and gloves and perform an accurate hand hygiene. once in the exit room, ppe is sequentially removed, starting from the lead garment followed by the surgical hood, goggles, shoe covers and the respirator. hand disinfection should be repeated after removing each piece of ppe. 5. exit dressing room. surgical personnel can change and leave the operative complex. after surgery, suspected or covid-19 + patients should be transferred to an isolation room with contact and droplet precautions, or to the icu if needed. in case of a negative test, patients may be routinely treated with standard precautions [55] . several strategies to reduce contacts with inpatients have been proposed. utilizing long-lasting wound dressings may reduce the need for repeated visits. massey et al. proposed to position monitors and machines for intravenous drug administration outside patient rooms, so as to manage vital parameters, fluids and medications without the need to touch the patients [31] . visiting hours should be restricted and a maximum of one visitor per room should be allowed. an early discharge strategy should be adopted whenever appropriate [37] . departmental activity may be compartmentalized by establishing different teams [10] : (1) an inpatient team, responsible for visits in the ward, interdepartmental consultations and on-call services; (2) an outpatient team, deputed to attend urgent and undeferrable postoperative visits in the clinic; (3) a surgical team, devoted to operating on the cases that have been selected according to the criteria discussed above. this may be further divided into sub-teams consisting of different subspecialists (i.e. spine, knee, hip, shoulder, trauma surgeons) working on an in-house or on-call basis. each team should rotate every 1 or 2 weeks, followed by a preventive isolation of 14 days. moreover, teams should have dedicated workstations and avoid contacts among each other, in order to reduce the risk of cross-contamination [31] . if one provider desires not to return home after caring for covid-19 + or suspected cases, healthcare institutions should provide the possibility for alternative temporary housing [37] . following orthopaedic surgery, early physical therapy is fundamental to recover joint mobility, function and flexibility as well as to avoid the complications of prolonged immobilization. however, as physical therapists work in close contact with patients, covid-19 poses a great risk towards their health as well. international societies recommend suspending physical therapy treatments for all orthopaedic issues excepting trauma and post-operative immobilization. telerehabilitation should be encouraged for all non-essential treatments. if hypomobility might negatively impact on patient's health, hands-on treatment may be considered but with adequate ppe [2, 35] . during the pandemic, face-to-face visits should be limited to urgent cases and post-operative care that cannot be self-provided or remotely delivered. the latter include wound check, suture removal, evaluation of fracture reduction, highly symptomatic patients suspected for healing-related complications and follow-up visits that may likely change the management of the case [45] . all patients accessing the clinic should wear a face mask and undergo temperature check. in case of flu-like symptoms or exposure to confirmed or suspected cases, patients should be redirected to the emergency department for further evaluation [10] . companions should not be allowed, except for non-ambulatory and disabled patients. all table 1 orthopaedic conditions needing urgent care [4, 11, 15, 16, 19, 23, 31, 36, 42, 46, 62] providers should perform frequent and accurate hand hygiene, adopt droplet precautions and wear appropriate ppe (a disposable gown, non-sterile gloves, a face shield or goggles, a ffp2/n95 respirator or a surgical mask if unavailable) [10] . in all cases not needing urgent face-to-face visits, telemedicine may be employed as a useful adjunct to minimize the spread of covid-19 while ensuring continuous care [30] . in addition to phone consultations, telemedicine offers the possibility to perform remote virtual visits through the use of video-based platforms (e.g. microsoft teams™, skype™). such applications are now widely available and accessible by most smartphones and notebooks. this technology may be useful to triage new consults and conduct follow-up or non-urgent post-operative visits in quarantined patients [37] . direct visualization may allow for a rapid inspection and implementation of wearable sensors may facilitate outcome assessment in certain situations (e.g. knee range of motion after total knee arthroplasty) [10] . in addition, these platforms can facilitate the diffusion of educational media, deliver outcome evaluation questionnaires and enhance patience rehabilitation [35] . among these advantages, telemedicine also abates the use of ppe, reduces the risk of loss to follow-up and avoids that patients feel abandoned by their physician. however, the use of public virtual platforms raises concerns regarding privacy violations and unwanted data sharing. thence, patients should be preventively informed about such risks before using third-party software [24] . nevertheless, it is imperative to make patients aware that a virtual visit cannot replace face-to-face examination and the ultimate diagnosis of their condition. due to the reduced volume of orthopaedic cases, several departments have adopted a "residency surge plan", with a part of trainees committed to routine hospital duties and the remaining quarantined at home or redeployed in covid-19-dedicated wards [28] . disruption of orthopaedic residency routine, usually consisting of surgical training, inpatient and outpatient care, will likely have an enormous impact on resident education [13] . this is particularly relevant when considering that surgical training is practical in nature and is normally delivered in a climate of increasing autonomy, responsibility and complexity. therefore, preserving orthopaedic education integrity while safeguarding resident health is a priority. schwartz et al. [43] have recently proposed a structured strategy to reorganize the orthopaedic residency program based on five basic principles: (1) patient and provider safety: interpersonal distancing is required together with proper use of ppe and patient contact restricted to the minimum needed; (2) provision of necessary care: orthopaedic residents must continue to participate in the diagnosis and treatment of musculoskeletal disorders; (3) system sustainability: resident workforce should be disposed to obtain the maximum output with minimum effort in respect of resource availability and institutional necessities; (4) system flexibility: the strategy should be tailored to the evolving pandemic and able to adapt to future unpredictable changes; (5) preservation of command and control: hospital overload, redeployment in covid-19 departments and disruption of the daily routine are posing a significant stress for residents and trainees. emotional overwhelming, inadequacy and uncertainty of the future are all factors that may promptly lead to burnout and must be acquainted by program directors [18] . bearing these principles in mind, residents may be divided in two teams: "active-duty" and "remotely working". while "active-duty" members are mainly involved in clinical tasks, "remotely working" residents may support the active group with administrative assignments and bureaucratic practices. whenever possible, clinical and surgical care should be limited to the faculty so as to reduce resident exposure, considering their front-line involvement in patient care [43] . removal from routine orthopaedic duties inevitably interrupts the learning flow typical of residency. therefore, program directors must provide residents with novel learning tools and possibilities. in this regard, virtual learning is an efficacious solution with multiple advantages, including the possibility to review recorded content, access imaging data and share relevant media without the need of personal contact. apart from scheduled lectures, these platforms may be also employed to deliver case presentations, multidisciplinary meetings and conference talks. to date, several applications are available for this scope (e.g. microsoft teams™, google classroom™, zoom™) [28] . the reduced surgical volume poses a double-edged condition to residents: whilst the absence of strict time constrains (as occurring during ordinary elective practice) may allow in-house trainees to acquire surgical techniques in a more relaxed environment, the overall decrease of surgical activity abates the chance of handson learning for most residents. in this regard, surgical simulation may be useful to improve practical skills away from the or. cadaveric dissection and procedural courses [25] , virtual reality training [48] and arthroscopic simulators [21] are useful resources that may be improved and exploited to implement surgical education in the covid-19 era. in addition, video-based education may further promote surgical training by providing audiovisual contents on indications, preoperative workup, or setting, operative techniques and postoperative care [12] . furthermore, diminished clinical and surgical demands offer the opportunity to intensify independent study, research activity and future career planning [28] . since millennia, the patient-physician relationship has been founded on mutual respect, empathy and shared decision-making, with the absolute priority of defending patients' health. for orthopaedic surgeons, this implies selecting the most appropriate strategy to deal with pain and disability while considering patients' comorbidities and expectations. most often, this does not lead to save one's life but to preserve his quality of life, which is not always less important. in presence of a global pandemic, each clinician is required to move his own focus from the individual to the collectivity, in order to satisfy the needs of the general population rather than the single patient. in this public health framework, a physician may not be allowed to do what he considers the best for his patients. in certain situations, some providers may be compelled to judge which patients should be intensively treated or not, thus incontrovertibly impacting on their prognosis [17] . as orthopaedic surgeons, appropriately selecting which patients should undergo surgery is essential not to drain vital resources from icus and covid-19 departments. in case of clinical equipoise, i.e. when both conservative and operative management may likely lead to equivalent results, the former should be preferred whenever possible [37] . preserving provider safety is essential to guarantee further care to the general population. to date, more than 500 healthcare providers have died of covid-19 [32] . fighting on the front line against sars-cov-2, especially when the limited availability of ppe cannot ensure an adequate protection, poses a vital risk on clinicians, especially the elder and the ones affected by serious comorbidities [22, 27] . this risk may be further increased in case of redeployment, which inevitably causes to work outside of one's comfort zone, where errors are more likely to occur and lack of competency may lead to undecidedness, with terrible consequences [17, 41] . the covid-19 pandemic imposes a significant psychological burden on every healthcare provider involved in the crisis [18] . in order to prevent such discomfort, it is imperative to develop proper protocols to rationalize personnel working hours and departmentalization, guide resource allocation and promote the belief that everyone is struggling for the greater good. what to expect from the future? the covid-19 pandemic has precipitated an unequalled global health crisis. despite the prompt response in most countries, the different chronology of local outbreaks and the disparity among containment measures adopted pose a great hurdle to provide universal indications applicable for all facilities [49] . furthermore, pandemic dynamics are continuously evolving thus needing careful monitoring and formulation of flexible dispositions that may be more or less permissive depending on covid-19 prevalence, workforce availability and ppe supplies. surgical indication should be continuously reassessed based on local, regional and national situations in accordance with both facility requirements and regulations from the authorities. redeployment in covid-19 units may be necessary and should not be disregarded, especially if reallocation might protect elder and weaker coworkers. safety of all providers must be guaranteed with no exceptions. nowadays, telemedicine offers incomparable advantages to remotely check our patients, although its limitations should not be neglected. departmental activities should be adapted to actual clinical needs and education for resident and fellows should be promptly reorganized: they are the future of our profession. covid-19 has rapidly disrupted our routine in ways that would have been considered unconceivable in the contemporary era. nonetheless, the fight against such a common enemy is awakening a sense of fraternity that is bringing the scientific community together with efforts never seen before. whether these strategies are to be successful, history will judge us. clinical considerations during covid-19 covid-19 statement from the american academy of physical medicine & rehabilitation board of governors consideration for optimum surgeon protection guidelines for triage of orthopaedic patients covid-19: recommendations for management of elective surgical procedures visualizing speech-generated oral fluid droplets with laser light scattering annotation: the covid-19 pandemic and clinical orthopaedic and trauma surgery presumed asymptomatic carrier transmission of covid-19 medical masks vs n95 respirators for preventing covid-19 in health care workers a systematic review and meta-analysis of randomized trials. influenza other respir viruses novel coronavirus and orthopaedic surgery: early experiences from singapore practical techniques to adapt surgical resident education to the covid-19 era covid-19 -considerations and implications for surgical learners surgical helmets and sars infection spondylodiscitis: standards of current treatment triaging spine surgery in the covid-19 era a bioethical perspective for navigating moral dilemmas amidst the covid-19 pandemic what's important: facing fear in the time of covid-19 orthopaedic surgery case triage precautions for operating room team members during the covid-19 pandemic) surgical experience correlates with performance on a virtual reality simulator for shoulder arthroscopy survey of covid-19 disease among orthopaedic surgeons in wuhan, people's republic of china aaos guidelines for elective surgery during the covid-19 pandemic what's important: weathering the covid-19 crisis: time for leadership, vigilance, and unity cadaveric hands-on training for surgical specialties: is this back to the future for surgical skills development? clinical features of patients infected with 2019 novel coronavirus in wuhan geospatial mapping of orthopaedic surgeons age 60 and over and confirmed cases of covid-19 orthopaedic education during the covid-19 pandemic what's important: what is our role in the covid-19 pandemic? departmental experience and lessons learned with accelerated introduction of telemedicine during the covid-19 crisis orthopaedic surgical selection and inpatient paradigms during the coronavirus covid-19 pandemic memoriam: healthcare workers who have died of covid-19 characteristics and early prognosis of covid-19 infection in fracture patients covid-19 and the risk to health care workers: a case report italian physical therapists' response to the novel covid-19 emergency covid-19 and ortho and trauma surgery: the italian experience oe-best-practices-for-surgeons-covid-19-evidence-based-scoping-review n95 respirators vs medical masks for preventing influenza among health care personnel: a randomized clinical trial preparing to perform trauma and orthopaedic surgery on patients with covid-19 a review of state guidelines for elective orthopaedic procedures during the covid-19 outbreak what's important: redeployment of the orthopaedic surgeon during the covid-19 pandemic: perspectives from the trenches managing resident workforce and education during the covid-19 of 9 pandemic: evolving strategies and lessons learned how to risk-stratify elective surgery during the covid-19 pandemic? the orthopaedic trauma service and covid-19 -practice considerations to optimize outcomes and limit exposure expert consensus on management principles of orthopedic emergency in the epidemic of corona virus disease 2019 what we do when a covid-19 patient needs an operation: operating room preparation and guidance robotic spine surgery and augmented reality systems: a state of the art novel coronavirus covid-19: current evidence and evolving strategies working through the covid-19 outbreak: rapid review and recommendations for msk and allied heath personnel advice-on-the-use-of-masks-in-thecommunity-during-home-care-and-in-healthcare-settings-in-the-context-ofthe-novel-coronavirus-(2019-ncov)-outbreak coronavirus disease 2019 (covid-19) situation report-112 coronavirus disease 2019 (covid-19) situation report-51 global surveillance for covid-19 caused by human infection with covid-19 virus infectionprevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125 covid-19) in suspected human cases: interim guidance q&a on coronaviruses (covid-19) rational use of personal protective equipment for coronavirus disease (covid-19) and considerations during severe shortages characterization of aerosols produced during surgical procedures in hospitals taiwan's traffic control bundle and the elimination of nosocomial severe acute respiratory syndrome among healthcare workers minimally invasive surgery and the novel coronavirus outbreak: lessons learned in china and italy advice on standardized diagnosis and treatment for spinal diseases during the coronavirus disease 2019 pandemic not applicable. authors' contributions la conceptualized the review, wrote the manuscript and prepared the figs. fr and gv performed the critical revision of the manuscript. rp and vd supervised the manuscript. all authors read and approved the final manuscript. the publication 20-037 was kindly supported by a literature grant from the on foundation, switzerland.ethics approval and consent to participate not applicable. (2020) 7:35 page 7 of 9consent for publication not applicable. the authors declare that they have no competing interests.received: 28 april 2020 accepted: 15 may 2020publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-346894-iy35298o authors: miranda-schaeubinger, monica; blumfield, einat; chavhan, govind b.; farkas, amy b.; joshi, aparna; kamps, shawn e.; kaplan, summer l.; sammer, marla b. k.; silvestro, elizabeth; stanescu, a. luana; sze, raymond w.; zerr, danielle m.; chandra, tushar; edwards, emily a.; khan, naeem; rubio, eva i.; vera, chido d.; iyer, ramesh s. title: a primer for pediatric radiologists on infection control in an era of covid-19 date: 2020-07-07 journal: pediatr radiol doi: 10.1007/s00247-020-04713-1 sha: doc_id: 346894 cord_uid: iy35298o pediatric radiology departments across the globe face unique challenges in the midst of the current covid-19 pandemic that have not been addressed in professional guidelines. providing a safe environment for personnel while continuing to deliver optimal care to patients is feasible when abiding by fundamental recommendations. in this article, we review current infection control practices across the multiple pediatric institutions represented on the society for pediatric radiology (spr) quality and safety committee. we discuss the routes of infectious transmission and appropriate transmission-based precautions, in addition to exploring strategies to optimize personal protective equipment (ppe) supplies. this work serves as a summary of current evidence-based recommendations for infection control, and current best practices specific to pediatric radiologists. electronic supplementary material: the online version of this article (10.1007/s00247-020-04713-1) contains supplementary material, which is available to authorized users. a cluster of patients with severe viral pneumonia was first described in wuhan, china, in december 2019. the following month, genome sequencing of the virus isolated from a patient's lower respiratory tract revealed the pathogen to be a novel coronavirus, now known as severe acute respiratory syndrome coronavirus 2 (sars-cov-2), causing the disease covid-19 (coronavirus disease 2019) [1, 2] . since first described, covid-19 has spread rapidly across the globe; it was declared a pandemic by the world health organization (who) on march 11, 2020 [2] . as our understanding of covid-19 evolves, hospitals around the world have been rapidly modifying practice guidelines. each institution struggles with maintaining the critical balance between resource availability and safety for staff and patients. pediatric radiology departments are inextricably linked to this struggle because urgent diagnostic imaging and image-guided procedures continue despite reduction in outpatient volume. the goal of the authors in this paper is to review current infection control practices in the literature and online across the multiple institutions that represent the society for pediatric radiology (spr) quality and safety committee. the discussion is informed by current evidence and societal guidelines, though these concepts may change with time. additional information is available in the online supplementary material regarding examples of institutional practices for personal protective equipment (ppe) usage depending on covid-19 status, as well as tutorials for donning and doffing ppe. put succinctly, the current concern for most pediatric radiologists is this: what level of ppe is required for a mask-off, likely aerosol-generating procedure in a child of uncertain covid-19 status? the answer is complex and varies based on institutional guidelines and equipment availability. this paper better informs the radiologist's decision during such an encounter. infections are commonly transmitted by contact, droplet and airborne routes (tables 1 and 2) [3, 4] . contact transmission occurs when infectious organisms are transferred from an infected person to a susceptible individual, either directly through physical contact, or indirectly via contaminated objects (e.g., us transducer, fluoroscopy table, doorknob, computer mouse); susceptible individuals could then inoculate themselves by touching their eyes, nose or mouth with contaminated fingers. droplet transmission occurs when larger infectious particles (>5 μm) travel from the infected individual to the mucosal surfaces of a susceptible person's eyes, nose or mouth; droplets might travel in the air as far as 6 ft. airborne transmission occurs when smaller infectious particles (generally <5 μm), known as aerosols, remain suspended in the air for prolonged periods ranging from minutes to days; these particles might contact mucosal surfaces or be inhaled. importantly, an organism might be spread by more than one of these routes. for example, there is strong evidence of influenza virus transmission by droplet, airborne and contact modes [5] . these pathogenic particles are absorbed via the respiratory mucosa and potentially across the conjunctivae. both droplets and aerosols can be generated during coughing, sneezing, talking and exhaling, which generates different numbers of respiratory particles. the particle size and infective capacity also varies among these activities. coughing and sneezing expel a cloud of respiratory particles of many different sizes, ranging from 0.1 μm to greater than 500 μm [5] [6] [7] . a sneeze generally contains more particles than a cough [8] . although particles are somewhat arbitrarily categorized as either aerosols or droplets, their behavior varies along a spectrum. for example, settling times (i.e. the time it takes particulate matter to fall 3 m, or approximately the height of a room) for particles of different diameters are 10 s for 100 μm, 4 min for 20 μm, 17 min for 10 μm, and 62 min for 5 μm [9] . this behavior can be further affected by environmental factors like airflow and humidity [8] [9] [10] . aerosols typically travel longer distances in the air and are more likely to be inhaled deeper in the lungs, while larger droplets are typically trapped in the upper airways [8, 10] . airflow dynamics of coughing, sneezing, breathing, speaking, toilet flushing and even vomiting have been studied and shown to generate aerosols [5] , but there is little available evidence regarding airflow dynamics of many other processes that might be encountered by the pediatric radiologist, such as crying, burping and passing flatus. the most common symptoms of covid-19 include fever, cough, dyspnea, fatigue and myalgia [1, 2] . patients might also experience headache, loss of smell or taste, nasal congestion and gastrointestinal symptoms (e.g., vomiting, diarrhea) [2, 6] . about 15-29% of affected adults progress to severe pneumonia, adult respiratory distress syndrome (ards) and respiratory failure [2, 11] . reported mortality rates among different countries range 0.8-12.7%, including an estimated 3.6% mortality rate in the united states, though these figures might be inaccurate because there could be a large number of people with the disease who have not been tested [12] . in children, covid-19 is generally milder than in adults, and gastrointestinal symptoms are more prevalent [13, 14] . as of this writing, the etiology and pathophysiology of the newly identified multisystem inflammatory syndrome in children (mis-c) associated with covid19 have not yet been elucidated (https://www.cdc.gov/coronavirus/2019-ncov/daily-lifecoping/children/mis-c.html). children younger than 18 years account for only 2% of severely affected patients. however, of greater public concern, children might be asymptomatic viral carriers and transmit the disease to more vulnerable individuals [15] . the sars-cov-2 virus binds to the angiotensin-converting enzyme-2 (ace2) receptor, which is abundant in respiratory epithelial cells [16] , accounting for the high prevalence of respiratory symptoms in this disorder. before it reaches the lungs, the virus must first come in contact with mucosal cells in the lips, nasal cavity, or conjunctivae that also express the ace2 receptor [1] . ace2 receptors are also expressed in the gastrointestinal tract, which might explain the gastrointestinal symptomatology occurring in 2-10% of patients. this might be of special interest in children in whom gastrointestinal symptoms are more common [13] . our understanding of the virus is still growing, but early data suggest that sars-cov-2 is primarily spread through the respiratory droplets of sick individuals. there is still concern that airborne transmission occurs; data from the university of nebraska have demonstrated aerosolization of the virus both within and outside the rooms of patients hospitalized with covid-19 [17] . it is also clear that asymptomatic infection occurs. while it is uncertain to what degree asymptomatic people transmit the virus, these individuals can have high viral loads in their airway [18, 19] , and the virus can be recovered from the environment that they inhabit [20, 21] . this potential for airborne transmission of sars-cov-2 is particularly concerning for pediatric radiology departments regarding aerosol-generating procedures (discussed later). although viral load for covid-19 is certainly the highest in sputum and upper respiratory secretions, another potential route of transmission is through viral shedding in stool. several studies demonstrated the presence of viral ribonucleic acid (rna) in 15-53% of stool samples of covid-19 patients, with persistence of viral rna in the stool even after respiratory samples became negative. furthermore, it was found that stool samples were positive at a higher rate in patients who experienced diarrhea [22] [23] [24] [25] . although viral rna is present in covid-19 patients' stool, feco-oral transmission has not been documented, and there is no convincing evidence of viable pathogenic sars-cov-2 particles cultured from these stool samples. aerosol-generating medical procedures are increasingly recognized as a source of nosocomial infections that pose risk for health care professionals, particularly in the covid-19 era. many procedures performed by radiologists have the potential of inducing aerosol formation by patients either with coughing, or with aerosolization of bowel contents. aerosolgenerating procedures may be classified as: (1) procedures that mechanically create and disperse aerosols and (2) procedures that induce the patient to produce aerosols. the first classification includes nebulizer treatment, suctioning, manual ventilation and noninvasive ventilation (e.g., bilevel positive airway pressure, continuous positive airway pressure, and high-frequency oscillatory ventilation). the second classification includes endotracheal intubation, bronchoscopy, cardiopulmonary resuscitation, and sputum induction (produced by the patient coughing) [26] . personal protective equipment (ppe) ( table 1) the purpose of wearing ppe is to minimize exposure to hazards that can cause injuries and illnesses in the workplace [27] . the use of ppe should meet standards specifically developed for each exposure risk level of a particular task. in the context of the current covid-19 pandemic, it is of utmost importance that each workplace prepares for the corresponding levels of exposure defined by the occupational safety and health administration [28] . in pediatric radiology departments, the risk involved ranges from low (e.g., office workers, remote workers, telemedicine) to very high (e.g., workers performing aerosol-generating procedures on known or suspected covid-19 patients), depending on the job task assigned [28, 29] . when caring for anyone with confirmed or suspected sars-cov-2 infection, health care personnel should adhere to standard and transmission-based precautions [30] [31] [32] . the preferred ppe for these covid-19 precautions includes a face shield or goggles, a n95 or higher respirator, non-sterile gloves and an isolation gown ( fig. 1 , online supplementary material 1 and 2) [33] . the u.s. department of labor's occupational safety and health administration has established the following standards for eye and face protection (these are designated as cfr 1910.133) [34] . & eye protection: goggles or shields can be used to protect from splashes of blood and body fluids [35, 36] . eye glasses and contact lenses do not meet requirements for eye protection but may be used underneath goggles or shield [37] . reusable eye protection should be cleaned and disinfected prior to reuse [38] . & face shields: face shields are used to protect the facial area and associated mucous membranes, and must cover the front and sides of the face [38, 39] . while there is no current standard for face/eye protection for airborne pathogens, the current recommendations by the occupational safety and health administration for bloodborne pathogens include "masks in combination with eye protection devices, such as goggles or glasses with solid side shields, or chin-length face shields" [39, 40] . face shields have been shown to reduce a respirator's contamination by 97% and to block 68% of inhalational exposure immediately after a cough (3.4 μm particles at a distance of 18 in.) [41] . & surgical masks: surgical masks are loose-fitting disposable devices. these masks protect the wearer's mouth and nose with a physical barrier [42] . surgical masks are fluidresistant, and they guard others from the wearer's respiratory emissions (>2 μm) [43] . these masks also protect against large droplets, splashes and sprays of bodily or other hazardous fluids. & respirators: respirators are used to reduce the risk of inhaling hazardous airborne particles, gases or vapors, and should cover at least the nose and mouth [38] . respirators • extended use of equipment • use of alternate equipment (e.g., cloth gowns, coveralls, equipment meeting international standards) • selectively cancel elective and non-urgent procedures and appointments for which eye protection is typically required • shift eye protection supplies from disposable to reusable devices such as goggles and face shields • selectively cancel elective and non-urgent procedures and appointments for which facemask, gown or eye protection is typically used by the provider • prioritize use of facemask, gown and eye protection equipment by activity type (use during aerosol-generating procedures or other high-contact patient care activities) • consider using safety glasses (e.g., trauma glasses) that have extensions to cover the side of the eyes • reprocess eye protection with effective cleaning methods when no equipment is available • exclude provider at higher risk for severe illness from covid-19 (e.g., immunocompromised) from contact with known or suspected covid-19 patients • designate convalescent provider for provision of care to known or suspected covid-19 patients • consider using gown alternatives that have not been evaluated as effective (preferably with long sleeves and closures such as snaps, buttons) • if facemask not available, consider: use of face shield that covers the entire front (extends to the chin or below) and sides of the face with no facemask; use of expedient patient isolation rooms for risk reduction; use of ventilated headboards, and provider use of homemade masks (e.g., bandana, scarf) protect either by removing contaminants from the air or by supplying clean air from a different source [44] . they are certified by the centers for disease control and prevention (cdc) and the national institute for occupational safety and health (niosh) [45] . & n95 respirators: these masks are filtering facepiece respirators (ffr) that efficiently filter out at least 95% of large and small (≥0.3 μm) airborne particles. they fit close to the face and are non-resistant to oil-based aerosols [38, 42, 43, 46] . of note, most n95 respirators are not manufactured to be used in health care. prior to patient care, n95 respirators should be fit-tested and seal-checked. the wearer should meet facial hair requirements because n95 masks cannot be used when facial hair comes between the sealing surface of the facepiece and the wearer's face [38, 45, 47] . the wearer of an n95 should be medically cleared to use a respirator because it could prove hazardous for people with certain breathing conditions [48] . & powered air purifying respirators (paprs): certified by occupational safety and health administration, paprs are battery-powered respirators that use a blower to force filtered ambient air to the inlet covering [45] . in contradistinction to n95 respirators, these are loose-fitting, provide eye protection, do not obscure the mouth, may be used with facial hair, and do not require a fit test. challenges when using a papr might include impeded hearing for the user because of the sound of the fan, pediatric patient apprehension, and decontamination after use [38, 49, 50] . current guidelines do not require gowns to conform to specific standards [51] .the choice of gown depends on the risk level for contamination [52] . there should be enough fabric in the gown to wrap around the body and cover the back, even while sitting down or squatting [52] . isolation gowns and surgical [33] gowns, which are commonly used fluid-resistant and impermeable protective gowns, provide moderate to high barrier protection [51] . surgical gowns should be prioritized for sterile procedures; disposable isolation gowns are sufficient for most patient encounters in pediatric radiology departments, even with high risk of contamination [51, 53] . nonsterile disposable patient examination gloves are appropriate when caring for patients with suspected or confirmed covid-19, similar to all contact precaution encounters [52] . double gloves are not recommended for caring for covid-19 patients [52] . standard precautions to minimize the spread of infection within health care facilities from direct contact with contaminations include hand hygiene, use of ppe based on anticipated contact with contaminated material, respiratory hygiene/ cough etiquette, cleaning and disinfection of the environment, and proper handling of patient care equipment and waste [10] . the who and the cdc provide guidelines for transmissionbased precautions to be taken for patients with proven or suspected infection with certain pathogens [10, 31] . transmission-based precautions are based on the mode of transmission of the pathogen and can be categorized as contact, droplet and airborne. these precautions are used for infections that can be transmitted through hand-to-hand contact and self-inoculation of nasal mucosa or conjunctiva [10] . contact precaution measures include patient placement in a single room (if available), limiting the transport and movement of the patient outside the room only for medically necessary purposes, using disposable or dedicated patient-care equipment whenever possible, and frequent cleaning and disinfection of rooms. the appropriate ppe for contact precautions includes gloves and a gown, which must be worn for all interactions with the patient or the patient's environment. health care workers should wash their hands and don ppe before entering the room, and discard ppe before exiting and wash hands after doffing gloves. droplet precautions are used for patients who might be infected with pathogens transmitted via respiratory droplets. to control the source of pathogen spread, the infected patient should wear a surgical mask, be placed in a single room (if fig. 2 proposed triage mechanism for resource allocation for aerosol-generating procedures (reprinted with permission from the society of interventional radiology). papr powered air purifying respirator, ppe personal protective equipment, pui person under investigation available), and instructed to follow respiratory hygiene and cough etiquette (e.g., covering mouth and nose with a tissue when coughing or sneezing, disposing the tissue in the nearest waste bin, and performing frequent hands hygiene). transport and movement of the patient must be limited to medically necessary purposes. as per cdc recommendations, upon entry into a patient room or space, the health care worker's eyes, nose and mouth should be covered with appropriate ppe, including a surgical mask and goggles. while recommendations regarding eye protection in the form of goggles or a face shield are still an "unresolved issue" as per the cdc, eye protection should be implemented during procedures and patient care activities that are likely to generate splashes or spray of body fluids or secretions [54] . these precautions are appropriate for patients who might be infected with pathogens transmitted by an airborne route, including sars-cov2, according to cdc guidelines. other examples of common airborne infections include tuberculosis, measles and chickenpox. the patient must wear a mask to control the source of infection. the best placement for the patient is an airborne infection isolation room, which is a negative-pressure room with dedicated exhaust. if an airborne infection isolation room is not available, the patient should be placed in a negative-pressure room without dedicated exhaust, or a private room with the doors closed. if transport is necessary, the patient must wear a surgical mask and follow respiratory hygiene and cough etiquette. for health care workers caring for these patients, the cdc recommends a fit-tested n95 or higher-level respirator as ppe. the cdc also recommends restricting susceptible health care personnel from entering the room of the patient, and immunizing susceptible people as soon as possible following unprotected contact (if a vaccine is available for the particular pathogen). appropriate personal protective equipment usage stratified by covid-19 status (table 3) because of the possibility of airborne transmission of the virus, the cdc recommends respirators for care of all patients with covid-19 if adequate supplies are available. if respirators are not available, facemasks are a reasonable alternative. in contrast to the cdc guidelines, the who calls for airborne precautions only for aerosol-generating procedures. according to cdc guidance and general concepts of infection prevention, use of ppe in pediatric radiology departments should be determined by the principles underlying standard precautions (e.g., a basic risk assessment of the likelihood of contact with infectious material) and transmission-based precautions (e.g., routes of transmission of the proven or suspected pathogens). because contact with bodily secretions is expected during aerosolgenerating procedures, providers should at least wear a gown, gloves, a mask and eye protection. the conditions of the covid-19 pandemic demand judicious use of limited ppe supplies. to that end, patients can be stratified into five groups. the group raising highest concern among providers is those with positive reverse transcription polymerase chain reaction (rt-pcr) tests. a second, similar group consists of patients who have not been tested but are symptomatic, and have traveled to a high-risk area in the last 14 days, or have had close contact with a person with covid-19. the 14-day cut-off is based on the viral incubation period [55] . this group should be presumed and treated as though covid-19-positive, and testing may or may not be sent for these individuals. inpatient and emergency department settings might have the capacity for more widespread testing than outpatient environments, and might test mildly symptomatic or asymptomatic patients prior to an aerosol-generating procedure. once a covid-19 test has been sent, some consider this a third category, with the term "person under investigation" (pui) applied. turnaround time for these tests currently varies from 5 min to a few days. therefore, patients with pending tests can be treated as presumed covid-19 positive until test results return [56] . a fourth category is those who have been tested and whose rt-pcr test is negative. finally, the fifth category is those who are presumed covid-19-negative, in whom suspicion of covid-19 is low and for whom no test is sent. depending on hospital workflow, patients might pass through several of these categories during the course of an encounter. providing n95, eye protection, gloves and gowns to health care workers seeing all patients would be reasonable, but is not possible in most cases because of limitations on supplies [57] . therefore, during this pandemic, ppe should be distributed where it will be most effective at preventing the spread of covid-19. the highest risk of transmission arises during aerosol-generating procedures, especially those involving airway procedures or support. in the setting of limited ppe, respirators (n95 masks or paprs) should be reserved for these procedures, with papr used by those who cannot wear an n95. all covid-19-positive patients need these expanded precautions during aerosolizing procedures. for emergent cases, patients with pending tests or presumed positive patients need similar precautions to those with confirmed disease. for less urgent cases, it might be possible to wait for a covid-19 test to return. a more difficult question is how to approach aerosolizing procedures on patients who are either covid-19-negative or who have not been tested. many practices require a covid-19 test be sent prior to performing an aerosol-generating procedure. a provider might want to consider the sensitivity of that test [58] when deciding how heavily to rely on test results for categorizing risk [59, 60] . for example, while many of the laboratory-developed tests have high analytical sensitivity (>90-95%), some automated platforms and point-of-care tests are less sensitive. clinical sensitivity of any test is difficult to confirm because there is no established gold standard. ultimately, if the provider is uncomfortable with the possibility of a false-negative test, then the provider should don airborne precaution ppe and perform the aerosol-generating procedure without waiting for test results. finally, for patients who test covid-19-negative, standard ppe should be used. the cdc has published strategies for optimizing the supply of ppe and ventilators, and for managing surge capacity. three levels of surge capacity are described (table 4) : conventional no change in normal daily practices; contingencymeasures may change daily standard practices, but may not have significant impact on patient care or health care provider safety; and crisisnot commensurate with u.s. standards of care. these measures, alone or in combination, may be necessary during periods of shortages [61, 62] . extended use of ppe is a contingency capacity strategy in which the same ppe is used by one provider when interacting with more than one patient. for respirators, this strategy has been used during previous outbreaks for patients housed in the same location (cohorted). the maximum recommended extended use period is 8-12 h. reuse ("limited reuse") of ppe is a crisis capacity strategy in which the same ppe is used by one provider for multiple encounters with different patients, but is removed after each encounter or periodically. for respirators, a maximum of five uses per device is recommended. ppe should be discarded if it is grossly contaminated with patient bodily fluids or if it loses structural integrity. if possible, the cdc proposes a strategy where five respirators are issued to each provider who might be caring for covid-19 patients. the provider wears one per day, then stores the respirator in a breathable paper bag at the end of shift until the next week, allowing a minimum of five days between each use (the expected survival time of the sars-cov2 virus under these conditions is 72 h). a number of other reprocessing or sterilization strategies have been proposed and have been validated to varying extents [63, 64] . the increased demand for ppe and other medical devices has caused a breakdown in the supply chain. additive manufacturing (3-d printing) groups are addressing the resultant shortages. the first reported experience during the covid-19 pandemic was from an italian engineering team that re-created respirator parts [65] . different sectors of the additive manufacturing industry have long shared their information through open-source file platforms, expanding their expertise into public and academic spaces, from forums like thingiverse [66] to the national institute of health (nih) 3-d printing exchange [67] . as an example, the 3-d printing team from the radiology department at children's hospital of philadelphia has partnered with supply chain management to produce or begin development of face shields and goggles, mask ear strap adaptors, papr hosing connectors, disposable exhalation ports, and reusable n95 respirators. on a local level, crowdsourced efforts might bring together additive manufacturing laboratories to share files, diversify machine styles and materials, collect limited raw materials, and ramp up productionsuch that a process that would usually take months, or even years, could be pared down to days or weeks. this could also reduce competition for raw materials in high demand, like thermoplastics and polymers. if distribution of these materials is also hampered by a supply chain breakdown, they could possibly be deemed non-essential and their production halted. in the near future, these efforts could be supported by industry partners with printing farms and large industrial machines. the speed of production in additive manufacturing is certainly an advantage, but it is essential to consider safety, both in quality control of the processes and in regulatory aspects of the products. a quality-control method entails documentation of manufacturing (e.g., confirming materials, printed files, and resolution) and use to ensure consistent output (e.g., inspecting and fixing burrs, delamination gaps, and cracks). it also establishes checkpoints for inspection and cleaning before each part enters the general supply. these methods are particularly important in efforts to solicit public donations. from a regulatory standpoint, now might be an opportune time to test the boundaries of approved applications like those in emergency use authorization [68]. however, it must be done in a controlled fashion defined by specific conditions (e.g., the fda enforcement discretion policy [69] ) to prevent a free-for-all beyond the scope of the situation. other considerations with additive manufacturing in this setting are: the limited supply of some of the necessary raw materials, such as clear polymers for face shields; and prioritizing design plans that result in products that can be cleaned and are durable enough for reuse. appropriate personal protective equipment usage specific to pediatric radiology (table 5, online supplementary material 3, 4 pediatric radiology staff can be exposed to covid-19 while performing fluoroscopic or interventional procedures, scintigraphy or exams associated with anesthesia use. for these exams, there is increased risk from direct contact with body fluids, either in droplet or aerosolized form, to unprotected mucous membranes of the eyes, nose or mouth. at many institutions, all patients presenting for a radiology exam from the emergency department or as outpatients receive covid-19 tests. however, at the time of exam, test results from emergency department patients are often unavailable because test results can take up to 8 days. despite the lack of evidencebased standards related to radiology procedures in the setting of covid-19, many evolving practices are similar across the authors' institutions. lists of aerosol-generating procedures have been compiled by professional societies, but none is specific to pediatric radiology (fig. 2) [70] . standard aerosol-generating procedures remain undefined for many areas of practice, and the debate continues in the setting of the covid-19 pandemic. based on our collective experience, as well as recent guidelines published by the society of interventional radiology (sir) and society for nuclear medicine and molecular imaging (snmmi), common pediatric fluoroscopic, scintigraphic, and interventional procedures requiring ppe for airborne (aerosol) precautions are described in table 5 . nasoenteric tube placements and exchanges are common for urgent or emergent fluoroscopic procedures performed in pediatric patients. both types are considered aerosol-generating because of the potential for sneeze or cough induction. upper gastrointestinal exams can also lead to aerosol formation in the setting of aspiration and cough. air enemas for intussusception reduction are typically considered aerosol-generating procedures, given their similarity to lower endoscopic procedures where the colon is insufflated and that they can lead to generation of aerosols containing fecal material while gas is evacuated [71] . some argue that liquid contrast agent might be safer for intussusception reductions because it might decrease risk of aerosolization compared with droplets. however, given that luminal pressure is still elevated in combination with increased intraabdominal pressure, and that there is evidence that viral shedding in stool may be found 4 weeks after resolution of fever in covid-19-positive patients [72] , many think that aerosolization remains a risk in all intussusception reductions, regardless of contrast agent, because of the risk of spraying fecal material. discussions about aerosol-generating procedure risk between air-and liquid-contrast intussusception reductions should also incorporate safety profiles, which tend to favor air reductions because of their comparable success rate with lower radiation [73, 74] . for all aerosol-generating procedures in children who have either unknown or confirmed positive covid-19 status, radiologists should adhere to the highest level of respiratory protection available: a respirator, an eye shield, a disposable gown and gloves. additional measures to augment safety might include requiring the child to also wear a mask. only essential personnel should be present in the fluoroscopy suite during the procedure. if the covid-19 test is negative, appropriate ppe for the specific patient encounter should be used for aerosol-generating fluoroscopy exams, which might include precautions against viral droplets or spray of bodily fluids (following cdc standard precautions philosophy) [32] . pediatric interventional radiology procedures are often performed under sedation or anesthesia. accordingly, all such procedures are considered aerosol-generating because of airway manipulation from intubation and airway rescue or suctioning during the exam. many institutions, such as seattle children's hospital, require all patients undergoing anesthesia or sedation to have a covid-19 test performed within 72 h prior to the procedure. for patients with positive covid-19 test results, the highest level of respiratory protection is required for all health care workers involved throughout the duration of the procedure. for sterile procedures, scrubbed personnel close to the sterile field should use papr shrouds to prevent air blown into the sterile field. in nuclear medicine, ventilation scans use xenon-133 or, l e s s c o m m o n l y , a e r o s o l i z e d t e c h n e t i u m -9 9 mdiethylenetriamine pentaacetate (tc-99 m-dtpa). if a ventilation/perfusion (v/q) scan is requested, aerosolgenerating procedure risk can be mitigated by performing perfusion only [75] . scintigraphic gastric emptying, esophageal reflux, and salivary gland exams can also induce vomiting or coughing in children, and therefore aerosol-generating procedure precautions might be taken. because of the length of time required for many scintigraphic exams, patients should wear a mask if possible. because of the broad net cast by the sir in classifying sedated procedures as aerosol-generating procedures [70] , further clarifications are warranted regarding the true risks of airborne transmission in what would inherently be a nonaerosol-generating procedure. for example, one might reasonably question whether a sedated voiding cystourethrogram in a child with unknown covid-19 status should necessitate airborne ppe precautions because of the low risk of airway rescue. while the authors think that many such procedures are not necessarily aerosol-generating procedures because of the low risk of additional airway manipulation and subsequent aerosolization, evidence to support or dispute this rationale has not been established. such nonurgent examinations are uncommon during this pandemic, but speak to the need to establish clear guidelines around aerosol-generating procedures as outpatient imaging volumes return to normal levels. for all children undergoing examinations in the radiology department, ppe usage by patients should be consistent with the appropriate level of transmission precautions required for their care, following cdc standard precautions [32] . all patients should wear masks and follow basic respiratory hygiene and cough etiquette principles if possible, if they are symptomatic for a viral upper respiratory infection [32] . wearing a mask might not be possible for children undergoing an aerosol-generating procedure that requires access to nose or mouth (e.g., upper gastrointestinal series or nasogastric tube placement), for infants and young children, or for cognitively impaired children. the accompanying caregiver may be encouraged or required to wear a mask, even when asymptomatic, depending on the particular hospital's policies. symptomatic caregivers should be asked to leave and find an asymptomatic caregiver to accompany the child whenever possible. limiting the number of caregivers in these encounters minimizes the possibility of exposure between an asymptomatic adult carrier of the virus and health care provider. risk of exposure is particularly high for technologists, who perform a wide variety of radiology exams across the department and have direct contact with patients. consequently, radiologists should be sensitive to and supportive of their technologists' workflow. technologists should wear the highest level of protection when interacting with emergency department patients who are symptomatic for viral infection, regardless of a verified covid-19 status. for patients who are asymptomatic, technologists should take respiratory (droplet) precautions (mask and face shield), with or without additional contact precautions (gown and gloves). technologists also have more interaction with other health care staff while performing portable exams or receiving patient care teams at the scanner. it is important that the ppe worn by radiology technologists is similar to that worn in the patient care environment, with increased protection as necessary depending on the technologist's task. similarly, other critical support staff in the radiology department, such as nurses, should adhere to ppe precautions commensurate with each encounter because of their close contact with patients. of note, the presence of child life specialists to optimize chances for a successful study should be balanced with the need to minimize exposure between staff and patient. the ppe available to radiology staff might be limited by hospital supply chains. radiologists should advocate for safe ppe for department personnel, as those distributing hospital ppe might have a limited understanding of the varied roles technologists have. finally, we return to the initial question posed regarding appropriate ppe usage for the pediatric radiologist about to perform an aerosol-generating procedure on a child with unknown covid-19 status. a conservative approach, and one that is backed by current cdc guidelines, would recommend that radiologist don airborne and contact transmission precautions, which include a respirator if available, eye protection, gown and gloves. however, droplet and contact precautions eye protection, surgical mask, gown and glovesmight be a reasonable alternative depending on ppe availability. health care providers are faced with an overwhelming amount of data and constantly evolving recommendations regarding the covid-19 pandemic. it can be challenging to remain current with evolving guidelines while also providing optimal patient care and fulfilling other professional obligations. first and foremost, each radiology department should align with institutional guidelines regarding infection control. current versions of these materials should be distributed to all radiology personnel. the cdc is also actively adapting ppe recommendations as the situation evolves [76] . professional societies, including the american academy of pediatrics and the society for healthcare epidemiology of america, refer directly to the cdc for guidance on the recommended use of ppe. health care organizations with early experience in managing covid-19 patients have also developed extensive policies and protocols, including ppe recommendations, which are available for review. additional resources and clinical guidelines are provided by the university of washington medicine covid-19 resource site [77] and the brigham and women's hospital [78] . the covid-19 pandemic has presented an array of unique and daunting challenges, not the least of which is maintaining the safety of health care providers while they care for patients. although respiratory droplet transmission of the virus is most likely, our current understanding indicates health care providers should nonetheless don a respirator, if available, whenever caring for a covid-19-positive patient. in pediatric radiology departments, this is particularly true for aerosolgenerating procedures that might result in cough or spray of fecal matter, such as intussusception reductions. this precaution also applies to procedures involving intubated and sedated children. fundamental knowledge of ppe and infectious transmission is crucial for pediatric radiologists as we navigate through this pandemic and enter a world of heightened awareness of infection control. covid-19 epidemic: disease characteristics in children epidemiology, virology, and clinical features of severe acute respiratory syndrome -coronavirus-2 (sars-cov-2; coronavirus disease-19) microbiology for radiologists: how to minimize infection transmission in the radiology department how infections spread aerosol transmission of infectious disease endonasal instrumentation and aerosolization risk in the era of covid-19: simulation, literature review, and proposed mitigation strategies the role of particle size in aerosolised pathogen transmission: a review personal protective equipment during the covid-19 pandemic -a narrative review review of aerosol transmission of influenza a virus controversy around airborne versus droplet transmission of respiratory viruses: implication for infection prevention imaging and clinical features of patients with 2019 novel coronavirus sars-cov-2: a systematic review and meta-analysis coronavirus update (live): 1,997,666 cases and 126,597 deaths from covid-19 virus pandemic a comparativedescriptive analysis of clinical characteristics in 2019-coronavirus-infected children and adults coronavirus disease (covid-19): characteristics in children and considerations for dentists providing their care covid-19 in children and altered inflammatory responses ace2 receptor expression and severe acute respiratory syndrome coronavirus infection depend on differentiation of human airway epithelia transmission potential of sars-cov-2 in viral shedding observed at the university of nebraska medical center a well infant with coronavirus disease 2019 (covid-19) with high viral load asymptomatic and presymptomatic sars-cov-2 infections in residents of a longterm care skilled nursing facility public health responses to covid-19 outbreaks on cruise ships -worldwide environment and personal protective equipment tests for sars-cov-2 in the isolation room of an infant with infection a case series of children with 2019 novel coronavirus infection: clinical and epidemiological features faecal-oral transmission of sars-cov-2: practical implications evidence for gastrointestinal infection of sars-cov-2 gastrointestinal manifestations of sars-cov-2 infection and virus load in fecal samples from the hong kong cohort and systematic review and metaanalysis nosocomial transmission of emerging viruses via aerosol-generating medical procedures united states department of labor occupational safety and health administration (2020) personal protective equipment united states department of labor occupational safety and health administration (2020) covid-19: control and prevention united states department of labor occupational safety and health administration (2020) covid-19: hazard recognition coronavirus disease 2019 (covid-19): using ppe transmissionbased precautions standard precautions for all patient care use personal protective equipment (ppe) when caring for patients with confirmed or suspected covid-19. cdc infographic standard number 1910.133 -eye and face protection world health organization (2020) rational use of personal protective equipment for coronavirus disease 2019 (covid-19) infection prevention and control of epidemic -and pandemic-prone acute respiratory infections in health care infection control and prevention -personal protective equipment (ppe) coronavirus disease 2019 (covid-19): infection control guidance: summary of changes to the guidance face shields for infection control: a review united states department of labor occupational safety and health administration (2012) 1910.1030. toxic and hazardous substances: bloodborne pathogens efficacy of face shields against cough aerosol droplets from a cough simulator personal-protective-equipment-infection-control/n95-respiratorsand-surgical-masks-face-masks n95 respiratory masks for covid-19: a review of the literature to inform local responses to global shortages centers for disease control and prevention national institute for occupational safety and health (niosh) (2020) respirators: overview united states department of labor occupational safety and health administration (2011) 1910.134. personal protective equipment: respiratory protection centers for disease control and prevention national institute for occupational safety and health (niosh) (1996) niosh guide to the selection and use of particulate respirators: certified under 42 cfr 84 filtering out confusion: frequently asked questions about respiratory protectionuser seal check united states department of labor occupational safety and health administration (2020) transcript for the osha training video entitled medical evaluations for workers who use respirators centers for disease control and prevention national institute for occupational safety and health (niosh) (2013) infection control preparing for a covid-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore coronavirus disease 2019 (covid-19): gowns centers for disease control and prevention (2020) coronavirus disease 2019 (covid-19): faq about ppe: gowns ansi/aami pb70:2012: liquid barrier performance and classification of protective apparel and drapes intended for use in health care facilities guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings covid-19 and the risk to health care workers: a case report absence of contamination of personal protective equipment (ppe) by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) respiratory virus shedding in exhaled breath and efficacy of face masks johns hopkins bloomberg school of public health center for health security (2020) serology-based tests for covid-19 detection of sars-cov-2 in different types of clinical specimens diagnostic performance of ct and reverse transcriptase-polymerase chain reaction for coronavirus disease 2019: a meta-analysis coronavirus disease 2019 (covid-19): n95 respirators coronavirus disease 2019 (covid-19): optimize ppe supply effectiveness of n95 facepiece respirators in filtering aerosol following storage and sterilization the incubation period of 2019-ncov from publicly reported confirmed cases: estimation and application updateing] italian hospital saves covid-19 patients [sic] lives by 3d printing valves for reanimation devices challenge 2: face covering national institutes of health (2020) nih 3d print exchange food and drug administration (2020) emergency use authorization food and drug administration (2020) enforcement policy for ventilators and accessories and other respiratory devices during the coronavirus disease 2019 (covid-19) public health emergency aerosol generating procedures performed by interventional radiology clinical notification from the society of interventional radiology aga institute rapid recommendations for gastrointestinal procedures during the covid-19 pandemic prolonged viral shedding in feces of pediatric patients with coronavirus disease 2019 intussusception reduction: effect of air vs. liquid enema on radiation dose meta-analysis of air versus liquid enema for intussusception reduction in children society of nuclear medicine & molecular imaging (2020) covid-19 and ventilation/perfusion (v/q) lung studies how to protect yourself uw medicine covid-19 resource site hospital (2020) brigham and women's hospital covid-19 clinical guidelines publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgments the authors wish to thank lydia sheldon for her editorial contributions to this manuscript. key: cord-309956-topo2bc6 authors: zheng, kenneth i.; rios, rafael s.; zeng, qi-qiang; zheng, ming-hua title: covid-19 cross-infection and pressured ulceration among healthcare workers: are we really protected by respirators? date: 2020-09-10 journal: front med (lausanne) doi: 10.3389/fmed.2020.571493 sha: doc_id: 309956 cord_uid: topo2bc6 nan opinion anticipated vaccination development delay rendered non-pharmaceutical strategies crucial for the control of the coronavirus disease 2019 (covid-19) pandemic. thus, personal protective equipment (ppe) is the key for preventing potential amplification of nosocomial infection and viral transmission as demonstrated during the 2003 sars outbreak (1) . as of april 8 2020, 22,073 health care workers (hcws) from 52 countries have reportedly been infected by the severe acute respiratory syndrome (sars) coronavirus 2 (sars-cov-2) (2). this might imply that there is a certain limitation in the ability of ppe to protect hcws from cross-infection. also, it is surmisable that unequal access to ppe and limited instruction in its correct use, may drastically reduce its utility. for hcws, the world health organization recommended the use of respirators including united states national institute for occupational safety and health (niosh)-certified n95, european union standardized ffp2, or equivalently certified respirators, when performing or working in settings that require aerosol-generating procedures (3). the occupational safety and health administration respiratory protection regulations at 29 cfr 1910.134 mandated that hcws be fit-tested and seal checked prior to the initial use of a respirator and whenever a different respirator face piece (size, style, model, or make) is used (4). however, not strictly following the aforementioned protocol and design flaws of current ppe are most likely what contributed to the high number of reported cases of sars-cov-2 infections among hcws (5) . in the current pandemic, although trained hcws are highly adherent to strict protocols, they may not have access to respirators that fit him/her the best. normally, a respirator should fit over the nose and under the chin with appropriate sealing through an arched metal nosepiece to prevent leakage. however, this is not always achieved due to variance in facial and nose bridge bone structure causing incomplete sealing. to combat this problem, hcws may resort to manually shortening and fastening the straps that connect the respirator around the neck and over the head causing pressure ulcerations on facial skin along the edges of the respirator (figure 1 ) (6) . even then, the safety of hcws is not guaranteed. in a randomized clinical trial investigating the protection efficacy of n95 respirators (with daily usage of 5-h on average) in 949 hcws, 37 (3.9%) had a clinical respiratory illness, while 13 (1.4%) had a laboratory-confirmed viral respiratory infection (7) . in addition, 52.2% of users felt pressure on the nose, 41.9% felt uncomfortable, and 5% had skin rash. preliminary analysis estimated the prevalence of skin damage from prolonged use (>6 h per day) of n95 respirator among 542 hcws managing the covid-19 pandemic in hubei, china, to be 58.5% (8) . additionally, 526 hcws reported skin damage due to respirator use, while most sites of skin lesions appeared on the nasal bridge (83.1%) and cheek (78.7%) (8) . while it is obvious that the use of respirators can cause discomfort and harm to hcws, there is a need to evaluate adherence of protocol and to assess the risk of infection from skin lesions due to ppe. nevertheless, it is recognized that hcws in the current covid-19 pandemic, through prolonged wearing of respirators, might be exposed to a higher risk of cross-infection and skin damage. in order to reduce pressure ulcerations caused by prolonged respirator usage, relieving the pressure from the mask every 2 h was suggested by gefen (6) ; however, this is not achievable, realistically, as hospitals are often short-staffed and hcws must work around the clock to manage covid-19 patients. the metal nose piece used to secure a respirator suggests a certain inadequacy in design. this implies the need for a better designed and improved respirator to strengthen its sealing capability and to reduce skin damage. one alternative solution to decrease facial pressure suggested was applying hydrocolloid padding along the sealing edges of respirators, creating a minute gap between the two (9). this technique may effectively lower the friction and chafing between ppe and the face, thereby drastically reducing skin lesions, although the integrity of the overall sealing is subject to further investigation. recently, increasing evidence demonstrated the application of silicone foam dressing in reducing pressure ulcers (10, 11) . the application of padding a double-sided silicone foam dressing on the inner surface of the respirator (along the nose arch) might provide a better seal between the face and edges of the respirator (supplementary figure 1) . both hydrocolloid padding and nonallergenic silicone foam dressing may reduce the facial pressure, while the latter is superior for reducing pressure ulcers incidents (any stage) and less prone to skin irritation (12) . however, their applicability to ppe requires further investigation and testing. in summary, the proper use of respirators among hcws is pertinent for effectively preventing covid-19 transmission. unfitted and improperly fitted respirators are prone to leakage and may lead to an increased risk of sars-cov-2 cross-infection as well as pressure ulcerations in the skin, especially when used for a long time. it is necessary to improve the design of currently certified respirators in order to achieve better sealing capabilities and reduce pressure ulcerations. m-hz and q-qz: conception, design, and administrative support. kz and rr: manuscript writing. all authors: final approval of manuscript. epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in hong kong available online at advice-on-the-use-of-masks-in-the-community-during-homecare-and-in-healthcare-settings-in-the-context-of-the-novel-coronavirus-(2019-ncov)-outbreak occupational safety and health administration. 1910.134-respiratory protection personal protective equipment during the covid-19 pandemica narrative review devicerelated pressure ulcers: secure prevention a cluster randomized clinical trial comparing fit-tested and nonfit-tested n95 respirators to medical masks to prevent respiratory virus infection in health care workers. influenza other respir viruses skin damage among health care workers managing coronavirus disease-2019 the preventive effect of hydrocolloid dressing to prevent facial pressure and facial marks during use of medical protective equipment in covid-19 pandemic clinical effectiveness of a silicone foam dressing for the prevention of heel pressure ulcers in critically ill patients: border ii trial foam dressings for treating pressure ulcers. cochrane database syst rev dressings and topical agents for preventing pressure ulcers the supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fmed. 2020.571493/full#supplementary-material conflict of interest: the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © 2020 zheng, rios, zeng and zheng. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-306090-i8sriw08 authors: tan, zihui; khoo, deborah wen shi; zeng, ling antonia; tien, jong-chie claudia; lee, aaron kwang yang; ong, yee yian; teo, miqi mavis; abdullah, hairil rizal title: protecting health care workers in the front line: innovation in covid-19 pandemic date: 2020-05-15 journal: journal of global health doi: 10.7189/jogh.10.010357 sha: doc_id: 306090 cord_uid: i8sriw08 nan t he covid-19 pandemic has now infected almost 700 000 people, killing more than 30 000 people. although singapore was previously able to control the rapid rise in daily cases through tight quarantine, rapid contact tracing and strict social distancing measures, our health care institutions are now facing a second surge from imported cases. the protection of health care workers (hcws) is vital in continuing patient care in health care systems that are currently challenged by the pandemic, but also important in ensuring they do not spread the virus. in our country, there are no guidelines or unified practices as to the degree of hcw protection required for performing routine throat swabs. a unique feature of many testing venues in singapore is that they are outdoors with the average of 30°c tropical weather, rendering the prolonged use of conventional personal protective equipment (ppe) or full-body protection uncomfortable. the widespread incidence and expected protracted duration of the covid-19 pandemic has also prompted concerns for minimising the use of ppe especially for high-volume or brief procedures with a short duration of high-risk patient contact, such as throat swabbing. we offer this invention as a versatile component of a modular system that can be adapted to several situations and clinic setups. hcws no longer have to change their disposable face shield, cap and gown between patients. this has allowed us to conserve our current ppe supply. in time when testing may be carried out more extensively in community settings, we hope that this would ease logistic difficulties in streamlining the need to test a heavy caseload. it has been close to three months since the first covid-19 case was diagnosed in singapore [1]. the co-vid-19 pandemic has now infected almost 700 000 people, killing more than 30 000 people [2]. although singapore was previously able to control the rapid rise in daily cases through tight quarantine, rapid contact tracing and strict social distancing measures, our health care institutions are now facing a second surge from imported cases. given our country' s unique geographical location, and inherent lack of natural resources and raw materials, we are ultimately dependent on open trade borders to maintain our supply chain. as more countries start to implement travel and border restrictions and in various countries; a total lockdown, this will compromise our ability to maintain a comfortable supply of personal protective equipment. the protection of health care workers is vital in continuing patient care in health care systems that are currently challenged by the pandemic, but also important in ensuring they do not spread the virus. in hubei, china more than 3000 health care workers have been infected and in italy 20% of responding health care workers were infected [3,4]. our singapore public health institutions have had 8 cases of co-vid-19 infections among staff [5] . singapore also depends on an intensive testing programme with one of the highest rates of testing globally at 6800 tests per million people as of 25 march 2020 [6]. since january, our emergency department colleagues have been at the frontline battling the surge in attendance due to the pandemic. throat swabs of suspected patients from the community are taken in a designated fever area (figure 1) . up to 70 patients are seen daily in this area and the number will only increase. although full personal protective equipment (ppe) is provided, concerns regarding ppe wastage and the need for conservation have surfaced. this is due to the continuing rapid increase in the number of patients seen in the community. another important consideration is the proximity of the health care worker to the suspected patient especially when the patient sneezes, coughs or gags. whilst nasal swabs were initially taken, there has been a shortage of these. therefore, we have moved to throat swabs for testing. one study showed that throat swabs have a lower pick up rate as compared to nasal swabs [7] , hence the importance of proper swabbing technique to accurately diagnose cov-id-19. by providing better protection for the health care workers (hcw), we hope to reduce the incidence of false negatives and hence false assurance. together with a local bioengineering company, the biofactory pte ltd, we proposed a screen between the patient and the hcw that fits the following criteria: • protect hcw from droplet ± aerosol contamination, • clear barrier for visualization, • light source to visualize oropharynx, • good dexterity, ie able to use both hands for tongue depressor and swab, • easy to clean, meets local infection control standards, • mobile, • easy for storage, • dual functionality, ie, it can be inverted to contain the patient as well. the first prototype was subsequently tested and used in the emergency department (figure 2) . hcw expressed increased confidence for personal safety despite the high number of suspected patients seen daily. more importantly, hcws no longer have to change their disposable face shield, cap and gown between patients. this has allowed us to conserve our current ppe supply in view of the potential supply shortage if the pandemic continues for a prolonged period of time. innovation in health care is itself difficult, balancing the competing concerns for patient and operator safety, infection control, resource conservation and cost. the current pandemic has exacerbated these restrictions, but ironically made it all the more urgent that efficient and innovative solutions are sought out to address surging patient loads and high infectivity. reported examples of innovation in this pandemic range in scale from individuals repurposing scuba diving masks with 3d-printed "charlotte valves" [8] to vacuum cleaner and automotive manufacturers producing ventilators [9, 10] . testing suspected patients is a cornerstone of epidemiologic control of this outbreak. various devices have been described, from the south korean "phone booth" [11] to simple plastic shields shown in media from the uk and taiwan [12] the aim of these devices is both to contain infection as well as protect a hcw exposed to tens to hundreds of suspect cases. some of the features of these existing devices are seen in table 1 . in our country, there are no guidelines or unified practices as to the degree of hcw protection required for routine testing. a unique feature of many testing venues in singapore is that they are outdoors with the average of 30-degree-celsius tropical weather [13] , rendering the prolonged use of conventional ppe or full-body protection uncomfortable. the widespread incidence and expected protracted duration of the cov-id-19 pandemic has also prompted concerns for minimising the use of ppe especially for high-volume or brief procedures with a short duration of high-risk patient contact, such as throat swabbing. while single-use items have been the erstwhile gold standard of hcw protection and reduction of cross-contamination, we recognise that this is also reliant on supply chains and in many cases overseas manufacturer capacities (that are themselves subject to stresses of the pandemic in their own countries). we offer this invention as a versatile component of a modular system that can be adapted to several situations and clinic setups. in time when testing may be carried out more extensively in community settings, we hope that this would ease logistic difficulties in streamlining the need to test a heavy caseload. our innovation allows for a reversal of the traditional model where an infectious patient is in a negative pressure room, as this requires significant time and labour to disinfect the room between patients. by allowing the health care worker to be protected inside and the patients to pass through outside in an outdoor setting, it will allow for much shorter times between patients and thus be able to rapidly collect swabs for large numbers of patients if the outbreak worsens. difficulties encountered in the production of this device were exacerbated by the rapid evolution of management strategies for the pandemic. as a relatively "unknown enemy", the requirements of infection control policy and organisational directives were developing as practitioners on the ground sought to counter practical challenges such as the heat and fatigue from rapid and repeated donning and doffing of ppe. ready access to bioengineering expertise enabled the rapid production of a prototype. the use of technology to visualise and transmit ideas allowed for multiple practitioners to give their input remotely. video-conferencing platforms allowed for immediate remote previewing of a physical prototype, while mobile messaging facilitated rapid transfer of images and feedback to and from multiple parties and stakeholders. more importantly, tele-communication also reduced the need for physical meetings and also prevented spread of infection by allowing for physical distancing without hampering or slowing the innovation process. emergency grants would accelerate device production in view of the ongoing pandemic, similar to the additional publication of covid-19 related research in medical literature. an extraordinary time in evaluating the accuracy of different respiratory specimens in the laboratory diagnosis and monitoring the viral shedding of 2019-ncov infections james dyson designed a new ventilator in 10 days. he' s making 15,000 for the pandemic fight ford to build 50,000 ventilators in 100 days south korea dials up covid-19 testing with hospital "phone booths taiwanese doctor creates cheap protective device amid virus crisis -focus taiwan the authors would like to acknowledge the division of anaesthesiology and perioperative medicine, singapore general hospital. the views expressed in the submitted article are his or her own and not an official position of the institution or funder. human history calls for special measures to match the needs of a shifting and transforming battleground. as various industries turn their efforts to addressing the needs of health care, those on the ground should be equipped to contribute their first-hand expertise by all means possible. key: cord-340799-1awmtj52 authors: krajewska, joanna; krajewski, wojciech; zub, krzysztof; zatoński, tomasz title: review of practical recommendations for otolaryngologists and head and neck surgeons during the covid-19 pandemic: recommendations for otolaryngologists during the covid-19 pandemic date: 2020-06-06 journal: auris nasus larynx doi: 10.1016/j.anl.2020.05.022 sha: doc_id: 340799 cord_uid: 1awmtj52 introduction: otolaryngologists are at very high risk of covid-19 infection while performing examination or surgery. strict guidelines for these specialists have not already been provided, while currently available recommendations could presumably change in course of covid-19 pandemic as the new data increases. objectives: this study aimed to synthesize evidence concerning otolaryngology during covid‐19 pandemic. it presents a review of currently existing guidelines and recommendations concerning otolaryngological procedures and surgeries during covid-19 pandemic, and provides a collective summary of all crucial information for otolaryngologists. it summarizes data concerning covid-19 transmission, diagnosis, and clinical presentation highlighting the information significant for otolaryngologists. methods: the medline and web of science databases were searched without time limit using terms ‘‘covid-19”, “sars-cov-2” in conjunction with “head and neck surgery”, “otorhinolaryngological manifestations”. results: patients in stable condition should be consulted using telemedicine options. only emergency consultations and procedures should be performed during covid-19 pandemic. mucosa-involving otolaryngologic procedures are considered high risk procedures and should be performed using enhanced ppe (n95 respirator and full face shield or powered air-purifying respirator, disposable gloves, surgical cap, gown, shoe covers). urgent surgeries for which there is not enough time for sars-cov-2 screening are also considered high risk procedures. these operations should be performed in a negative pressure operating room with high-efficiency particulate air filtration. less urgent cases should be tested for covid-19 twice, 48 hours preoperatively in 24 hours’ interval. conclusions: this review serves as a collection of current recommendations for otolaryngologists for how to deal with their patients during covid-19 pandemic. at the end of 2019 in wuhan, china, a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (sars-cov-2) led to a rapidly spreading respiratory disease [1] . the new disease induced by sars-cov-2 was named "covid-19" by world health organization (who) on 11 february, 2020 [1] . the high contagiousness of sars-cov-2 resulted in its rapid spread throughout china and subsequently throughout the world, resulting in global pandemic [1] . currently, covid-19 disease is considered a major public health crisis threatening humanity. because of the high virulence and rapid spread of sars-coc-2 via aerosol or droplet transmissions, until may 12, 2020, a total of 4 058 252 confirmed cases of covid-19 and 281 736 deaths worldwide have been reported by who [1] . the main aim of this review was to synthesize existing scientific evidence concerning otolaryngology during the covid-19 pandemic. the study analyzed disease transmission, diagnosis, and clinical presentation extracting the information significant for otolaryngologists/head and neck surgeons. the study summarizes the currently existing practice guidelines and recommendations concerning otolaryngological procedures and surgeries during covid-19 pandemic and provides a collective summary of all crucial information for ear, nose, and throat (ent) specialist. the medline and web of science databases were searched without time limit but focusing on the newest reports, using the terms "covid-19", "sars-cov-2", "novel coronavirus", and "coronavirus from wuhan" in conjunction with "ent surgery", "otolaryngological surgery", "head and neck surgery", "otorhinolaryngological manifestation", "ent", "upper respiratory tract", "head and neck oncology", "olfaction", "smell", "taste", "ear", "nose", "throat"", "oral cavity", "pharynx", and "larynx". boolean operators (not, and, or) were also used in succession to narrow and broaden the search. auto alerts in medline were also considered, and the reference lists of original articles and review articles were searched for further eligible sources. opinions of medical societies were also included if applicable. the search included articles without language limitations. a total of 227 articles were originally identified using our search criteria. 170 articles were excluded after abstract or full-text analysis because they did not exactly address the topic. therefore, the total number of 57 studies were finally chosen to prepare this manuscript. this article was prepared on studies conducted on both, large cohorts and small cohorts, as a great majority of reports included sparse cohorts of patients. according to the fact that covid-19 is a novel disease, randomized controlled studies and precise evidencebased recommendations for covid-19 management are not available yet. a number of otolaryngologic societies worldwide are currently working on preparing recommendations for ent specialists/head and neck surgeons. despite the initially suggested animal to human transmission of sars-cov-2, human to human transmission is currently believed to be the main source of the virus transmission [1] . sars-cov-2 spreads directly through small aerosol particles (less than 5 μm in size) or droplets (bigger than 20 μm in size) while a covid-19 positive individual is coughing, sneezing or speaking in a distance less than 2 meters from another person [2] . aerosolization, a process during which small particles are generated and dispersed in the air, is an essential source of sars-cov-2 infection for ent specialists. unlike droplets, aerosolized sars-cov-2 particles do not require direct contact with the infected individual [2] . additionally, aerosolized sars-cov-2 particles were considered to remain viable in the air for at least three hours [3] . hands" contact with the surfaces contaminated with the live virus followed by touching one"s nostrils, mouth or eyes could also result in contagion, as sars-cov-2 could stay viable on some surfaces for up to 24-72 hours [2, 4] . nasolacrimal duct, a structure through which tears are transported to the nasal cavity, could potentially explain why eyes contaminated with sars-cov-2 led to covid-19 development [4] . the estimated incubation period for covid-19 ranged between 0 to 14 days after exposure, while the mean incubation period reported by various authors ranged between 4.4 and 6.9 days [5] . importantly, covid-19 positive patients within the first days after exposure and before developing symptomatic disease could be an important source of further virus transmission [5] . additionally, approximately 7-13% of individuals with covid-19 could remain asymptomatic or oligosymptomatic throughout the whole disease duration [6] . interestingly, zou et al. implied that viral loads in nasal and throat swabs were similar in symptomatic and asymptomatic individuals with covid-19 emphasizing the role of asymptomatic patients in transmitting the virus prior to the development of the symptoms [7] . the sars-cov-2 ability to invade human organism and to induce covid-19 is based on the presence of spike (s) glycoprotein on the virus" surface and its interaction with host cells" proteins, namely angiotensinconverting enzyme 2 (ace2) and transmembrane protease serine 2 (tmprss2) [8] . viral s protein binds to host ace2 after initially being primed by a cell surface protease tmprss2 [8] . subsequently, viral rna could be incorporated into the genetic material of the infected host cell [8] . the presence of ace2 and tmprss2 in the epithelium covering the structures of the upper respiratory tract (urt), including oral cavity, pharynx, larynx or nasal cavity, enables the invasion of sars-cov-2 into the host cells via urt and could explain the high concentration of the virus in these areas [8] . it was suggested that differences in the population susceptibility to covid-19 might be related to the modulation of ace2 and tmprss2 levels in urt induced by air pollution or chronic inflammatory respiratory diseases, such as asthma, chronic obstructive pulmonary disease or atopy [4] . covid-19 diagnosis is currently based on sars-cov-2 detection using real-time a reverse transcriptase-polymerase chain reaction (rt-pcr) test. nevertheless, the sensitivity of rt-pcr to detect sars-cov-2 does not reach 100%. rt-pcr could give false-negative results, as, according to various authors, the reported sensitivity of this molecular test ranged between 60 and 90% [9] . the most commonly recommended samples for sars-cov-2 evaluation are nasopharyngeal and oropharyngeal swabs, however, sputum, bronchoalveolar lavage (bal) or endotracheal aspirates could also be obtained for examination [9] . the analysis of nasopharyngeal swabs, that should be taken from the posterior nasopharyngeal tonsil region, was recommended mostly, as nasopharynx harbors high viral loads [10] . testing tracheal aspirates could be of great importance in patients after laryngectomy as the primary airflow in these individuals is via the tracheostomy [11] . testing bal was considered to be the most sensitive in analyzing sars-cov-2 in intubated patients [12] . chest computed tomography (ct) has a sensitivity of 97% and, according to observational studies, could be even more precise tool than rp-pcr in detecting covid-19 in particular cases, if revealing infiltrates, ground-glass opacities, and bronchovascular thickening consolidations [13] . laboratory examination in covid-19 positive patients usually revealed leukopenia and lymphopenia, elevated levels of c-reactive protein, d-dimer, lactate dehydrogenase, aminotransferases, and serum creatinine [9] . procalcitonin tended to remain in the normal range in the majority of covid-19 positive individuals [9] . currently, the criteria for confirmed and suspected covid-19 cases proposed by who were presented in table 1 . the majority of patients infected with sars-cov-2 suffer from fever, dry cough, muscle pain and fatigue [14] . otorhinolaryngological symptoms are not the most common manifestations of covid-19. among all otolaryngological organs, the sinonasal cavity is considered to be the main site of the infection induced by sars-cov-2, as approximately 90% of the inhaled air goes through the sinonasal cavity [4] . importance of the sinonasal cavity in covid-19 development could also result from the high concentration of the genes predisposing to sars-cov-2 infection, namely genes encoding ace2 and tmprss2 [4] . individuals with covid-19 may experience sore throat or swelling of the pharyngeal lymphoid tissue, runny nose, nasal congestion or edema, sudden loss of smell that sometimes accompanied by dysgeusia, cough that is mainly unproductive, dyspnea, hoarseness or cervical lymphadenopathy [15] . laryngitis and laryngeal edema are other covid-19-induced symptoms that ent specialists and anesthesiologists must be aware of, especially while intubating and extubating tracheas of critically ill individuals [16] . parathyroid glands and salivary ducts may also be affected, nevertheless, these are a rare manifestations of covid-19 [17] . isolated urt symptoms were usually reported in patients with a mild or moderate form of the disease. however, they might also precede the conversion to the severe form of covid-19 [15] . additionally, younger individuals were more prone to present urt manifestations of covid-19 than older patients [15] . sudden smell/taste disorders (std) occurred especially in younger individuals (below 60 years old) and appeared as the initial symptom of covid-19 in the majority of studied patients [18] . std was mainly reported in individuals without other coexisting symptoms of covid-19 or in those with mild ones and was considered to be an especially useful tool in detecting sars-cov-2 infection in young subjects [18, 19] . the meta-analysis conducted by tong et al. revealed that the prevalence of olfactory dysfunction reached 52.73%, ranging between 5.14% and 98.33%, while gustatory dysfunction was demonstrated by 43.93% (range 5.61%-92.65%) of covid-19 positive patients [20] . because of the fact that gustation is significantly linked to olfaction, it was implied that covid-19-induced dysgeusia was mainly related to the primary failure in the sense of smell [20] . it could explain the frequent cooccurrence of these two symptoms. beltra-corbellini et al. reported that in 35.5% of patients with covid-19, olfactory or gustatory dysfunction was the initial symptom of the disease, and the onset of std was acute in the vast majority of cases (70.95%) [18] . the complete return to normal smell and taste was observed in 40% of patients after 7.4 ± 2.3 days, while the partial recovery was reported in 16.7% after approximately 9 days [18] . because in several covid-19 cases olfactory function returned to normal or improved after a relatively short period, it was proposed that olfactory dysfunction resulted from an inflammatory response in the nasal cavity that transitionally disrupted odorants from reaching the olfactory neurons [18] . nevertheless, it is currently unknown whether sars-cov-2 is able to permanently damage olfactory neurons or just to induce temporary dysfunction [18] . the occurrence of sudden onset loss of smell, not accompanied by nasal obstruction, was considered to be highly predictive of covid-19 [4] . it was reported that in the cohort of 55 individuals with sudden anosmia, not accompanied by nasal obstruction, 94% tested positive for covid-19 within 7 days of the anosmia onset [4] . in several patients, the return of the sense of smell tended to start after 5-10 days, nevertheless the duration to complete recovery remained unknown [4] . similarly, beltran-corbellini et al. reported that subjects suffering from std did not present nasal obstruction [18] . therefore, the authors concluded that sars-cov-2 expressed a high affinity to olfactory epithelium [18] . it was implied that anosmia could occur in patients affected by sars-cov-2 as a result of the infection of the sustentacular cells located in the nasal cavity [21] . sustentacular cells are responsible for the support, protection and nourishment of the sensory nerves, to which these cells are adjacent to [21] . the high expression of ace2 and tmprss2 proteins that are responsible for virus invasion was found in sustentacular cells [21] . it implied that the infection of these non-neural cells and not the sensory nerves, might be responsible for the loss of smell in patients with covid-19 [21] . educating the society that sudden loss of smell/taste may suggest covid-19 could help in the early implementation of self-isolation, which subsequently could prevent further spread of the disease [18] . for otolaryngologists, sudden std could be a symptom strongly suggesting covid-19 [18] . it was suggested that anosmia/hyposmia/dysgeusia should be incorporated into the list of screening tools for potential sars-cov-2-induced infection [22] . according to various authors, sudden anosmia in the absence of other manifestations was strongly related to covid-19 infection [20] . european rhinologic society recommended against prescribing nasal or systemic corticosteroids in patients with sudden anosmia and it was consistent with other reports [23] . corticosteroids use for the sudden loss of smell could escalate covid-19 infection and should be avoided [24] . so far, any medical treatment for sudden covid-19-related anosmia had been given a strong recommendation [19] . because of the lack of proven pharmacotherapy for covid-19-related anosmia, olfactory training was suggested as a main form of treatment in these cases [19] . ent uk recommended that adults with sudden anosmia not accompanied by other symptoms should isolate themselves for 7 days. decreasing the number of otherwise asymptomatic patients, who act as vectors, could significantly reduce the transmission of sars-cov-2 [24]. in contrast to anosmia, rhinorrhea, nasal congestions or edema are considered to be less frequent symptoms of covid-19 [4] . nasal congestion and rhinorrhea were rarely reported in covid pharyngodynia should not be considered as a specific covid-19 symptom, as it could result from intensive coughing [27] . nevertheless, in a number of individuals, sore throat was not accompanied by cough [15] . nasal and pharyngeal symptoms appeared mainly in patients with mild form of the disease [25]. the estimated prevalence of cough in covid-19 patients ranged between 60 and 82%, while the prevalence of dyspnea ranged between 9% and 37% [25] . both symptoms were more commonly observed in individuals with a severe form of covid19 [25] . otolaryngologists should be highly suspicious of covid-19 infection in individuals with mild urt symptoms especially in afebrile ones, as, in the majority of cases, they are first specialists to be contacted by these patients [28] . it was reported that the rate of work-related sars-cov-2 infection was higher in ent specialists that in other specialties [28] . ent specialists are exposed to sars-cov-2 infection as they examine urt, and, as they perform procedures that generate aerosolized secretions and bleeding [7] . ent-related procedures that result in inducing aerosolization include tracheotomy, repeated endotracheal tube exchange, bronchial tree suctioning, endoscopy, sinus surgery, mastoid drilling, cauterization, positive pressure ventilation, nebulizer usage or oxygen supplementation [3] . additionally, many ent operations, especially oncologic ones, require general anesthesia that involves a number of aerosol-generating procedures (agps), such as intubation, bagvalve mask ventilation, post-extubation cough, cuff leakage or accidental disconnection of the ventilatory closed-circuit [6] . currently, less is known about the risk of sars-cov-2 infection for ent surgeons while performing not agps such as parotidectomies or neck dissections [6] . laryngectomy patients and individuals after tracheotomy with covid-19 carry a particularly high risk of infecting ent specialists and other members of medical staff as the way of breathing is these individuals is modified and enables the easy spread of sars-cov-2 containing aerosolized tracheal secretions [11] . additionally, tracheostomy generates a greater aerosol volume than the respiration through a physiological way [11] . in accordance with such high risk of infection, only emergency consultations and procedures should be performed by ent specialists in times of covid-19 pandemic in areas with confirmed sars-cov-2 cases [23, 28] . patients in stable condition, those with properly managed chronic ent diseases, and others not requiring urgent in person visit should be consulted using telemedicine options [23, 28] . in person appointments should be postponed [28] . individuals necessitating in person ent assessment must undergo preappointment screening that comprises body temperature measurement, symptoms-adjusted triaging and obtaining the recent travel history [23]. ent specialist should be equipped with enhanced ppe that comprise n95 respirator and full face shield or a powered air-purifying respirator (papr), disposable gloves, surgical cap, gown, and shoe covers, while performing procedures on positive or suspected covid-19 patients [3] . in cases of urgent surgery for which there is not enough time for sars-cov-2 screening, the clinical staff must be limited to the essential personnel equipped with enhanced ppe [29] . these operations should be performed in a negative pressure operating room with high-efficiency particulate air (hepa) filtration [29] . american academy of otolaryngology-head and neck surgery (aao-hns) recommended that all otolaryngologic procedures should be postponed unless really necessary or until reliable preoperative testing for sars-cov-2 presence can be done [22] . american head and neck society, aao-hns, and the american colleges of surgeons, recommended that preoperative testing for sars-cov-2 presence should be performed in all individuals undergoing high-risk procedures [22, 30] . nevertheless, precise guidelines for preoperative sars-cov-2 testing including establishing the best time to perform the sars-cov-2 detection test in relation to the operation date, and the required number of negative tests to consider patients as covid-19 negative, are currently not available. according to topf et al. procedures not involving mucosa (thyroidectomy and parathyroidectomy, neck dissection, parotidectomy, local resection of skin cancers, and branchial cleft excision) should be considered low-risk procedures, while trans-mucosal (all transoral surgeries such as glossectomy, buccal resection or transoral robotic surgery, laryngeal surgeries and direct laryngoscopy, tonsillectomy, intranasal surgery, maxillectomy or mandible resection)the high-risk ones [31] . the high-risk procedures must be performed using enhanced ppe [31] . the algorithm for proceeding with ent patients requiring surgery during the covid-19 pandemic was presented in figure 1 . interestingly, mady et al. proposed a novel strategy for the intranasal and intraoral preoperative use of povidone-iodine (pvp-i), a potentially virucidal agent, in both, patients and ent surgeons, to reduce the risk of virus aerosolization and transmission [32] . the recommendations of pvp-i administration were presented in table 2 . rhinologic surgeries, including endoscopic or open sinus and skull base surgery, carry an extremely high risk sars-cov-2 infection for ent surgeons and should be postponed in all non-acute cases [10, 23] . the high risk of infecting ent providers is mainly related to the high concentration of the virus in the sinonasal cavity, and the formation of aerosols induced by surgical instruments commonly used during endoscopic procedures, such as a drill, microdebrider, balloons or suction electrocautery [7, 10] . saline irrigation used for sinuses washing or for cleaning the endoscope also carries a risk of virus aerosolization [10] . in general, all actions induced on urt mucosa by high-speed flow, even administration of the anesthetic sprays to the nasal cavity, led to aerosolization of the mucosa [10] . according to recommendations, performing endoscopic sinus/skull base surgery should be done after a patient tested negative for sars-cov-2 within 48 hours prior to the operation [10] . because of the relatively high level of false negative results, two tests should be performed if possible [33] . interestingly, zhu et al. reported that an endonasal pituitary surgery for pituitary adenoma performed on a single individual who was diagnosed with covid-19 several days postoperatively when he developed fever, cough, dyspnea, bilateral opacities in chest ct, and reduced oxygen saturation requiring non-invasive ventilation, resulted in postoperative covid-19 infection in 14 medical staff members, none of whom participated in the surgery [34] . the covid-19 infection developed in 4 nurses, not wearing protective equipment, who took care of the patient directly before the quarantine was incorporated, and in 10 more members of the medical staff from the department who did not have contact with the affected patient [34] . a position statement from the european academy of allergy and clinical immunology (eaaci) and allergic rhinitis and its impact on asthma (aria) recommended that covid-19 positive patients with allergic rhinitis should continue therapy based on intranasal corticosteroid (including sprays) at the previous dose [35] . treatment cessation should be avoided, as topical corticosteroid-induced suppression of the immune system in these patients had not been reported [35] . strict guidelines concerning head and neck oncology management during the covid-19 pandemic have not been developed yet. aao-hns suggested classifying oncologic cases as "time-sensitive" or "emergent" [22] . all "emergent" surgeries should be performed within 48 hours, while "time-sensitive" but not urgent operations ought to be postponed for a "few weeks" [6] . managing oncologic patients is very challenging during the covid-19 pandemic as these individuals are at higher risk of becoming infected or developing severe covid-19-induced complications than average society members [31] . it was recently reported that individuals with cancer were at 3.5 times higher risk of requiring mechanical ventilation, intensive care unit (icu) hospitalization or death than individuals without the oncologic disease [36] . as head and neck squamous cell carcinoma (hnscc) may progress and deteriorate the patient"s condition if treatment initiation is delayed, establishing the "potentially safe" postponement duration before treatment incorporation is needed [31] . according to centers for medicare & medicaid services (cms) adult elective surgery and procedures recommendations, oncologic surgeries were classified as tier 3a procedures and should not be delayed [37] . according to the french consensus, patients requiring surgical management of hnc during the covid-19 pandemic should be assigned to one of the three following groups (group a, b or c) depending on the urgency of treatment [38] . these recommendations were presented in table 3 . authors from the united states of america proposed categorizing patients requiring ent surgeries into one of four groups: urgent (surgery should be performed without delay), less urgent (postponing surgery for more than 30 days should be considered), less urgent (postponing surgery for 30-90 days should be considered), and case-by case basis [31] . precise information concerning the classification of certain diseases into one of the four groups was presented in table 4 . it was strongly recommended that sars-cov-2 positive patients without the need for urgent ent surgery must initially undergo covid-19 treatment [38] . the follow-up in patients with a history of oncologic surgery, except for those requiring first postsurgical evaluation, those with post-surgical complications, those with tracheoesophageal prosthesis (tep) complications, and symptomatic ones, should be performed using telemedicine with video options [38] . individuals with deterioration or the presence of symptoms suggesting potential disease relapse that were identified during teleconsultation, as well as potential new oncologic cases, should be examined in person by an ent specialist [38] . prescriptions ought to be provided using telemedicine. 1.6.3. potential technical problems during head and neck oncological surgeries certain ent procedures for oropharyngeal, hypopharyngeal or laryngeal cancers could be technically difficult or even impossible to perform while wearing enhanced ppe [6] . the usage of the davinci console during transoral robotic surgery (tors) is one of them [6] . using papr or eye protection with loupes or microscope for transoral laser microsurgery or microvascular anastomosis could be difficult [6] . enhanced ppeinduced inconveniences may force the surgeon to perform open surgery rather than less invasive surgical methods that subsequently could worsen the surgical outcomes [6] . it was recommended that laryngectomy patients with positive or unknown status of covid-19 should always be examined using enhanced ppe [11] . cases with confirmed negativity for covid-19 may be cautiously evaluated using standard ppe, as described by the occupational health and safety administration [39] . specialists performing high-risk procedures should use parp rather than n95 respirator and full face shield [11] . papr was also recommended for all procedures involving manipulation within the airway [11] . if a patient requires an in-office visit, tracheostomy ought to be equipped with a heat moisture exchanger (hme) that filters viral or bacterial particles, and adhesive baseplates [11] . hme attached to the stoma using a baseplate was strongly encouraged in individuals after laryngectomy [11] . cuffed tracheostomy tubes were recommended for covid-19 positive individuals as they could reduce the risk of local leakage around hme and tracheostomy tube [3] . tracheostomy must additionally be covered by a surgical mask or at least by scarf [11] . the surgical mask should also cover the patient"s mouth and nose [11] . laryngectomy patients with positive or unknown status for covid-19 who must be hospitalized require special care, as they cannot be oxygenated, bag-masked, or intubated via urt in order to prevent the spread of aerosolized particles [11] . individuals with a lot of tracheal secretions and cough should be supplied with tracheostomy tubes with an attached hepa filter and closed-line suction. interestingly, using a closed-circuit system like a mechanical ventilator, even if positive-pressure ventilation is not needed, was considered to be effective in reducing the amount of aerosolized viral particles [11] . the closed-circuit system should always be accompanied by the use of cuffed tracheostomy tubes to reduce leaks in the circuit [3] . patients with tracheostomy should perform bronchial tree toilets including suctioning, on their own. nebulizer usage ought to be avoided or used carefully as it carries a high risk of virus aerosolization [3] . additionally, ent specialist should educate patients not to touch their tracheostomy needlessly, and to wash their hands every time they have a contact with the stoma [11] . the minimal number of necessary medical stuff should be present during patients" examination, medical procedures, and surgeries [11] . nasopharyngo-and tracheoscopies, if not absolutely required, ought to be postponed. in cases in whom nasopharyngo-or tracheoscopy is necessary, lidocaine anesthesia was recommended to prevent mucosal irritation and subsequent coughing induction [11] . local anesthesia based on lidocaine-soaked pledgets rather than spray distribution of the drug was advised [11] . decongestants should also be used similarly [11] . patients" self-suctioning during nasopharyngo-or tracheoscopy was encouraged [11] . in individuals with possibly dislocated tep, radiographic imaging rather than broncho-or tracheoscopy was recommended [11] . tep present in the respiratory tract is an indication for urgent intervention irrespective of the patient"s covid-19 status [11] . to avoid the closure of the fistula or potential food/liquid aspiration rubber catheter should be placed into the fistula [11] . for patients with the leakage around tep, non-permanent plug and thickened liquids should be applied [3] . 1.6.5. surgical vs. non-surgical treatment in head and neck oncology during covid-19 pandemic because of the fact that surgery and non-surgical treatment could both be used as first-line therapy for the majority of mucosal sccs, it was recommended that the non-surgical way of treatment should be preferred during covid-19 pandemic [6] . in patients with cancers for which the treatment of choice is surgery, the decision whether to perform an operation during covid-19 pandemic or not should be made after analyzing all potential pros and cons in the context of oncologic outcome [6] . for patients with t1/t2 laryngeal cancer requiring undelayed treatment, definitive radiotherapy rather than microsurgery using potassium titanyl phosphate (ktp)/carbon dioxide laser (co2) was suggested to be a better treatment option, as the laryngeal microsurgery carries a high risk of sars-cov-2 infection for ent surgeon [29] . nevertheless, oncologic individuals referred to radiotherapy with or without chemotherapy will be exposed to radiotherapy +/-chemotherapy-related consequences including frequent visits in the radiotherapy center or chemotherapy-induced immunosuppression [6] . in contrast, individuals with t1an0 glottic/t1n0 tonsil scc could undergo a single, definitive surgery [6] . this therapeutic option, on the one hand, carries a high intraoperative risk of sars-cov-2 transmission to ent surgeon, but on the other hand, protects the patient from the repeated visits to the radiotherapy center, and the consequences of radiation treatment [6] . managing patients with advanced cancers of the upper aerodigestive tract is more challenging, as these individuals usually require long post-operative hospitalization and intensive medical care [6] . primary radiation with or without chemotherapy could be considered for individuals with t4a laryngeal, oral cavity or advanced sinonasal scc [6] . during covid-19 pandemic neoadjuvant chemotherapy with or without cetuximab or neoadjuvant chemotherapy with or without immunotherapy could be considered in some cases. besides not being normally used in cases of primary or recurrent mucosal scc referred to surgery, neoadjuvant chemotherapy could reduce symptoms and subsequently delay the need for operation in these patients [6] . however, chemotherapy-induced toxicity could lead to serious complications if a patient during chemotherapy turns out to be covid-19 positive [6] . neoadjuvant immunotherapy alone is currently not recommended because of the lack of sufficient data on its side effects during the covid-19 pandemic [6] . initiating or continuing adjuvant therapy in individuals with solid tumors in whom adjuvant therapy could potentially be curative, should not be delayed [3] . postponed surgical intervention for individuals with surgically low-grade salivary carcinomas and welldifferentiated papillary thyroid carcinomas is unlikely to worsen the patient"s oncologic outcome [6] . it was recommended that decisions concerning establishing treatment strategies for oncologic patients should be based on a multidisciplinary evaluation of every individual patient [29] . endoscopic procedures may aerosolize sars-cov-2 and, if possible, should be avoided in both, outpatients and inpatients [29] . nasal-and laryngoscopies, as well as oropharyngeal examination could easily induce sneezing or coughing subsequently leading to the dispersion of the virus containing aerosol particles. it was established that both, nasal cavity and nasopharynx, exhibit high viral loads, thus all not urgent nasal-and laryngoscopies should be postponed to reduce the risk of virus transmission to ent specialist [29, 38] . nasal endoscopy should be postponed except for cases of unilateral symptoms, rhinosinusitis complications, failed previous appropriate therapy, evaluation in immunocompromised patients, and individuals in whom malignancy is highly suspected [33] . in not urgent cases ct rather than nasal endoscopy should be considered [33] . according to american laryngology community, indications for flexible laryngoscopy comprise hemoptysis, odynophagia impeding hydration and nutrition, and airway obstruction mainly secondary to infection or malignancy [40] . in other conditions, ct or ultrasound, rather than laryngoscopy were advised [40] . prior to the urt endoscopy, testing for covid-19 should be performed [40] . if the endoscopic examination is needed, e.g. for patients with airway obstruction or malignancy, disposable nasal pledgets soaked with local anesthetic and decongestants were recommended [29] . using the smallest diameter scope was advised to reduce the chance of inducing sneezing or coughing [10] . ent specialist should be equipped with ppe while performing urt endoscopies. observers should not be attending the procedure to reduce potential exposures, and to save ppe [10, 40] . various methods of endoscopes sterilization including automated reprocessing, gas sterilization with ethylene oxide, and chemical reprocessing with isopropyl alcohol, glutaraldehyde, chlorine dioxide, or ortho-phthalaldehyde could be used, except for except 70% isopropyl alcohol [40] . high level disinfection (2% to 3% hydrogen peroxide, 2 to 5 g/l chlorine disinfectant, or 75% alcohol) should be used for cleaning rooms, in which the procedure was performed [10, 40] . patients with acute airway obstruction requiring tracheotomy should be considered as covid-19 positive, as there is no time for sars-cov-2 testing in case of such urgent surgery [29] . high-flow nasal cannulas in individuals with airway obstruction and positive or unknown covid-19 status should not be used, as they carry a high risk of virus aerosolization [29] . the patient ought to be preoxygenated and subsequently rapidly intubated, preferably using video laryngoscopes, to reduce the viral aerosolization [29] . the use of disposable laryngoscopes could reduce the risk of virus spread [29] . if necessary, second-generation laryngeal mask airways rather than first-generation devices should be used, as they are less likely to provide leakage [29] . extra-corporeal membrane oxygenation (ecmo) was recommended over the emergent surgical opening of the airway in a "can"t intubate, can"t ventilate" scenario, to prevent virus particles aerosolization [29] . intubation in covid-19 positive or suspected cases is supposed to be performed by a specialist equipped with papr gear [10] . during the covid-19 pandemic, surgical tracheotomy rather than ecmo should be performed in individuals with obstructive laryngeal tumors, profuse oropharyngeal hemorrhage, trismus precluding the opening of the oral cavity and intubation, and in other cases that will potentially require long-lasting protection of airway patency [29] . tracheostomy should be performed in a negative pressure operating theater equipped with hepa filtration and by an ent surgeon wearing enhanced ppe [29] . if papr gear is not available, ffp3/n95 masks could be covered by a surgical mask to provide multilayer protection [41] . if negative pressure operating room is not available, an aerial-isolated room should be used to perform the surgery [41] . in patients hospitalized in icu tracheostomy should be performed in icu rather than in the operating room to avoid transport-related procedures, including disconnection of the circuit for transfer or manual ventilation [42] . besides the surgeon, other members of medical staff attending the procedure should also wear enhanced ppe [29] . the patient is supposed to be completely paralyzed using neuromuscular blockade to prevent coughing and swallowing [10] . propofol and rocuronium bromide administration prior to the tracheal intubation was recommended to avoid coughing and droplet production. the use of glycopyrrolate could be considered to reduce secretions [12] . intraoperatively, electrocautery usage should be avoided, while suction use should be limited. oxygenation must be accomplished with positive end-expiratory pressure (peep) [41] . opening the anterior tracheal wall must be done extremely gently to prevent perforating the cuff and to maintain a closed circuit [29] . the mechanic ventilation should be stopped while incising the tracheal wall and inserting a cuffed, non-fenestrated tracheotomy tube into the trachea [43] . heat and moisture exchanger (hme) must be immediately combined with the tracheostomy tube to prevent the virus particles from spreading [43] . after tracheostomy tube insertion, end tidal co2 and tidal volumes must be confirmed [42] . a closed circuit gear, the same as used for individuals connected to a mechanical ventilator, could be used after tracheotomy [44] . ventilation with lower ventilator settings (40-50% fio2, peep <12) for more than 21 days was recommended [42] . weaning patients from a ventilator should be performed with the cuff inflated, because its deflation during this procedure would lead to aerosol generation [42] . tracheotomy care differs from typically used. after the surgery, the tracheostomy tube should not be changed or manipulated as long as the patient"s covid-19 status remains positive or unknown [43] . it was suggested that the tube should not be exchanged for at least 7-10 days after the surgery [45] . further tube change should be postponed for 30 days [41] . dressing around the tube should be left unchanged unless there is evidence of local infection [41] . additionally, only closed in-line suction and closed circuit maintenance were recommended the british association of otorhinolaryngology -head and neck surgery (ent uk) [43] . the humidified wet circuit must be avoided to prevent the risk of the room contamination in case of unexpected circuit disconnection [43] . percutaneous dilation tracheotomy was not recommended, as it exposes ent surgeon for the contact with the open tracheostomy for a longer period of time [29] . as awake patient tracheotomy or percutaneous cricothyrotomy are procedures during which air-flow suspension cannot be achieved, surgical tracheotomy performed on an intubated or sedated individual is the preferred procedure to reduce the viral aerosolization [41] . besides the fact that tracheotomy performed within the first 7 days after intubation was associated with a decrease in the length of mechanical ventilation, mortality rate and duration of stay in icu in a systematic review conducted in 2018 [46] , currently, there are no clear recommendations regarding the timing of tracheostomy in individuals with covid-19-induced acute respiratory distress syndrome (ards) [47] . similarly, no recommendation for performing tracheotomy within 7 days in covid-19 patients with ards has been proposed [47] . no data indicating improvement of these patients" clinical conditions after tracheotomy is currently available [47] . new york head and neck society recommended that, in the majority of cases, approximately 21 days" delay prior to consideration of tracheostomy after intubation was reasonable [12] . according to this society, in individuals with high mortality risk tracheostomy should not be performed [12] . it should also be avoided in patients with respiratory instability [42] . new york head and neck society recommended that all intubated patients should have cuff pressure of approximately 30mm hg to prevent tracheal/laryngeal necrosis and subsequent stenosis, as well as to sustain appropriate seal to avoid aerosolization [12] . nevertheless, with the use of modern low-pressure cuffs, the prevalence of symptomatic stenosis is 1-2% [12] . the cuff pressure should be checked every 4 hours [12] . vukkadala et al. suggested that covid-19 is improbable to induce the need for prolonged ventilation requiring tracheostomy, as individuals in a critical condition either recover or decease [10] . otologic surgeries are considered high risk procedures for ent surgeons because of intraoperatively generated virus aerosolization [48] . virus aerosolization could, on the one hand, result from the middle ear connection with the nasopharynx via eustachian tube, and on the other hand, from the use of high-speed drills during transmastoid procedures [48] . nevertheless, data on the viral loads in the middle ear and mastoid cavity are limited [48] . because of the fact that the transconjunctival spread of sars-cov-2 was reported, drillinginduced dust generation that enters eyes intraoperatively could potentially transmit the virus [48] . operation using a rigid otoscope with a camera instead of a microscope may be performed if wearing ppe disturbs effortless microscopic surgery [24] . as for all high risk procedures, enhanced ppe with papr was recommended while performing otologic operations [48] . while the majority of otologic procedures are not urgent ones, some of them require emergency intervention [48] . a classification of otologic conditions depending on the urgency of surgical intervention and the proposed surgical recommendations were presented in table 5 . emergency procedures including nasal bleeding management, peritonsillar abscess drainage or facial wound repair should be considered high risk procedures and performed by ent specialists wearing enhanced ppe [24, 29, 49] . treatment of nasal bleeding should be initially based on compression [49] . tranexamic acid and local decongestion using soaked pledgets instead of spray were also advised [49] . silver nitrate cautery could be used if bleeding continues. nasal packing should be performed in case of unsuccessful non-invasive management or potentially life-threatening bleeding [49] . resorbable nasal packing was strongly advised to prevent the need for the next visit [49] . in cases of resorbable nasal packing failure, non-resorbable packing was recommended [24] . management of posterior nasal bleeding requiring sphenopalatine artery ligation should be preceded by covid-19 testing [49] . while managing epistaxis, the suction system should be used within a closed system with a viral filter [49] . individuals with maxillofacial trauma and its subsequent complications such as rectus muscle entrapment, retrobulbar hemorrhage, massive hemorrhage, and exposed brain should immediately be operated. surgeries in this area are considered high risk ones [29] . maxillofacial traumas require emergency procedures in the majority of cases. therefore all patients, even asymptomatic ones should be considered covid-19 positive, as there is usually not enough time to perform sars-cov-2 testing [29] . in these cases enhanced ppe must be used by all staff members [29] , and the preoperative use of chlorhexidine gluconate or povidone-iodine to swish and spit was advised [50] . according to the stanford university guidelines, those with less urgent maxillofacial injuries should be tested for covid-19 twice, 48 hours preoperatively in 24 hours" interval, and should be kept in quarantine until the results are obtained [29, 50] . in cases of at least one positive result surgery should be performed with the use of papr [29] . patients with skull base injury and cerebrospinal fluid (csf) leak should be initially not-surgically treated and closely monitored [50] . in cases of persistent leakage after 7 days, surgery preceded by covid-19 testing should be performed to reduce the risk of meningitis [50] . covid-19 in children is less common than in adults. it was reported that children constituted approximately 5% of all confirmed covid-19 cases [51] . children, except for those under 12 months of age, were more prone to develop an asymptomatic or relatively milder form of covid-19 than adults [10] . 1.11.1. airway endoscopy recommendations for flexible nasal endoscopy in children are similar to those proposed for adults [51] . endoscopy should be considered in cases of the strong probability of foreign body presence in the airways. in children without definitive symptoms suggesting the presence of the foreign body in the respiratory tract, ct scan should be performed initially, and followed by endoscopy in those with suspicious ct results. endoscopy should also be performed in cases of button battery or caustic agent ingestion [51] . newborn hearing evaluation could be done if the child"s mother does not present covid-19 symptoms and if a procedure is performed by personnel not working directly with covid-19 individuals [51] . saline nasal irrigation could be used only to reduce the nasal obstruction, mainly in infants [51] . corticosteroids for polyposis, infectious sinusitis and anosmia were not recommended during the covid-19 pandemic [51] . in contrast, short corticosteroid treatment could be used in cases of severe forms of acute facial paralysis (grades 5 and 6 of the house brackmann classification) and ssnhl [51] . according to the french association of pediatric otorhinolaryngology and french society of otorhinolaryngology, the only surgeries that should be performed during covid-19 pandemic are those that cannot be delayed for more than 2 months, and those for which surgery is the only therapeutic option [51] . these guidelines implied that tonsillectomies should be postponed [51] . endonasal surgeries, except for operation for bilateral choanal atresia and poorly tolerated congenital piriform aperture stenosis, should also be delayed [51] . tympanostomy tube placement and tympanoplasties for cholesteatoma or retraction pockets should be postponed unless complications such as meningeal exposure, labyrinthine fistula or facial nerve paralysis occur [51] . indications for tracheotomy must be discussed on a case-by-case basis [51] . preoperative covid-19 testing within 48 hours was recommended for children similarly to recommended for adults [51] . performing procedures on covid-19 positive or suspected children requires the same precautions as for adults [51] . ent specialists are at a very high risk of covid-19 infection while performing examination or surgery because of the nature of this specialty. strict guidelines for otolaryngologists/head and neck surgeons have not already been provided, and currently available recommendations could presumably change in course of covid-19 pandemic as the new data increases. we hope that this review will serve as a collection of current recommendations for ent specialists for how to deal with their patients during the covid-19 epidemic, and will constitute a valuable hint in their clinical practice. examination: -otoscopy -binocular microscopy -cerumen removal -evaluation of covid-19 positive/unknown demanding close contact (less than 1 meter) should be performed in enhanced ppe*/ † ttp-tympanostomy tube placement *enhanced ppe includes n95 respirator and full face shield/a powered air-purifying respirator (papr) † , disposable gloves and doublegloving, surgical cap, fluid-resistant gown, and shoe covers † papr rather than n95 respirator and full face shield is preferred in high-risk procedures world health organisation. coronavirus disease (covid-19) pandemic managing head and neck cancer patients with tracheostomy or laryngectomy during the covid-19 pandemic sinonasal pathophysiology of sars-cov-2 and covid-19: a systematic review of the current evidence head and neck oncology during the covid-19 pandemic: reconsidering traditional treatment paradigms in light of new surgical and other multilevel risks sars-cov-2 viral load in upper respiratory specimens of infected patients sars-cov-2 cell entry depends on ace2 and tmprss2 and is blocked by a clinically proven protease inhibitor covid-19 in otolaryngologist practice: a review of current knowledge covid-19 and the otolaryngologist: preliminary evidence-based review commentary on the management of total laryngectomy patients during the covid-19 pandemic. head neck tracheostomy during cov-sars-cov-2 pandemic: recommendations from the new york head and neck society. head neck chest ct findings in coronavirus disease-19 (covid-19): relationship to duration of infection clinical characteristics of coronavirus disease 2019 in china laryngeal oedema associated with covid-19 complicating airway management covid-19: protecting our ent workforce acute-onset smell and taste disorders in the context of covid-19: a pilot multicenter pcrbased case-control study a primer on viral-associated olfactory loss in the era of covid-19. int forum allergy rhinol the prevalence of olfactory and gustatory dysfunction in covid-19 patients: a systematic review and meta-analysis non-neural expression of sars-cov-2 coronavirus disease 2019: resources the royal college of surgeons (ent uk). covid-19 clinical, laboratory and imaging features of covid-19: a systematic review and meta-analysis response to: sore throat in covid-19: comment on "clinical characteristics of hospitalized patients with sars-cov-2 infection: a single arm meta-analysis otolaryngology providers must be alert for patients with mild and asymptomatic covid-19. otolaryngol head neck surg american head & neck society. how covid-19 is affecting our head and neck community: ahns covid-19 bulletin a framework for prioritizing head and neck surgery during the covid-19 pandemic. head neck consideration of povidone-iodine as a public health intervention for covid-19: utilization as "personal protective equipment" for frontline providers exposed in high-risk head and neck and skull base oncology care covid-19 and rhinology: a look at the future a covid-19 patient who underwent endonasal endoscopic pituitary adenoma resection: a case report intranasal corticosteroids in allergic rhinitis in covid-19 infected patients: an aria-eaaci statement cancer patients in sars-cov-2 infection: a nationwide analysis in china french consensus on management of head and neck cancer surgery during covid-19 pandemic. eur ann otorhinolaryngol head neck dis safety recommendations for evaluation and surgery of the head and neck during the covid-19 pandemic flexible laryngoscopy and covid-19. otolaryngol head neck surg corona-steps for tracheotomy in covid-19 patients: a staff-safe method for airway management tracheostomy protocols during covid-19 pandemic guidance for surgical tracheostomy and tracheostomy tube change during the covid-19 pandemic practical aspects of otolaryngologic clinical services during the novel coronavirus epidemic: an experience in hong kong a framework for open tracheostomy in covid-19 patients timing of tracheostomy in patients with prolonged endotracheal intubation: a systematic review tracheostomy in the covid-19 pandemic a commentary on safety precautions for otologic surgery during the covid-19 pandemic. otolaryngol head neck surg clinical recommendations for epistaxis management during the covid-19 pandemic. otolaryngol head neck surg a guide to facial trauma triage and precautions in the covid-19 pandemic covid-19 and ent pediatric otolaryngology during the covid-19 pandemic. guidelines of the french association of pediatric otorhinolaryngology (afop) and french society of otorhinolaryngology (sforl) *enhanced ppe includes n95 respirator and full face shield/a powered air-purifying respirator (papr)*, disposable gloves and double-gloving, surgical cap, fluid-resistant gown high-risk procedures (involving mucosa): all transoral surgeries such as glossectomy, buccal resection or transoral robotic surgery, laryngeal surgeries and direct laryngoscopy, tonsillectomy, intranasal surgery, maxillectomy or mandible resection; low-risk procedures (not involving mucosa): thyroidectomy and parathyroidectomy, neck dissection, parotidectomy, local resection of skin cancers hepa -high-efficiency particulate air filtration; ct-computed tomography; or-operating room conflicts of interests: the authors declare that they have no conflicts of interests key: cord-319232-qowtuhh6 authors: brazil, victoria; lowe, belinda; ryan, leanne; bourke, rachel; scott, clare; myers, simone; kaneko, hellen; schweitzer, jane; shanahan, brenton title: translational simulation for rapid transformation of health services, using the example of the covid-19 pandemic preparation date: 2020-06-03 journal: adv simul (lond) doi: 10.1186/s41077-020-00127-z sha: doc_id: 319232 cord_uid: qowtuhh6 healthcare simulation has significant potential for helping health services to deal with the covid-19 pandemic. rapid changes to care pathways and processes needed for protection of staff and patients may be facilitated by a translational simulation approach—diagnosing changes needed, developing and testing new processes and then embedding new systems and teamwork through training. however, there are also practical constraints on running in situ simulations during a pandemic—the need for physical distancing, rigorous infection control for manikins and training equipment and awareness of heightened anxiety among simulation participants. we describe our institution’s simulation strategy for covid-19 preparation and reflect on the lessons learned—for simulation programs and for health services seeking to utilise translational simulation during and beyond the covid-19 pandemic. we offer practical suggestions for a translational simulation strategy and simulation delivery within pandemic constraints. we also suggest simulation programs develop robust strategies, governance and relationships for managing change within institutions—balancing clinician engagement, systems engineering expertise and the power of translational simulation for diagnosing, testing and embedding changes. healthcare simulation is at a cross roads as healthcare professionals, teams and systems deal with the covid-19 pandemic. many simulation centres have shut their doors, in line with social distancing rules, and combined with the urgent needs of health services to draw faculty back to the front line. however, simulation services and programs that are 'truly translational' [1, 2] -integrated and focused on emerging clinical priorities-are undertaking unprecedented volumes of simulation activity. this article explores our institution's simulation strategy for covid-19 preparation and reflects on the lessons learned-for simulation programs and for health services seeking to utilise translational simulation during and beyond the covid-19 pandemic. we describe our strategy development and context, simulation delivery activities and outcomes and offer principles and practical suggestions for how simulation can directly and rapidly respond to urgent need for health service transformation. healthcare simulation offers numerous opportunities for pandemic preparation [3, 4] . training healthcare professionals for effective use of personal protective equipment (ppe), for new and expanded roles (e.g. critical care skills and procedures) and for public health tasks (swabs, contact training) can be accelerated and perfected using simulation. the structure and skills used for debriefing in healthcare simulation offer guidance for teams using clinical event debriefing to learn and adapt in a rapidly changing environment [5] . teams are challenged in novel ways-difficulties in communicating due to ppe and isolation rooms, changed procedures and protocols-and simulation can help shape and practice new routines. system level issues, including intra-hospital transfers, team interfaces and re-tooling spaces for new functions (e.g. expanded intensive care capacity) can be addressed using multilayered simulation approaches. more sobering learning objectives may include simulation for communicating with patients and families about end of life and resourcing constraints [6] (using facetime and wearing ppe) and other palliative care skills. but simulation may also cause harm during times of crisis. for example, the abrupt introduction of modified airway management simulations to embed covid-19 changes into an emergency department may create confusion and anxiety if undertaken without clear objectives, clinician leadership and engagement and careful pre-briefing and debriefing. turning the promise of simulation into reality for covid-19 preparation requires a translational approacha simulation program that is attuned to emerging priorities, has strong relationships with clinicians and service leadership and with the skills and capacity to apply (or develop) simulation strategies to address those issues. translational simulation describes healthcare simulation focused directly on health service priorities, improving teams and systems through 'diagnostic' functions and through iteratively developed simulation-based interventions [1] . in the context of the covid-19 pandemic, this method offers a 'rapid prototyping' approach to reviewing and revising care processes that need significant change to accommodate the need to protect staff from covid infections. on march 8th, 2020, we introduced a simulation strategy for covid-19 preparation for the gold coast hospital and health service (gchhs). at that time, there were 70 coronavirus cases identified in australia, but experience in wuhan and europe had prompted health services to begin pandemic preparation in earnest. we developed a six-point strategy and initial actions to guide the simulation team approach (fig. 1) . the gchhs is comprised of a number of services and healthcare facilities, including the main gold coast university hospital, an 850-bed tertiary referral hospital which employs over 6000 clinical staff. the gchhs simulation service was established in 2013, focused on developing high performing teams and systems. the program includes educationally focused simulation but extends to 'in situ' simulation in clinical areas designed for translational impact-diagnosing and addressing important process and teamwork issues in patient care. over 200 in situ simulations were run at gchhs in 2019, through partnership with clinical services wishing to target various quality improvement goals. these services include emergency medicine, maternity, paediatrics, outpatient clinics, cardiac catheter suite, trauma, mental health, operating theatre, stroke services, rehabilitation, medical emergency team (met) calls and the afterhours care unit. the work of the simulation service was originally driven by partnerships within clinical areas in a 'bottom up' approach. in 2019, a formal high-performance clinical teamwork strategy was endorsed by the gchhs board and executive, in which the simulation service is collaborating with the quality and safety unit, relational coordination unit, professionalism programs and bond university faculty of health sciences and medicine. the simulation service staffing includes three simulation educators with nursing and technical expertise, a clinical facilitator (nursing) and a part time medical director. this core group all have had dedicated simulation educator training and collective experience of more than 30 years in healthcare simulation delivery. however, the activity of this group is leveraged by a larger network of simulation educators within the health service, including medical and nursing simulation experts in emergency medicine, anaesthetics, perioperative services, women's health and other areas. this community of practice has evolved over time and been strengthened through internal faculty development. the faculty development program is conducted three times per year and comprises four sessions of approximately 4 h: designing and delivering simulation, technical aspects of simulation delivery, debriefing and a debriefing masterclass. these structured sessions are complemented by subsequent peer support and coaching of attendees by the simulation service team, with the aim of enabling departments to deliver simulation autonomously. we anticipated institutional needs for covid-19 preparation at the individual, team and system level. given our existing relationships with clinical services, our focus was on team and system challenges. we felt that our specific expertise in building relationships and shaping culture through simulation [7, 8] was likely to be more important than ever as we undertook rapid and urgent high stakes change. our strategy was aligned with the queensland health pandemic influenza plan [9] and guided by the local health emergency operations centre (heoc), to whom we provided biweekly reports. the overall approach and specific activities were also informed by a global network of simulation educators, connected through social media, a small amount of published literature and many personal communications [4, [10] [11] [12] . the simulation team met 1-2 times per week during this period to review progress and plan next steps. in the 30 days from march 8th, 2020, we delivered more than 250 translational simulations, involving more than 1500 healthcare staff, across multiple hospital departments. this is a greater volume of translational simulation than we delivered in all of 2019. there were common and important findings in our early experience in working with teams across a range of clinical contexts (fig. 1) . initially, concerns and uncertainties about ppe dominated many team discussions, and simulation sessions were a chance to inform and practice ppe skills. individual and teams rapidly improved in this regard with both real and simulated experience. in this early phase, clinicians sought out exposure to simulation sessions with a sense of urgency. many clinical care pathways required review and modification to protect staff from droplet, aerosol and contact exposure. teams needed to adapt to a new balance between the urgent patient care needs and compliance with protective measures. these logical next steps in our simulation activity involved changes to tasks, changes to team structure and function and changes to physical environments and equipment. examples included as follows: medical emergency team response emergency department intubation endotracheal intubation for elective procedure on operating theatre management of vaginal delivery post-partum haemorrhage management urgent transfer of maternity patient to operating theatre transfers of patients to icu care of deteriorating patient in interventional radiology and cardiac catheter lab major trauma reception management of acute behavioural disturbance in the emergency department and in psychiatric unit cardiac arrest management infection control staff were present for many of the diagnostic phase simulations and provided advice on the application of guidelines in specific, dynamic care contexts. the evolution of one unit's simulation activity during the 30-day preparation period is illustrated in fig. 2 . although conceptually considered as discrete stages of 'diagnosis', 'testing' and 'embedding', the communication strategies for overcoming the physical barriers between 'inside teams' (with patients in isolation rooms, wearing ppe) and 'outside teams' (in clean areas, supporting the needs of inside team with variable visual observation of inside team) emerged as the greatest challenge for teams. walkie talkies, mobile phones, baby monitors and video conference options were all imperfect. the urgency and priority of pandemic preparation created a high degree of collaboration within and between clinical units. although participating in simulation activity was initially limited by clinicians busy with 'business as usual' care, this changed rapidly once the institution moved to 'tier2' with elective surgery and other nonessential activity (including much of our purely educationally focused simulation work) cancelled. in the later phases of our preparation, clinical teams were applying lessons from simulation to the real or suspected covid-19 patient care (e.g. ed intubation, operating theatre flows, maternity care). this provided valuable feedback for the conduct of simulations, as well as iterative improvement in revised clinical care processes, enabled by the close connection of the simulation and clinical teams. "thanks for all the sims that have been done -i can say firsthand that they're very helpful! it would be great if more anaesthetic nurses can get through them as mine hadn't and so a lot of my cognitive load was going through what we can and can't do" (anaesthetic registrar) lessons for rapidly responding to health service crises using simulation at 7th april, australia had 5908 confirmed cases of covid-19 and a falling rate of new cases each day. at the time of writing, we have not seen the dramatic increase in covid-19 patient numbers than have occurred in other parts of the world in our health service, and we make no claim as to the 'success' of this preparation in terms of patient care or service outcomes. our translational simulation service has been able to rapidly increase simulation activity and adapt focus to covid-19 pandemic preparation. we have increased staff confidence with ppe, rapidly developed new pathways and procedures for patient care, embedded those pathways through various training modalities and increased teams' confidence in approaching the possible task ahead. we suggest there are lessons for simulation programs to build current and future capacity for responding to a crisis such as the covid-19 pandemic preparation, based on reflection on the strengths and weaknesses of our approach. in the midst of urgent and high stakes change, we were tempted (and did) conduct high volumes of familiar simulation techniques focussed on familiar targets (e.g. in situ simulation for airway management). however, a translational simulation approach requires a guiding strategy-ensuring simulation targets and techniques that are fully integrated with emerging, broad priorities and plans of health services. we developed our strategy based on longstanding formal and informal connections with multiple areas within the health service-at both executive level and with frontline clinicians. our simulation teams worked with frontline clinicians to undertake urgent, high stakes change processes that would normally take months or years to occur (fig. 3) . teams were highly motivated and engaged, and previous extensive experience of in situ simulation and working with the simulation service allowed early and rapid simulation activity as part of pandemic preparation. however, our impact was also limited by our previous scope and relationships. we gave limited support to those parts of the institution we had not collaborated with before, e.g. patient transfer officers, security staff and non-clinical areas. we had no simulated patient or consumer involvement; only patients and essential staff were allowed within the hospital during this period, and hence there was limited focus on patient experience during this preparation. the simulation service had the clinician relationships and simulation skills to rapidly design, update and train staff in new processes. initially, the simulation team was conceptionally ahead of other teams in the hospital, with a vision for the process adaptations required of teams to accommodate protecting staff from covid-19. however, this put the simulation team in a precarious position where we were trialling new equipment and processes, based on first principles and emerging literature, but without the usual management approval and protracted evidence-based practice. governance and oversight of changes were variable-some were approved/ ratified by relevant oversight groups, while others were informally adopted by teams or departments. the boundaries between the simulation service supporting and enabling change processes versus taking responsibility for those changes were not always clear. this dilemma is not new for those healthcare simulation programs that seek to engage in quality improvement activities [13] , but the urgency of the covid-19 preparation exacerbated both the strengths and weaknesses of translational simulation for this purpose. overall, clinicians and clinical leaders dramatically over-estimated the ability of individuals and teams to adapt to new processes and had limited appreciation of unintended consequences of changes. our simulation activities revealed inadequacies in lengthy documents that had been produced to guide clinicians for covid-19 care, in a classic illustration of the gap between 'work as imagined' and 'work as done' [14] . in an effort to close that gap, the simulation service produced videos, infographic summaries and cognitive aids to summarise findings and changes and to help disseminate messages (additional files 1, 2, 3 and 4). our team lacked formal expertise in human factors and systems engineering. integration of simulation within a more formal user centred design approach [15] , including task analysis and 'desktop' cognitive walk throughs, may have allowed better targeting of manikin-based live simulations and complemented clinician-led change. develop a wide range of simulation skills and approaches to rapidly adapt to novel simulation objectives the nature of the covid-19 infection presented specific challenges to conducting in situ simulation with clinical teams. these included the need for physical distancing in pre-briefs and debriefs (fig. 4) , inability to use real ppe in simulation to conserve stocks and the possibility of manikins and other training equipment harbouring viral particles. these practical challenges were addressed in a variety of ways including using simulated ppe (figs. 5 and 6), video conference enabled debriefs and modifying scenario delivery to be as simple as possible to achieve the objective of the simulation session. we quickly became aware of the power of a simulation session to lessen or exacerbate team anxiety and emphasised the need for short but clear prebriefings and debriefings. more traditional challenges to embedding simulation delivery-e.g. shift work, clinician engagement-were lessened with the intense motivation of staff during this period but not absent. we were flexible in targeting night shift staff and identifying champions within specific subgroups, e.g. surgeons. a translational approach requires a suite of techniques, not limited to in situ simulation [1] and including focused skills training (including lab-based simulation), table top exercises and instructional videos. mental rehearsal is a valuable simulation tool [16] , especially when ppe cannot be spared, and for practising new procedural task sequences (e.g. covid airway management). build a strong community of practice of simulation educators throughout the institution-to share techniques and maximise simulation delivery capacity during a crisis delivering a year's volume of simulation in 1 month was only possible through a leveraged approach involving our network of 'clinician simulationists' with adequate skills and a translational simulation perspective to be fig. 6 simulated ppe semi-autonomous. opportunities were taken to share generalisable findings and lessons between units (e.g. the challenges of airway management in ppe or the transit of patients from different areas to and within the operating theatre). despite our enormous increase in activity, we were still unable to provide the volume of training required to train individuals and teams to a level of proficiency in new processes. advocate for a translational simulation service within the health service to enable rapid responsiveness to a crisis carefully targeted and effectively delivered simulation activity cannot be just 'tuned on' in the face of a crisis. our experience has illustrated the need for health services to have a fully integrated, resourced and skilled translational simulation service that can quickly respond to health service needs in a rapidly unfolding crisis. covid-19 preparation has been a 'time to shine' [17] for healthcare simulation, and simulation leaders should be showcasing their work, demonstrating value and thoughtfully reflecting with other health service leaders about how to best approach future challenges. our experience with using simulation for covid-19 pandemic preparation has sharped reflection on the role of simulation in health service performance and change management, albeit in a unique and urgent context. we encourage simulation leaders to embrace this unique opportunity to innovate and to advocate for healthcare simulation as an integral component of healthcare delivery. translational simulation: not 'where?' but 'why?' a functional view of in situ simulation preparing for covid via simulation (webinar) a practical guide for developing and conducting simulation exercises to test and validate pandemic influenza preparedness plans. geneva: world health organization preparing and responding to 2019 novel coronavirus with simulation and technology-enhanced learning for healthcare professionals: challenges and opportunities in china circle up for covid-19 2020 https:// harvardmedsim.org/resources/circle-up-for-covid-19-infographic/ accessed covid ready communication playbook 2020 improving the relational aspects of trauma care through translational simulation doing our work better, together: a relationship-based approach to defining the quality improvement agenda in trauma care published by the state of queensland (queensland health) covid-19 simulations: simulation canada helpful links and information on covid-19: society for simulation in healthcare lessons learned in sim and education: a montage of friends of simulcast connecting simulation and quality improvement: how can healthcare simulation really improve patient care? why is work as imagined different from work as done? in: wears r, hollnagel e design thinking-informed simulation: an innovative framework to test, evaluate, and modify new clinical infrastructure emcrit -mental practice in the covid19 era: mastering ppe. emcrit blog publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we would like to thank the staff at gold coast hospitals and health service for their effort and engagement in the covid-19 pandemic preparation.authors' contributions vb designed the manuscript concept and contributed to data collection, wrote and revised the manuscript. bl, rb and lr contributed to data collection, initial manuscript drafts and revisions. bs, cs, sm, hk and js contributed to data collection, simulation strategy development and manuscript revisions. all authors read and approved the final manuscript. there was no funding provided for this study outside of usual employment arrangements for the authors. the datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.ethics approval and consent to participate the project was reviewed by the human research ethics committee at the gold coast health service, and ethical waiver granted (lnr/2020/qgc/ 62707). consent for publication was obtained from all persons represented in images. the manuscript contains no other data from individual persons. supplementary information accompanies this paper at https://doi.org/10. 1186/s41077-020-00127-z.additional file 1. cath lab report covid.additional file 2. covid intubation skills anaesthetics. additional file 4. covid pph theatre management. key: cord-316632-rr9f88oi authors: kimura, yurika; ueha, rumi; furukawa, tatsuya; oshima, fumiko; fujitani, junko; nakajima, junko; kaneoka, asako; aoyama, hisaaki; fujimoto, yasushi; umezaki, toshiro title: society of swallowing and dysphagia of japan: position statement on dysphagia management during the covid-19 outbreak date: 2020-07-23 journal: auris nasus larynx doi: 10.1016/j.anl.2020.07.009 sha: doc_id: 316632 cord_uid: rr9f88oi on april 14, the society of swallowing and dysphagia of japan (ssdj) proposed its position statement on dysphagia treatment considering the ongoing spread of severe acute respiratory syndrome coronavirus 2 (sars-cov-2). the main routes of transmission of sars-cov-2 are physical contact with infected persons and exposure to respiratory droplets. in cases of infection, the nasal cavity and nasopharynx have the highest viral load in the body. swallowing occurs in the oral cavity and pharynx, which correspond to the sites of viral proliferation. in addition, the possibility of infection by aerosol transmission is also concerning. dysphagia treatment includes a broad range of clinical assessments and examinations, dysphagia rehabilitation, oral care, nursing care, and surgical treatments. any of these can lead to the production of droplets and aerosols, as well as contact with viral particles. in terms of proper infection control measures, all healthcare professionals involved in dysphagia treatment must be fully briefed and must appropriately implement all measures. in addition, most patients with dysphagia should be considered to be at a higher risk for severe illness from covid-19 because they are elderly and have complications including heart diseases, diabetes, respiratory diseases, and cerebrovascular diseases. this statement establishes three regional categories according to the status of sars-cov-2 infection. accordingly, the ssdj proposes specific infection countermeasures that should be implemented considering 1) the current status of sars-cov-2 infection in the region, 2) the patient status of sars-cov-2 infection, and 3) whether the examinations or procedures conducted correspond to aerosol-generating procedures, depending on the status of dysphagia treatment. this statement is arranged into separate sections providing information and advice in consideration of the covid-19 outbreak, including “terminology”, “clinical swallowing assessment and examination“, “swallowing therapy”, “oral care”, “surgical procedure for dysphagia”, “tracheotomy care”, and “nursing care”. in areas where sars-cov-2 infection is widespread, sufficient personal protective equipment should be used when performing aerosol generation procedures. the current set of statements on dysphagia management in the covid-19 outbreak is not an evidence-based clinical practice guideline, but a guide for all healthcare workers involved in the treatment of dysphagia during the covid-19 epidemic to prevent sars-cov-2 infection. on april 3, 2020, the society of swallowing and dyspha-2 gia of japan (ssdj) issued an emergency announcement enti3 tled "emergency statement on dysphagia management during 4 the novel coronavirus outbreak". shortly thereafter, on april 5 14, the ssdj proposed a concrete statement for dysphagia 6 treatment in consideration of the ongoing spread of severe 7 acute respiratory syndrome coronavirus 2 (sars-cov-2). 8 the main routes of transmission of sars-cov-2 are phys9 ical contact with infected persons and exposure to respiratory 10 droplets. in cases of infection, the nasal cavity and nasophar-11 ynx have the highest viral load in the body. swallowing oc-12 curs in the oral cavity and pharynx, which correspond to the 13 sites of viral proliferation. in addition, the possibility of in-14 fection by aerosol transmission is also concerning. dyspha-15 gia treatment includes a broad range of clinical assessment 16 and examinations, dysphagia rehabilitation, oral care, nurs17 ing care, and surgical treatments, and any of these can lead 18 to the production of droplets and aerosols, as well as con19 tact with viral particles. recent studies have reported that 20 nosocomial infection, originating from caregiving staff, may 21 occur during meals. moreover, it should be noted that per22 sons with asymptomatic infections in japan or other countries 23 can form in-hospital clusters leading to the spread of infec-24 tion regardless of whether they are healthcare professionals or 25 patients [1] . 26 most patients with dysphagia are elderly and have com27 plications, such as heart diseases, diabetes, respiratory dis-28 eases, and cerebrovascular diseases. they might be at a higher 29 risk for severe illness from the novel coronavirus disease is anticipated during the covid-19 epidemic. the timing 44 of dysphagia rehabilitation and indication for treatment will 45 differ from the usual. prioritizing the maintenance of medical 46 infrastructure will be paramount in consultation with teams 47 of medical experts at each facility. 48 this statement is arranged into separate sections provid-49 ing information and advice considering the covid-19 out-50 break, including "clinical swallowing assessment and ex-51 amination", "dysphagia rehabilitation", "oral care", "nursing 52 care", "surgical procedure for dysphagia", and "tracheotomy 53 care". 54 as ssdj proposed these statements for the purpose of 55 crisis management during the covid-19 outbreak, based 56 on case series and guidelines from other countries where 57 the spread of covid-19 occurred earlier, these statements 58 are not an evidence-based clinical practice guideline. thus, 59 these statements would require later evaluation and revision 60 as needed. it should also be considered that patients could 61 receive appropriate care, but the care may be limited under 62 these circumstances where this statement is widely accepted 63 among healthcare professionals. 2.1. regional division by infection status [ 2 , 3 ] the following precautions are recommended in addition 149 to the use of ppe when engaging in agps (strongly recom-150 mended for procedures possibly producing large amounts of 151 aerosols): • use an n95 mask and always perform a seal check when 153 donning the mask. • wear eye protection (goggles/face shield). • wear clean long-sleeved gowns (sterilization not neces-156 sary) and gloves. • observe hand hygiene before and after contact with pa-160 tients and surrounding environmental surfaces, as well 161 as after removing ppe. 162 164 the selection of ppe should be made according to the 165 risk of infection due to the procedure. in this proposal, ppe 166 for dysphagia management is described as follows, according 167 to the purpose. • nasal/oral protection: n95 mask * or powered air purifying 182 respirator (papr) 183 * before using an n95 mask, conduct a user 184 seal check ( fig. 2 ) . 185 • eye protection: face shield ± goggles * 186 * recommend using an anti-fogging agent in advance, 187 when using goggles. should be followed ( table 1 ) . 210 removal of ppe may inadvertently spread the infec-212 tion. conduct training for donning and doffing ppe be-213 forehand. consideration should also be given to the sep-214 aration of spaces for the donning and doffing ppe (clean 215 areas/passage areas/semi-contaminated areas/contaminated ar-216 eas) as much as possible at each facility. 217 the standard methods for donning and doffing of ppe are 218 described in detail at the following websites (the research 219 group of occupational infection control and prevention in 220 japan homepage) [ • gloves: https://www.safety.jrgoicp.org/ppe-3-usage-glove. 230 html. and pharyngeal and laryngeal function 255 in the current pandemic context, the clinical swallowing as-256 sessment without producing aerosols is more preferable com-257 pared to agps. dysphagia screening tools, such as the eating 258 assessment tool-10 [8] and the seirei questionnaire of swal-259 lowing, can be utilized to detect dysphagia. pharyngeal sen-260 sory testing or flexible endoscopic evaluation of swallowing 261 with sensory testing are considered as agps, can be incredi-262 bly high risk, and require different ppe that do not produce 263 aerosols. screening tests for dysphagia are intended to select the 267 patients who are strongly suspected without videofluorogra-268 phy (vf) and fiberoptic endoscopic evaluation of swallow-269 ing (fees, ve), and include repetitive saliva swallowing test 270 (rsst), cervical auscultation of swallowing, water swallow 271 test, modified water swallow test, and food test. among them, 272 rsst and cervical auscultation of swallowing can be per-273 formed for patients wearing a mask without oral intake, and 274 thus, the risk of aerosol generation is very low. however, 275 some screening tests, such as water swallow test and modi-276 fied water swallow test, are agps ( table 2 ) . 277 considering some procedures such as water swallow 278 test and modified water swallow test may induce cough-279 ing, adoption of the highest level of ppe is highly rec-280 ommended when undertaking these procedures for patients 281 with suspected or confirmed covid-19. concerning water 282 swallow test, modified water swallow test (3 ml) overrides 283 the original version of the water swallow test (30 ml). 284 the nasopharynx carries a higher viral load than the 286 oropharynx. thus, fees has a higher risk of aerosoliza-287 tion from the nasal passage and nasopharynx. fees can trig-288 ger sneezing and/or coughing, leading to aerosolization during 289 healthcare professionals, who provide dysphagia therapy 320 in close patient proximity, can be at high risk of transmitting 321 the covid-19 virus. both indirect exercises (non-swallowing 322 exercises) and direct exercises (swallowing exercises) involve 323 direct contact with a patient's oral mucosa and secretions and 324 exposure to droplets/aerosols that can be generated by cough-325 ing and sneezing. furthermore, if a healthcare professional 326 is an asymptomatic or pre-symptomatic carrier of covid-327 19, the virus can be transmitted to patients from the healthcare 328 professional through rehabilitation and may cause hospital-329 acquired infections. 330 it is strongly advised that standard and additional precau-331 tions for agps, including use of ppe, hand hygiene, and dis-332 infection of environmental surfaces and equipment, be imple-333 mented during swallowing therapy. if ppe, disinfectants, and 334 other materials are in short supply, and adequate infection pre-335 vention cannot be achieved, swallowing therapy should be 336 suspended under the covid-19 outbreak. especially for dysphagic patients, oral hygiene is necessary 444 because aspiration of oropharyngeal flora into the lung may 445 cause aspiration pneumonia. however, we must be thoroughly 446 cautious to avoid spreading the virus through oral care during 447 the covid-10 outbreak. 448 oral care can involve a visible spray that contains saliva 449 and microorganisms. from the study of spattering during oral 450 care using an adenosine triphosphate (atp) monitoring sys-451 tem [9] , large amounts of atp, which denotes the presence 452 of organic material and living cells, were detected on the 453 as the patients may choke on water during rinsing, it 479 is recommended to wipe oral mucosa with wet tissue for oral 480 use, wet gauze, or swab after mechanical cleaning. among 481 water rinsing, wiping with wet tissue for oral use, and wip-482 ing with sponge brush, wiping with wet tissue is the most 483 effective method to decrease bacteria on the tongue, palate, 484 or gingivobuccal fold [13] . 485 2 denture cleaning of patients with suspected or con-486 firmed covid19. 487 to avoid the spread of the microorganisms from the den-488 ture, disinfect the denture before washing with water. after 489 cleaning, rinse the denture with enough water to eliminate the 490 chemical agents. it would be recommended to sink the den-491 ture for 30 min into 0.05-0.5 % of sodium hypochlorite aque-492 ous solution or ethanol for disinfection or wiping the denture 493 with gauze saturating with it [14] ) . the spray on the denture 494 may cause airborne infectious agents [15] ) . for dentures with 495 metal clasps or metal bases, rust-preventive additive sodium 496 hypochlorite aqueous solution should be used [16] . 497 3) consideration for reducing the aerosol generation during 498 oral care 499 1 tooth brushing with water-based mouth moisturizer 500 as a substitute for tooth paste, teeth should be brushed 501 with water-based mouth moisturizer, which can contribute to 502 preventing the spread of dental plaque by retaining it in the 503 mouth [ 17 , 18 ] . given that tracheostomy is a high-risk procedure that can 559 generate aerosols, to protect the staff members that are in-560 volved in tracheostomy care, it is essential that staff wear 561 appropriate ppe prior to any intervention. there is no other 562 choice of wearing available ppe as an alternative countermea-563 sure for viral infection, when the stock of appropriate ppe is 564 insufficient. 565 it is recommended that clinicians consider that any crit-566 ically ill patient recovering from covid-19 pneumonitis is 567 considered high risk of infection to staff during tracheostomy 568 insertion. be careful not to generate aerosols during tra-569 cheostomy care as follows. 570 • tracheostomy procedures such as dressing, cuff care, tube 571 care, and heat moisture exchanger change are consid-572 ered high risk for staff as aerosols can be generated. • when suctioning to remove respiratory secretions, pay at-574 tention not to cause coughing. • closed suction systems should be used. • a simple face mask may be applied over the face of pa-577 tients if the cuff is deflated to minimize droplet spread 578 from the patient. • use of double lumen tracheostomy tube is recommended 580 for patients with covid-19, and to reduce the frequency 581 of changing tracheostomy tube, only inner tube change 582 may be permitted. • after withdrawing mechanical ventilation, a heat moisture 584 exchanger should be put on a tracheostomy tube. be sure 585 to prevent the heat moisture exchanger from being de-586 tached from the tube. • tracheostomy tube change can be delayed until the patient 588 is confirmed as covid-19 negative or covid-19 symp-589 toms improve. however, an individual assessment must be 590 made for each patient. • avoid use of fenestrated tubes for patients with suspected 592 and confirmed covid-19 to reduce the aerosol risks to 593 staff. cuffed non-fenestrated tubes should to be used until 594 the patient is confirmed as covid-19 negative. • not changing the tracheostomy tube and dressings can be 596 allowed, unless obvious signs of infection or problems. 597 in view of the change in the domestic and oversea situa-598 tions, tracheostomy tubes can be in a short supply. you should 599 check the stock status of tracheostomy tubes in the medical 600 facilities and in the country. subsequent planned tube changes 601 can be postponed unless signs of infection or problems such 602 as bleeding or severe granulation are observed. nurses provide various forms of care to patients with dys-605 phagia, such as oral care, and indirect/direct swallowing ex-606 ercises as dysphagia therapy, meal support, and oral or tra-607 cheal suctioning. patients with dysphagia often have multiple 608 underlying conditions, which are more likely to become se-609 vere in conjunction with infection by sars-cov-2. with the 610 ongoing spread of sars-cov-2 infection, there is a possi-611 bility that infections will be transmitted between healthcare 612 workers, asymptomatic carriers, and patients. thus, appropri-613 only if unavoidable * as usual as usual * suggested priority for covid-19 testing. recommended management of meal support and suctioning. q3 negative and 2-week change to negative after confirmation criticized it as unrealistic. in the background, there is a lack 715 of medical resources, such as ppe and rubbing alcohol, but 716 healthcare professionals must recognize that they may need 717 to diverge from conventional protective measures. moreover, 718 management of dysphagia produces droplets and aerosols in 719 many situations. we must recognize that procedures should al-720 ways be performed using the same ppe and knowledge. these 721 standards should apply not only for sars-cov-2, but other 722 dysphagia cases suspected to be complicated because of infec-723 tion from multidrug-resistant bacteria or unknown pathogens. 724 therefore, as a responsible medical association in this field, 725 it is inevitable that our society repeatedly uses the terms for 726 standard precautions and abbreviations of equipment, such as 727 ppe and full ppe, which are globally used, in creating this 728 statement. although these terms may make it difficult to read 729 this statement, please be sure to read the first section "termi-730 nology used in this statement and basic concept of classifica-731 tion" before reading each medical treatment category because 732 they have been briefly explained. this committee consists 733 of medical doctors, dentists, speech therapists, and registered 734 nurses who are experts in the medical treatment of dyspha-735 gia with a deep knowledge of infectious diseases and public 736 health selected from the members of this society. needless 737 to say, this statement is not a standard manual for dysphagia 738 management but a guide for all healthcare workers involved 739 in treatment of dysphagia during the covid-19 epidemic. we 740 would appreciate it if you could operate it flexibly according 741 to the supply of medical resources at each medical institution. 742 toshiro umezaki, md, phd. 743 ssdj president 2020-2021. 744 anl [mns cov-2, all patients and their families should be advised 672 of the necessity of observing the general requests to 673 avoid close contact, narrow spaces suctioning must be considered as an agp, although it con-683 ventionally requires protection only against droplet infection • during suctioning, anticipate splashes due to coughing and 685 gag reflex and do not stand in front of the patient • outdoor-air ventilation (entrance door should be closed) regarding suctioning at tracheostomy sites, refer to the 693 previous chapter appendix: message from the president of ssdj on the 708 premise of this alert, this position statement, which consists 709 of all seven chapters, was released on epidemiology of covid-19 in a long-term care facil-747 ity in king county, washington ministry of health, labour and welfare. reported number of 750 covid-19 patients in japan by prefecture covid-19 japan. sars-cov-2 countermeasures dashboard 755 asha guidance to slps regarding aerosol gener-756 ating procedures aerosol-generating procedures in ent guide-761 lines for responding to cases of sars-cov-2 infection at medical 762 facilities research group of occupational infection control and prevention in 765 japan homepage validity and reliability of the eating assessment tool investigation of spattering and intraoral envi-771 ronment during oral care of patients society of swallowing and dysphagia of japan: position statement on dysphagia management during the covid-19 outbreak the covid-19 response the japanese society of oral care. considerations of oral hygiene 777 care for the patients who are suspected the infection of covid-19 first report the japanese society of oral care. considerations of oral hygiene care 781 for the patients who are suspected the infection of covid-19 comparisons of methods eliminating contaminants after oral care. 786 -preliminary study in healthy individuals labour and welfare. revision of the disinfec-789 tion/sterilization guideline based on the infectious disease law q&a about new coron-792 avirus infection control guidelines during 795 prosthodontic procedures et 798 al. introduction of oral care method with use of moistening agent a new oral care gel to prevent aspiration during oral 802 care guidelines for nosocomial in-804 fection control during general dental care transmission 807 routes of 2019-ncov and controls in dental practice the oto-rhino-laryngology society of japan. guidance for tra-810 cheostomy key: cord-301582-922zyhti authors: bury, gerard; smith, susan; kelly, maureen; bradley, colin; howard, william; egan, mairead title: covid-19 community assessment hubs in ireland—the experience of clinicians date: 2020-09-26 journal: ir j med sci doi: 10.1007/s11845-020-02381-6 sha: doc_id: 301582 cord_uid: 922zyhti background: covid-19 required rapid innovation in health systems, in the context of an infection which placed healthcare professionals at high risk; general practice has been a key component of that innovative response. in ireland, gps were asked to work in a network of community assessment hubs. a focused training programme in infection control procedures/clinical use of personal protective equipment (ppe) was rapidly developed in advance. university departments of general practice were asked to develop and deliver that training. aim: the aim of this article is to describe infection control procedure training in ireland, the uptake by gps and the initial experience of gps working in this unusual environment. design and setting: two anonymous cross-sectional online surveys are sent to participants in training courses. method: survey 1 followed completion of training; survey 2 followed establishment of the hubs. results: six hundred seventy-five participants (including 439 gps, 156 gp registrars) took part in the training. two hundred thirty-nine (50.3%) out of four hundred seventy-five responded to survey 1—over 95% reported an increase in confidence in the use of ppe. two hundred ten (44.2%) out of four hundred seventy-five participants responded to survey 2; 195 had completed hub shifts. younger, female gps predominated. very high levels of infection control procedures were reported. participants commented positively on teamworking, environment and systems. however, ‘real-time’ ambulance service data suggest the peak of the surge may have passed by the time the hubs were established. conclusion: academic departments, gps and the irish health system collaborated effectively to respond to the need for community assessment of covid-19 patients. by july 2020, ireland had 25,500 confirmed covid-19 cases and 1740 deaths related to the disease [1] . around 60% of all deaths have occurred in residential care facilities and around 30% of cases have been in healthcare workers; more than 50% of all cases have occurred in the greater dublin area/eastern counties [2] . given a population of 4.9 m, these figures indicate high incidence and fatality rates. the importance of clinical, procedural, organisational and even ethical frameworks to minimise transmission of sars-cov2 among patients and healthcare staff is therefore very clear. in march 2020, the hse announced the establishment of around 50 'covid-19 community assessment hubs' in which confirmed or presumptive cases of covid-19 would be assessed by gps, public health nurses (phns) and other clinical members of primary care teams, following referral by the patient's own doctor [3] . the hse system closely reflects that established around the same time in the uk [4, 5] . on april 3, a hse request was made to the university departments of general practice to support the training of those clinicians in their roles within the hubs. a half-day training course-'clinical ppe training'-was developed by the departments, with significant input from the national ambulance service (nas) staff with experience and expertise in the use of personal protective equipment (ppe) from the already established covid-19 testing sites. gps were invited to volunteer to work in hubs while gp registrars and primary care staff were directed by their employer, the hse, to work in specified units. those aged over 60, with pre-existing health conditions or who were pregnant were advised not to take part. hubs began to accept referrals during the week of 5 april and continue to operate in certain parts of ireland, although now on a much-reduced basis. this article reports on two follow-up surveys of the clinicians who undertook this training-the first was a simple demographic/feedback exercise for those who had participated in training and the second explored experience of working in the community assessment hubs. the purpose of both was to examine the experience of clinicians with a focus on improving their safety while working in this environment. the timing of hub availability-and therefore, potential exposure of clinicians to risk-is also considered by comparing department of health national data on daily case occurrence with 'real-time' covid-19-related emergency calls to dublin fire brigade ambulance service. the principles underpinning immediate care training courses provided the framework, delivery by peers, significant practical content, clear links between skills training and underpinning clinical purpose and supervised small-group skills training; satisfactory completion required full attendance and completion of all tasks, without formal assessment [6] . a course curriculum was developed using these principles, with content and format agreed on a consensus basis-while use of ppe was central, undertaking simulated clinical work in a series of skills stations while rigorously observing infection control procedures making up the bulk of the course. the hse nominated most candidates and provided funding and ppe supplies for each candidate and the universities provided access to their facilities. candidates were asked to watch the standard hse ppe training videos before attendance [7] . courses were delivered in dublin, galway and cork/kerry. the settings were mainly large university sports halls which allowed for social distancing and candidates wore surgical masks and used hand gel throughout. brief introductory and concluding sessions provided updates on sars-cov2, epidemiology, aerosol generating procedures, operational principles for the hubs and demonstrations of 'donning' and 'doffing' ppe by experts. due to evolving ppe supplies and specifications, the emphasis was on the principles of ppe use and on the rigorous use of demarcated 'clean' and 'dirty' areas to be established in the hubs. two hours of the course consisted of small groups circulating through taught simulated clinical scenarios while observing strict ppe and 'clean/dirty area' principles; cases included a 'worried well' patient, a covid-19 patient with community-acquired pneumonia and a covid-19 patient who developed cardiac chest pain. the hse logistics unit expeditiously provided ppe for each session; training focused on the use of gown/mask/ gloves but all candidates were also introduced to 'hazmat-type suits'/goggles/visors/ffp2/3 masks and particularly the challenges of safe doffing. all specifications of ppe were supplied to hubs at various times. the hse indicated that phns and other primary care staff would receive training within their own hubs-however, when requests were made by these colleagues to attend clinical ppe training, they were facilitated when possible. both surveys were carried out anonymously using 'google surveys'. because courses delivered in cork/kerry used a different method of contact, no email addresses were available and this group is not included in the study; no valid email addresses could be located for 18 other individuals and 41 messages were to non-responding addresses or to individuals who were not eligible to work in hubs, giving a denominator of 475. survey 1 gathered demographic and satisfaction data while survey 2 explored the working environment and procedures and perceived exposure to risk; both surveys offered a free text comments section, which was analysed thematically. no attempt was made to examine workload, clinical content or outcomes of care. data on activity within hubs has not yet been published by the hse. exemption from full ethical approval was provided by the ucd human research ethics committee. the study also reports data from dublin fire brigade ambulance service (which provides most emergency ambulance services in the greater dublin area) on covid-19related calls from march to june 2020. the data provides a real-time daily context for the establishment of hub services [8] . eighteen courses were provided to 675 participants (439 gps, 156 gp registrars, 69 phns and 11 primary care staff) from april 6 to april 23 by staff of the university departments and nas volunteers at sites around the country. training sites included dublin (461 participants), galway (72 participants) and cork/kerry (142 participants). valid email addresses were available for 475 course participants. two hundred thirty-nine (50.3%) out of four hundred seventyfive participants responded to survey 1 (feedback on training)-this included 207 gps/gp registrars. table 1 summarises demographic characteristics of respondents. most participants were female (61.5%) and 41% were aged less than 46 years old. overall, 228 (95.4%) reported that they had increased confidence in using ppe as a result of the training, 10 (4.2%) reported somewhat increased confidence and one individual reported no change. respondents were invited to make suggestions or comments on the training course and 192 (80.7%) choose to do so-the vast majority of comments were positive and indicated the course met key needs: 'initially i didn't think 4 hours was necessary to learn to don ppe but afterwards i didn't feel there was anything that i would have wanted cut from the program. great job.' 'it was very well run. very competent delivery by facilitators. we are all new to this & the familiarising with the ppe removed my personal fear of using it. there will always be slight variations but the basic fundamental safe use was very well explained & delivered.' suggestions included more operational information, greater consistency in types of ppe used and increasing or decreasing the time spent on practical skills. two hundred ten (44.2%) out of four hundred seventy-five participants responded to survey 2, of whom 15 had not completed any shifts within the hubs. the 195 clinicians who had completed shifts provide the denominator for reported experience-this included 170 gps/gp registrars. although all provinces were represented, 72% of all respondents worked in hubs in the east of the country (leinster). table 2 summarises demographics and reported shift patterns and indicates that 126 (64.6%) clinicians were female and 122 (62.6%) were in the 25-45 age group. most shifts were of 6 h or 12 h duration. of 119 gps, 34 (28.6%) had completed more than five shifts. of 51 gp registrars, 34 (65.4%) had completed more than five shifts. supplies of ppe were said to be adequate by 194 (99.9%) respondents. in terms of compliance with ppe procedures, 181 (92.8%) said compliance was very good and 14 (7.2%) said compliance was adequate. during their shifts, 23 (1.2%) clinicians reported that aerosol generating procedures were carried out, with one respondent reporting more than three such interventions; no clinical information was gathered on the nature of those procedures. overall, 163 (83.6%) clinicians reported that it systems within the hubs were adequate or very good but 32 (16.4%) described these systems as 'poor'. many of the comments from respondents related to experience with the it systems: 'i found the it software difficult to use. not at all intuitive. with a once weekly shift it felt like you had to learn it all over again each time.' 'it system very cumbersome/not user friendly/apart from that the experience in the hub has been excellent.' the large majority of respondents felt that referral systems to the hubs and reporting systems back to referring gps worked well; just 14 (7.2%) clinicians felt that referral systems to the hubs were poor and 34 (17.4%) clinicians felt that reporting systems back to the referring gp were poor. in addition, 20 (10.3%) felt that ease of referral to support services was poor. where deficits were noted, suggestions were offered for change. overall, dissatisfaction with it and administration systems focused on ease of use compared with mainstream gp electronic platforms, rather than on any identified deficits in the content. the hubs system used a 'swiftqueue' regional booking system which appeared to work very efficiently while most comments related to the patient electronic record system are used in consultations. ninety (46.2%) of respondents chose to make additional comments about their experiences. key themes included: 'i'll be happy to work in the hubs when a further wave occurs. thank you for the training.' figure 1 illustrates the number of covid-19-related emergency ambulance calls identified by the dfb ambulance service in the greater dublin area together with the national report of confirmed cases of covid-19. national reporting of covid-19 cases was not necessarily a 'real-time' event, as the department of health stressed that these figures were compiled from many sources over varying time periods. figure 1 shows that the peak of covid-19-related emergency ambulance calls was approximately 2 weeks earlier (7 april) than the peak of reported covid-19 cases (25 april) and then fell rapidly. irish general practice has responded at many levels to the covid-19 pandemic [9] . this study describes the high level of general practice support in bringing community assessment hubs into operation, at a time of very significant covid-19related demand on general practice, amid great change in normal operational routines. more than 500 gps and gp registrars came forward to complete relevant clinical training in order to work in hubs, during april 2020-this represents around 15% of the general practice population. almost all hse regions required completion of this training programme by gps and gp registrars, so it is likely that participants represent the large majority of gps and gp registrars who eventually worked in hubs. data on hub activity is not yet available from the health service but the original 50 hubs appear to have been rapidly reduced in numbers and opening hours as workload was evaluated. no data exists on the total number of clinicians who worked in hubs but the 170 gps and gp registrars who responded to this study are likely to be a significant proportion of the doctors who carried out shifts and may therefore provide useful insights into this novel clinical setting. it is striking that young, female doctors contributed so heavily to the operation of the hubs, with two-thirds of gp registrars having completed more than five shifts when only one-third of gps had done so. ireland has around 3000 gps and approximately 300-340 gp registrars working in general practice. because gps could volunteer their services and the hse advised against the involvement of older doctors, practices may have made their own decisions about which members of staff would participate, with a resulting emphasis on younger gps with no health problems coming forward. many respondents expressed concerns at the fact that gp registrars were required to work within hubs and were scheduled at a high level of activity, whereas gp principals were invited to volunteer and self-selected their workload. attendance at clinical ppe training was very high and participants reported high levels of satisfaction with the training and with the preparation they received for work in the hubs. clinicians working in the hubs generally reported good working conditions in terms of availability of ppe and use of appropriate procedures; also, aerosol generating procedures seem to have been very infrequent. the challenges of general practice have been much highlighted internationally in recent years in terms of increasing workload, financial difficulties, limited recruitment and poor morale. it is noteworthy that the sentiments of respondents working in hubs were significantly different-praise for the health service was strongly expressed, clinicians were enthusiastic about participation in the service and where criticism was offered, it was focused and constructive. perhaps counterintuitively, involvement in an innovative clinical service perceived to be very challenging but of real importance seems to have had a significant positive effect on the morale of gps, at a time when general practice itself was under tremendous pressure. the potential benefits of such positivity in dealing with the many future covid-19 challenges for general practice will be interesting to explore [10] . it is noteworthy that in times of unprecedented change, within a 3-week period, almost 600 gps had completed standardised training at three national sites. collaboration between academic departments, the health service and clinical experts within the national ambulance service allowed the urgent operational need for training to be identified and an effective solution developed and implemented within a period of days. the potential for collaborations like these to meet the needs of systems, staff and patients in the future should be acknowledged and developed further. many respondents reported low or falling levels of clinical activity and no respondent reported a high demand role, with reductions in hub availability being introduced later in april. the timing of the introduction of the hubs is an important potential learning opportunity for future covid-19 surges. emergency ambulance usage in the greater dublin area peaked 2 weeks before the peak of reported positive cases, at which time emergency ambulance use had fallen by 50%. perhaps availability of hub services 2 or 3 weeks earlier might have better matched demand within the community. it seems likely that emergency ambulance use might in the future be a sensitive marker for morbidity in the community which might guide the need for re-introduction of hub services. this study has significant limitations including limited responses to both surveys, potential self-selection by respondents with specific views or experience, the absence of any operational/utilisation data to provide context and limited potential depth using this survey strategy. however, the data represent a 'first look' at the contribution of gps in ireland to a major health crisis and provide insights into the experience and lessons learned by those doctors. more formal evaluation of the utility of the hubs is required when national data on activity, costs and healthcare workerassociated morbidity become available and will guide system development. however, the contributions and experience of gps and other primary care staff have been extremely positive and bode well for further iterations of the service. ten years of cardiac arrest resuscitation in irish general practice chief fire officer, dfb covid-19 and irish general practice a brave new world: the new normal for general practice after the covid-19 pandemic publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements the authors thank the academic, general practice, nursing, dfb and nas clinicians who came forward to develop and implement this programme and the administrative staff who made it happen. authors' contributions all authors have contributed to the design and preparation of the study.funding no funding support was provided for this study.data availability data and materials can be made available by application. conflict of interest no author has any conflict of interest. key: cord-311795-kvv3fx2n authors: barratt, ruth; shaban, ramon z.; gilbert, gwendoline l. title: clinician perceptions of respiratory infection risk; a rationale for research into mask use in routine practice date: 2019-08-31 journal: infection, disease & health doi: 10.1016/j.idh.2019.01.003 sha: doc_id: 311795 cord_uid: kvv3fx2n abstract outbreaks of emerging and re-emerging infectious diseases are global threats to society. planning for, and responses to, such events must include healthcare and other measures based on current evidence. an important area of infection prevention and control (ipc) is the optimal use of personal protective equipment (ppe) by healthcare workers (hcws), including masks for protection against respiratory pathogens. appropriate mask use during routine care is a forerunner to best practice in the event of an outbreak. however, little is known about the influences on decisions and behaviours of hcws with respect to protective mask use when providing routine care. in this paper we argue that there is a need for more research to provide a better understanding of the decision-making and risk-taking behaviours of hcws in respect of their use of masks for infectious disease prevention. our argument is based on the ongoing threat of emerging infectious diseases; a need to strengthen workforce capability, capacity and education; the financial costs of healthcare and outbreaks; and the importance of social responsibility and supportive legislation in planning for global security. future research should examine hcws' practices and constructs of risk to provide new information to inform policy and pandemic planning. abstract outbreaks of emerging and re-emerging infectious diseases are global threats to society. planning for, and responses to, such events must include healthcare and other measures based on current evidence. an important area of infection prevention and control (ipc) is the optimal use of personal protective equipment (ppe) by healthcare workers (hcws), including masks for protection against respiratory pathogens. appropriate mask use during routine care is a forerunner to best practice in the event of an outbreak. however, little is known about the influences on decisions and behaviours of hcws with respect to protective mask use when providing routine care. in this paper we argue that there is a need for more research to provide a better understanding of the decision-making and risk-taking behaviours of hcws in respect of their use of masks for infectious disease prevention. our argument is based on the ongoing threat of emerging infectious diseases; a need to strengthen workforce capability, capacity and education; the financial costs of healthcare and outbreaks; and the importance of social responsibility and supportive legislation in planning for global security. future research should examine hcws' practices and constructs of risk to provide new information to inform policy and pandemic planning. preventing the transmission of infectious diseases in healthcare settings, and in society more broadly, is a core goal of contemporary public health and infection prevention and control (ipc). in recent years outbreaks of emerging infectious diseases caused by respiratory viruses have drawn considerable global attention, in particular severe acute respiratory syndrome (sars), middle east respiratory syndrome (mers) and pandemic influenza a, h1n1 2009 (table 1) . consequently, global and national planning for pandemic diseases is grounded in the expectation that a novel respiratory infection is most likely to be responsible for the next pandemic or infectious disease emergency [1] . respiratory infectious diseases are transmitted via contact, droplet and/or airborne modes, necessitating healthcare worker (hcw) use of surgical masks or respirators and other personal protective equipment (ppe) together with appropriate hand hygiene. hospital-based transmission of respiratory infectious diseases of high consequence, such as influenza, can be minimised by limiting the part hcws play as vectors or victims of disease. hcws may continue to work with mild respiratory illness (presenteeism), which can be serious or life-threatening if transmitted to vulnerable patients, but they also may suffer serious effects from occupationally-acquired respiratory infections, leading to increased staff absenteeism, which will compromise patient care during epidemics. while policies and protocols for optimal use of ppe and other transmission-based precautions exist in the majority of healthcare facilities, hcw compliance with them is typically limited, particularly in non-outbreak situations or in the early stages before an outbreak is recognised [2, 3] . in particular, hcws' use of protective masks when caring for patients with respiratory infections is an important and well-documented ipc measure [4] . yet hcw use of protective masks, and ppe in general, during routine care is often suboptimal and can result in healthcare-associated acquisition of infection [5] (table 2) . while hcw compliance with the use of protective masks during infectious disease outbreaks has been well reported [6] , there has been limited examination of hcw behaviours with respect to protective mask use during routine clinical care [3] . consistent routine use of protective masks, based on relevant clinical indications, is important in preventing or delaying transmission from an unrecognised initial/index case [7] . the appropriate use of ppe, including respiratory protection, and hand hygiene in routine care is critical to minimising pathogen transmission to staff and other patients; sub-optimal use exposes both hcws and patients to infection. compliance of hcws with wearing a protective mask may be related to their perception of risk and their risk-taking behaviours. the existing ipc literature primarily focuses on this topic in the context of sars or other pandemic respiratory diseases, with few papers investigating risk constructs for healthcare workers in routine care. the first and classic response to suboptimal behaviour is educative, with the provision of in-service and other training. we argue that the factors that lead to suboptimal use go far beyond knowledge and education, as well a subsequent national outbreak resulted in 186 healthcare associated cases within the first month with over one fifth of these cases being hcws. one reason for so many hais has been attributed to sub-optimal use of routine protective equipment by hcws and the potential for infected hcws to act as vectors of infection [13] . documented in other behaviours such as hand hygiene [8] . interventions, and the research efforts used to generate evidence to support them, must take account of individuals' constructs and perceptions of risk and risk-taking behaviour. these perceptions are necessarily heterogeneous and vary between individuals and clinical settings. therefore, an understanding of the perceptions and behaviours regarding ppe use in different contexts is needed to inform successful behaviour change interventions [9] . the importance and urgency of addressing suboptimal mask use by hcws is, in our view, based on a range of interconnected reasons all of which are critical to global health and security. these are as follows: the continuing burden of emerging infectious diseases for many centuries, since the age of the plague and smallpox epidemics to the 20th century outbreak of hiv/ aids, human infectious diseases of high consequence have presented a significant global public health challenge. these pandemics have resulted in deaths and disability of millions of people across the world, as well as causing social and economic disruption. despite improvements in communicable disease prevention and control, including effective sanitation, vector control, vaccines, and the international health regulations developed by the world health organization (who) [10] , the new, emerging infectious diseases continue to threaten the well-being and economic stability of society and impose a significant burden on healthcare. although some infectious diseases, such as plague or smallpox, no longer present an active global pandemic threat, this century has seen both new and re-emerging infectious diseases give rise to widespread outbreaks. of particular current concern is re-assortment of rna in viruses such as influenza a which contributes to emerging pandemic influenza strains [11] . furthermore, several zoonotic viral diseases that have infected humans through animal-to-human contact have also demonstrated human-to-human transmission, such as nipah virus [12] . antecedents for the increasing burden of infectious diseases include a global population boom, changes in the use of land and environment, loss of wild life habitat, increased contact between wild and domestic animals and humans, the expansion in travel, an ageing population and developments in medical interventions. the latter two have led to an increase in the number of immunecompromised people who are susceptible to significant disease from emerging infections. many of these people attend, or are frequent inpatients of, healthcare facilities and therefore are at risk of healthcare-associated infections (hais). cheaper, easier and faster modes of travel, particularly by air, have enabled emerging infectious diseases to disperse more widely in short periods of time, than ever before. a clear example of this was sars, which spread from one "super-spreader" in a hotel in hong kong to numerous other countries via international guests who were infected, by contact, while staying in the same hotel [13] . similarly a large outbreak of mers involving 186 cases resulted from a single traveller returning to south korea from the middle east and attending several hospital emergency departments after he became unwell [14] . the number of active outbreaks that are present around the world will vary on any given day; however at time of writing there were traveller alert notices for at least twelve different infectious diseases in more than 50 countries [15] and, on average, 90 global infectious diseases emergencies are notified via the who each day [16] . the use of protective respiratory masks has a human resource impact in healthcare organisations. clinicians are at a higher risk of acquiring influenza and other respiratory diseases than adults working in non-healthcare settings [17] . sub-optimal protective mask use can increase this risk, which is exacerbated during high-risk periods such as the winter respiratory virus season. staff illness from respiratory infections has a direct impact on the workforce resulting in loss of productivity and associated economic burden within the healthcare setting, particularly with influenza [18] . other respiratory viral diseases, such as the common cold, also contribute to a reduced work output [19e21] . productivity is affected if workers take leave to care for family members who are ill or children, because schools have been closed. although annual influenza vaccination is widely promoted as a means to reduce staff illness, average uptake by hcws is poor, unless is it mandatory. seasonal vaccine efficacy varies from year to year because of variable matching between vaccine and circulating strains, but is generally less than 50e60% [22] . even when hcw flu vaccine uptake is high the risk remains, because of vaccine mismatch with circulating strain, limited vaccine efficacy and/or mild or subclinical (but transmissible) infection in vaccinated subjects [23] . consequently, hcws should still use respiratory protection when caring for patients with respiratory symptoms and/or patients at high risk of infection during outbreaks or high levels of respiratory infections in the community. not wearing a protective mask increases the risk of occupationally-acquired respiratory disease. hcw absenteeism due to influenza increases on average by two days per hcw, both during pandemic and a seasonal virus outbreaks [24] . ip et al. [25] examined overall sickness absences including sick leave due to acute respiratory infection (ari) for four distinct influenza periods between 2004 and including the 2009 influenza a(h1n1)pdm09 pandemic in hong kong. results showed that the daily hcw absenteeism rate for ari increased from the pre-pandemic in september 2018 a uk healthcare worker contracted monkeypox after caring for a patient with the disease prior to diagnosis. in a eurosurveillance report (add in ref) about the case, public health officials said that some hcws had been exposed as they were not wearing optimal personal protective equipment. baseline by 26.5% and 90.9% during the epidemic and pandemic periods respectively [24] . similarly in canada, researchers demonstrated a significant increase in the rate of sick hours between the pre-influenza and 2012/2013 influenza period with only 14% of staff having zero sick hours productivity losses related to the common cold [26] . a study examining the effect of influenza vaccination on emergency department workers' absentee rates reported that 30% of vaccinated and 55% of non-vaccinated workers required sick leave for influenza-like illness [27] , although significant absenteeism during the h1n1 influenza pandemic was not noted in the australian emergency workforce [28] . staff illness compromises the quality and safety of patient care by loss of continuity of care through the requirement to employ agency staff in place of regular staff, who may be unfamiliar with the specialism of the clinical setting [28] . staff absenteeism during outbreaks of emerging or high consequence infectious diseases, may also be due to hcws fear of acquiring the infection [29] . similarly, presenteeism, or coming to work when ill, also results in a loss of productivity due to staff not working at full capacity [30] . the health and safety of other staff are put at risk by hcws who continue to work while ill, while patient safety may be compromised through impaired clinical judgement. in a study undertaken in a children's hospital in philadelphia, 299 (55%) of medical staff who were surveyed, reported that they would work with significant respiratory symptoms, despite acknowledging the infection risk to their co-workers and patients [31] . in another study over 40% of us hcws who were surveyed worked with symptoms of influenza-like illness [32] . whilst it is important to avoid presenteeism, it may be occasionally unavoidable e.g. because of significant or specialised staff shortages. if so, the risk may be mitigated by appropriate mask use. the hcws work capability may also be impaired by any physical and psychological consequences of wearing a mask, such as claustrophobia, respiratory distress, discomfort and skin irritation. the financial costs to society for respiratory infectious diseases can be significant. a us study estimated the annual economic burden of influenza, in 2003, to be around us$90 billion [31] , while lost productivity due to influenza in france and germany was estimated at us$10e15 billion per year [33] . sub-optimal mask use is likely to be associated with an increase in financial costs for individuals, the healthcare system and subsequently the wider society. although existing research has not examined the direct costs of not wearing a protective mask, van buynder et al. (2015) estimated the financial cost of hcws absenteeism due to influenza-like-illness to be greater than can$1 million during the 2012/2013 winter season in a health district in british columbia [26] . in addition, there are sick leave payments for staff and the costs incurred to replace them with casual staff. workers compensation fees may be driven up by hcws who take risks by not wearing masks. furthermore, there are significant monetary costs associated with patients acquiring a healthcare associated respiratory infection. the probability of a patient acquiring an influenza-like-illness increases when exposed to an infectious hcw, with one study reporting a relative risk of 5.48 when compared to no documented exposure [34] . expenses for a hai include the overall cost of care for any additional inpatient bed days as a result of the infection, antiviral medication, other supportive therapy, radiology, laboratory and direct costs associated with the use of isolation and ppe measures. a korean study reported an average medical cost for a patient hospitalised with influenza in 2013/2014 was us$ 3104.3 ae 4638.1 [35] . when a higher level of ipc measures is required e.g. mers or other emerging infectious disease, these costs can be excessive. veater et al. (2017) calculated an additional cost of 119 pounds sterling per person per day, mainly due to staff time and ppe costs [36] . third, sub-optimal mask use is associated with reductions in cost effectiveness of training methods in the use of ppe. effective training in ppe use is resource intensive and thus expensive to execute, whether delivered as demonstration learning by experts or technology-based education. inadequate training in ppe protocols is cited as one of the causes for poor compliance with ppe [37] . these findings question the cost-effectiveness of current training methods. there is also a financial cost attached to the incorrect choice or unnecessary use of a mask, particularly in the case of the more expensive particulate respirator mask, or during a global outbreak event where stocks may be limited. the knowledge and skills of hcws are factors that affect protective mask use, therefore investigating how knowledge and cognition impacts on the hcw decision-making for mask use can inform the delivery of education and how policies are implemented. some of the aspects of knowledge related to mask use that may influence hcw behaviour include the source of knowledge, the indications for mask use, which type of mask to choose, how the mask functions to provide protection and how to put on and remove the mask safely. in the context of an emerging infection and limited available information, personal experience can influence hcws' perceptions of risk and behaviours related to protective mask use [38, 39] . in contrast, a study undertaken in an outpatient paediatric setting, demonstrated that the use of ppe was not influenced by infectious risk perception [40] . prior education and training will provide some of the essential information and skills required for optimal mask use but, in practice, routine training in the use of ppe is often cursory or non-existent. in a survey of healthcare workers in the us, 43% of doctors reported having received ppe training only as students (including clinical rotations) or not at all (c.f. 8% of nurses) [41] . despite prior education, hcws may not apply their knowledge to the workplace [42] . the method of training is therefore an important consideration for effective retention of knowledge and skills over time. several studies argue for improving the evaluation and training of hcws using ppe for infectious diseases and examining the effectiveness of various teaching approaches [43, 44] . the recent ebola virus disease (evd) outbreak instigated intensive ppe training around the world, with a focus on donning and doffing protocols to maximise hcw safety. unsafe use of ppe has been blamed for some hcws becoming infected with evd or sars; subsequently several research studies have reviewed the effectiveness of different training techniques for the safe donning and doffing of ppe [45] . these have included interactive online courses, and classroom teaching that incorporates fluorescent dye or harmless bacteriophages as surrogate markers of contamination [46] . video-reflexive ethnography (vre) has been used as an interventional methodology to improve ipc practices [47] . this method allows the hcw to view video footage of themselves making decisions around and subsequently using protective masks in every-day complex work. the clinicians can then reflect on their behaviour and suggest ways in which their own and colleagues' mask use can be optimised. although the techniques taught for donning and doffing protective masks as part of routine ppe are generally heterogeneous around the world, there are variations in mask design which may affect skills. there is also a lack of standardisation between and within institutions as to which clinical indications warrant a n95 or surgical mask. within society in general, individuals are not only motivated to protect themselves from infectious disease but often demonstrate a moral responsibility to protect others if they themselves are infectious [48] . during periods of high-risk for respiratory infectious disease, such as the annual influenza season or a novel influenza pandemic, health departments have, and may, encourage or mandate the use of a protective respiratory mask by the general public to minimise the transmission from symptomatic people to others [49] . in healthcare facility waiting rooms it is recommended that symptomatic patients be given a respiratory mask to wear to protect others as part of respiratory hygiene [49] . this social behaviour may alter the perception of risk for staff towards mask use in two ways, particularly in the emergency department. firstly, hcws may take a view that it is the patient's, not their own, responsibility to abide by these infection prevention measures and purposefully choose not to wear a mask on the basis of responsibility. secondly, they may not perceive a risk of becoming infected if a patient is wearing a mask and so will not use one. there are several risks for hcws adopting this behaviour. the patient may not wear the mask correctly or remove it at any time, especially if they are kept waiting for long periods, thus exposing other patients and hcws. additionally, the patient may not be able to tolerate a mask for long if unwell and will then remove it. clinical examination may put the hcw at higher risk of exposure, even if the patient is wearing the mask correctly when they enter the room or cubicle and certain procedures, such as taking a swab for influenza testing, collection of an induced sputum specimen or intubation, require removal of the patient's mask. if an hcw fails to adequately explain why they are wearing a mask it can erect a social barrier between the hcw and patient. patients may feel stigmatised if staff wear a mask to care for them [50] while staff may feel that wearing a mask in the ed can inhibit empathy and rapport with a sick patient [51] . hcws working in paediatric units have expressed concern that ppe may frighten their patients [52] . social interactions within the workplace can influence the health-related behaviour of workers. the safety climate and group norms at hospital unit level have been shown to influence the risk-taking behaviour associated with facial protective equipment [53] . the use of protective masks in the healthcare setting is governed locally by policies in health and safety and ipc. as indicated earlier, adherence to such policies and guidelines is often poor. similar to other types of ppe and ipc measures, there is no strong culture of enforcement of policy relating to protective masks in the healthcare setting. this raises questions about the efficacy of mask policies, their awareness by hcws and how they are judged by clinical staff. in some countries, state-wide legislation mandates the use of a protective mask for various categories of clinical staff during the annual influenza season, if they have not received the influenza vaccination [49] . this enforced measure has been resisted by some clinical staff because of its impact on personal choice [54] and by others as illogical when considering the risk from all respiratory pathogens [55] . although many countries provide national occupational safety and health policy direction, few enforce protective mask use in healthcare settings. nevertheless, sub-optimal mask use reinforces poor behaviour in the workplace and contravenes workforce health and safety responsibilities of employees [56] . the behaviours of hcws towards protective mask use can affect the progression of a respiratory infectious disease outbreak and, if inappropriate, facilitate a pandemic. the consequences of a pandemic on a global scale are significant, with substantial negative societal effects. ease of access to international travel has been a significant factor in the worldwide spread of recent pandemics such as pandemic influenza a h1n1 2009 , sars and mers, therefore international travel and trade are often restricted [57] . personal freedom of movement is also affected by public health quarantine measures and the prohibition of public gatherings. education is disrupted through school closures which results in parents taking time off work as a consequence. in addition to the consequences described above, the provision of healthcare to the general population can be disrupted. in 2009, the influenza a h1n1 2009 pandemic impacted severely on the normal functioning of emergency departments in australia [58] . more than three times the number of patients were seen, most with non-serious influenza symptoms. staff reported that heavy workloads, lack of infection control facilities and distraction from their core business compromised the care of non-flu patients. large numbers of patients requiring care will lead to bed shortages and hospital admission gridlock, probable loss of critical care beds which are blocked with long stay respiratory patients and the cancellation of routine surgical lists [59] . furthermore, there will be fewer hcws available to provide the care due to their own illness or having to look after family members. in this paper we detail why we need to know more about hcws' decision-making and risk-taking behaviour in relation the use of masks for protection against infectious respiratory diseases. we argue that the value of such research would be its potential impact on the ongoing threat of emerging infectious diseases, workforce capability, capacity and educational needs, the financial costs of healthcare and outbreaks and the importance of social responsibility and appropriate legislation in planning for global security. specifically, research is required to determine whether hcws' perception of risk as it relates to the protection of themselves and others against transmission of infection influences their behaviour towards the use of a protective mask. there is also a need to determine the personal, professional and contextual factors that impact on hcws' perceptions of risk and their use of protective masks for infectious diseases. an exploration of the practices and constructs of risk by hcws will therefore provide valuable information to inform policy and pandemic planning. the sub-optimal use by hcws of protective masks for respiratory diseases has a significant impact at individual, organisational, societal and global levels. furthermore, the consequences of poor mask use will be exacerbated during a widespread outbreak or pandemic of a novel infectious respiratory disease, when pharmacological agents or vaccination are unavailable. minimising the transmission of respiratory disease through protective mask use leads to better outcomes for healthcare, workforce capability and economic stability. this paper has presented the background and justification for research into the attitudes and behaviour of hcws towards protective mask use for respiratory infectious diseases during non-outbreak situations so as to optimise the use of masks when indicated in every day practice. the research can provide insight into perceptions of risk and risk-taking behaviour in respect of mask use for respiratory infectious diseases and help to bridge the gap between theory and practice (see table 3 ). rb and rs originated the concept for the paper and rb drafted the manuscript. glg and rs had critical review and input into the preparation of the manuscript. all authors approved the final version of the manuscript. rzs is a senior editor and glg a section editor of infection, disease and health but neither had a role in peer review or editorial decision-making of the manuscript. the authors declare no other conflict of interest. this work is supported by the australian partnership for preparedness research on infectious diseases emergencies (apprise) of which author glg is a chief investigator and author rb is recipient of a doctoral scholarship. this research presented in this article is solely the responsibility of the authors and does not reflect the views of apprise. not commissioned; externally peer reviewed. ethics approval is not required as this is a discussion paper. table 3 tribute to the mask. there was a sick traveller in bed who had an airborne infection to spread the staff did their tasks, but didn't wear masks, and now many people are dead! development of framework for assessing influenza virus pandemic risk standard precautions but no standard adherence health care workers' perceptions predicts uptake of personal protective equipment australian guidelines for the prevention and control of infection in healthcare. national health and medical research council middle east respiratory syndrome coronavirus transmission among health care workers: implication for infection control evaluation of respiratory protection programs and practices in california hospitals during the 2009e2010 h1n1 influenza pandemic scope and extent of healthcare-associated middle east respiratory syndrome coronavirus transmission during two contemporaneous outbreaks in riyadh, saudi arabia applying psychological frameworks of behaviour change to improve healthcare worker hand hygiene: a systematic review the behaviour change wheel: a new method for characterising and designing behaviour change interventions world health organisation. international health regulations rna virus reassortment: an evolutionary mechanism for host jumps and immune evasion in-depth assessment of an outbreak of nipah encephalitis with person-to-person transmission in bangladesh: implications for prevention and control strategies responding to global infectious disease outbreaks: lessons from sars on the role of risk perception, communication and management mers-cov outbreak following a single patient exposure in an emergency room in south korea: an epidemiological outbreak study travel health notices j travelers' health j cdc flu and ebola map j virus and contagious disease surveillance incidence of influenza in healthy adults and healthcare workers: a systematic review and meta-analysis annual burden of occupationally-acquired influenza infections in hospitals and emergency departments in the united states productivity losses related to the common cold more than a cold: hospital-acquired respiratory viral infections, sick leave policy, and a need for culture change effects of upper respiratory tract illnesses on mood and performance over the working day seasonal influenza vaccine effectiveness chasing seasonal influenzadthe need for a universal influenza vaccine estimation of sickness absenteeism among italian healthcare workers during seasonal influenza epidemics increases in absenteeism among health care workers in hong kong during influenza epidemics healthcare worker influenza immunization vaccinate or mask policy: strategies for cost effective implementation and subsequent reductions in staff absenteeism due to illness does vaccinating ed health care workers against influenza reduce sickness absenteeism? pandemic (h1n1) 2009 influenza in australia: absenteeism and redeployment of emergency medicine and nursing staff factors influencing emergency nurses' ethical problems during the outbreak of mers-cov assessing workplace infectious illness management in australian workplaces reasons why physicians and advanced practice clinicians work while sick: a mixed-methods analysis working with influenza-like illness: presenteeism among us health care personnel during the 2014e2015 influenza season the annual impact of seasonal influenza in the us: measuring disease burden and costs mandatory influenza vaccination of healthcare personnel disease burden of 2013e2014 seasonal influenza in adults in korea resource impact of managing suspected middle east respiratory syndrome patients in a uk teaching hospital behind the mask: determinants of nurse's adherence to facial protective equipment risk perception and compliance with quarantine during the sars outbreak compliance with recommended protective actions during an h7n9 emergency: a risk perception perspective barriers to the use of ppe to prevent pertussis exposures in a pediatric primary care network are health care personnel trained in correct use of personal protective equipment? healthcare workers' decision-making about transmission-based infection control precautions is improved by a guidance summary card personal protective equipment processes and rationale for the nebraska biocontainment unit during the 2014 activations for ebola virus disease the individual, environmental, and organizational factors that influence nurses' use of facial protection to prevent occupational transmission of communicable respiratory illness in acute care hospitals risk of self-contamination during doffing of personal protective equipment human factors risk analyses of a doffing protocol for ebola-level personal protective equipment: mapping errors to contamination beyond hand hygiene: a qualitative study of the everyday work of preventing cross-contamination on hospital wards prevalence of preventive behaviors and associated factors during early phase of the h1n1 influenza epidemic clinical excellence commission. infection prevention and control practice handbook. principles for nsw public health organisations behind barriers: patients' perceptions of source isolation for methicillin-resistant staphylococcus aureus (mrsa) perceived barriers to adherence to tuberculosis infection control measures among health care workers in the dominican republic the cookie monster muffler": perceptions and behaviours of hospital healthcare workers around the use of masks and respirators in the hospital setting hospital unit safety climate: relationship with nurses' adherence to recommended use of facial protective equipment nurses' attitudes towards enforced measures to increase influenza vaccination: a qualitative study influenza vaccination of healthcare workers: critical analysis of the evidence for patient benefit underpinning policies of enforcement australian government. workplace health and safety domestic politics and the who's international health regulations: explaining the use of trade and travel barriers during disease outbreaks pandemic (h1n1) influenza 2009 and australian emergency departments: implications for policy, practice and pandemic preparedness the practical experience of managing the h1n1 2009 influenza pandemic in australian and new zealand intensive care units key: cord-313528-rp15vi1o authors: wallace, douglas w.; burleson, samuel l.; heimann, matthew a.; crosby, james c.; swanson, jonathan; gibson, courtney b.; greene, christopher title: an adapted emergency department triage algorithm for the covid‐19 pandemic date: 2020-08-10 journal: j am coll emerg physicians open doi: 10.1002/emp2.12210 sha: doc_id: 313528 cord_uid: rp15vi1o the novel coronavirus disease 2019 (covid‐19) pandemic, with its public health implications, high case fatality rate, and strain on hospital resources, will continue to challenge clinicians and researchers alike for months to come. accurate triage of patients during the pandemic will assign patients to the appropriate level of care, provide the best care for the maximum number of patients, rationally limit personal protective equipment (ppe) usage, and mitigate nosocomial exposures. the authors describe an adapted covid‐19 pandemic triage algorithm for emergency departments (eds) guided by the best available evidence and responses to prior pandemics, with recommendations for clinician ppe use for each level of encounter in the setting of an ongoing ppe shortage. our algorithm adheres to centers for disease control and prevention guidelines and supports discharge of patients with mild symptoms coupled with explicit and strict return precautions and infection control education. with over 12.3 million cases and 550,000 deaths worldwide at the time of this writing, the global impact of covid-19 is ever increasing. 1, 2 widespread community transmission is occurring in the united states (us) and health systems around the world continue to face challenges in the management of covid-19 patients. 3 hospitals across the united states have adapted to the covid-19 pandemic by limiting nonessential patient interaction and transforming their emergency departments (eds) to treat patients who are both critically ill and highly contagious. 4 with the looming threat of recurrent patient surges ever on the horizon, emergency clinicians must thoughtfully consider how to best supervising editor: angela lumba-brown, md. this is an open access article under the terms of the creative commons attribution-noncommercial-noderivs license, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. © 2020 the authors. jacep open published by wiley periodicals llc on behalf of the american college of emergency physicians. handle an influx of patients while limiting the exposure of themselves and others. 4 this article offers triage tools that the authors believe will help us provide better care for our patients, protect our colleagues and patients alike, and contribute to the greater public health response to the pandemic. us healthcare systems are structured such that emergency clinicians stand on the frontline of any pandemic. although other departments can regulate patient flow and volume with scheduled encounters or operating room allocation, eds must respond efficiently and effectively to any patient surge. worldwide data indicates that ∼25% of jacep open 2020;1-6. wileyonlinelibrary.com/journal/emp2 covid-19 patients require critical care resources. 5 a number of protocolized approaches borne out of this need. 13 the majority of prediction rules designed for allocation of critical care resources during a pandemic were developed in response to influenza outbreaks during the 20th century. these rules rely largely on laboratory and radiologic findings performed after the initial evaluation to categorize patients, and are therefore less helpful in the immediate triage setting. 15, 16 of more acute relevance, the centers for disease control and prevention (cdc) created a "pandemic influenza triage algorithm" (pita) in response to the 2009 h1n1 pandemic. pita incorporates triage data to categorize patients into 5 levels ranging from those requiring immediate resuscitation (red, level 1), to those requiring only a cursory evaluation before discharge (green, level 5). the pita algorithm was designed to triage patients rapidly and effectively upon initial evaluation, rationally minimize ppe usage, and limit nosocomial transmission. its core tenets are readily translatable to the covid-19 outbreak. 17 the authors adapted the pita algorithm into a specialized covid-19 triage algorithm (see figure 1 ) with the same primary goals of assigning arise. in our system, the algorithm was designed and implemented at the a lack of required testing prior to level of care designation is felt to be a major strength of the algorithm as it expedites the triage process. the algorithm was designed prior to the widespread availability of rapid covid-19 testing, and as such, it was intentionally not mandated in the algorithm. additionally, on initial presentation and subsequent triage, covid-19 testing results are not routinely available for rapid decisionmaking in the ed setting. all testing should be adapted to local and institutional guidelines. "need resuscitation-red" patients are defined in our algorithm as patients in full arrest or extremis, patients with an inability to protect their airway, patients with frank respiratory failure or apnea, patients with significant hypoxemia (<88% at sea level), patients in shock, or patients with significant alteration in mental status. these patients are universally assumed to be puis. we recommend use of the highest level of ppe for these patients (as indicated in figure 1 ), because they may need to undergo high risk aerosolizing-generating procedures (ie, endotracheal intubation, non-invasive ventilation). [25] [26] [27] [28] the authors additionally recommend use of an airborne infection isolation room (aiir, or "negative pressure room") for patients under-going aerosolizing-generating procedures given the significant risk for airborne disease transmission during such procedures. [25] [26] [27] [28] the patient can be transferred or dispositioned to a non-aiir if appropriate filtration devices are used. these patients should be admitted to an intensive care setting. further, we recommend considering a chest x-ray prior to, or immediately following, admission along with testing for covid-19 as available and other testing as indicated. patients not in extremis must have "1 or more symptoms consistent with covid-19" identifying them as a pui. we initially defined these criteria as fever, cough (dry or productive), or shortness of in addition to providing a framework for clinical triage, our algorithm describes the recommended levels of personal protective equipment (ppe) for each type of expected encounter. significant rates of infection among health care workers and nosocomial infection illustrate the need for adequate clinician protection and infection control. 21, 27 sars-cov-2 seems to have a viral shedding pattern similar to influenza. 34, 35 high viral loads have been detected in completely asymptomatic patients, calling for a minimum level of protection from respiratory droplets for all clinicians. 30,36 sars-cov-2 was also noted in stool in 50% of patients tested, and extensive surface contamination has been reported. 37, 38 the potential for stool or fluid transmission suggest the need for concomitant contact precautions for providers within reach of a patient or contaminated surface. 30, 34 the most significant controversy involving sars-cov-2 transmission seems to be the potential for routine airborne or aerosol spread. it is thought that the highest risk for airborne transmission occurs during aerosolizing-generating procedures, but the virus has been found to be viable in aerosols for at least 3 h. 24 droplet: distance >6 feet (greens, some yellows) we recommend clinicians approaching all green and yellow patients wear, at minimum, a procedural mask and gloves if remaining at least 6 feet from the patient (a widely accepted range for typical droplet transmission). we recommend clinicians evaluating patients at a distance <6 feet follow the contact + droplet precautions below. all puis should be given a procedural mask on entry. clinician exposure to low acuity patients should be rapid and at the safest feasible distance to obtain an accurate assessment of the patient with the minimum amount of ppe necessary to adequately and safely care for a patient. contact + droplet: distance <6 feet (some yellows, blues, pinks, some reds) many well-appearing patients may require more extensive evaluation, typified by those with relevant risk factors and abnormal vital signs as above. 30 for those patients requiring the clinician to approach within 6 feet to auscultate, examine, or intervene, we recommend at minimum a procedural mask, face shield or goggles, isolation gown, and gloves, consistent with who, cdc, and canadian guidelines. 26, 29, 39 this level of ppe provides respiratory droplet and contact protection. patients presenting in extremis or requiring immediate resuscitation will likely require aggressive respiratory support or invasive proceour algorithm also assumes that a facility will have nursing providers available for use in triage as well as a physician or advanced practice providers readily available for further stratification of patients. we recognize that many eds will not have equivalent capabilities and some aspects of the algorithm may have to be adapted to local circumstances. we support the use of an experienced nursing provider in place of a physician or app in the triage setting if necessary. our algorithm was designed with thoughtful resource allocation in mind and aims to provide adequate protection for the most providers in the setting of limited resources and ppe, an unfortunate and continued reality of the covid-19 pandemic. recent data lends more support to the possibility of airborne transmission of the virus even in the absence of aerosolizing-generating procedures. 35 in light of this, the authors again recommend the use of constant airborne and contact precautions by all providers experiencing close contact as with puis as resource allocation allows. as the covid-19 pandemic continues to evolve, so too will our understanding of the best patient care and management strategies. dynamic changes in who and cdc guidelines have already occurred with incorporation of evidence-based clinical features, and it is vital to continually update our approach to any pathogen as new information is obtained. the proposed triage algorithm was designed to facilitate the timely evaluation of puis in an organized fashion that optimizes patient triage, minimizes unnecessary clinician exposure, standardizes care, and maximizes appropriate resource use in the setting of an ongoing ppe shortage. these measures will continue to be essential in the coming months. it is the authors' hope that use of this triage algorithm and ppe recommendations will aid frontline emergency clinicians in the ongoing response to covid-19. douglas w. wallace md https://orcid.org/0000-0002-7714-8156 coronavirus disease 2019 (covid-19): what we know facing covid-19 in italy -ethics, logistics, and therapeutics on the epidemic's front line the calm before the storm': emergency departments brace for patient surge coronavirus disease 2019 (covid-19) in italy characteristics and outcomes of 21 critically ill patients with covid-19 in washington state effect of emergency department crowding on outcomes of admitted patients impact of the fall 2009 influenza a(h1n1)pdm09 pandemic on us hospitals unique epidemiological and clinical features of the emerging 2019 novel coronavirus pneumonia (covid-19) implicate special control measures characteristics of health care personnel with covid-19-united states protecting healthcare workers from subclinical coronavirus infection at war with no ammo": doctors say shortage of protective gear is dire ciottone's disaster medicine-9780323286657 evolution of triage systems development of a triage protocol for critical care during an influenza pandemic pandemic influenza triage tools clinical characteristics of hospitalized patients with sars-cov-2 infection: a single arm meta-analysis evaluation and treatment coronavirus (covid-19) treasure island, fl: statpearls characteristics of covid-19 infection in beijing clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china epidemiologic and clinical characteristics of 91 hospitalized patients with covid-19 in zhejiang, china: a retrospective, multi-center case series epidemiology and case management team, korea centers for disease control and prevention. early epidemiological and clinical characteristics of 28 cases of coronavirus disease in south korea situation summary wax rs, christian md. practical recommendations for critical care and anesthesia teams caring for novel coronavirus (2019-ncov) patients infection prevention and control for coronavirus disease (covid-19): interim guidance for acute healthcare settings. government of canada respiratory care committee of chinese thoracic s. expert consensus on preventing nosocomial transmission during respiratory care for critically ill patients infected by 2019 novel coronavirus pneumonia expert recommendations for tracheal intubation in critically ill patients with novel coronavirus disease 2019 air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) from a symptomatic patient management of patients with confirmed 2019-ncov sars-co-v-2 viral load in upper respiratory specimens of infected patients 1-minute sit-to-stand test: systematic review of procedures, performance, and clinimetric properties step oximetry test: a validation study association between hypoxemia and mortality in patients with covid-19 epidemiologic features and clinical course of patients infected with sars-cov-2 in singapore chinese clinical guidance for covid-19 pneumonia diagnosis and treatment. 7th ed. china national health commission aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 transmission potential of sars-cov-2 in viral shedding observed at the university of nebraska medical center infection-preventionand-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125 key: cord-338365-9sd62a2w authors: patrício silva, ana l.; prata, joana c.; walker, tony r.; duarte, armando c.; ouyang, wei; barcelò, damià; rocha-santos, teresa title: increased plastic pollution due to covid-19 pandemic: challenges and recommendations date: 2020-08-17 journal: chem eng j doi: 10.1016/j.cej.2020.126683 sha: doc_id: 338365 cord_uid: 9sd62a2w plastics have become a severe transboundary threat to natural ecosystems and human health, with studies predicting a twofold increase in the number of plastic debris (including micro and nano-sized plastics) by 2030. however, such predictions will likely be aggravated by the excessive use and consumption of single-use plastics (including personal protective equipment such as masks and gloves) due to covid-19 pandemic. this review aimed to provide a comprehensive overview on the effects of covid-19 on macroplastic pollution and its potential implications on the environment and human health considering shortand long-term scenarios; addressing the main challenges and discussing potential strategies to overcome them. it emphasises that future measures, involved in an emergent health crisis or not, should reflect a balance between public health and environmental safety as they are both undoubtedly connected. although the use and consumption of plastics significantly improved our quality of life, it is crucial to shift towards sustainable alternatives, such as bio-based plastics. plastics should remain in the top of the political agenda in europe and across the world, not only to minimise plastic leakage and pollution, but to promote sustainable growth and to stimulate both green and blueeconomies. discussions on this topic, particularly considering the excessive use of plastic, should start soon with the involvement of the scientific community, plastic producers and politicians in order to be prepared for the near future. since december 2019, the world was affected by a pandemic originated by a novel coronavirus (sars-cov-2) responsible for a severe respiratory syndrome known as covid-19 [1] . the severity of covid-19 disease, allied with its high contagiousness (e.g., direct human contact or contact with contaminated surfaces/waste, airborne/respiratory droplets and oral-faecal transmission [2] [3] [4] ) and the absence of a safe and effective vaccine, has raised attention and fear from governments, medical staff, the scientific community, and the general public towards prevention and control of its transmission. as an attend to flatten the epidemic curve (r 0 ≤1), governments worldwide have implemented several precautionary measures. some include partial or total lockdown of cities/regions/municipalities (e.g., italy and spain on 10 th and 16 th march, respectively), restrictions on social contact and social distance, reduced mobility of goods and passengers, reduced economic activities and businesses to essential supply chains only [5] . alongside, the creation of provisory treatment facilities for covid-19 patients with moderate to severe symptoms, the limited access to hospitals and healthcare facilities by family/visitors, the mandatory quarantine (self-isolation) of covid-19 patients with minor symptoms, and the mandatory use of personal protective equipment (ppe) by frontline workers (which use dramatically increased in the infectious disease units), have been implemented to protect the hospitals and other healthcare system of breaking down [6, 7] . however, what started as a health crisis promptly evolved into an economic, social and environmental threat. with public health now being of utmost priority, along with close monitoring of economic and social impacts, the implications of covid-19 in the environment remains largely undervalued [8] . unmanaged plastics waste is particularly concerning due to its implications to natural ecosystems and public health and safety. nonetheless, environmental health problems have received less and less attention from governmental agencies, the scientific community and general public. this can be perceived by the withdrawal of several national and state-wide agreements on the use and consumption of plastics [9] , and the numerous publications in international peer-review journals (fig.1) . even though publications on covid-19 pandemic have increased in the last 3 months, the number of studies in environmental sciences (< 3%) is considerably lower than other fields, such as medicine and health (65%). from those on environmental sciences, only approximately 20 % addressed the effect of covid-19 disease on waste and plastic pollution ( fig.1a and b). or "waste" (b). data retrieved from scopus on 29 th of april and 19 th july 2020. scientific documents include scientific article, letter, editorial, note, review, short survey, conference paper, data paper. this paper provides a comprehensive review on the potential impact of covid-19 pandemic precautionary measures in the environment while considering the shift on public behaviour and policies towards single-use items and waste management. it provides an in-depth discussion on both short-and long-term environmental effects of covid-19 pandemicparticularly considering plastics use, consumption and waste mismanagement -that remained poorly covered by the recently published critical reviews on similar topics [8, [10] [11] [12] . it also identifies the main challenges and discusses mitigation measures to overcome them, with particular emphasis on the reduction of plastic production and waste generation. at first glance covid-19 pandemic seems to be indirectly contributing towards the un 2030 sustainable development goals (namely 11, 12, 13, 15 sgds) by increasing overall health and safety of cities by reducing the greenhouse gas emissions (ghg), outdoor air pollution, environmental noise level (including underwater noise due to reduced marine transportation activities), land and wildlife pressure. however, it is failing considering the poor indoor air quality, increased use-consumption patterns of single-use-plastics (including ppe) and a shifted priority on waste management, behavioural that is contrary to environmental sustainability (including the green and circular economies) ( table 1) . while the positive impacts of covid-19 in the environment are resulting from a "postponed" anthropogenic activity that soon will entail after the pandemic scenario; the negative short-term effects (that are mostly related with plastic use, consumption and waste mismanagement as discussed below) will shortly add-up to the current environmental issues, aggravating their impact in the natural ecosystems and compromising potential mitigation/remediation measures. cities facing high covid-19 incidence rates are struggling to manage the dramatic increase in medical waste production by healthcare facilities. for instance, the king abdullah university hospital in jordan produced tenfold higher medical waste (~650 kg per day, when considering an occupation of 95 covid-19 patients) than the average generation rate during the regular operational day of the hospital [24] . a drastic increase in medical waste was also reported in other parts of the world, such as in catalonia, spain, and in china, with an increment of 350% and 370%, respectively [29] . the dramatic increase in medical waste is overloading the capacity of each country or municipality, to manage/treat it adequately. due to the persistence and high contagiousness of sars-cov-2 virus, many countries are classifying all hospital waste as infectious, which require to be incinerated under high temperatures, allowing sterilisation, followed by landfilling of residual ash . while some countries or municipalities will manage alternatives to treat medical waste properly, others (with less economic and waste management resources) might be forced to apply inappropriate management strategies, which will likely entail adverse effects to the environment, human health and safety, while raising the potential for a second wave of epidemy. as examples, wuhan inhabitants in china (~11 m) produced 200 tons of medical waste on a single day (on february 24, 2020), which is four times higher than can be incinerated by the city's only dedicated facility, forcing authorities to deploy mobile treatment facilities [8] . conversely, some indian municipalities are following a flawed system of medical waste disposal and management, which mostly rely on landfilling and local burning strategies [29] . uncontrolled incineration of medical waste, which is mostly made of plastic, is not recommended, as it contributes to the release of ghg, as well as other potentially dangerous compounds, such heavy metals, dioxins, pcbs and furans [31] . to prevent virus transmission, the use of ppe, such as medical masks and gloves, by medical staff and health workers, and later on by ordinary citizens became essential. the demand for ppe increased significantly worldwide. for instance, an estimated monthly use of 129 billion face masks and 65 billion gloves would be necessary to protect citizens worldwide [32] . the use of ppe, especially of face masks, has been incentivised in some highly impacted areas (regions/municipalities), but quickly spread to the worldwide population driven by anxiety and the perceived feeling of safety. the increased demand and indiscriminate use of ppe by ordinary citizens quickly became controversial due to the lack of correct handling and disposal, and the shortage of this material in healthcare facilities, where such material is mandatory and of utmost importance [33] . surgical masks and gloves should not be worn longer than a few hours and should be adequately discarded to avoid cross-contamination. in this sense, several countries have tried to implement safety measures considering the disposal of potentially infected ppe. as an example, the portuguese environmental agency recommended that all potentially contaminated ppe used by ordinary citizens should be disposed of as mixed wastes (not recyclables) in sealed and leak-proof garbage bags, that will likely follow to incineration facilities (preferable), or daily landfilling [34] . several states in the u.s. have also stopped recycling programs, as authorities have been concerned about the risk of covid-19 spreading in recycling centres [25] , thus prioritising both incineration and landfilling. such a reduction in waste recycling is divergent from the goals of circular economy [35] and sustainable development, and even contributing to plastic waste pollution. in most cases, ppe will likely end up discarded without precautionary measures along with empty bottles of hand sanitiser and organic solid wastes in regular municipal solid waste, or worse, littered in the environment. incorrect disposal of disposable gloves and masks, along with other plastic items, have been found littering in several public places. for instance, a considerable amount (compared with only one or two items observed per month) of disposable masks was observed in a 100 m stretch in soko's islands beach, hong kong, during an environmental survey carried out by the ngo oceans asia (http://oceansasia.org/beach-mask-coronavirus/). the increased waste production related to ppe soon became accompanied by the increased use and disposal of other single-used-plastics (sup). for instance, demand on plastics is expected to increase by 40% in packaging and 17% in other applications, including medical uses [32] . safety concerns related to shopping in supermarkets during covid-19 led to a preference of consumers and providers for fresh-food packaged in plastic containers (to avoid food contamination and to extend shelf-life), and for the use of single-use food packaging and plastic bags to carry groceries. in order to address customers concerns and assure their safety, supermarkets implemented additional health safety measures such as social distance, cleanliness, hygiene, and, in some cases, by providing home delivery and/or a pick-up service. taking advantage of these preferences, plastic industry lobbyists have raised doubts with governmental leaders concerning food safety, hygiene and cross-contamination when using reusable containers and bags during the covid-19 pandemic. although lobbyists from the plastics industry have capitalised on these concerns before (e.g., [29] ), recent concerns over covid-19 safety have then resulted in a reversal of policies to ban or reduce sup and fee payments in some jurisdictions. for example, in new york and maine, sup ban was delayed to 15th of may 2020 and 15th january 2021, respectively; while massachusetts and new hampshire reintroduced sups and even banned the use of reusable shopping bags due to potential health threats to workers and customers [9] . viable sars-cov-2 virus persists longer on plastic surfaces than other materials, such as cardboard [as reviewed by 9, 32]; thus it could be argued that rescinding sup bans could be premature, as many consumers have already adjusted to using non-plastic alternatives following the implementation of these policies these policies in many jurisdictions worldwide [38, 39] . besides, it is unclear how reusable grocery bags could contribute to higher risk compared to clothes or shoes, a potential risk that could also be mitigated with proper hand hygiene and decontamination bath (i.e., soaked in liquid soap and water temperature > 40 ºc). the end-of-life waste management for many sup during covid-19 is likely as mixed municipal solid waste, as recycling streams are being restricted worldwide. thus, as covid-19 disease continues to spread across the world, the indiscriminate use and incorrect disposal of medical and plastic waste by billions of citizens (most of them with low biodegradation rates in open environments) is rapidly becoming a global and emerging issue. as covid-19 is transmitted by contaminated surfaces, several disinfection campaigns have been applied to several facilities such as hospitals, offices, clinics, universities, airports; and public places such streets, public gardens and even beaches. yet, the choice of the chemical disinfectants and the places for disinfection have been highly questionable. for instance, the majority of products used to disinfect against covid-19 that meets the environmental protection agency (epa) criteria contain quaternary ammonium and sodium hypochlorite (bleach) [17, 40] . but other mixtures of hydrogen peroxide, isopropanol, among others, have also been applied. according to several studies, the regular use of ammonium and bleach have been leading to a negative impact on human health. for instance, several studies report a link between the use of disinfectants and chronic obstructive pulmonary disease among healthcare workers, and between asthma and exposure to cleaning products and disinfectants in household settings [41, 42] . furthermore, foetuses and very young children are sensitive to the effects of such toxic chemicals, which had been also related with childhood cancer and asthma [43] . moreover, most disinfectants used, such as quaternary ammonium and sodium hypochlorite, are rapidly exhausted in the presence of organic matter, reducing their activity and efficacy when simply sprayed over surfaces where organic matter can be found (e.g. streets) [44] likewise, the disinfection of a natural environment brought negative impacts on local fauna and flora. as an example, the regional government in andaluzia, spain, even sprayed a 1.9 km beach in zahara de los atunes with a diluted bleach solution as an overwhelming attempt to stop covi-19 spread. nevertheless, such a measure was quickly questioned by biologists and conservationists, as it might bring severe negative consequences to local nidificant avifauna, crab species and beach flora. the application of disinfectants in farms has also a high probability of occurring, and previous studies already highlighted the connection of the application of disinfectants with increased health risk factor in farm animals (e.g., pigs) and farm workers [45, 46] . although the plastic demand and waste generation are yet to be assessed for the first semester of 2020, it can be predicted a generalised increment on packaging and on medical sectors due to the demand for sup (also boosted by the shift in ban policies) and ppe due to covid-19 [9, 29] . sup was already one of the major contributors to marine litter [47] . and, considering the mandatory use of ppe (particularly masks of single usage) will soon contribute with a great share. for instance, in united kingdom (66.7 million inhabitants), it is predicted that if every citizen used one masks per day would generate at least 60 000 tonnes of contaminated plastic waste [70] . plastic pollution before covid-19 pandemic was already scaling in terrestrial, aquatic, and atmospheric environments [47] . an estimated 4.8-12.7 million metric tons (mt) of mismanaged plastic waste generated on land entered the marine environment in 2010 alone [49] , with much of this (1.2 -2.4 million mt) delivered by rivers [50] . a study by eriksen et al. [51] reported that over 5 trillion plastic debris was estimated floating in the world's oceans. however, even this staggering statistic is dwarfed on a planetary scale when compared to the 7 trillion plastic debris estimated to enter san francisco bay each year [52] . the recommended n95 masks are made of plastics such as polypropylene (pp) and polyethylene terephthalate (pet). similarly, surgical gloves and masks are made of nonwoven materials (e.g., spunbond meltblown spunbond) that often incorporate other polymers such as polyethylene (pe), pp and pet [53, 54] . such masks will likely degrade into smaller microplastic pieces [32] . in the magdalena river, columbia, the degradation of nonwoven synthetic textiles was the predominant origin of microplastic microfibres found in both water and sediment samples [32] . thus, the disposal of such items in open fields will endure the "never-ending-story" of plastics in the environment. once littered in open environments (terrestrial or aquatics), both ppe and plastic litter will likely induce sewage system blockage in towns and cities (particularly in developing countries) and will also negatively affect water percolation and normal agricultural soils aeration, with repercussions on land productivity (as reviewed by [32] ). moreover, plastic pollution in the environment will deteriorate and fragment, originating plastic particles of micro-and nano-size [32] . the persistence and ubiquity of plastic debris, allied with polymer type, shape and size, are known to impose serious threats to biodiversity as they can be easily ingested and cause physical effects, such as internal abrasions and blockages [56] [57] [58] . although plastic pollution is typically considered as biochemically inert [59] , plastic additives are being incorporated during manufacturing processes to improve their properties [60, 61] . furthermore, plastic pollution can also act as a vector of different contaminants, invasive species, and pathogens such as sars-cov2 [62] [63] [64] [65] . plastic additives and/or absorbed contaminants that can leach out and eventually percolate into various environmental compartments, decreasing soil and water quality and inducing adverse effects on terrestrial and aquatic biota, at different levels of biological organisation [66, 67] . also, plastic littered in open environments, particularly in aquatic environments such as lakes, ponds and puddles, may provide breeding grounds for vectors of zoonotic diseases, such as mosquito aedes spp. which is the vector of dengue and zika [68] , which may also threaten general public health and safety [8] . life cycle assessment (lca) standards is providing the best framework for the evaluation of the environmental footprint (i.e., environmental damage -such as emission of ghg and hazardous chemicals, energy consumed from its production to disposal) of a specific product available in the market [69] . although the absence of data on the demand/use of ppe and sup, and subsequent increment of plastics waste and changes in waste management strategies, during the first semester of covid-19 evolution, several reports tried to estimate their environmental footprint considering different scenarios. for instance, and considering the use of masks, the ucl plastic waste innovation report [70] carried out an lca on ukwide face mask-adoption scenarios (single use mask/day, reusable mask with no filter with manual or machine wash, reusable masks without filters with manual or machine wash). such study showed that the use of reusable masks significantly reduces the amount of waste by 95%, followed by reusable masks with disposable filters (60%). reusable masks without filters (washing method: washing machine) had the general lowest contribution to climate change (<2.00e+008 kg co 2 eq), when considering manufacturing, transport, and use. conversely, single use masks and reusable masks with disposable filters had the highest contribution to climate change (~1.47e+009 and 1.50e+009; respectively kg co 2 eq). thus, the use of single use masks would aggravate climate change by 10 times than using reusable masks. even though there is no such assessment for gloves, previous research has shown their production and use may be detrimental to the environment. for synthetic rubber gloves produced in malaysia, the production of each kilogram of product consumes up to 10.0413 mj of energy, with impacts highly dependent on energy production [70] . in thailand, the total carbon footprint emission of 200 pieces of rubber glove was about 42 kg co 2 -eq [72] . considering the estimated recommended monthly consumption of 65 billion gloves globally [32] , and the previously estimated carbon footprint emission (by [72] ), it would result in the emission of 1.44 x 10e+010 kg co2 eq kg (14 mt co 2 eq). the use and preference of sup, particularly plastic bags, over paper and cotton bags has also been questioned during covid-19. however, in such cases, lca studies remains not conclusive. as examples, a previous study carried out by lewis et al. [73] based on lcas on those options, reported that paper has higher environmental impacts in most categories when compared to single-use plastic bags. however, mattila et al. [74] could not discern differences between plastic, paper, and cotton bags when they took different end of life scenarios into account. lcas provide important insights on their environmental footprint during production and usage, but such studies have been widely criticised for not considering waste mismanaged (i.e., leakage) and therefore not accounting for all impacts in the environment. boucher and billard [75] argue that lcas neglect plastic pollution. schweitzer et al. [76] criticise lcas for not considering environmental leakage in waste management scenarios. fortunately, there have been some recent studies which have started to develop effect factor approaches for risks associated with littering of plastic bags and entanglement of biota with plastic [77] . notwithstanding, the reusable alternatives should be the road ahead to reduce the global warming potential below that of single-use plastic and ppe [70, 78] . with medical and municipal solid waste (msw) generated being considered as potentially infectious during covid-19 pandemic, incineration and landfilling are being prioritised over recycling, which will result in a deterioration on air quality in a medium-to long-term [32] . production of ghg, such as co 2 and ch 4 , is released in significant amounts during plastic waste decomposition in landfills, or during the burning of plastics waste [32] . for instance, in united kingdom, the carbon footprint of msw incineration is −0.179 t co 2 eq./t msw while that from landfilling is 0.395 t co 2 eq./t msw [110] . open burning of plastics waste can also release other hazardous chemicals such as heavy metals, dioxins, pcbs, dioxins and furans, which are linked to health risks allied to respiratory disorders. air pollution is one of the major environmental threats to public health, and it is responsible for more than 6 million deaths worldwide [80] . numerous international agreements on plastics and plastic pollution have been established to address and reduce their impact on global economies, societies and natural environments. however, the covid-19 pandemic has clearly outgrown the perceived threat of plastic pollution, leading to a sudden shift in the hierarchisation of values, i.e., where health is considered as a value in spite of environmental care, which shows a clear decrease in its perceived importance [81] . the withdrawal in several national and state-wide agreements that set environmental sustainability as the stepping-stone, followed by change in waste production and management to ensure health needs. a long-term shift in such value hierarchisation will likely cause "damage" to already considerably high environmental threats, compromising the earth's supporting ecosystems and future generations to meet their own needs. thus, it is imperative to re-think the undertaken measures during covid-19 to minimise the negative consequences in a future outbreak scenario. some strategies to better manage medical and plastic waste may include: during epidemic and pandemic events, it is of utmost importance to gather reliable information about quantity and type of waste (i.e., accurate characterisation data), and how much material can be reused or recycled (stimulated by proper decontamination) to then determine what indeed goes for incineration or landfill. it is also crucial to determine valid goals, such as complying with regulations and follow the hierarchy of waste management (reduce, reuse, recycle, and recover) to conserve resources. waste management is especially important during the pandemic due to the increased risk of pathogen transmission and increased domestic waste production. likewise, it should be mandatory and reinforced the use of ppe for workers related to waste management. therefore, municipalities responsible for waste collection and treatment should create guidelines and procedures to apply during pandemics regarding waste reduction recommendations, protective measures, collection frequency, and end-of-life. during pandemic events, all medical waste and ppe should be carefully monitored by specialised personnel to guarantee health safety. disinfection technology, including uv, ozone or bioengineering approaches, can offer a sustainable strategy to treat waste and wastewaters [82] [83] [84] [85] [86] . the choice of an appropriate disinfection technology should rely on the amount of waste, type of waste, costs and maintenance. for high volumes of infectious medical waste (> 10 t/d) the incineration continues to be the best option as it completely kills pathogens due to the high-temperature applied (over 800ºc). if the amount of medical waste is not too high (< 10 t/d), chemical disinfection (i.e., use of chemical disinfectants) or physical disinfection (microwave or high temperature steam) might be an option [84] . alongside, decontamination of ppe, including face shields, surgical masks and n95 respirators, could be useful to maintain adequate supplies, and to promote its extended, reuse and recyclability options. moreover, recycling technologies of non-woven textiles, from which most ppe is made, is still very limited due to the lack of technology and their composition (e.g. combination of materials as composites) [87] . the use of uv-c light, ozone gas, ionised hydrogen peroxide, and microwave-and heat-based seem to be valid decontamination approaches to apply to ppe and n95 masks, improving their reusability and reducing the production of waste [82] [83] [84] [85] [86] 88, 89] . several recommendations for optimising the available ppe have been proposed by who (interim guidance, 27 feb. 2020), such as: the use of physical barriers on trials, registrations, general attendance to reduce exposure to infectious viruses, such as a glass or plastic windows; the stimulation of telemedicine (in case of healthcare facilities to evaluate suspected cases of infected patients and to avoid overcrowded emergency rooms), telemarketing and online/tele-shopping; mandatory ppe for front-line workers involved in the direct care of infected patients, or involved in the management of infected medical wastes (and such ppe might be reused after a proper disinfection [90] . it is also important to choose ppe of high quality (i.e., with high potential for disinfection and reuse purposes). this rational use and reuse of materials could lead to reductions in the production of medical waste, also lifting pressure on the overwhelming of medical waste treatment facilities. reusable grocery bags (preferable plastic or fabric) should be encouraged but highlighting the need for implementing mitigation strategies to ensure the complete elimination of the pathogenic agent. such mitigations strategies could involve proper hand hygiene and decontamination bath of the reusable bags (i.e., soaked in liquid soap and water temperature > 40 ºc). online shopping with food delivery or drive-through windows could also be implemented. home-delivery should, however, be delivered in paper bags or cardboard boxes, and service workers should be wearing protective equipment, and frequently sanitising their hands. it is worth recalling that the phasing of single-use plastics in europe prevented the emission of 3.4 million tonnes of co 2 , environmental damages with predicted of €22 billion by 2030, and consumer costs of €6.5 billion [91] . moreover, in some european countries, consumption of single-use plastic carrier bags was estimated as high as 466 per capita, with up to 10% being littered in the case of hdpe plastic bags [92] . therefore, the reversal of measures such as the ones implemented by the eu could lead to great economic losses as well as environmental damages while motivated by unproven benefits in the prevention of the sars-cov-2 transmission. confinement measures leaded to a dramatic increase in the use and consumption of disposable plastics, but such patterns seem to remain after deconfinement. as an example, beauty salons and hairdressers are implementing precautionary measures to ensure customers safety against covid-19, among them the mandatory use of masks by workers and customers and the distribution of individual kits with disposable plastic items (feet protection and coats) (e.g., [93] ). such items are partially or completely based on polymers such as pe, pa, pp and pet. such polymers are derived from fossil fuel (non-renewable) resources and present low degradability in open environments. besides, they are among the most commonly found polymers found in terrestrial and marine debris and, in the micro-size (1 m -5 mm, [94] ), are known to induce deleterious effects on several aquatic species [95] . the preference for use of single-use-plastics over reusable alternatives is actually not sustained by the scientific literature, when considering proper hygiene and sterilisation procedures to eliminate sars-cov2 viability. thus, the preference for reusable alternatives should be encouraged. in a circular economy, bio-based plastics (polymers partially or totally derived from biomass) have been emerging as a sustainable but short-term alternative to conventional plastics, by replacing fossil fuel with renewable resources. besides, biobased plastics have the potential to decrease carbon footprint and increase recycling targets (such as home composting) and waste management efficiency, therefore lowering the economic and environmental pressure caused by conventional plastic litter [96, 97] . bio-based biodegradable options offer additional benefits as they break down by enzymatic or biological activity in open environments [98] . aliphatic polyesters (e.g., polylactic acid, pla and polyhydroxyalkanoates, pha) and furanic-aliphatic polyesters (e.g., polyethylene 2,5-furandicarboxylate, pef and polyethylene 2,5-furandicarboxylate -co-polylactic acid, pefco-pla) are of particular interest as building-blocks for ppe and other single-use plastics due to their sustainable thermophysical properties and adjustable degradation rates [99] . however, the transition from fuel-based to biobased plastics must be considered after overcoming the current production limitations and lack of scientific support towards the environmental safety of the greener solution. current biobased plastics still represents a minor percentage on the global plastic production (~7.4 of 348 million mt in 2017) [100] . this is mainly due to the intense requirement for land use and related financial investment, the undeveloped recycling and/or disposal routes, unknown toxicological effects of their biodegradation in open environments [9] . some biobased plastics are also designed to be durable and mechanically resistant, which compared to the fossil-fuel counterpart, the only benefit might rely on the feedstock and lower carbon footprint during their production and usage. biobased solutions might be an option, but there is still a need to scale up in innovation and technology to move towards a sustainable solution. worldwide plastic economies must adapt plastic production to variety feedstocks with lower land-use impacts, along with the use of renewable electricity in the production process, and to integrate plastic production in biorefineries that can make multiple products from the available feedstocks [9] . likewise, bioplastics must be safe-by-design and should be environmentally friendly and free of hazardous chemicals/additives. nevertheless, policies should prioritise plastic prevention and overall reduction [102] . the increasing danger of plastic waste (particularly sup and ppe) due to covid-19 is already an unquestionable reality, which calls for remediation/mitigation strategies. however, such knowledge is based on in-situ visual census. there is a need to develop new technological approaches to improve monitoring and mapping of plastic pollution (e.g., drones). along with the plastic prevention and reduction (e.g., sup and microbeads) and the concept of responsibility against plastic pollution, it is important to develop and/or optimise remediation approaches. there are already strategies and approaches that proved their efficiency and should be prioritised and implemented in the next coming years. for instance, clean-up technologies such as automated waste collection boats/ floaters proved to be efficient for plastics removal from surface waters (e.g., the interceptor, launched by the ocean cleanup; the bubble barrier and the waternet). wastewater treatments seem to eliminate a considerable percentage of plastic debris, but there is still a need of complementary treatments when considering particles of smaller size such as microplastics [103] . with this purpose, and in addition to the membrane treatments and filtrations already applied, the application of cleaner technologies, such as the application of membrane processes, regenerative filters systems or precipitation with magnetic nanoparticles, and application of inorganic-organic hybrid silica gels -organosilanes, have been developed and proved to be successful [103] [104] [105] [106] . there are other experimental techniques that are being devolved for this purpose, such as dynamic membranes, photocatalysis, elimination with fats and constructed wetlands (a horizontal subsurface-flow that uses vegetation, soil and organisms to treat wastewater) [103] . for drinking water, there are few advance techniques that proved efficiency on plastic debris removal, such as electrocoagulation, magnetic extraction and membrane separation [103] . in soil systems, the application of synthetic, or improved natural microbial community for plastic bioremediation processes seems to be a low-cost, highly efficient and green approach [107] . it is imperative to rethink our attitudes towards plastic usage, by promoting sustainable behaviours, breaking old habits and adopting new ones. to achieve this, it is important to stimulate scientific research and solutions for an effective communicative strategy as decision-makers struggle to find relevant communication channels and tonalities to increase environmental awareness of the public and persuade people to change their lifestyle, consumption patterns and behaviour. in addition, knowledge communication forums using science communication and citizen science through public participatory approaches should be stimulated [9] . raising awareness over plastic waste and contamination should not be interrupted nor reversed, as it required long-term efforts to results in behavioural changes, which may be loss due to disruption or contradictory information. given the concerning trend, it must be acknowledged the urgent need for a reassessment of the world's fundamental goals and priorities without neglecting consequences on economies, societies but mostly to the environment. enormous amounts of plastic waste (including medical waste) are being generated at a global scale, with the majority being landfilled or incinerated (which are less favourable with higher negative environmental impacts) and minor fraction being recycled. this will aggravate current estimations (4-12-million tonnes/year of plastics go into the seas and oceans) [108] . plastic waste will not be the only that need to be addressed when health-related issues are overcome, but all the consequences (indirect effects) that will arise from our shift in priorities without thinking in a long-run. it is of utmost importance to recognise that human health is connected and dependent on the health of our environment and ecosystems, and if humanity does not respect such connection, and continuing thinking on "today" instead of "today in prole of a sustainable future", there will not exist a future. in this matter, the scientists should embrace (more tightly) their ethical obligation to become active as knowledge brokers enabling a common goal-oriented debate among politicians, producers, and the general public [81] . likewise, governors should seek to implement a more efficient plastic waste management system for plastic waste recovery; accompanied by restrict laws and regulation for production, use, and consumption of plastic products (including incentives for recycling and redesigning). plastics indeed offers a panoply of characteristics and properties that greatly improved our quality of life, thus being difficult to imagine a plastic-free economy and life. yet, we must seek sustainable options. biobased plastics might be a solution at an early stage, but it is important to scale up in innovation to ensure their environmental friendliness and their integration in the circular economy. likewise, such process must be accompanied by extended producer responsibility, with the producer (distributors and sellers) internalising the cost of management of waste (recycling and disposal) of their products. plastics should, therefore, remain in the top of the political agenda in europe and across the world, not only to minimise plastic leakage and pollution but to promote a circular economy, and to ensure sustainable growth, underlining both green and blue-economies. thanks are due to cesam (uidp/50017/2020+uidb/50017/2020), with the financial support from fct/mctes through national funds; and to the research projects compet [17, 18]  decreased household food waste [19]  decrease energy consumption and  decreased indoor air quality [14, 23]  increased medical waste [24]  decline in waste recycling with increase in incineration and landfilling [25]  increased disinfection routines with ghg emissions [20, 21]  global decrease on wildlife trade [22]  decrease on deforestation [22]  increase in surface water quality [109] hazardous chemical substances in household and outdoor environments [26, 27]  increased ecological risk to natural ecosystems due to the use of disinfectants [28] world health organization director-general's opening remarks at the media briefing on covid-19 detail/who-director-general-s-openingremarks-at-the-media-briefing-on-covid novel coronavirus (covid-19) pandemic: built environment considerations to reduce transmission, msystems sars-cov-2 in wastewater: state of the knowledge and research needs covid-19 faecal-oral transmission: are we asking the right questions? evaluation of the lockdowns for the sars-cov-2 epidemic in italy and spain after one month follow up preparing for a covid-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore se pre ṕarer pour la pande ḿie de covid-19: revue des moyens de ṕloye ś dans un bloc ope ŕatoire d'un grand hoˆpital tertiaire au singapour on the front lines of coronavirus: the italian response to covid-19 environmental perspective of covid-19 rethinking and optimising plastic waste management under covid-19 pandemic: policy solutions based on redesign and reduction of single-use plastics and personal protective equipment coronavirus lockdown helped the environment to bounce back observed and potential impacts of the covid-19 pandemic on the environment effects of covid-19 outbreak on environment and renewable energy sector changes in air quality during the lockdown in barcelona (spain) one month into the sars-cov-2 epidemic covid-19 as a factor influencing air pollution? covid-19 pandemic and environmental pollution: a blessing in disguise? correlation between climate indicators and covid-19 pandemic in esa esa covid-19 virus outbreak lockdown: what impacts on household food wastage? environ climate affects global patterns of covid-19 early outbreak dynamics, medrxiv pre-print (2020) 1-15 a preliminary assessment of the impact of covid-19 on environment -a case study of china covid-19 outbreak: migration, effects on society, global environment and prevention a field indoor air measurement of sars-cov-2 in the patient rooms of the largest hospital in iran statistical analysis and characteristics of hospital medical waste under novel coronavirus outbreak indirect effects of covid-19 on the environment disinfection technology of hospital wastes and wastewater: suggestions for disinfection strategy during coronavirus disease 2019 (covid-19) pandemic in china cleaning and disinfectant chemical exposures and temporal associations with covid-19 -national poison data system disinfection threatens aquatic ecosystems minimising the present and future plastic waste, energy and environmental footprints related to covid-19 slum health: arresting covid-19 and improving well-being in urban informal settlements 11 -the valorization of plastic via thermal means: industrial scale combustion methods pandemic repercussions on the use and management of plastics world health organization, rational use of personal protective equipment for coronavirus disease 2019 (covid-19) gestão de resíduos em situação de pandemia por sars-cov-2 (covid-19) circular economy in plastic waste -efficiency analysis of european countries aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 stability of sars-cov-2 in different environmental conditions international policies to reduce plastic marine pollution from single-use plastics (plastic bags and microbeads): a review reducing marine pollution from single-use plastics (sups): a review esa inhalation lung injury associated with humidifier disinfectants in adults association of occupational exposure to disinfectants with incidence of chronic obstructive pulmonary disease among us female nurses inhalation toxicity of humidifier disinfectants as a risk factor of children's interstitial lung disease in korea: a case-control study neutralization of the activity of eight disinfectants by organic matter lung function and chronic respiratory symptoms of pig farmers: focus on exposure to endotoxins and ammonia and use of disinfectants bronchial hyperresponsiveness and exposure in pig farmers international policies to reduce plastic marine pollution from single-use plastics (plastic bags and microbeads): a review solutions and integrated strategies for the control and mitigation of plastic and microplastic pollution plastic waste inputs from land into the ocean river plastic emissions to the world's oceans microplastic pollution in the surface waters of the laurentian great lakes the gyres institute, san francisco bay microplastics project nonwoven materials and technologies for medical application impact of microplastic fibers from the degradation of nonwoven synthetic textiles to the magdalena river water column and river sediments by the city of neiva, huila (colombia) are we speaking the same language? recommendations for a definition and categorization framework for plastic debris plastic pollution in islands of the atlantic ocean distribution and biological implications of plastic pollution on the fringing reef of mo'orea the physical impacts of microplastics on marine organisms: a review degradable polyethylene: fantasy or reality components of plastic: experimental studies in animals and relevance for human health the plastic in microplastics: a review plastic resin pellets as a transport medium for toxic chemicals in the marine environment microplastics as vectors for environmental contaminants: exploring sorption, desorption, and transfer to biota adsorption of trace metals to plastic resin pellets in the marine environment impact of contaminants on pelagic ecosystems do microplastics affect the zoanthid zoanthus sociatus? ingestion of small-sized and irregularly shaped polyethylene microplastics affect chironomus riparius life-history traits solid wastes provide breeding sites, burrows, and food for biological disease vectors, and urban zoonotic reservoirs: a call to action for solutions-based research european platform on life cycle assessment (lca) the environmental dangers of employing single-use face masks as part of a covid-19 exit strategy life cycle optimization for synthetic rubber glove manufacturing carbon footprints of rubber products supply chains (fresh latex to rubber glove) evaluating the sustainability impacts of packaging: the plastic carry bag dilemma uncertainty and sensitivity in the carbon footprint of shopping bags the challenges of measuring plastic pollution a study by zero waste europe and friends of the earth europe for the rethink plastic alliance. justifying plastic pollution: how life cycle assessments are misused in food packaging policy life cycle assessment of carrier bags and development of a littering indicator life cycle assessment of supermarket carrier bags: a review of the bags available in 2006 public and environmental health effects of plastic wastes disposal: a review combating plastic air pollution on earth's day. vital strategies environmental health division environmental choices vs. covid-19 pandemic fear -plastic governance re-assessment effectiveness of ultraviolet-c light and a high-level disinfection cabinet for decontamination of n95 respirators ozone gas: scientific justification and practical guidelines for improvised disinfection using consumergrade ozone generators and plastic storage boxes microwave-and heat-based decontamination of n95 filtering facepiece respirators (ffr): a systematic review, (2020) 1-43. doi:osf preprints ultraviolet germicidal irradiation: possible method for respirator disinfection to facilitate reuse during covid-19 pandemic ultraviolet-c and other methods of decontamination of filtering facepiece n-95 respirators during the covid-19 pandemic utilization of various nonwoven waste forms as reinforcement in polymeric composites disinfection of n95 respirators by ionized hydrogen peroxide during pandemic coronavirus disease 2019 (covid-19) due to sars-cov-2 decontamination and reuse of n95 respirators with hydrogen peroxide vapor to address worldwide personal protective equipment shortages during the sars-cov-2 (covid-19) pandemic decontamination and reuse of n95 respirators with hydrogen peroxide vapor to address worldwide personal protective equipment shortages during the sars-cov-2 (covid-19) pandemic single-use plastics: new eu rules to reduce marine litter the existing situation and challenges regarding the use of plastic carrier bags in europe microplastics: finding a consensus on the definition studies of the effects of microplastics on aquatic organisms: what do we know and where should we focus our efforts in the future? environmental performance of bio-based and biodegradable plastics: the road ahead environmental deterioration of biodegradable, oxo-biodegradable, compostable, and conventional plastic carrier bags in the sea, soil, and open-air over a 3-year period are biodegradable plastics a promising solution to solve the global plastic pollution? biobased polyesters and other polymers from 2,5-furandicarboxylic acid: a tribute to furan excellency plastics -the facts 2019. an analysis of european plastics production, demand and waste data designing biobased recyclable polymers for plastics joint position paper: bioplastics in a circular economy: the need to focus on waste reduction and prevention to avoid false solutions case studies of macro-and microplastics pollution in coastal waters and rivers: is there a solution with new removal technologies and policy actions? case studies in chemical and environmental engineering a concept for the removal of microplastics from the marine environment with innovative host-guest relationships membrane processes for microplastic removal technological approaches for the reduction of microplastic pollution in seawater desalination plants and for sea salt extraction bacteria as key players of plastic bioremediation analysis and prevention of microplastics pollution in water: current perspectives and future directions covid-19 and surface water quality: improved lake water quality during the lockdown energy from waste: carbon footprint of incineration and landfill biogas in the uk key: cord-347381-nn6jqqy5 authors: mazzola, santina m.; grous, carolyn title: maintaining perioperative safety in uncertain times: covid‐19 pandemic response strategies date: 2020-09-29 journal: aorn j doi: 10.1002/aorn.13195 sha: doc_id: 347381 cord_uid: nn6jqqy5 nan demic has presented health care leaders with the unprecedented challenge of maintaining patient and staff member safety amidst the rapid spread of a novel virus. in march and april 2020, many us state officials issued declarations that prohibited elective surgery in an effort to conserve beds and equipment in anticipation of a surge in patients with covid-19, and officials continue to modify the declarations. 1 one researcher examined global elective surgery cancellation rates and estimated that approximately 28 million procedures were canceled or postponed worldwide as a result of the covid-19 pandemic. 2 despite decreased surgical volumes, many health care personnel still cared for patients (with and without covid-19) who required emergent surgery. perioperative and organizational leaders at the hospital of the university of pennsylvania (hup) were challenged to establish and implement a variety of strategies quickly to help ensure patient and staff member safety during the covid-19 crisis. in perioperative and other health care environments, the covid-19 virus can be spread via common respiratory patterns (eg, expiration, coughing, sneezing) and through aerosols created during certain medical procedures-also known as aerosol-generating procedures (agps). 3 activities that create and disperse respiratory aerosols-such as intubation, bronchoscopy, noninvasive ventilation, and surgical procedures involving the aerodigestive tract-are inherent to the or. available evidence suggests that patients with covid-19 experience increased perioperative morbidity and mortality and are at a higher risk of developing acute respiratory distress syndrome, cardiac injury, and kidney failure postoperatively. 4, 5 initially, there was a lack of information on the risk of infection associated with covid-19 and agps, which raised concern among health care workers. when the number of patients with covid-19 in the united states began increasing, quantities of personal protective equipment (ppe) began dwindling; further, the recommendations for ppe use during the pandemic evolved and changed frequently. as a result, health care leaders and workers experienced confusion about which recommendations they should follow. in early march 2020, experts from the world health organization called on health care supply industries and national governments to increase ppe manufacturing by 40% to meet the rising global demand. 6 however, much of the global ppe supply is manufactured in asia, particularly in china, where the first outbreak originated. 7 increased global demand for ppe (eg, gloves, masks, gowns) resulted in a severe disruption of the supply chain, and health care leaders experienced difficulty acquiring the necessary supplies for their staff members. 6 an online survey of 978 facilities in the united states revealed a critical shortage of ppe in early april 2020. 7 at the time of the survey, personnel from all types of health care facilities reported that most ppe supplies at their facility would be depleted in one or two weeks. although ppe availability increased as the number of infected patients decreased, the struggle for health care personnel to conserve ppe continues to be a challenge. at hup, administrators requested that health care leaders and their teams develop protocols to prioritize patient and staff member safety while also conserving the ppe inventory. to address the multifaceted safety concerns associated with the covid-19 pandemic (eg, ease of spread, lack of a vaccine), hup leaders reviewed recommendations from national regulatory bodies and recently published peerreviewed literature. based on this information, the leaders implemented several different strategies for containing the virus and protecting the safety and well-being of their patients and staff members. the hup leaders consulted the most recent us centers for disease control and prevention (cdc) and world health organization covid-19 recommendations before deciding to require all employees, patients, and visitors to wear face masks while inside the health care facility. covering the mouth and nose minimizes the potential for individuals who are infected but may be asymptomatic or presymptomatic to expose others to the virus. 8, 9 a systematic review and meta-analysis of 172 observational studies and 44 comparative studies indicated that face masks and respirators reduced the risk of transmission. 10 the hup personnel distributed face masks at employee and visitor entrances so all individuals could don them before entering the building. health care personnel caring for patients with covid-19 or for patients who were undergoing an agp followed additional ppe guidelines when providing direct patient care. physician and perioperative leaders and organizational administrators developed a specific set of guidelines for perioperative services' ppe stewardship that provide a risk stratification of agp by department and division. the leaders assigned a risk level of high, intermediate, or low to all procedures based on the anticipated amount of aerosol generation. the document outlines guidance for • the use of n95 respirators during high-and intermediate-risk procedures for patients who did not have a confirmed covid-19 diagnosis and were not suspected to be infected, • respiratory protection for health care workers involved in a procedure on a patient with suspected or confirmed covid-19, • the conservation of masks and eye protection, • recommended distancing practices in the or, and • room cleaning practices after the procedure. the leaders directed all perioperative personnel to wear a surgical mask during low-risk agps on patients who tested negative for covid-19, a practice unchanged from the standard process used when preparing the sterile field. 11 the leaders directed all personnel who came into contact with any patient longer than 10 minutes to wear eye protection (ie, either face shields or goggles) in addition to any prescriptive lenses. when caring for patients who tested negative for covid-19, perioperative personnel used standard precautions and wore routine surgical attire (eg, scrubs, hair covering), surgical masks, gowns, and gloves when indicated. the leaders instructed the staff members to wear n95 respirators during • all procedures involving patients who tested positive for covid-19 and • intermediate-or high-risk agps involving patients who tested negative for covid-19. the leaders also recommended that staff members wear a full face shield when wearing an n95 respirator to protect their eyes and the respirator from contamination. a core group of perioperative staff members distributed ppe in a centralized location in the surgical department. the leaders instructed the staff members to label their respirator with their name and the date they received it. in accordance with centers for disease control and prevention crisis standards, 12 materials service partners used ultraviolet germicidal irradiation (uvgi) to decontaminate n95 respirators that staff members wore during agps on patients who tested negative for covid-19 as long as the respirators were not soiled or damaged. available research findings show that uvgi is a promising disinfection method for n95 respirators because it has minimal effect on fit 13 or filtration 14 performance. in addition, researchers found that when studying respirators soiled with an influenza virus, uvgi reduced contamination. 15 because disinfection efficacy when uvgi depends on dose and uvgi lamps from different manufacturers may provide differing intensities, degradation of the respirators can occur. 12 the hup leaders decided respirators could be disinfected with uvgi five times before discarding. staff members could collect their disinfected n95 respirator two hours after dropping them off in one of the ors that served as the uvgi processing area. any n95 respirator that became moist, visibly soiled, damaged, or worn during care of a patient with covid-19 could not be decontaminated with uvgi. in accordance with the us food and drug administration's covid-19 emergency use authorization related to decontaminating compatible n95 respirators, 16 the instrument processing department staff members used hydrogen peroxide gas plasma sterilizers to decontaminate n95 respirators worn during the treatment of patients with suspected or confirmed covid-19. the staff members inspected the n95 respirators for damage or soil before sterilization and returned the respirators to perioperative personnel in sterilization pouches. the hup leaders decided respirators that were not soiled or damaged could be decontaminated with hydrogen peroxide gas plasma two times before discarding. these conservation practices helped maintain an adequate supply of n95 respirators. the cdc considers a fever as a measured temperature of 100° f (38° c) or higher. 17 patients infected with covid-19 may experience this symptom 2 to 14 days after viral exposure. 18 although a fever may be intermittent or absent in patients infected with covid-19, the cdc considers febrile health care workers potentially infectious and suggests they self-isolate and contact their physician for medical evaluation and testing. 19 based on available recommendations, 19,20 the hup leaders encouraged employees to self-monitor for symptoms of covid-19 and to remain at home if they felt ill. although evidence supporting the efficacy of mass temperature-screening programs is limited, 21, 22 hup leaders initiated daily temperature screenings for all employees, patients, and visitors who entered the facility to help identify individuals who may exhibit symptoms of the virus. as a result of the decrease in elective surgeries because of the pandemic, more than 50 perioperative rns were available to work at the employee and visitor entrance temperaturescreening stations. leaders scheduled nurses to staff the screening stations based on the time of day, day of the week, and anticipated number of individuals who would be entering the building. employees had limited access to the hospital and were only allowed entry after successfully completing the temperature-screening process. statistics indicate that many individuals infected with covid-19 are asymptomatic, yet may still be capable of shedding and spreading the virus. 23 the hup leaders thought it was important to implement universal preprocedure testing to establish isolation practices, guide the use of ppe, and consider it as a factor when determining if patients were appropriate candidates for surgery. in april 2020, it became important for perioperative leaders to identify asymptomatic patients infected with covid-19 to prevent inadvertent disease transmission when elective surgeries resumed. the leaders assessed the available guidance from national organizations, 24, 25 and in mid-april, they implemented required preprocedure covid-19 testing for patients 24 hours before surgery. the testing continues as of july 2020 and patients can visit one of several locations for the test; if a patient is unable to undergo testing the day before his or her scheduled procedure, facility staff members perform a rapid test when the patient arrives at the hospital. if the test results are positive, the patient's provider considers the nature and urgency of the procedure before determining whether to proceed. another strategy to facilitate decision making and identify patients who will undergo medically necessary, time-sensitive procedures was the implementation of a scoring system that systematically integrated an individual patient's risks with risk factors unique to the covid-19 pandemic (eg, limited resources, high transmission risk) to aid in the decision to proceed with or postpone procedures. 26 to justify proceeding with a procedure despite any capacity and resource constraints, the surgeons at hup assign each patient scheduled for surgery a medically necessary, time-sensitive procedure score. this system is a useful conceptual framework for leaders to analyze and prioritize clinical needs in the context of the unique limitations imposed by the covid-19 pandemic. perioperative leaders designated a specific or for surgical patients who tested positive for covid-19 or who were expected to have the disease. the leaders worked with the facilities department staff members to build a negative-pressure anteroom with a scrub sink located immediately adjacent to the or entry. perioperative staff members maintained an adequate stock of predetermined essential equipment and supplies. the charge nurse generated an e-mail and a text message alert to notify individuals across a variety of disciplines, including nursing, surgery, anesthesia, instrument processing, and pharmacy, when scheduling a procedure in the designated or. perioperative leaders limited the individuals involved in the procedure to essential personnel only and assigned an observer to assist with the donning and doffing of ppe, monitor hand hygiene compliance and use of clean gloves, and obtain additional supplies. the leaders also assigned an additional staff member to remain outside the or and function as a runner to obtain any needed equipment or supplies outside the immediate area. 27 an infection control subject matter expert also was available outside the or to assist with donning and doffing of ppe and to act as the team leader. because clinicians may be more likely to infect themselves when removing ppe than when directly caring for a contagious patient, using a buddy system to monitor the donning and doffing of ppe ensures staff members use proper technique and helps them avoid self-contamination. 28 the perioperative team members participated in a huddle before every procedure to discuss the surgical and anesthesia plans and review the proper ppe for the procedure. a pharmacy staff member prepared a medication box that contained disposable anesthesia supplies and the anticipated required medications. an anesthesia professional was available outside the room at all times to obtain additional medications needed throughout the procedure. at the end of the procedure, the or remained empty for one hour after patient transport to allow for a full air exchange before staff members began postprocedure cleaning. in general, standard perioperative instrument handling and decontamination practices did not change. the stress of responding to the challenges of covid-19, both on the front lines and behind the scenes, can negatively affect the mental health of health care personnel. 29 these results also indicated that the most severe mental health symptoms occurred in women; nurses; workers on the front line; and workers in wuhan, china. 29 providing psychological support during such a crisis is an important part of maintaining employees' safety and well-being. the hup leaders recognized the significance of providing mental health support during this difficult time; they created an online resource platform for clinicians, faculty members, and staff members to help them maintain their physical and mental health, access basic needs (eg, food), care for their families, and connect with colleagues experiencing similar situations. some resources can assist individual employees and their families with personalizing their coping and support strategies. the hup team members found that temperature screenings, objective prioritization of procedures, and modified workflows helped maintain safety for patients and personnel and still allowed the team to provide high-quality care. as new information became available, leaders used the most up-to-date, evidence-based information to create flexible and effective guidelines that addressed the patient care challenges that staff members were experiencing. adaptability, critical thinking, and resilience can help perioperative nurses thrive, especially during a pandemic. the perioperative setting is a dynamic and evolving work environment that requires nurses to process new information on a daily basis, and the pandemic intensified these requirements. it is important for perioperative nurses to be active participants in the decision-making process for developing or modifying workflows and identifying opportunities and barriers. perioperative nurses' foundational knowledge of aseptic technique gives them a unique advantage to care for patients infected with covid-19 because many of the complex donning and doffing protocols are already inherent to their practice. it also is critical for perioperative nurses to use their voices and speak up if they have a question or concern because reaching out for help, asking questions, and communicating are key elements for creating a safe environment for both patients and health care providers. although the effects of the pandemic have created competing priorities, the goal of maintaining patient and staff member safety remains at the forefront. facility leaders should include perioperative nurses as leaders in implementing infection control measures when possible. it is critical for perioperative leaders to collaborate with interdisciplinary colleagues in their departments and throughout their organizations. strategic partnerships between surgical services, infection control, occupational medicine, and the administrative leadership team can help to bridge the gap between clinical care and environmental safety. open and honest communication between leaders and frontline staff members is crucial to maintain a safe work environment using the most up-to-date information. as the information about covid-19 increases and evolves, leaders must continue to create and modify applicable policies and procedures. staff members may find frequent e-mail updates helpful; however, in-person communication in the form of huddles or departmental rounding provides an opportunity for the frontline staff members to ask questions and offer feedback. virtual town-hall style meetings afford the opportunity for leaders to answer questions or provide updates in a streamlined manner. although some information may become redundant, to help maintain staff members' morale, it is important for leaders to continue to share that information and to be available to answer impromptu questions and address concerns. leaders also should reiterate that the situation is fluid and emphasize the importance of being flexible. at hup, leaders implemented a variety of interventions throughout the organization to maintain patient and employee safety. these leaders believe that strategies such as diligent ppe use, temperature monitoring, and staff member education with town hall discussions helped to contribute to lower rates of infection transmission in their facility. covid-19: executive orders by state on dental, medical, and surgical procedures elective surgery cancellations due to the covid-19 pandemic: global predictive modelling to inform surgical recovery plans nosocomial transmission of emerging viruses via aerosol-generating medical procedures covid-19 outbreak and surgical practice: unexpected fatality in perioperative period clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid-19 infection shortage of personal protective equipment endangering health workers worldwide world health organization short age-of-perso nal-prote c tive-equip ment-endan gering-health-worke rs-world wide begging for thermometers, body bags, and gowns: u.s. health care workers are dangerously ill-equipped to fight covid-19 interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 (covid-19) pandemic advice on the use of masks in the context of covid-19. interim guidance. world health organization covid-19 systematic urgent review group effort (surge) study authors. physical distancing, face masks, and eye protection to prevent person-to-person transmission of sars-cov-2 and covid-19: a systematic review and meta-analysis guideline for sterile technique decontamination and reuse of filtering facepiece respirators research to mitigate a shortage of respiratory protection devices during public health emergencies a method to determine the available uv-c dose for the decontamination of filtering facepiece respirators ultraviolet germicidal irradiation of influenza-contaminated n95 filtering facepiece respirators advanced sterilization products (asp) sterrad sterilization system definitions of symptoms for reportable illnesses guidance for risk assessment and work restrictions for healthcare personnel with potential exposure to covid-19. centers for disease control and prevention public-health-manag e ment-perso ns-inclu ding-healt hcare-worke rs-hav ing-had-conta ct-with-covid-19-cases-in-the-europ ean-union -second-update_0 non-contactthermometers for detecting fever:a review of clinical effectiveness. ottawa, on: canadian agency for drugs and technologies in health simple infrared thermometry in fever detection: consideration in mass fever screening covid-19: four fifths of cases are asymptomatic, china figures indicate jointstatement:roadmapforresumingelective surgeryaftercovid-19pandemic anesthesia patient safety foundation. asa/apsf statement on perioperativetestingforthecovid-19virus. schaumburg medically necessary, time-sensitive procedures: scoring system to ethically and efficiently manage resource scarcity and provider risk during the covid-19 pandemic what we do when a covid-19 patient needs an operation: operating room preparation and guidance protecting health care workers from sars and other respiratory pathogens: organizational and individual factors that affect adherence to infection control guidelines factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019 maintaining perioperative safety in uncertain times: covid-19 pandemic response strategies 1.2 www.aornj ournal.org/conte nt/cme t his evaluation is used to determine the extent to which this continuing education program met your learning needs. the evaluation is printed here for your convenience. to receive continuing education credit, you must complete the online learner evaluation at http://www.aornj ournal.org/conte nt/cme. rate the items as described below. to provide the learner with knowledge of practices to promote patient and staff member safety during the coronavirus disease 2019 (covid-19) pandemic. to what extent were the following objectives of this continuing education program achieved? 7a. how will you change your practice? (select all that apply.) 1. i will provide education to my team regarding why change is needed. 2. i will work with management to change/implement a policy and procedure. 3. i will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. i will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. key: cord-290456-cgrn5c36 authors: soliman, mohamed a. r.; elbaroody, mohammad; elsamman, amr k.; refaat, mohamed ibrahim; abd-haleem, ehab; elhalaby, walid; gouda, hazem; safwat, amr; shazly, mohamed el; lasheen, hisham; younes, abdelrahman; el-hemily, yousry; elsaid, ahmed; kandel, haitham; lotfy, mohamed; refaee, ehab el title: endoscopic endonasal skull base surgery during the covid-19 pandemic: a developing country perspective date: 2020-09-25 journal: surg neurol int doi: 10.25259/sni_547_2020 sha: doc_id: 290456 cord_uid: cgrn5c36 background: although primarily a respiratory disorder, the coronavirus pandemic has paralyzed almost all aspects of health-care delivery. emergency procedures are likely continuing in most countries, however, some of them raises certain concerns to the surgeons such as the endoscopic endonasal skull base surgeries. the aim of this study is to present the current situation from a developing country perspective in dealing with such cases at the time of the covid-19 pandemic. methods: a cross-sectional analytical survey was distributed among neurosurgeons who performed emergency surgeries during the covid-19 pandemic in cairo, egypt, between may 8, 2020, and june 7, 2020. the survey entailed patients’ information (demographics, preoperative screening, and postoperative covid-19 symptoms), surgical team information (demographics and postoperative covid-19 symptoms), and operative information (personal protective equipment [ppe] utilization and basal craniectomy). results: our survey was completed on june 7, 2020 (16 completed, 100% response rate). the patients were screened for covid-19 preoperatively through complete blood cell (cbc) (100%), computed tomography (ct) chest (68.8%), chest examination (50%), c-reactive protein (crp) (50%), and serological testing (6.3%). only 18.8% of the surgical team utilized n95 mask and goggles, 12.5% utilized face shield, and none used paprs. regarding the basal craniectomy, 81.3% used kerrison rongeur and chisel, 25% used a high-speed drill, and 6.3% used a mucosal shaver. none of the patients developed any covid-19 symptoms during the first 3 weeks postsurgery and one of the surgeons developed high fever with negative nasopharyngeal swabs. conclusion: in developing countries with limited resources, preoperative screening using chest examination, cbc, and ct chest might be sufficient to replace reverse transcription polymerase chain reaction. developing countries require adequate support with screening tests, ppe, and critical care equipment such as ventilators. e coronavirus pandemic has affected virtually all aspects of human existence with social and psychological repercussions that generations have not witnessed. it has devastated the world economy through massive layoffs, business disruption, and collapse of financial markets. elective surgeries at all levels have been suspended and dayto-day interactions have changed as the virus is projected to afflict large portions of the world's population. [5, 10, 11, 29] severe acute respiratory syndrome coronavirus-2 (sars-cov-2) was first identified in wuhan, china, in december 2019. [20] on march 11, 2020 , the world health organization (who) declared the infection a pandemic. [42] by august 8, 19 ,187,943 cases were reported worldwide resulting in 716,075 deaths. [12] for many nations, the epidemic has just begun, with few nations reaching peak incidence at the time of this writing. repeated waves of infection over an indefinite future continue to threaten global health-care security. [14] e impact on health care has also varied ranging from continued routine services to almost complete shutdown. responses have largely varied by region, but also by where a community is temporally on the epidemic curve. in many countries, patients are finding nonemergency services cancelled or delayed including consultations and elective surgeries. in other regions, more aggressive measures have been taken suspending all nonemergency procedures. [9, 13, 34, 36] emergency procedures are likely continuing in most countries, however, some of them raises certain concerns to the surgeons such as the endoscopic endonasal skull base surgeries which carries an additional risk of the sinuses harboring a high covid-19 viral load as well as potential aerosolization during endoscopic endonasal instrumentation. [24] when health care has to be delivered, it is incumbent on our institutions to provide such care in the safest manner possible. is has been another challenge across the planet with the lack of availability of essential testing, medical equipment, and personal protective equipment (ppe), especially in lowincome countries. a worldwide survey study was conducted during the current pandemic and was published recently showing that 12% of the neurosurgeons did not utilize ppe while dealing with the patients. is was more common in the developing countries. [16] e aim of this study is to present the current situation from a developing country perspective in dealing with emergency endoscopic endonasal skull base surgeries at the time of the covid-19 pandemic in terms of preoperative patients' screening, surgical techniques, and intraoperative ppe utilization. we conducted a cross-sectional analytical survey study to take a snapshot of the situation of the emergency endoscopic endonasal skull base surgeries during the covid-19 pandemic in a developing country. to elicit prompt responses, data collection was performed electronically. e survey was distributed electronically (facebook messenger and whatsapp) among neurosurgeons from cairo university, egypt, who performed an urgent endoscopic endonasal skull base surgeries during the covid-19 pandemic. we collected data between may 8, 2020, and june 7, 2020. e survey was administered through google forms (google, mountain view, ca, usa). all responses were collated with excel (microsoft, redmond, wa, usa) and cross-verified by three members of our team. e survey consisted of 12 questions designed to explore three domains; patients' information (age, clinical manifestations [neurological and covid-19 related], diagnosis, preoperative covid-19 screening, and covid-19 symptoms during the first 3 weeks postsurgery), surgical team information (age, chronic medical conditions, and covid-19 symptoms during the first 3 weeks postsurgery), and operative information (ppe utilization and basal craniectomy). e questions were in a checkboxes format so they can choose multiple answers. covid-19-related symptoms included any of the following symptoms; fever, new onset of cough, worsening chronic cough, shortness of breath, difficulty breathing, sore throat, hoarse voice, difficulty swallowing, decrease or loss of sense of taste/smell, chills, headaches, unexplained fatigue/malaise/ muscle aches, diarrhea, abdominal pain, nausea/vomiting, pink eye (conjunctivitis), runny nose/sneezing without other known cause, and nasal congestion without other known cause. we first drafted a pilot survey and administered this to two neurosurgeons. based on their feedback, the survey was revised before full administration. we used spss (v24, ibm corp., usa) for data analysis. descriptive statistics were used to summarize quantitative data and histograms for qualitative data. neurosurgeons were informed first about the objectives of this survey and then had the option of not participating. we maintained strict confidentiality regarding participant responses and personal data (helsinki declaration [43] ). as for its retrospective nature, ethics board approval was not required. is manuscript was prepared in accordance with strengthening the reporting of observational studies in epidemiology (strobe) guidelines. [41] we received 16 responses (response rate, 100%) with a total of 16 patients operated on by cairo university neurosurgeons and ear, nose, and throat surgeons (n=48) since the start of this pandemic in egypt. e mean age of the patients was 44.9 ± 17.7 years (range, 8-78 years) with 18.8% (n = 3) above the age of 60 years. about 81.3% (n = 13) of the patients presented by rapid visual deterioration (one of them was associated with cranial nerve deficit), 12.5% (n = 2) presented with pituitary apoplexy without visual deterioration, and 6.3% (n = 1) presented with cranial nerve deficit only [ figure 1a ]. regarding the pathological diagnosis, 81.3% (n = 13) were nonfunctioning pituitary adenoma (one of them was recurrent), 12.5% (n = 2) were prolactinoma, and 6.3% (n = 1) were gh secreting adenoma [ figure 1b ]. all of the patients were screened by a preoperative complete blood picture and plain chest x-ray. while only 68.8% (n = 11) of the patients were screened through a ct chest, 50% (n = 8) through chest examination, 50% (n = 8) through c-reactive protein (crp), and only 6.3% (n = 1) through immunoglobulins serological testing [ figure 1c ]. all of the above tests were normal in all patients. none of the patients were screened using the real-time reverse transcriptasepolymerase chain reaction (rt-pcr) from a nasopharyngeal swab. none of the patients developed any manifestation of covid-19 such as fever or pneumonia-related symptoms during the first 3 weeks after surgery. about 16.7% (n = 8) of the surgical team were above 60 years old [ figure 2a ] and only 10.4% (n = 5) of them have chronic medical conditions [ figure 2b ]. ere was only one surgeon who developed a high-grade fever, malaise, and bony aches in the first 3 days after surgery who had undergone two nasopharyngeal swabs with rt-pcr testing 1 week apart and both came back negative representing 2.1% of the surgical team members [ figure 2c ]. about 62.5% (n = 30) of the surgical team used regular surgical masks only covering nose and mouth, while only 12.5% (n = 6) used regular surgical mask and goggle, and only 6.3% (n = 3) of the surgeons used regular surgical mask with protective shield, regular surgical mask, protective shield, and n95 mask, regular surgical mask and n95 mask, or n95 mask only [ figure 3a ]. all of the surgeons used regarding the basal craniectomy, 81.3% (n = 13) used kerrison rongeur and chisel, 25% (n = 4) used a high-speed drill, and 6.3% (n = 1) used a mucosal shaver. ere was only one case where the surgeons used the kerrison rongeur, chisel, high-speed drill, and mucosal shaver [ figure 3b ]. e covid-19 pandemic has been a major threat to global health care. e impact on health systems worldwide is unprecedented. all areas of medicine have had to undergo rapid transformation. nonessential care has been eliminated in many regions and continues unscathed in some places. preparedness for this crisis also has varied by nation. a worldwide survey study was conducted during the current pandemic showed that hospitals from low-income countries were insufficiently prepared. [16] when health care has to be delivered, it is incumbent on our institutions to provide such care in the safest manner possible. is has been a challenge in developing countries with the lack of availability of essential screening tests (pcr) and ppe. physicians, nurses, and other health care workers are stressed for these reasons. furthermore, the lack of treatments, incomplete understanding of the disease, absence of a vaccine, and misinformation have further compounded this stress. now in the midst of the pandemic, health-care facilities in developing countries are overwhelmed by covid-19 patients. ese hospitals were already overcrowded with patients suffering from acute and chronic medical conditions and patients requiring surgical treatment. furthermore, developing countries will not be able to reduce significantly the surgical volumes to make room for patients with covid-19. is is due to the largest portion of the surgical volume in developing countries cannot be postponed safely due to their urgent and emergent nature. [33] another major challenge that we did not face until now is the shortage of intensive care (icu) beds. [30] even if the icu beds are abundant, there will be a significant shortage of supplies such as ventilators and oxygen, and all of the other supplies required for severe respiratory failure patients' care. [28] e egyptian authorities announced the first case infected with covid-19 on february 14, 2020. [19] e absence of open screening due to the lack of supplies has attributed to the underreporting of positive covid-19 cases similar to other developing countries. is underreporting may reach up to 7.4 times the reported covid-19-positive patients. [19] despite the low reported numbers, it was recommended by the ministry of health to postpone all elective surgeries due to the fact that all the hospitals are quickly becoming hot zones for transmission and treatment of the covid-19 patients. starting from early april 2020, the daily number of new infections started to escalate with the increase of screening parameters [12] with the rapid increase in the covid-19-related physician mortality rate among the nationwide mortality rate reaching 4.4% on may 29, 2020. [15] by june 7 (last day of the survey), 32,612 cases were reported in egypt resulting in 1198 deaths. [12] emergency procedures were continued similar to most countries, however, there are some of these procedures require more precaution due to high viral load of the sars-cov-2 in the upper airway with potential aerosolization during the procedure such as endoscopic endonasal surgeries. [24] most of the sellar-suprasellar lesion patients present subacute or chronic symptoms and can wait, however, patients presenting with progressive neurological deficits, pituitary apoplexy, and high-flow cerebrospinal fluid (csf) leak secondary to a sellar-suprasellar lesion which is considered urgent. it will be unforgivable to allow such patients to be blind or develop meningitis during this pandemic. in this study, we are presenting 16 patients with pituitary adenoma and their management from a developing country perspective during the current pandemic. according to reports from the cdc, italy and china, patients with underlying chronic medical problems and the elderly are associated with more severe covid-19 disease. [7, 22, 18] in our series, 18.8% of the patients and 16.7% of the surgical team were older than 60 years. regarding chronic medical conditions, 10.4% of the surgical team have chronic medical conditions. tedros ghebreyesus, the world health organization (who) chief executive, said, "you cannot fight a fire blindfolded" and his key message was "test, test, test. " e who has criticized countries that have not prioritized covid-19 testing. [42] e positive rt-pcr test for nasopharyngeal swab is the gold standard for the diagnosis of covid-19. [8, 20] according to several recent reports, the initial rt-pcr is less sensitive than ct chest and many suspected patients with atypical findings on the ct chest and the rt-pcr came back negative. [2, 17, 21, 44] e other advantage of ct is that it is a relatively quick, simple, and available screening tool for covid-19 in countries with limited availability of the rt-pcr. [35, 39] about 30% of asymptomatic patients and 56% of mildly symptomatic patients can transmit sars-cov-2 infection. [25] in china, several reported cases presented with either no symptoms or mild flu-like symptoms who undergone endoscopic trans-sphenoid surgery and multiple members of the surgical team became infected with covid-19. [32, 37] is led them to recommend that all patients undergoing endoscopic trans-sphenoid surgery to be dealt with as suspected covid-19 positive and should be investigated fully for covid-19 (blood test, ct chest, and rt-pcr) and all providers utilize enhanced ppe. [27] in developing countries such as egypt with limited testing for the sars-cov-2, [19] focused testing is only done to severely symptomatic patients leading to less strain on health-care systems. is led to stretching the laboratory and radiographic investigations beyond our capacity as well as relying on clinical history and examination. is is evident in this series where none of the patients were investigated in the form of rt-pcr and we relied only on complete blood cell (cbc) (100%), ct chest (68.8%), clinical history and examination (50%), crp (50%), and serological test (immunoglobulins) (6.3%). e basic clinical examination, cbc, crp, and chest imaging were the main preoperative diagnostic tools used and created convenient prophylactic measures that served in operating on 16 urgent patients at the time of the pandemic uprise in egypt without any report for a surgery-related spread of infection. ere is enormous demand for ppe around the world and will be more difficult in obtaining them in developing countries. e endoscopic trans-sphenoid surgery creates clouds of aerosols and droplets which may contaminate the operating theater environment when operating on a positive covid-19 patient. [40, 45, 46] however, there is uncertainty regarding the exact mechanisms of viral transmission, viral load amount exposure, degree of aerosolization, and inadequate data on the appropriate ppe utilization during endoscopic trans-sphenoid surgeries. furthermore, due to the limited availability of the gold standard test (rt-pcr) makes us deal with all the patients as covid-19 positive. is is supported by the american association of otolaryngology-head and neck surgery (aao-hns) recommendations that advocated the use of enhanced ppe regardless of the status of the covid-19 testing. [1] e enhanced ppe includes n95 respirator, face shield, goggles, double-layered gloves, and three-layered gowns to achieve maximum contact/droplet isolation precautions. [26, 31, 38] despite all these measures including n95 respirator utilization, in wuhan, the ent surgeons were one of the worst specialties affected. [23] is led to formal guidelines from china as well as informal us and uk advisories that recommended the use of full paprs in endoscopic trans-sphenoid surgeries which reduced the rate of transmission. [27, 32] however, the utilization of paprs or even n95 masks is challenging in limited resource hospitals. in our hospital, the or supplies the surgical team with only one regular surgical mask and one overhead per surgeon per day whatever the number of cases the surgeon operating upon. apart from single-layered gloves and singlelayered gown, the ppe utilization is surgeon dependent. is can be seen in our results where a surgical mask was utilized in 93.8%, n95 and goggles were utilized only in 18.8%, and a protective face shield was used in only 12.5%. e sars-cov-2 aerosolization during upper airway procedures and sinonasal procedures is very high, especially with the use of powered instruments such as drills and debriders due to the upper airway high viral load. [23, 46] is attributed to recommendations to avoid the utilization of power instruments and the use of chisels and kerrison rongeur instead without affecting surgical exposure. [6] furthermore, if drilling is mandatory, meticulous irrigation is recommended to avoid aerosolization. [27] in this series, 81.3% of the cases kerrison rongeur and chisel were utilized in the basal craniectomy, 25% of the cases a high-speed drill was used, and in 6.3% of the cases, a mucosal shaver was utilized. ere was only one case where the surgeons used the kerrison rongeur, chisel, high-speed drill, and mucosal shaver. e aim of decreased utilization was to avoid aerosolization. our recommendation is to deal with the patient as suspected covid-19 positive as long as we are not able to perform an rt-pcr nasal swab to them. all the patients are transferred to the regular single-bed room for isolation and postoperative care. daily body temperature assessment and respiratory history were done and in consistence with recommendations. [38] any patient with cough or new-onset fever should be isolated and investigated thoroughly to rule out covid-19 infection. [4] e isolation should be in a negative pressure single room with sufficient nebulization and oxygen supply. [3] none of our patients were in a negative pressure room due to inadequate preparation of the hospital. fortunately, all of our patients did not develop any covid-19-related symptoms such as fever or pneumonia-related symptoms in the 1 st 3 weeks postsurgery. medication administration and postoperative rounds should be done by the health-care personnel under full ppe, however, our team was only using a surgical mask and gloves. [38] in positive covid-19 patients, all health-care personnel that dealt with the patient should be quarantined for 14 days. [38] ere was one surgeon in our series who developed a high-grade fever, malaise, and bony aches in the 1 st 3 days after surgery who had undergone two nasopharyngeal swabs with rt-pcr testing 1 week apart and both came back negative. at the time of this submission, the situation is rapidly evolving in our country, and all of the above policies might change in the near future. furthermore, fortunately, all our cases did not present with covid-19-related symptoms whether pre-or postoperative which might be due to asymptomatic form of the disease or they are covid-19 negative despite that most cases were during the uprise of covid-19 reported cases in egypt. is series of patients is from single-center surgeons and there might be other covid-19 confirmed positive cases operated n in other centers. although this study was discussing the urgent trans-sphenoid skull base cases that were operated on during this pandemic, it is missing the number of nonurgent cases that presented to our clinics or emergency department with clinical signs of covid-19. however, in case of a patient that requires urgent surgery and is clinically or radiographically suspected of covid-19, an urgent craniectomy will be indicated [ figure 4 ]. e surgeons' safety should be placed at the highest priority and the governments should balance the limited resources and surgeons' safety. e idea of waking-up nearly every week on a loss of one of the neurosurgical or skull base teams to this virus is terrifying. we highlight the situation of urgent endoscopic skull base practice from a developing country with limited resources, preoperative screening using chest clinical history and examination, cbc, and ct chest might be sufficient to replace rt-pcr. all patients should be managed as suspected covid-19 until 2 weeks postsurgery with enhanced ppe whenever possible and avoiding power drills whenever possible. if the patient requires urgent surgery and the above test are suggesting covid-19, transcranial excision is recommended. developing countries require adequate support with screening tests, ppe (n95 masks and paprs), and critical care equipment such as ventilators. patient's consent not required as patients identity is not disclosed or compromised. nil. ere are no conflicts of interest. american academy of otolaryngology-head and neck surgery correlation of chest ct and rt-pcr testing for coronavirus disease 2019 (covid-19) in china: a report of 1014 cases surgery during the covid-19 pandemic: a comprehensive overview and perioperative care covid-19 outbreak and surgical practice: unexpected fatality in perioperative period e psychological impact of quarantine and how to reduce it: rapid review of the evidence skull-base surgery during the covid-19 pandemic: e italian skull base society recommendations preliminary estimates of the prevalence of selected underlying health conditions among patients with coronavirus disease 2019-united states detection of 2019 novel coronavirus (2019-ncov) by real-time rt-pcr covid-19 and public health preparedness in the united states economic analysis and policy division, department of economic & social affairs covid-19 educational disruption and response. unesco; 2020 covid-19 situation reports covid-19: guidance for triage of non-emergent surgical procedures. american college of surgeons we need to be alert': scientists fear second coronavirus wave as china's lockdowns ease letter: e impact of the coronavirus (covid-19) pandemic on neurosurgeons worldwide sensitivity of chest ct for covid-19: comparison to rt-pcr clinical characteristics of coronavirus disease 2019 in china estimation of covid-19 burden in egypt clinical features of patients infected with 2019 novel coronavirus in wuhan, china use of chest ct in combination with negative rt-pcr assay for the 2019 novel coronavirus but high clinical suspicion characteristics of covid-19 patients dying in italy letter: transmission of covid-19 during neurosurgical procedures-some thoughts from the united kingdom neurosurgical management of brain and spine tumors in the covid-19 era: an institutional experience from the epicenter of the pandemic e incubation period of coronavirus disease 2019 (covid-19) from publicly reported confirmed cases: estimation and application surgical treatment for esophageal cancer during the outbreak of covid-19 endonasal neurosurgery during the covid-19 pandemic: e singapore perspective challenges experienced by health care professionals working in resourcepoor intensive care settings in the limpopo province of south africa if the world fails to protect the economy, covid-19 will damage health not just now but also in the future intensive care unit capacity in low-income countries: a systematic review infection prevention measures for surgical procedures during a middle east respiratory syndrome outbreak in a tertiary care hospital in south korea letter: precautions for endoscopic transnasal skull base surgery during the covid-19 pandemic emergency-to-elective surgery ratio: a global indicator of access to surgical care covid-19) pandemic: increased transmission in the eu/ eea and the uk-eighth update. european centre for disease prevention and control managing covid-19 in resource-limited settings: critical care considerations how to risk-stratify elective surgery during the covid-19 pandemic? 20200125a07tt200?uid=&devid=bdf e70cd-5bf1-4702-91b7-329f20a6e839&qimei=bdfe70cd-5bf1-4702-91b7-329f20a6e839 recommendations for general surgery clinical practice in novel coronavirus pneumonia situation technical aspects of ct imaging of the spine aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 strengthening the reporting of observational studies in epidemiology (strobe) statement: guidelines for reporting observational studies available from: https:// www.who.int/dg/speeches/detail/who-director-general-sopening-remarks-at-the-media-briefing-on-covid world medical association declaration of helsinki. ethical principles for medical research involving human subjects chest ct for typical coronavirus disease 2019 (covid-19) pneumonia: relationship to negative rt-pcr testing suggestions for prevention of 2019 novel coronavirus infection in otolaryngology head and neck surgery medical staff sars-cov-2 viral load in upper respiratory specimens of infected patients key: cord-316918-mz5r7yiy authors: rubin, geoffrey a.; biviano, angelo; dizon, jose; yarmohammadi, hirad; ehlert, frederick; saluja, deepak; rubin, david a.; morrow, john p.; waase, marc; berman, jeremy; kushnir, alexander; abrams, mark p.; garan, hasan; wan, elaine y. title: performance of electrophysiology procedures at an academic medical center amidst the 2020 coronavirus (covid‐19) pandemic date: 2020-04-20 journal: j cardiovasc electrophysiol doi: 10.1111/jce.14493 sha: doc_id: 316918 cord_uid: mz5r7yiy a global coronavirus (covid‐19) pandemic occurred at the start of 2020 and is already responsible for more than 74 000 deaths worldwide, just over 100 years after the influenza pandemic of 1918. at the center of the crisis is the highly infectious and deadly sars‐cov‐2, which has altered everything from individual daily lives to the global economy and our collective consciousness. aside from the pulmonary manifestations of disease, there are likely to be several electrophysiologic (ep) sequelae of covid‐19 infection and its treatment, due to consequences of myocarditis and the use of qt‐prolonging drugs. most crucially, the surge in covid‐19 positive patients that have already overwhelmed the new york city hospital system requires conservation of hospital resources including personal protective equipment (ppe), reassignment of personnel, and reorganization of institutions, including the ep laboratory. in this proposal, we detail the specific protocol changes that our ep department has adopted during the covid‐19 pandemic, including performance of only urgent/emergent procedures, after hours/7‐day per week laboratory operation, single attending‐only cases to preserve ppe, appropriate use of ppe, telemedicine and video chat follow‐up appointments, and daily conferences to collectively manage the clinical and ethical dilemmas to come. we discuss also discuss how we perform ep procedures on presumed covid positive and covid tested positive patients to highlight issues that others in the ep community may soon face in their own institution as the virus continues to spread nationally and internationally. global economy and our collective consciousness. aside from the pulmonary manifestations of disease, there are likely to be several electrophysiologic (ep) sequelae of covid-19 infection and its treatment, due to consequences of myocarditis and the use of qt-prolonging drugs. most crucially, the surge in covid-19 positive patients that have already overwhelmed the new york city hospital system requires conservation of hospital resources including personal protective equipment (ppe), reassignment of personnel, and reorganization of institutions, including the ep laboratory. in this proposal, we detail the specific protocol changes that our ep department has adopted during the covid-19 pandemic, including performance of only urgent/emergent procedures, after hours/7-day per week laboratory operation, single attending-only cases to preserve ppe, appropriate use of ppe, telemedicine and video chat follow-up appointments, and daily conferences to collectively manage the clinical and ethical dilemmas to come. we discuss also discuss how we perform ep procedures on presumed covid positive and covid tested positive patients to highlight issues that others in the ep community may soon face in their own institution as the virus continues to spread nationally and internationally. which has disrupted the international economic order and significantly altered activities of daily living and personal interactions for nearly everyone on earth, due to requisite social distancing, "shelter-at-home" and lockdown orders instituted in many locations. in new york state, as of april 6, 2020 there are over 130 000 confirmed covid-19 cases, the most in the united states. the vast majority of covid-19 diagnoses have been made within the densely populated new york city, which itself has 72 000 confirmed cases and is now considered a covid-19 epicenter. at newyork-presbyterian hospital (nyph), the case rate is nearly doubling every day, which mirrors the overall state trend. personal protective equipment (ppe), as has been reportedly nationally, is at a critical shortage. the coronavirus principally causes pulmonary manifestations of fever, cough and dyspnea with occasional rapid progression to severe respiratory failure and acute respiratory distress syndrome in both high-risk and healthy patient populations. yet between 7.2% and 12% of total covid-19 patients manifest cardiac injury and progression to fulminant myocarditis was recently described. [2] [3] [4] importantly, there are likely to be several electrophysiologic (ep) sequelae of covid-19 infection. wang et al 2 describe arrhythmia burden of 16.7% in 138 total covid-19 patients and 44.4% of covid-19 icu patients. as yet, it is unknown whether the virus directly seeds the cardiac conduction system. electrophysiologists will play an important role in the upcoming months, especially since covid-19 treatments such as hydroxychloroquine carry known deleterious electrophysiological effects. 5 eps may see more cases of drug-induced torsades in the near future. there have also been recent reported cases of ventricular arrhythmias due to covid myocarditis. 6 it was therefore important to institute specific ep laboratory protocols not only to treat the inevitable covid-19-infected patient requiring any urgent or emergent procedures, but also so that we may continue to treat sick, non-covid infected patients with a high quality standard of care. management operations are in flux during this crisis and may even change from day-to-day. we present our overarching workflow model to optimize laboratory function with the aim of both adequately protecting providers, successfully treating patients and conserving ppe during this unprecedented period. this has been an urgent collaborative formulation by the columbia university electrophysiology subdivision at columbia university medical center, and is not a reflection of official nyph policy. we present this as a model for other ep labs in the nation who are facing or soon may be faced with this healthcare challenge. as per the recent consensus statement from the heart rhythm society, american heart association and american college of cardiology, only urgent and emergent procedures were performed during the current upswing of the covid-19 infection curve to minimize virus transmission between patients and providers. 7 emergent procedures according to clinical discretion may include cardioversion, implantation of temporary or permanent pacemaker (ppm), or ablation for arrhythmias refractory to medical management. the goal is to reduce nonurgent person-to-person interactions. "elective" cases that ultimately may be life-prolonging or symptomrelieving have been delayed, since incidental and unpredictable infection with covid-19 in a stable out-patient would be regrettable and harmful. as of march 16, nyph suspended elective cases to concentrate equipment, supplies, and providers on responding to the covid-19 public health crisis. before performing a procedure on patients from both the in-or outpatient setting, covid testing is performed on all patients with the understanding that there may be false negative results. it is important to ensure sufficient standard ppe for procedures is identified ahead of time, as hospital resources diminish quickly. we have prioritized and performed due to their urgent/emergent nature: ppm for symptomatic, high-grade or wide-complex complete heart block, generator change for ppm-dependent patient with device nearing end of life (eol), cardiac resynchronization therapy devices nearing eol to prevent detrimental hemodynamic consequences, vt ablation in unstable/hospitalized patients with vt storm refractory to medication, accessory pathway ablation in pre-excited af, and device/lead extraction in an unstable patient with active sepsis. we have also performed pacemakers immediately after urgent/emergent transcatheter aortic valve replacement with resultant heart block to facilitate discharge on the same day. the expedition of urgent procedures for patients waiting in intensive care units (icus) is paramount. we have structured a multidisciplinary approach with icu and nursing staff to facilitate performing procedures on extended weekday and weekend hours to minimize use of institutional resources and free up much-needed icu beds for the growing covid-19 patient population. the more challenging decision involves semi-urgent indications for ep procedures such as secondary prevention icd, primary prevention icd in a very high-risk patient (ie, ischemic heart disease with nonsustained vt, muscular dystrophy or sarcoid), or lead revision/replacement in the setting of malfunction/dislodgment in patients who are currently or imminently will be hospitalized. it may be necessary to rely on a wearable defibrillator (lifevest, zoll, chelmsford, ma) for the secondary prevention patient population until the inflection point of covid-19 cases is reached and transmission risk is lower. furthermore, maximal medication management has been implemented for patients with symptomatic, recurrent svt at the current time. alternatively, these procedures must be evaluated and performed on an individual case-by-case basis to weigh risk versus benefit from the procedure. if it is decided that cardiovascular benefit outweighs the risk, then scheduling the patient for the earliest daytime slot possible to facilitate same-day discharge is advisable. coordination with infectious disease (id) prevention and control colleagues is also essential. unless urgent/emergent, we have avoided performing procedures on covid-19 infected patients in the ep laboratory to prevent transmission not only during transport to the laboratory, but also to prevent seeding the lab itself in the case of a prolonged operation. the coronavirus may maintain aerosolization for an unspecified time period and was recently shown to stay viable for up to 72 hours on stainless steel surfaces, 8 which are readily found in ep laboratories. in light of myocarditis and elevated inflammatory markers in active covid infection, there are likely to be patients that develop clinically-significant bradyarrhythmias during their course. since these will presumably be more severely-ill patients amidst a prolonged hospitalization, we have used medical management with dopamine and avoiding any medications that may be overtly catecholaminergic due to concern of myocarditis. if clinically significant bradycardia persists, then temporary ventricular pacemaker (tvp) placement is the best option. tvp placement is quick (typically <10 minutes), may be performed at bedside, involves less hospital transport with the potential for aerosolization and health care provider exposure, and allows temporization until the patient either recovers from their systemic illness or deteriorates further. if it is decided that a covid-19 infected patient must have a procedure performed in the ep laboratory, we have a protocol illustrated by figure 1 . if the patient is not intubated, a mask is placed on the patient before transport and there is a specific room designated for infected patients. that room is thoroughly disinfected after the procedure. to prevent virus transmission, preserve ppe and protect patients, the typical and familiar pre-procedure workflow patterns should be significantly altered. first, with regard to ep attending allocation, each day there is only one designated procedure attending in-house. a back-up attending is on-call within range of the hospital in case of a second emergent case. this shift-based arrangement is meant to prevent the potential for widespread and unintentional doctor-to-doctor transmission, and thus minimize the risk of "wiping out" an entire ep department, which would be devastating. additionally, elderly (>60-years-old) attendings at high-risk for severe covid-19 infection are encouraged to avoid hospital-based patient care and instead focus their attentions on telehealth visits or urgent out-patient clinic consultations. patient time in the pre-procedure "holding area" is minimized as possible and in-patients are brought down directly to the procedure room to prevent lingering in multiple different hospital areas. although it is not current nyph policy, with the medicallegal team and laboratory directors, we have considered transition of patient consent to a strictly verbal process to minimize patient-provider contact through touchscreen, pen or clipboard exchange. since the majority of cases performed during the present era of exponentially rising covid-19 infections are implantable devices, the rule for us has been single-operator cases only. our academic attending role as educator currently plays a secondary role to efficiency and safety at this time. performing single-operator cases has been adopted to preserve the critically low ppe supply. for more complex procedures such as unstable vt or system extraction, the ep fellow assists either by running the console stimulator or lending an extra set of operative hands. our ep fellows have served as scrub nurses and circulating nurses since there has been redeployment of our highly trained nurses to the emergency room or icu. if available, a negative pressure procedure room is ideal for treating covid-19 infected patients. in emergent cases, where there is no covid testing and little patient medical history available, it may be prudent to treat the patient as covid-19 positive, since coughing or vomiting during emergent circumstances may pose an exposure threat to the health care providers. if anesthesia deems a patient to be at high-risk of respiratory failure, it is prudent to perform endotracheal intubation before the procedure (ie, in the patient's room) to prevent aerosolization of viral particles in the case of emergent intra-procedure intubation and suctioning. the closed-system mechanical ventilator is preferred to the higher-risk bi-level positive airway pressure or nonrebreather systems. additionally, during ablations or extractions, it is advisable for the proceduralist to use intracardiac echocardiography instead of anesthesia-operated transesophageal echocardiography to prevent aerosolization. before the case, the procedure attending, scrub nurse or technician should don the appropriate ppe after proper hand hygiene is performed as recommended by id prevention and rubin et al. control. we have adopted using n95 for both intubated and nonintubated covid+ patients for two main reasons: (a) dislodgement of the endotracheal tube may occur during movement of the patient onto or off the operating table, or during emergency resuscitation and (b) previous studies on human papilloma virus suggest that laser or electrosurgery plume may cause infectious aerosol hazards resulting in viral transmission. 9 we don a surgical mask on top of the n95 mask as per nyph recommendation to preserve the length of use of the n95. our surgical ppe includes goggles that form a seal around the eyes for splash protection, a surgical cap, shoe coverings, at least two layers of sterile gloves and a sterile surgical gown. we have all been trained in proper doffing of ppe which is deliberate and meticulous to adhere to the strict protocol of doffing with proper hand hygiene between steps. scrub nurses and device representatives are an integral part of ep procedures and will remain as such. it is critical to avoid the loss of highly specialized ep nurses in the event of illness or home f i g u r e 1 this diagram illustrates interdisclipinary collaboration of electrophysiologic work flow for covid confirmed/suspected patient. ppe, personal protective equipment quarantine, therefore nurses ought to similarly stagger their hospital attendance to prevent multiple concurrent staff losses. in our laboratory, device representatives provide necessary functions such as lead selection counsel, intraprocedural interrogations and device programming. daily life around the world has changed significantly due to covid-19. in addition to adapting to new home life and social distancing, work life and work flow must also adapt. the ep laboratory is no exception. we are living in unprecedented and precarious times where resource shortages may demand previously unimaginable ethical choices of us, such as whether a patient should or should not undergo a lifesaving procedure. we find that close collaboration and frequent communications by phone or teleconference at least once a day allows us to share the burden together and support one another. it is also crucial to support and salute the selfless nursing, hospital staff during this challenging time of collective action. we also appreciate the executive leadership of newyork-presbyterian for their transparency and daily communications with clinical staff and faculty. much remains to be discovered about covid-19, especially with regard to the acute and chronic ep consequences. in light of viralinduced myocardial injury, it is likely that patients who recover from severe illness may develop cardiomyopathies or scar-related substrate for vt. the elucidation of viral shedding duration even after symptom resolution will be critical for future procedure timing in patients with history of covid-19 infection. lastly, it has been critical to establish covid-19 dedicated hospitals, such as converting college dormitories or unused sports stadiums into care centers, to not only to expand patient care and relieve the front-line health care workers, but also to allow safer treatment of noninfected patients in the ep laboratory. outbreak of pneumonia of unknown etiology in wuhan china: the mystery and the miracle clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china clinical features of patients infected with 2019 novel coronavirus in wuhan coronavirus fulminant myocarditis saved with glucocorticoid and human immunoglobulin life threatening severe qtc prolongation in patient with systemic lupus erythematosus due to hydroxychloroquine the variety of cardiovascular presentations of covid-19 guidance for cardiac electrophysiology during the coronavirus (covid-19) pandemic from the heart rhythm society covid-19 task force; electrophysiology section of the american college of cardiology; and the electrocardiography and arrhythmias committee of the council on clinical cardiology aerosol and surface stability of hcov-19 (sars-cov-2) compared to sars-cov-1 transmission of human papillomavirus dna from patient to surgical masks, gloves and oral mucosa of medical personnel during treatment of laryngeal papillomas and genital warts performance of electrophysiology procedures at an academic medical center amidst the 2020 coronavirus (covid-19) pandemic key: cord-310104-1c7q9m06 authors: sasangohar, farzan; jones, stephen l.; masud, faisal n.; vahidy, farhaan s.; kash, bita a. title: provider burnout and fatigue during the covid-19 pandemic: lessons learned from a high-volume intensive care unit date: 2020-04-20 journal: anesth analg doi: 10.1213/ane.0000000000004866 sha: doc_id: 310104 cord_uid: 1c7q9m06 nan t he novel coronavirus disease 2019 (covid19) pandemic has resulted in an overall surge in new cases of depression and anxiety and an exacerbation of existing mental health issues, with a particular emotional and physical toll on health care workers. 1 limited resources, longer shifts, disruptions to sleep and to work-life balance, and occupational hazards associated with exposure to covid-19 have contributed to physical and mental fatigue, stress and anxiety, and burnout. 2 similar to most hospitals in the covid-19-affected areas, the houston methodist hospital (hmh) system has experienced an overwhelming impact of this pandemic on personnel. for example, we have observed an unprecedented number of staff requesting americans with disabilities act exemptions. physicians and nurses are worried about their families, and some hesitate to go home in fear of exposing family members to infection. it is common to see emotional exhaustion in the intensive care unit (icu). we have observed front-line health care providers emotionally breaking down, mainly due to the added pressure to choose between family responsibilities and their inner sense of duty toward patients. at the same time, we have seen an overwhelming influx of support from medical leadership, public and private acknowledgments, community support (eg, food sent to care units), as well as additional services offered to staff, such as music therapy, counseling services, chaplain services, and accommodations in work schedules. other organizational adaptations include allocation of more resources (eg, float nurses, physicians, patient care assistants, and new equipment). moving forward, our institution has plans for marshaling resources from surgeons, anesthesiologists, other medical specialists across all disciplines, and, in extreme circumstances, anyone with medical training and background. in this article, we share the lessons learned collectively by an interdisciplinary team of icu leadership and collaborating scientists at the center for outcomes research at hmh about the experience of occupational fatigue and burnout of intensive care personnel as a result of responding to the covid-19 pandemic. we propose specific policy recommendations and guidelines for organizational readiness, resilience, and disaster mitigation. of urban, suburban, and rural settings. for more than 100 years, hmh has served the houston and global community with the highest quality patient care in a spiritual environment-indeed ironically, beginning its existence amidst the 1918 influenza pandemic. hmh has 952 operating beds (2393 systemwide) and 8294 employees (25,543 systemwide) . each year, it has 45,511 emergency room visits, 381,585 outpatient visits, and 41,976 admissions (more than 1.3 million outpatient visits and more than 126,000 admissions systemwide). 3 us news & world report has named hmh the no. 1 hospital in texas for 8 consecutive years, with placement among its top 20 "best hospitals honor roll" 3 times. in addition, hmh is nationally ranked in 9 specialties, 4 and has been named the no. 1 employer in texas by forbes. 5 of particular note regarding its critical care capacities during this pandemic, hmh has 5 icu units (cardiovascular, medical, coronary, surgical, and neonatal-with a total of 130 icu beds), with 311 icu beds systemwide across the community hospitals. at the time of this writing, hmh is caring for about 120 patients who have tested positive for covid-19. the novel severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is in the same family as the causative agent for previous middle east respiratory syndrome (mers) and severe acute respiratory syndrome (sars) outbreaks. covid-19 arose most likely from animal-to-human transfer in wuhan, china. unlike previous coronavirus outbreaks, the current covid-19 emergence was marked by high rates of person-to-person transmission, including from asymptomatic carriers, combined with high severity of illness in vulnerable populations, including those with very common preexisting chronic conditions like diabetes, heart disease, and lung disease. 6 the dilemma posed to health care workers is 2fold: first, the anticipated, and now experienced, overload on the health care system capacity to respond to this pandemic with a suitable flow of equipment; and second, the high risk posed to health care workers on the front lines and their family members as a result of constant exposure. the public has been repeatedly called on to "flatten the curve," in reference to the social and behavioral changes that we as a society can undertake to slow the spread of disease. this strategy has been prominent in us centers for disease control and prevention (cdc) reports since 2007, with maintenance of the guidelines as recent as 2017. 7, 8 this strategy was even deftly memed by medical experts on social media. 9 however, across several states, implementation of these preventive measures has fallen short of desired goals. 1,2,10-14 several factors may have exacerbated occupational fatigue and burnout in icus. given our overarching roles across various facets of the health care system and our first-hand experiences with the response, the "lessons learned" documented here provide a holistic overview of major system-level problems exposed by the pandemic. in what follows, 4 major contributors to covid-19-related occupational fatigue and burnout are discussed: (1) occupational hazards; (2) national versus locally scaled response; (3) process inefficiencies; and (4) financial instability. given the highly contagious nature of sars-cov-2, the us cdc has published strict infection control and prevention guidelines for front-line health care workers, including limited administrative access, strict workplace hygiene requirements, and usage of personal protective equipment (ppe). 15 the rapid spread of the covid-19 pandemic revealed an overall lack of preparedness and insufficient training as well as limited supplies of ppe for icu staff, including anesthesiologists, intensivists, pulmonologists, nurses, respiratory therapists, and other front-line providers in most affected areas. from the onset of the covid-19 outbreak, it was apparent that testing for the virus, detecting its distribution through widespread surveillance, and subsequent contact tracing were major public health gaps. most hospitals, including hmh, lacked the capacity to test significant portions of our patient population for novel infectious threats. this removed a highly effective infection control tool from our arsenal. unfortunately, such unpreparedness, potentially resulting in poor patient outcomes, had a significant psychological burden on personnel. the covid-19 outbreak also exposed the inadequacy of the us strategic national stockpile (sns) of ppe and ventilators during a pandemic affecting many states. in fact, to our knowledge, only 10%-25% of states' requested ppe is being delivered, about 1 month into the pandemic. in addition, there are many uncertainties about when and how more ppe-and most important, ventilators-will become available. the process to access the us sns should be as lean as possible, but it has proven slow and logistically cumbersome. while federal authorities are assembling practical guidelines to extend the life and use of ppe, such plans may void the warranty on ppe. 16 critical care personnel are well aware that the effectiveness of ppe deteriorates outside of recommended usage, and such awareness only worsens the psychological pressure on these personnel. the covid-19 pandemic has revealed several issues related to current processes and established practices. most importantly, the lack of established policies for pandemic triage, equipment ordering, and emergency management has led to systemwide inefficiencies and has increased the burden on health care workers. while new protocols were put in place in response to the pandemic, these protocols were perceived as complex and, in some cases, premature. for example, anecdotal evidence suggests that most health care workers' vulnerabilities and contamination were related to improper ppe doffing. while training videos on donning and doffing were shared with staff, such videos were not updated to reflect specific ppe used in our system, and instructions were not intuitive for less experienced personnel. another important issue was related to policy overload coupled with mismatching policy from different levels or sources. for example, each subspecialty (eg, anesthesiology, critical care medicine, respiratory therapy, nursing, and others) follow guidelines provided by their respective professional societies for various procedures, in addition to new policies developed by the hospital. however, holistic efforts to align such guidelines were largely absent at the system level, resulting in teamwork issues, confusion, and frustration. at hmh, our physician executive and chief medical officer have addressed this issue via regular and timely update communications. at the time of this writing, covid-19 has pushed the global economy to the brink of or already into a major recession. modifications of population dispersion (social distancing) and quarantine protocols, and a complete halt to large portions of the us economy, have resulted in unprecedented overall societal stress and anxiety. unfortunately, a disproportionate share of the sacrifice is borne by the portions of our population who are at greatest socioeconomic risk. while business is booming in health care, all indicators point to a likely sustained overall economic downturn. this undoubtedly contributes to health care workers' stress and anxiety. in addition, anecdotal and news report evidence suggests that some private anesthesia groups in the country have experienced financial distress, resulting in furloughs and layoffs because they depend heavily on providing services for routine, elective surgeries, which have been canceled or delayed in a number of states. 17 it is well documented that such uncertainty about future occupational stability (job security) is associated with a deterioration in mental well-being. 18 organizational adaptation and opportunities several traits of resilient performance and improvisation have been observed at hmh. the incident command team was rapidly assembled; leadershipemployee communication was constant and responsive; and human resources (hr) adapted policies to employee needs. to long-standing employees, these adaptations were not surprising, because our leadership and teams have literally weathered storms before, including in recent history, hurricane ike and hurricane harvey. hurricanes are not pandemics, but their local effects are similar in terms of financial and emotional strains on employees, as well as sudden geographical isolation of both employees and patients. in particular, the seamless way in which hmh executive leadership and hr adapted policies-including alternate paid time off options, advanced check dispersal with waived fees, telecommute policies, and waived copays for mental health services-was consistent with how the health system has previously assessed emerging disaster situations and responded with astute budget analyses to bolster employee bank accounts without breaking the hospital budget. likewise, procedures for maintaining sensitive research areas such as our animal laboratories, clinical trials, and expedited institutional review board (irb) approval mechanisms for disaster-critical research, much of which is now being implemented nationwide, are reminiscent of ride-out and recovery procedures already commonplace in a texas gulf coast medical center. these proactive, positive responses corroborate that the best way to weather a storm is to look where storms have repeatedly been weathered. in a more direct way, we have seen this for the covid pandemic in portions of asia like singapore and hong kong, which were previously affected most by sars and novel influenza a (h1n1pdm09) virus of 2009 (h1n1) avian influenza and have likewise adapted comparatively faster to covid-19. 19 digital communication tools have also shown promise in enabling remote work as well as intrainstitutional collaborative efforts. covid-19 has brought health care professionals together across cities, states, and countries. for example, in the greater houston area alone, there have been more than 200 intensivists, extracorporeal membrane oxygenation (ecmo) specialists, and other specialized providers communicating through popular social media platforms (eg, whatsapp) and learning from one another. in addition, this pandemic has opened the opportunity for innovations and adoption of alternative care delivery methods like telemedicine and virtual icus. hmh has been able to utilize these technologies for ecmotreated covid-19 patients and thus decreased traffic www.anesthesia-analgesia.org anesthesia & analgesia covid-19: lessons learned from an icu in and out of our icu patient rooms. resilience was also evident in the formation of interdisciplinary teams to design novel devices to help protect anesthesiologists in intubating covid-19-positive patients or persons under investigation. the covid-19 pandemic exposed several gaps in our health care system, including the need for proactive investment to increase large-scale epidemic and pandemic preparedness. the following recommendations are made to prevent burnout and mitigate occupational stress, especially among intensive care providers during a pandemic. • the national and regional disaster mitigation plans for future epidemics have to incorporate mechanisms to allow rapid and agile transformation of relevant industry to support massively increased demand for disinfectants, cleaning supplies, ppe, and other medical equipment for health care and community use. although certain industries and corporations have exhibited a heightened sense of responsibility during the current covid-19 pandemic, such efforts need to be preemptively planned, and specific industries should be earmarked, trained, and equipped for a rapid transformation. industries willing to step up in times of crises and invest in disaster readiness may be incentivized by tax breaks or other mechanisms. • access to updated information about the availability of covid-19 testing kits and ppe for health care workers may reduce the anxiety associated with uncertainty and reduce unproductive information seeking 20 and emotional distress. 21 daily rounds and huddles, along with communication technologies, such as huddle boards, can be used to serve as reliable information sources. • structured training on large-scale disaster management and response must be provided. the society of critical care management offers a fundamentals of disaster management course, which can build crucial mental models and support development of organization-specific structures for response management. 22 in addition, the federal emergency management agency (fema) offers a variety of free courses and resources. • disasters necessitate innovation. with the rise of covid-19, several innovative designs were proposed to protect the health care workers on the front lines from the rapidly and widely spreading virus. 23 however, there is a dearth of manufacturing capacity and materials to produce many of these solutions. systems of innovation that were developed and honed during other national emergencies when most resources were constrained (eg, the functional analysis systems technique [fast] developed during the manhattan project) 24 are being revisited to tackle the problem nationally and globally. we need these solutions to buy time for effective antiviral medications and a vaccine for covid-19. meanwhile, there is a need to provide technical oversight to ensure that new designs meet minimum safety requirements. for example, during this pandemic, an abundance of homemade masks and gowns were designed and adopted without proper attention to fit and leak protection, potentially leading to a false perception of protection among health care workers. • the united states has a well-trained yet largely untapped resource of medical professionals in the form of internationally trained physicians, nurses, medical technicians, and other health care providers. due to strict state licensing regulations, such individuals are barred from routine direct patient care. though we do not propose a blanket relaxation in medical licensure requirements, we feel it is imperative that willing and able individuals be periodically trained to maintain a medical reserve corps at the regional, state, and national level. we opine that the notion of wartime-like preparedness has to be a serious and deliberate consideration, and maintaining a readily deployable human capital reserve is part and parcel of such preparedness. • while studies emerged to investigate pandemicrelated mental health issues, 1 there is a need for feasible and practical methods to assess health care workers' fatigue and burnout. 25, 26 wearable sensors have shown promise 27 by providing an opportunity to monitor fatigue, stress, and sleep biomarkers noninvasively and then communicating this information to clinical unit managers for timely intervention. in addition, mobile health (mhealth) tools have shown promise to facilitate mental health self-management. simple methods such as breathing exercises, biofeedback, and mindfulness can be utilized to mitigate acute episodes of stress and anxiety, while telehealth services can be used to enable peer-support and occupational counseling. however, the integration of new technologies with current workflows may present additional burden and needs to be further examined. the lessons learned and documented here demonstrate that when confronted with seemingly inadequate xxx xxx • volume xxx • number xxx www.anesthesia-analgesia.org 5 federal-level logistics and response, it is perhaps time to recall the social virtues of local-level resilience and self-reliance. it is beyond the logistical capabilities of any government to provide what is needed to every citizen when the scope and magnitude of the disaster are beyond a localized event (eg, hurricanes, large-scale wildfires, and earthquakes). such disasters strain national capacity for response. it was local authorities, in many cases aided by private citizens, that kept us all together, as one (eg, the cajun navy's role during katrina 28 and houstonians' response during harvey 29 ). we can harness the government, industry, and individual efforts and resources to effectively mitigate such disasters and challenges. these efforts start with education and leadership that instill a sense of community and duty to the community, into the fabric of our society. pandemics of this scale occur roughly every 100 years, with more localized or less severe cases in the interim. 30, 31 we have learned from each of them, but we have still failed to devote enough of our public resources into providing adequate supplies and proactively planning to address these events. this is going to happen again, and it is our choice to act. e factors associated with mental health outcomes among health care workers exposed to coronavirus disease supporting the health care workforce during the covid-19 global epidemic about us: facts and statistics | houston methodist houston company ranks no. 1 in forbes list of best employers in texas. kprc covid-19) situation summary. cdc.gov layered use of nonpharmaceutical interventions. cdc cdc community mitigation guidelines work group. community mitigation guidelines to prevent pandemic influenza -united states the story behind "flatten the curve," the defining chart of the coronavirus. fast company state roundup: with a lack of compliance to social-distancing, gov. hogan orders all non-essential businesses shut new york city to fine people for violating social distancing rules 28 university of texas spring breakers test positive for covid-19 after group trip to mexico. nbc news florida college students test positive for coronavirus after going on spring break. cbs news the social-distancing culture war has begun. the atlantic covid-19) -interim guidance for businesses and employers recommended guidance for extended use and limited reuse of n95 filtering facepiece respirators in healthcare settings -niosh workplace safety and health topic. cdc.gov boise health care firm lays off 53 people. idaho statesman changes in mental well-being, blood pressure and total cholesterol levels during workplace reorganization: the impact of uncertainty singapore was ready for covid-19-other countries, take note. wired managing uncertainty in illness explanation: an application of problematic integration theory communicating crisis uncertainty: a review of the knowledge gaps students work to deliver automated bag valve mask to address covid-19 crisis function analysis and decomposition using function analysis systems technique design for stress, fatigue, and workload management physiological and psychological aspects continuous monitoring and detection of post-traumatic stress disorder (ptsd) triggers among veterans: a supervised machine learning approach how citizens turned into saviors after katrina struck voices: citizens with boats filled rescue void a year ago during hurricane harvey floods. usa today the mother of all pandemics is 100 years old (and going strong)! 100 years since 1918: are we ready for the next pandemic? influenza division the authors thank jacob m. kolman, ma (senior scientific writer, center for outcomes research, houston methodist hospital, houston, tx. contribution: content review and revision of the manuscript for flow and formatting). key: cord-302987-znogutwp authors: nguyen, anne x; gervasio, kalla a; wu, albert y title: differences in sars-cov-2 recommendations from major ophthalmology societies worldwide date: 2020-07-07 journal: bmj open ophthalmol doi: 10.1136/bmjophth-2020-000525 sha: doc_id: 302987 cord_uid: znogutwp objective: since the who declared the covid-19 outbreak as a public health emergency, medical societies around the world published covid-19 recommendations to physicians to ensure patient care and physician safety. during this pandemic, ophthalmologists around the world adapted their clinical and surgical practice following such guidelines. this original research examines all publicly available covid-19 recommendations from twelve major ophthalmology societies around the world. methods and analysis: twelve ophthalmology societies recognised by the international council of ophthalmology were included in this study. one society per each who region was included: the society selected was the one who had the highest number of national covid-19 confirmed cases on 11 may 2020. in addition to these countries, the major ophthalmology society in each g7 country was included. results: ten out of 12 major international ophthalmology societies from countries covering all six who regions have given recommendations regarding urgent patient care, social distancing, telemedicine and personal protective equipment when caring for ophthalmic patients during the covid-19 pandemic. while all guidelines emphasise the importance of postponing non-urgent care and taking necessary safety measures, specific recommendations differ between countries. conclusions: as there is no clear consensus on ophthalmology guidelines across countries, this paper highlights the differences in international ophthalmic care recommendations during the covid-19 pandemic. knowledge of the differences in ophthalmic management plans will allow ophthalmologists and all eye care providers to consider the variety of international approaches and apply best practices following evidence-based recommendations during pandemics. as of 11 may 2020, there have been more than 4 million confirmed cases of the coronavirus disease 2019, known as covid-19 or severe acute respiratory syndrome coronavirus (sars-cov-2), around the world. 1 since the emergence of this novel severe acute respiratory virus in november 2019, the number of patients with covid19 and deaths have been escalating, which prompted the who to declare the outbreak as a public health emergency of international concern (30 january 2020). 2 current evidence indicates that covid-19 is commonly spread by droplet transmission and by asymptomatic carriers. initial findings suggest that the virus may propagate via airborne transmission (eg, aerosol contact with conjunctiva and respiratory mucosa), especially in high-risk procedures like endotracheal intubation. 3 while conjunctivitis has less frequently been reported as a coronavirus symptom, it is still unclear if the virus can be transmitted through tears. 4 5 physicians are at great risk of contracting the virus due to their close proximity with patients. the 230,000 ophthalmologists around the world are particularly susceptible, as they routinely perform surgeries and slitlamp examinations at less than 20 cm from patients. in order to ensure physician safety and patient care, medical societies have issued what is already known about this subject? ► to date, no study has examined covid-19 recommendations from ophthalmology societies worldwide. what are the new findings? ► all major ophthalmology societies from the g7 countries in addition to sociedad española de oftalmología, all india ophthalmological society and ophthalmological society of south africa have provided valuable information regarding urgent patient care, social distancing, telemedicine and personal protective equipment for members on their websites. how might these results change the focus of research or clinical practice? ► knowledge of the differences in ophthalmic management plans will allow ophthalmologists and all eye care providers to consider the variety of international approaches and apply best practices following evidence-based recommendations during pandemics. open access recommendations about clinical and hospital-based practices to adopt during covid-19. the purpose of this article is to assess the major international ophthalmology societies' recommendations regarding patient care, social distancing, telemedicine and the use of personal protective equipment (ppe) when caring for ophthalmic patients during the covid-19 pandemic. the goal is to assist ophthalmologists and all eye care providers in understanding the diversity in international guidelines available and to apply best practices based on these recommendations. this original research examines all publicly available covid-19 recommendations from 12 major ophthalmology societies around the world. twelve ophthalmology societies, covering all six who regions (african region, region of the americas, southeast asia region, european region, eastern mediterranean region and western pacific region), were included in this paper. we selected the country with the highest number of confirmed covid-19 cases in each region on 11 may 2020: usa, spain, india, south africa, iran and china. 1 in addition to those countries, all g7 countries were examined: uk, usa, canada, france, germany, italy and japan. developed in 1976, the g7 countries refer to a group of seven industrialised nations who meet annually to discuss a variety of global issues (ie, economy, environment and security) (online supplementary table 1). the leading ophthalmology society in each of the 12 countries was selected from the international council of ophthalmology repertoire, which contains 179 members. these ophthalmology societies are the most popular national general ophthalmology societies in their respective countries, as per their number of members (table 1) . the publicly available data displayed on these societies' official websites were extracted, translated into english when applicable (sociedad española de oftalmología (seo), société française d'ophthalmologie (sfo), deutsche ophthalmologische gesselschaft (dog), società oftalmologica italiana (soi), japanese ophthalmological society (jos), iranian society of ophthalmology (irso) and chinese ophthalmological society (chos)) and analysed in this paper. it is important to note that this paper reflects the societies' respective status as of 11 may 2020 and that these guidelines are subject to change. patients were not directly involved in the design of this study. overview of ophthalmology societies the 12 ophthalmology societies examined include the following: the royal college of ophthalmologists (rcophth) in the uk, 6 the american academy of ophthalmology (aao), 7 the canadian ophthalmological society (cos), 8 seo, 9 sfo, dog, 10 soi, 11 jos, 12 the all india ophthalmological society (aios), 13 the ophthalmological society of south africa (ossa), 14 chos 15 and irso 16 (table 1) . eleven out of twelve societies have a website that releases information for their members and patients. chos does not have its own website, as the description of the society is found on the asia-pacific academy of ophthalmology web page and refers readers to the chinese medical association (cma) website. 15 on the cma's website, there are no guidelines for ophthalmologists in the context of the pandemic. out of these 11 societies, 10 websites had information regarding the covid-19 pandemic as there were no guidelines found on the irso webpage (table 1) . ophthalmology societies have promoted their first covid-19 guidelines from 11 february (soi) to 28 march 2020 (aios) (figure 1). the actual effect of the guidelines used is variable when looking at reported laboratory-confirmed covid-19 cases (online supplementary figure 1). table 2 highlights examples of urgent and non-urgent procedures provided by each society. for instance, rcophth displays uk-based resources, like the moorfields eye hospital national health service (nhs) foundation trust, and emits its own guidelines on urgent and non-urgent care. it also states that all routine ophthalmic surgeries and face-to-face outpatient must be delayed, except if patients are at elevated risk of harm. ophthalmology accident and emergency departments must remain open with appropriate support to ensure adequate patient triage and consultations. 17 aao listed 53 suggestions of 'urgent' surgical procedures associated with indications. for example, ophthalmologists should perform brachytherapy for intraocular malignancy. 18 cos, aios and jos display this comprehensive list on their website but also published their own guidelines. aios provided a list of twenty ophthalmic emergencies, which are very similar to aao's. in addition to those emergencies, it provides a list of 11 complaints in order to rule out emergencies (ie, chemical/thermal/mechanical eye injury, acute red eye, photophobia and sudden halos/floaters/discharge/eyelid drooping). 19 while referring its members to aao's resources, jos has its own list examples regarding urgent treatment, notably retinal detachment, ocular trauma and retinoblastoma. the list has then been updated to include more examples of urgent care (ie, paediatric glaucoma, orbital fracture and bulging cataracts). unlike the other societies that consider common adult cataract surgery as an elective treatment, jos mentions that delaying cataract surgeries depend on each patient's circumstances. 12 in contrast to cos, aios and jos, dog did not recreate a list of suggestions and directly refers its members to existing resources, like to aao's comprehensive recommendations. however, dog does highlight that all elective interventions and consultations, including cataract surgery, must be avoided. 20 seo used aao's list but translated it into spanish and classified the different procedures into clinically relevant groups in order to create a list of urgent ophthalmic surgical procedures for its members. seo also adapted moorfields eye hospital nhs foundation trust, a resource displayed on the rcophth's portal, to stratify the ophthalmological risk according to the type of pathology (eg, glaucoma, uveitis and strabismus). similarly to rcophth, sfo uses national resources and writes its own recommendations in association with other french societies. sfo strongly recommended that its members limit all surgical and medical elective surgeries and provides distinctions between urgent, semiurgent and elective cases. similarly to the previous societies, it mentions that retinal detachments that occurred within the past month and acute endophthalmitis with decreased vision were deemed emergencies. however, it gives examples of elective cases, such as macular holes and posterior intraocular lens dislocation, 21 and provides distinctions between urgent and semiurgent. semiurgent is defined as a risk of severe and permanent loss of vision without immediate surgery that is not as high as in urgent cases but management may only be delayed for a few days with very close monitoring. this includes retinal detachments of more than a month, as well as wounds of the globe with or without an intraocular foreign body, which are both deemed urgent by the aao. in contrast to the other societies, soi's president used the video medium to explain differences between urgent and nonurgent care. the italian video acts as a comprehensive 'user manual' for medical eye care. the president highlights that the hospitals are now dedicated to the care of patients with covid-19, but there will always be patients requiring immediate eye care (eg, patients with acute glaucoma). 22 ossa recommended that ophthalmologists cancel or postpone all non-essential surgeries and appointments but did not give examples of such non-urgent procedures. 23 shelter in place and telemedicine the ophthalmology societies follow their national guidelines. all nine societies, except jos, have mentioned that patients and physicians alike should always stay at home, except if absolutely necessary. 20 jos is the only society examined who acknowledges eye surgery risks and possible disease transmission in asymptomatic people, but jos does not insist on the importance of physicians staying at home as there is no lockdown rules in japan. table 3 lists the telemedicine resources available per society. for example, rcophth provides telehealth resources and compiled a telemedicine application list for ophthalmology consultations to its members. in its specific ophthalmic management plans, rcophth mentions which cases can be managed virtually (eg, uveitis patients on immunosuppression). 24 25 aao also has an entire section dedicated to telemedicine resources 26 : tips for success, 27 guide to start, 28 coding for telehealth consultations, 29 teleworking considerations 30 and statements from the academy and federal agencies. 31 other societies, like cos, simply recommend their members to consider virtual platforms, such as telephone and videoconferences, 32 and refer them to aao. ► endophthalmitis, corneal touch, corneal decompensation or exposed plate. ► glaucoma when uncontrolled or absolute with a blind and painful eye, or when catastrophic or rapidly progressive. ► haemodynamic instability or oculocardiac reflex. ► impending corneal compromise. ► implant/tube exposure that might be sight threatening, endophthalmitis, malpositioned tube endangering eye or excessive inflammation, a tube that might worsen vision due to corneal oedema or iritis or cystoid macular oedema or with a severe tube malposition causing rapid visual loss. ► injury or trauma to the canaliculus, cornea or sclera. ► intraocular malignancy. ► lacerations of eyelid or face. ► lacerations, blunt rupture or deeply embedded corneal foreign body. ► lens-induced glaucoma or angle-closure glaucoma. ► life-threatening or sight-threatening conditions (ie, congenital ptosis, hypotony due to trauma, infection, intractable pain, hyphaemia, progressive vision loss, uncontrolled intraocular pressure, suspected tumour or malignancy 25 33 in the usa, it is recommended that the retina clinic be restricted to indispensable visits only (ie, early postoperative visits, emergency cases and patients receiving intravitreal injection therapy). 34 open access and delaying anti-vegf treatment for retinal vein occlusion. 36 however, sfo mentions that injections should be kept for neovascular amd and other neovascular diseases associated with high myopia and inflammatory pathologies. 21 37 uveitis the uk provides specific guidance for uveitis: although most in-person consultations must be deferred, some patients must require a review within 4 months. 25 38-40 sfo has published a document detailing the approach when caring for patients with uveitis during the pandemic (mandatory use of gloves and use of angiography and oct only when deemed essential). 41 glaucoma rcophth and sfo have established management plans for patients with glaucoma. rcophth provides a comprehensive document detailing steps that physicians must undergo to best manage their patients. this management plan takes into account risk associated with vision loss (due to patients staying at home and not receiving appropriate care), population spread instead of physical distancing (due to in-person visits) and mortality resulting from medical setting acquired covid-19 (due to care provided in-person). 42 sfo specifically recommends applanation over air tonometry as the latter could spread infectious particles. 43 paediatrics these two societies give guidelines for paediatric patient management. 17 44 sfo indicates that all children suspected of having strabismus or leukocoria be brought to an emergency room or clinic for dilated fundus photography. rcophth mentions recent reports that conjunctivitis could be caused by covid-19 but states that it is unlikely that a person with viral conjunctivitis and no other covid-19 symptom (ie, fever or cough) would have covid-19 because conjunctivitis may be a late characteristic of the virus. 45 aao has reported that mild follicular conjunctivitis can occur in patients with covid-19 and that transmission might be by aerosol contact with the conjunctiva. conjunctivitis symptoms are not necessarily due to covid-19, as it can be due to alternate viral aetiologies. 46 47 as mentioned by jos on 1 april, the risk of contracting covid-19 via the conjunctiva is about 1%-3%, but this number may fluctuate as more studies are conducted. 48 sfo and jos have warned about the potential association between red eyes and conjunctivitis. aios recommends that patients with conjunctivitis should wait in an isolated waiting room before being seen by an ophthalmologist in full ppe in a designated room. 19 recommendations on hygiene, ppe and safety for ophthalmic use in the context of the pandemic, all 10 societies with covid-19 information on their website released statements regarding ppe and responsible resource stewardship. they all highlight the importance of hand hygiene. many societies, like seo, dog and jos, refer their members to the who's website, which emphasises five moments for hand hygiene (1: before touching the patient, 2: before clean/aseptic procedures, 3: after body fluid exposure risk, 4: after touching a patient and 5: after touching patient surroundings). 49 all 10 societies recommend their members to proceed to thorough surface disinfections after every patient. dog and soi even remind members to pay particular attention to door handles (table 4) . aao highlights the controversy regarding what qualifies as adequate ppe for ophthalmologists, in the context of the ppe shortages around the world and the efficacy of masks. guidelines differ from one hospital to another across the usa, varying from prohibition to mandatory use of masks. in stark contrast to cos, sfo, soi, dog, jos and rcophth, aao does not emit its own recommendations regarding ppe use and refers its members to the cdc's website. 46 apart from aao, the nine other societies have provided recommendations on the use of slit-lamp shields, single-use gloves, masks, face shields, goggles, gowns and even on shoe protectors. the level of detail associated with each recommendation is variable. for example, rcophth established a list of specific scenarios accompanied with appropriate ppe use and even mentions if ppe can be used for an entire session or is single use. 50 51 rcophth's ppe advice and principles are based on public health england recommendations. 52 53 cos specifies the use of large slit-lamp shields to protect ophthalmologist from patient breathing, coughing and sneezing. the canadian society further refers its members to three videos on how to make slitlamp and microscope shields and advertises free slit lamp breath shields. 32 other videos included videos on its website include some on how to don and doff ppe during routine care of all suspected patients with covid-19. 54 similarly to rcophth, sfo established clear guidelines and provided concrete examples for different ppe use. for instance, physicians caring for a suspected patients with covid-19 must wear a ffp2 mask, while those caring for confirmed patients with covid-19 must wear ffp2 mask in addition to gloves, a supplementary gown, hair cover and protection glasses. 55 56 a few additional variants exist between different countries, such as for the recommended safety distance between two people, seo, sfo and aios recommend a minimum distance of 1 m between patients, while dog recommends 2 m. other recommendations aao and cos included advice on stress management, health and wellness. these two societies and aios provide resources on financial wellness to their members. the use of hydroxychloroquine is discussed by sfo and seo. contact lenses recommendations are provided by sfo, soi and seo. ten out of the 12 societies examined created operational guidelines for ophthalmic practice during the outbreak. only irso and the chos have not provided recommendations on patient care during the covid-19 pandemic. all the other societies have displayed recommendations to their members through different formats on the ophthalmology societies' websites (ie, videos, articles, notices, resource list and task force reports) and have recommended that ophthalmologists only take care of urgent cases. all 10 ophthalmology societies with covid-19 information on their respective website have emphasised the following core principle: non-urgent medical and surgical care must be limited. care must only be provided to urgent cases, and elective surgeries must be cancelled or postponed, in order to minimise the risk of spreading infection. these societies urge physicians to consider the potential transmission risks and the patients' well-being, especially in the context of ophthalmic patients who are elderly and considered high risk. 17 20 the consensus is that ophthalmic care is deemed urgent if a patient risks irreversible vision loss if not treated in a timely fashion or managed appropriately. in contrast, non-urgent care can typically be postponed for several weeks to months without risking blindness. guidelines surrounding urgent care slightly vary between countries, as rcophth, aao and sfo have published their own guidelines. for instance, sfo has added a semiurgent category in order to help ophthalmologists distinguish high priority eye emergencies from other urgent procedures that can be postponed with cautious management. while each society recommends urgent versus elective care, a large portion of which can be provided from the ophthalmologists' home (telehealth consultations), only a few societies (rcophth, aao and aios) provide detailed telehealth resources for ophthalmologists. recommendations for procedures related to different ophthalmology subspecialties (ie, cornea, glaucoma, neuro-ophthalmology, ocular oncology, oculoplastics, paediatrics and retina) were directly provided by certain societies, namely sfo, or were found statements written by national ophthalmological subspecialty societies (eg, cos refers its members to the canadian retina society for the management of retinal diseases). some societies have warned ophthalmologists that conjunctivitis may be a covid-19 symptom and that covid-19 transmission via the conjunctiva might be plausible. as ophthalmologists' duty to provide care to patients may include covid-19 infected patients who eye care providers worldwide are facing unprecedented challenges in caring for patients. in the context of a global pandemic, decisions must be made in respect to priority setting. in hospitals and outpatient clinics, patients are inevitably being triaged to first manage the most critically ill and those with the best chances of survival. all major ophthalmology societies from the g7 countries in addition to seo, aios and ossa have provided valuable information concerning covid-19 for members on their websites. some of them have referred their members to other resources, such as cos, dog and jos that have redirect their members to aao reports. while there is no clear consensus on ophthalmology guidelines across the world (especially on ppe use), this paper provides ophthalmologists and all eye care providers a complete overview of international guidelines for ophthalmic care during the covid-19 pandemic and invites them to apply best practices based on these recommendations. contributors all authors have: substantial contributed to the conception of the work (the acquisition, analysis and interpretation of data for the work); drafted and revised the work; approved the final version to be published; and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy and integrity of any part of the work are appropriately investigated and resolved. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. competing interests none declared. patient consent for publication not required. provenance and peer review not commissioned; externally peer reviewed. data availability statement data are available upon request. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ 4. 0/. anne x nguyen http:// orcid. org/ 0000-0002-3999-946x kalla a gervasio http:// orcid. org/ 0000-0003-4277-7347 albert y wu http:// orcid. org/ 0000-0002-1360-8248 coronavirus disease: situation report-112 first covid-19 case happened in november, china government records show -report modes of transmission of virus causing covid-19: implications for ipc precaution recommendations assessing viral shedding and infectivity of tears in coronavirus disease 2019 (covid-19) patients evaluation of coronavirus in tears and conjunctival secretions of patients with sars-cov-2 infection the royal college of ophthalmologists. the royal college of ophthalmologists american academy of ophthalmology canadian ophthalmological society -eye physicians and surgeons of canada. canadian ophthalmological society -eye physicians and surgeons of canada rcophth: the royal college of ophthalmologists sfo: société française d'ophthalmologie/french society of ophthalmology irso: iranian society of ophthalmology recomendaciones para la atención a pacientes oftalmológicos en relación con emergencia covid-1 informationen zum thema covid-19 finden sie all india ophthalmological society -from darkness to light secondary iranian society of ophthalmology website covid-19 clinical guidance for ophthalmologists new recommendations for urgent and nonurgent patient care all india ophthalmological society. aios operational guidelines for ophthalmic practice during covid 19 outbreak coronavirus covid-19 quelle conduite tenir pour la prise en charge de pathologies chirurgicales vitréo-rétiniennes en cette période d'épidémie de covid-19 virus sars-cov-2 ? emergenza coronavirus: prestazioni medico oculistiche, manuale d'uso, video messaggio del presidente covid-19 information for the opthalmology patient telemedicine applications for ophthalmology consultations during a pandemic emergency medical retinal management plans during covid-19 coronavirus impact: telemedicine considerations teleophthalmology: how to get started coding for phone calls, internet and telehealth consultations coronavirus impact: teleworking considerations federal agencies issue new telehealth guidance in light of covid-19 cos and acupo guidelines for ophthalmic care during covid-19 pandemic vitreoretinal surgery during the covid-19 pandemic coronavirus and eye care covid-19: updates and resources additional considerations to help manage the anti-vegf injection burden during the covid-19 pandemic guidance on covid-19 coronavirus support & ressources covid-19: guidance for rheumatologists conduite tenir pour le suivi des patients atteints d'uvéite au cours de la pandémie covid-19 glaucoma management plans during covid-19 quelle conduite tenir pour le suivi des patients glaucomateux -épidémie au covid-19 consultations d'ophtalmopédiatrie -épidémie covid-19 the royal college of ophthalmologists and the college of optometrists important coronavirus updates for ophthalmologists pink eye may be a rare symptom of coronavirus, doctors say the japanese opthalmological society. information about eyes of new coronavirus infectious disease hand hygiene: why how & when? the royal college of ophthalmologists. ppe and staff protection requirements for ophthalmology the royal college of ophthalmologists. ppe and staff protection requirements for rop screening and treatment the royal college of ophthalmologists. ppe requirements for ophthalmology coronavirus (covid-19): what you need to do videos for donning & doffing ppe les urgences neuroophtalmologiques pendant l'infection covid19 française d'ophthalmologie. recommandations covid pour les ophtalmologistes -15 mars key: cord-317574-wyzscmtr authors: singh, narendra; tang, yuanyuan; ogunseitan, oladele a. title: environmentally sustainable management of used personal protective equipment date: 2020-06-29 journal: environ sci technol doi: 10.1021/acs.est.0c03022 sha: doc_id: 317574 cord_uid: wyzscmtr nan period either, with an estimated compound annual growth of 20% in facial and surgical masks supply from 2020 to 2025. 2 the sustainable management of ppe is a key challenge. the lack of a coordinated international strategy to manage the ppe production and waste lifecycle threatens to impact progress toward achieving key components of the united nation's sustainable development goals (sdgs), including sdg 3 good health and wellbeing, sdg 6 clean water and sanitation, sdg 8 decent work and economic growth, sdg 12 responsible consumption and production and sdg 13 climate action. 4 we propose product lifecycle strategies that should be integrated into solutions based on public-private partnerships. the increase in ppe manufacture and distribution is generating an equivalent increase in the waste stream, compounded by health and environmental risks along the waste management chain, especially in countries with an underdeveloped infrastructure. china produced approximately 240 tons of medical waste daily at the peak of pandemic in wuhan, amounting to six times higher than before the disease outbreak ( figure 1) . therefore, the local waste management agency deployed mobile incinerators in the city to dispose of the unprecedented quantities of discarded face masks, gloves, and other contaminated single-use protective gear. 1 similar increases in discarded face masks, hand gloves, and protective goggles have been observed worldwide. for example, more than 7 million residents of hong kong wear single-use masks daily. there are published reports of discarded masks in the ocean and on hong kong's beaches and nature trails. 5 the pandemic has impacted how solid-waste management activities are performed. the waste management and resource recycling sectors were not regarded as essential services and were placed under lock down. this disruption of routine waste management services has been documented worldwide, further exacerbated by china's earlier restrictions imposed in 2019 on the importation of "recyclable" solid waste. in response, impromptu procedures for collection and recycling of used ppe has been underway in some countries, a practice that may present hazard due to improper decontamination. 6 improper disposal or handling of contaminated waste can transmit viral pathogens to healthcare and recycling workers. for example, it has been estimated that up to 30% of hepatitis b, 1−3% of hepatitis c, and 0.3% of hiv rates have been communicated from patients to healthcare workers due to improper disposal of medical waste. studies conducted in pakistan, greece, brazil, iran, and india show that higher than normal prevalence of virus infection in solid waste collectors' can be traced directly to pathogens in contaminated wastes. 7 the united nation's basel convention on the transboundary movement of hazardous wastes and their disposal has recently urged member countries to treat waste management amid covid-19 as an urgent and essential public service to minimize possible secondary impacts upon health and the environment. therefore, safe and sustainable recovery and treatment of ppes should be intensified. it is important to clarify the role of informal recyclers in developing countries, where medical waste has not been adequately regulated. the ppe response to the covid-19 pandemic has also impacted plastic recovery and recycling and will increase landfilling and environmental pollution. the material composition of ppe includes plastics as major constituents representing 20−25% by weight. ultimately, if not recycled, their disposal contributes substantially to hazardous environmental pollutants such as dioxins and toxic metals. contrary to recommendations from the world health organization, which encourages safe practices that reduce the volume of wastes generated and that ensure proper waste segregation at origin, 7 plastic-based ppe discarded from households is mixed with other domestic plastic wastes such as single-use plastic bags, the use of which has multiplied rapidly since grocery stores disallowed customers to bring their own bags for fear of additional virus transmission routes. polypropylene is a common constituent of ppes such as n-95 masks, tyvek protective suits, gloves, and medical face shields. polypropylene also represents a substantial proportion of the approximately 25 million tons of plastic materials that are disposed of in u.s. landfills annually, with recovery and recycling accounting for only 3% of the polypropylene plastic generated. 8 the potential to recover polymers from mixed healthcare waste including ppe is challenging. recycling without risking infection of individuals working as recyclers in middle-and low-income countries is limited by the low proportion (15− 25%) of healthcare waste that is not contaminated. furthermore, the low recycling rates for plastic waste worldwide and the lack of coordinated governmental policies that require minimum recycling content in new products will likely lead to an increase in virgin plastic manufacturing in the postpandemic period. the u.s. plastics manufacturing industries have requested more than $1 billion in emergency funds to deal with the extra demands attributed to covid-19 impacts. 9 to ensure that increased plastic ppe production does not lead to increased pollution, restrictions on the emergency funds are warranted to support investments in research and development of used ppe collection, sorting, and recycling. implementing a sustainable ppe waste management system will benefit from public-private partnerships (ppps). in countries with economies in transition, the role of artisanal solid waste collectors and recyclers is indispensable. developing safe and sustainable ppe management beyond the healthcare settings (hospitals and clinics) under emergency conditions is complicated because it requires a clear understanding of best practices, monitoring, and enforcement of policies and regulations. in healthcare settings, thermal, chemical, irradiative, and biological processes can be implemented locally or scaled-up in regional facilities where collection and waste transportation are possible. single-use ppe is not a sustainable practice, and multidisciplinary technical expertise, including biomedical sciences, environmental science, public health, materials science, and engineering is essential for tackling the ppe pollution problem. new research since the beginning of the current pandemic indicates that ppe disinfection and reuse is possible on a large scale through methods such as infusion of hydrogen peroxide vapor, ultraviolet or gamma-irradiation, ethylene oxide gasification, application of spray-on disinfectants, and infusion of base materials with antimicrobial nanoparticles. 10 many of the disinfection methods are in the preliminary stage, and they must be calibrated to ensure that material degradation during each disinfection cycle does not compromise the primary function of ppes to prevent penetration of pathogens and human exposure. the circular economy principle focusing on reducing, reusing, and recycling resources should guide policy development for ppe management during and after the current pandemic. national policies should be designed to require that plastic manufacturers add minimum recycling content in new products, and product pricing should reflect environmental and health externalities. public education campaigns to promote appropriate ppe stewardship should be integrated into policy implementation, monitoring, and enforcement. development of infrastructure to ensure safety in informal waste collection environmental science & technology pubs.acs.org/est viewpoint and recycling in low-income countries is essential. to be sustainable, ppe management policies need be integrated into economic models that promote the adoption of green technology and alternative assessments to identify and adopt safer processes based on comprehensive materials life cycle assessments and consumer preferences. in summary, the covid-19 pandemic has strained solid waste management globally, while also highlighting the bottleneck supply chain challenges regarding ppe manufacture, demand-supply, use, and disposal. ppes will continue to be in high demand, and this is the time to invest in research and development for new ppe materials that reduce waste generation, and for improved strategies for safe and sustainable management of used ppe with policy guidance at the global level. ogunseitan − department of population health & disease prevention is supported by the national science fund of china (41977329), and the shenzhen postdoctoral funding (29/k19297523), respectively. o.a.o. codirects the lincoln dynamic foundation's world institute for sustainable development of materials (wisdom) at uc irvine the materials genome and covid-19 pandemic end-use industry (manufacturing, construction, oil & gas, healthcare) -global forecast to 2022 shortage of personal protective equipment endangering health workers worldwide health care waste management and the sustainable development goals discarded coronavirus masks clutter hong kong's beaches, trails sanitation workers at risk from discarded medical waste related to covid-19 facts and figures about materials, waste and recycling -plastics: material-specific data big plastic asks for $1 billion coronavirus bailout. the intercept is the fit of n95 facial masks effected by disinfection? a study of heat and uv disinfection methods using the osha protocol fit test key: cord-272182-5lunidrs authors: lim, wan yen; wong, patrick; teo, li-ming; ho, vui kian title: resuscitation during the covid-19 pandemic: lessons learnt from high-fidelity simulation date: 2020-05-22 journal: resuscitation doi: 10.1016/j.resuscitation.2020.05.024 sha: doc_id: 272182 cord_uid: 5lunidrs nan the coronavirus disease 2019 (covid-19) pandemic has caused an unprecedented global healthcare crisis, creating challenges to resuscitative efforts. cardio-pulmonary resuscitation (cpr) confers additional risks to healthcare workers due to exposure to aerosol generating procedures (agps) like chest compressions, face mask ventilation and intubation. the emergent and high-intensity situation may also result in lapses in infection control practices 1 . high-fidelity simulation sessions were conducted in our institution to identify latent threats in existing workflows, and to formulate modified life support protocols focusing on: protection of healthcare workers (hcw) and patients, minimizing aerosolization and reducing delays in resuscitation. sengkang general hospital, one of singapore's largest regional hospitals, comprises an acute care 1000-bedded facility and a 400-bedded community care hospital. suspected or confirmed covid-19 patients are managed in negative pressure, single-bedded rooms in the acute care hospital. in the community hospital, such patients are managed in cohort wards (4-6 bedded bays) with natural cross ventilation through large open windows. a single code blue team, based at the acute hospital, provides resuscitation services at both facilities. due to geographical reasons, the mean (sd) code blue response time to the acute and community care wards were 3.28 (1.76) and 6.67 (2.06) minutes, respectively. these timings were validated from actual code blue events pre-covid-19. in simulations, we adhered to hospital and covid-19 guidelines of full ppe (including n95 mask or powered air-purifying respirator (papr), gown, gloves, goggles and face shield or visor) 2 . a donning and doffing supervisor, or a buddy system can reduce selfcontamination amongst hcw 3 . the mean (sd) time taken by 19 hcw during simulations, for donning full ppe including cleanspace ® papr was 3.33 (0.73) minutes. our timings were comparable to donning full ppe that included n95 mask, which were 3.28 (1.15) minutes 4 . we identified two latent threats on two separate simulation sessions: 1. a participant, designated as the second responder, entered the resuscitation room without eye protection; 2. a participant tripped and fell while retrieving equipment, possibly contributed by impaired peripheral vision when wearing goggles. learning points from these include adopting a buddy system for donning and doffing of ppe, removing hazardous items and ensuring adequate resuscitation space. from our simulations in the community hospital where isolation facilities are unavailable, we observed that precautions to protect surrounding patients in the cohorted wards were required. these include use of waterproof shields or partitions to cordon off the resuscitation area, prompt evacuation of ambulant patients and minimizing aerosol generating procedures. due to the potential delay in response times, manual ventilation via sad 2 (preferred if hcw is trained and competent in sad insertion) or a well-fitting mask with a good seal may be required prior to code blue team arrival. we summarized our recommendations for resuscitation in acute and community hospital settings in table 1 . frequent training and simulation sessions including ppe familiarization minimizes delays in resuscitation, reduces risk of viral transmission, enhances communication, teamwork and coordination, and allows latent threats identification and workflow refinement. none. interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed covid-19: from the emergency cardiovascular care committee and get with the guidelines®-resuscitation adult and pediatric task forces of the american heart association in collaboration with the consensus guidelines for managing the airway in patients with covid-19 operation gritrock: the defence medical services' story and emerging lessons from supporting the uk response to the ebola crisis self-contamination during doffing of personal protective equipment by healthcare workers to prevent ebola transmission key: cord-332932-mq36xpai authors: wood, david a.; mahmud, ehtisham; thourani, vinod h.; sathananthan, janarthanan; virani, alice; poppas, athena; harrington, robert a.; dearani, joseph a.; swaminathan, madhav; russo, andrea m.; blankstein, ron; dorbala, sharmila; carr, james; virani, sean; gin, kenneth; packard, alan; dilsizian, vasken; légaré, jean-françois; leipsic, jonathon; webb, john g.; krahn, andrew d. title: safe reintroduction of cardiovascular services during the covid-19 pandemic: guidance from north american society leadership date: 2020-05-04 journal: j am coll cardiol doi: 10.1016/j.jacc.2020.04.063 sha: doc_id: 332932 cord_uid: mq36xpai nan the covid-19 pandemic has led to marked global morbidity and mortality [1] [2] [3] . there have been appropriate but significant restrictions on routine medical care to comply with public health guidance on physical distancing, and to help preserve or redirect limited resources. most invasive cardiovascular (cv) procedures and diagnostic tests have been deferred with north american cardiovascular societies advocating for intensified triage and management of patients on waiting lists 4 . unfortunately, patients with untreated cardiovascular disease are at increased risk of adverse outcomes 5 . delays in the treatment of patients with confirmed cardiovascular disease will be detrimental. similarly, reduced access to diagnostic testing will lead to a high burden of undiagnosed cardiovascular disease that will further delay time to treatment. although there will be a myriad of competing demands from multiple disciplines, this risk warrants the prioritization of cardiovascular patients as healthcare systems return to normal capacity 4 . while covid-19 has had a global impact, there are regional differences in the burden of the pandemic. some regions have not experienced a significant surge of cases variably related to social and health care adaptation measures, or the surge has passed and was less substantial than predicted. in these areas, there are available health sector resources that can be redeployed quickly. as regions move along the journey of managing the covid-19 pandemic, there is an opportunity to reintroduce regular cardiovascular care in a progressive manner with appropriate safeguards. cardiovascular societies have released a number of position or guidance statements which predominantly focus on the provision of cardiovascular care during the peak of the pandemic 6-12 . these documents highlight the central theme of balancing essential cardiovascular care services while reducing exposure and preserving health care resources to address the pandemic. as the covid-19 pandemic abates, developing appropriate strategies to reintroduce routine cardiovascular care will be crucial. unprecedented times require unprecedented collaboration. in this consensus report, we harmonize recommendations from north american cardiovascular societies and provide guidance on the safe reintroduction of invasive cardiovascular procedures and diagnostic tests after the initial peak of the covid-19 pandemic. similar to rationing decisions made in preparation for the initial surge of covid-19 cases, progressive and thoughtful reintroduction of cardiovascular services must be based on robust ethical analysis 13 . relevant values to be operationalized include 14 : 1) maximizing benefits such that the most lives, or life years are saved so that procedures or tests that are likely to benefit more people and to a greater degree are prioritized over procedures that will benefit fewer people to a lesser degree; 2) fairness such that like cases are treated alike, taking into consideration baseline health inequities; 3) proportionality such that the risk of further postponement is balanced against the risk of exacerbating covid-19 spread; and 4) consistency such that reintroduction is managed across populations and among individuals regardless of ethically irrelevant factors such as ethnicity, perceived social worth or ability to pay. finally the promotion of procedural justice, with the use of an ethical framework 15 , is essential to ensure all decisions reflect best available evidence with transparent communication. collaboration between regional public health officials, health authorities and cardiovascular care providers some regions have seen an escalation in covid-19 cases when social restrictions and physical distancing have been eased. hospital based cv teams must establish active partnerships with regional public health policy makers to exchange up-to-date information on both the local status of the pandemic and the growing morbidity and mortality on cardiovascular waiting lists. this is essential for the safe reintroduction of regular cv services. there should be a sustained reduction in the rate of new covid-19 admissions and deaths in the relevant geographic area for a prespecified time interval as determined by local public health officials before changes can be implemented. importantly, if covid-19 admissions and deaths start to increase, there must be immediate and transparent cessation of most elective invasive procedures and tests. resumption of these services would occur in collaboration with regional public health policy makers. as discussed below, covid-19 testing of potential patients and health care workers (hcw), as well as personal protective equipment (ppe), must also be carefully monitored to minimize the risk of shortages as the pandemic escalates and abates. a cohesive partnership with regional public health officials will facilitate management of the dynamic balance between provision of essential cardiovascular care and responding to ongoing fluctuations in covid-19 admissions and deaths. the protection of patients and hcws must be addressed before any reintroduction of cardiovascular procedures and tests. regions must have the necessary critical care capacity, ppe, and trained staff available before the recommendations summarized in table 1 can be implemented. importantly, a transparent plan for testing and re-testing potential patients and hcws for covid-19 must be operationalized before elective procedures and tests are resumed. additional considerations include: 1) physical distancing: consider strategies to minimize patient contact with hcws performing invasive cardiovascular procedures and diagnostic tests. these may include virtual pre-procedural clinics, virtual consenting for procedures and diagnostic tests, and minimizing the number of hcws in physical contact with any given patient. restrictions should be implemented on the number of people that can accompany a patient or visit a patient after a procedure or test. whenever possible, multiple tests or procedures should be consolidated into a single comprehensive visit. 2) covid-19 screening: encourage routine screening of all patients prior to any cardiovascular procedure or test to ensure the safety of hcws. this testing may include nasopharyngeal swabs and saliva or rapid antibody tests and should be guided by local institutional infectious disease experts and closely coordinated with regional public health officials. key considerations include the availability and accuracy of the above tests as well as the frequency and timing of covid-19 testing and re-testing. appropriate ppe is required to protect hcws even if patients are asymptomatic, as the sensitivity of available tests are low in this setting. a significant benefit of testing is the opportunity of defer covid-19 positive patients if they remain clinically stable. 3) ppe: the use of ppe for hcws during routine cardiovascular procedures and diagnostic tests will be an important consideration. the need to ensure staff safety must be balanced against the need to conserve ppe supplies in the event the pandemic escalates. emergent cases, such as st segment elevation myocardial infarction (stemi) patients and urgent surgeries, or aerosol-generating medical procedures (agmp) will likely continue to require the highest level of ppe for the foreseeable future and thus available supplies must be carefully monitored. leaders from the north american cardiovascular societies acknowledge that the recommendations in this guidance document are based predominantly on expert opinion. this reflects the global challenge of managing a new and rapidly evolving pandemic where evidence is limited. 2) a transparent collaborative plan for covid-19 testing and ppe use must be in place before a safe reintroduction of procedures and tests can occur. 3) it is expected that different regions will be at different response levels as the pandemic escalates and abates. 7) the language in table 1 was chosen to give clinicians, health systems and policy makers the maximum flexibility when moving between response levels in their region. covid-19 prevalence, admission and death rates as well as appropriate time intervals for safe reintroduction will change and thus, we utilized "selective" cases and "some" or "most" cardiovascular procedures in table 1 . this consensus report provides harmonized guidance from north american cardiovascular societies. it provides an ethical framework with appropriate safeguards for the gradual reintroduction of invasive cardiovascular procedures and diagnostics tests after the initial peak of the covid-19 pandemic. a collaborative approach will be essential to mitigate the ongoing morbidity and mortality associated with untreated cardiovascular disease. white db, lo b. a framework for rationing ventilators and critical care beds during the covid-19 pandemic. jama. 2020. • covid-19 status may be unavailable at time of stemi. use of ppe will be dictated by regional health authority and covid-19 penetrance. • ppci for most patients. selective pharmacoinvasive therapy as per regional practice. • if moderate/high probability or covid-19 +ve consider alternative investigations (tte and/or cct) prior to cath lab activation or pharmacoinvasive therapy • covid-19 status may be unavailable at time of stemi. use of ppe will be dictated by regional health authority and covid-19 penetrance. • ppci for most patients. selective pharmacoinvasive therapy as per regional practice. • if moderate/high probability or covid-19 +ve consider alternative investigations (tte and/or cct) prior to cath lab activation or pharmacoinvasive therapy • covid-19 status may be unavailable at time of stemi. use of ppe will be dictated by regional health authority and covid-19 penetrance. • ppci for most patients. selective pharmacoinvasive therapy as per regional practice. • if moderate/high probability or covid-19 +ve consider alternative investigations (tte and/or cct) prior to cath lab activation or pharmacoinvasive therapy • nstemi (high risk) -invasive strategy (refractory symptoms, hemodynamic instability, significant lv dysfunction, suspected lm or significant proximal epicardial disease, grace risk score >140) • a novel coronavirus from patients with pneumonia in china first case of 2019 novel coronavirus in the united states covid-19 in critically ill patients in the seattle region -case series cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease 2019 (covid-19) pandemic reduction in st-segment elevation cardiac catheterization laboratory activations in the united states during covid-19 pandemic precautions and procedures for coronary and structural cardiac interventions during the covid-19 pandemic: guidance from canadian association of interventional cardiology triage considerations for patients referred for structural heart disease intervention during the coronavirus disease 2019 (covid-19) pandemic: an acc /scai consensus statement ase statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak society of cardiovascular computed tomography guidance for use of cardiac computed tomography amidst the covid-19 pandemic adult cardiac surgery during the covid-19 pandemic: a tiered patient triage guidance statement cardiac surgery in canada during the covid-19 pandemic: a guidance statement from the canadian society of cardiac surgeons management of acute myocardial infarction during the covid-19 pandemic fair allocation of scarce medical resources in the time of covid-19 cases: • congenital heart disease • cardiac masses • vascular: thoracic aortic disease and pulmonary vein mapping key: cord-266173-gmz6oxf6 authors: tino, rance; moore, ryan; antoline, sam; ravi, prashanth; wake, nicole; ionita, ciprian n.; morris, jonathan m.; decker, summer j.; sheikh, adnan; rybicki, frank j.; chepelev, leonid l. title: covid-19 and the role of 3d printing in medicine date: 2020-04-27 journal: 3d print med doi: 10.1186/s41205-020-00064-7 sha: doc_id: 266173 cord_uid: gmz6oxf6 nan as of march 12, 2020, the world health organization classified coronavirus disease 2019 (covid-19) as a pandemic, at the time of writing affecting nearly every country and territory across the globe [1] . during this time of social and economic despair, global healthcare systems are under critical strain due to severe shortages of hospital beds and medical equipment. patients with covid-19, the disease caused by severe acute respiratory syndrome coronavirus 2 ( fig. 1) , are at risk for acute respiratory distress syndrome (ards) and a fraction will require high-level respiratory support to survive [2] . additionally, significant strain has been placed on personal protective equipment (ppe) supplies required to protect the healthcare workers helping to treat critically ill patients during this pandemic. at the time of writing, there are active disruptions of medical supply chains throughout europe and in the united states at the hospital level, particularly in the states of new york and washington. the purpose of this editorial is to highlight recent (as of april 1, 2020) initiatives and collaborations performed by companies, hospitals, and researchers in utilising 3d printing during the covid-19 pandemic and to support local 3d printing efforts that can be lifesaving. the 3d printing community can refocus its medical attention internationally, capitalizing on centralized large-scale manufacturing facilities as well as locally distributed manufacturing of verified and tested cad files. in addition, there are multiple medical, engineering, and other societies and groups that can pull together to work on common needs, many of which are outlined in this editorial. while models discussed here are primarily opensource necessities available at the time of writing, the cad file resources referred to in this editorial are intended for a discussion of an evolving collection of ready-to-print models and links to the relevant resources to aid in supporting urgent medical response. an example collection can be found at the nih 3d print exchange. we must acknowledge that at the time of writing, the clinical effectiveness of many of the devices manufactured according to the cad files described in this editorial has not been tested and many of these devices have not been approved for frontline clinical use by relevant regulatory bodies. the authors of this editorial cannot guarantee clinical effectiveness of the presented devices and would urge consideration of these resources at the users' discretion and only where no medically cleared alternatives are available. the recent impact of covid-19 in italy has caused regional shortages of key equipment, including masks and hoods for non-invasive ventilation in cpap/peep respiratory support. crucially, venturi valves, key components of such respiratory support equipment [3] proved difficult to reproduce or substitute in the setting of these shortages. while venturi valve design is subject to copyright and patent covers, certain emergencies resulting in life-or-death decisions may justify full use regardless of intellectual property, in the appropriate clinical setting. this critical demand has resulted in the 3d printing community of physicians and engineers at a local italian startup isinnova successfully developing methods for manufacturing these valves to bolster local supply [4] . additional methods of bolstering local ventilator supply include the use of a single ventilator for multiple patients with a 3d printed ventilator splitter. fortunately, the us fda does not object to the creation and use of certain devices such as the t-connector that meet specifications described in the instructions provided to the fda for use in placing more than one patient on mechanical ventilation when the number of patients who need invasive mechanical ventilation exceeds the supply of available ventilators and the usual medical standards of care have been changed to crisis care in the interest of preserving life. the fda's "no objection" policy in this regard applies during the duration of the declared covid-19 emergency. access to such models is still limited for many local 3d printing community members and will require close collaboration between companies and hospitals to ensure adequate manufacturing approaches and appropriate clinical use. the reverse-engineered 3d printable model of the isinnova valve is not widely available at the time of writing, with the authors maintaining the position that such resources should be adequately evaluated and used only when such equipment is not available from the original manufacturers. ongoing efforts by the engineers at isinnova are focusing on developing creative adaptations of existing products for respiratory support, for example by adapting a snorkelling mask into a non-invasive ventilator [5] . most recently, non-adjustable venturi valve designs were developed and made available by the grabcad user filip kober [6]. these valve designs achieve specific levels of inspired oxygen (fio 2 ) at set rates of supplemental oxygen supply (fig. 2) . model porosity may inadvertently alter intended fio 2 levels, requiring the use of printing technologies that ensure airtight parts. automated ventilators with flow-driven, pressurecontrolled respiratory support systems featuring safety valves, spontaneous respiration valves, and flexible membranes present an ongoing open source design challenge with some promising results, including the illinois rapid-vent design. while sourcing ventilators and ventilator parts from existing manufacturers is the clearly preferred option when feasible, the supply of these crucial devices is inadequate in many areas. a solution currently being applied to this challenge in europe and the united states is the creation of 3d printed ventilator splitters and adjustable flow control valves, such as the no2covid-one valve, to be able to adapt a single ventilator for use with multiple patients who have different oxygen requirements [7]. we anticipate new creative solutions for such increasingly complex challenges from emerging international open source design efforts such as the montreal general hospital foundation code life ventilator challenge [8] as the covid-19 health crisis emerges. quarantine measures in the setting of this pandemic have sparked tension and fear among the lay public. an unfortunate consequence of this is unnecessary panic buying, leaving those who need these products, such as health care workers, in limited supply. members of the global 3d printing community have designed a plethora of reusable personal protective equipment devices with insertable filters, primarily manufactured using low-cost desktop filament extrusion printers. to our best knowledge, ppe items in need at the time of writing include splash-proof face shields, surgical masks, n95 masks, n90 masks, powered air-purifying respirator (papr) hoods, and controlled air purifying respirator hoods (capr). many of the ppe designs highlighted here are works in progress, and the effectiveness of locally manufactured derivatives of these devices should be carefully evaluated locally. additionally, these ppes are intended to be reusable, and therefore local manufacturing efforts should carefully consider compatibility with the available sterilization techniques and the condition of all ppe devices should be monitored following sterilization on an ongoing basis. to ensure the best fit, personalizing these masks may be achieved by printing in several sizes, experimenting with flexible materials, or surface scanning intended users' faces and carrying out additional cad to virtually fit these masks on an individual basis [9] . while this individualized approach may limit manufacturing throughput, the improved functionality may justify this impact on throughput. in general, throughput may be the most challenging factor to address in developing 3d printed ppe in smaller-scale local 3d printing laboratories. many of the models highlighted here require several hours to print on conventional desktop printers. while many 3d printing laboratories can parallelize this process with multiple printers, throughput will likely remain limited to dozens of masks per printer and 3d printing resources should therefore be assigned judiciously. this section refers to ppe used to protect the wearer from airborne particles and liquid contaminants on the face. for the purpose of this article these are referred to as "face masks" and there are several 3d printed solutions. the fda, nih 3d print exchange, and the united states veterans' association are working together in this regard, including developing a prototype n95 mask currently being tested. in the meantime, numerous face mask designs have been proposed and tested by individual users, researchers, physicians, and commercial entities alike with variable degrees of success. in all cases, the end users must clearly understand that only prototypes are available at this point and local testing procedures, potentially modified from established routine n95 fit testing, are crucial to assess the quality of ppe. the copper3d nanohack mask [10] demonstrates the limitations of the community-generated designs and the need for design improvements based on local testing and available technical base. this mask can be printed with polyactic acid (pla) filament as a flat piece, and is intended to be subsequently manually assembled into its final three-dimensional configuration after heating to a temperature of 55-60°c (131-140°f) via forced hot air (e.g. a hairdryer) or by submerging it in hot water (fig. 3) . crucially, all seams must be manually sealed to ensure an airtight fit. the mask includes a simple air intake port into which two reusable filters may be inserted, with a screw-in cover to hold the filters in place. this design fig. 2 open-source non-adjustable venturi valve design for an fio2 of 33% at supplemental oxygen flow rate of 10 l per minute. the cross-sectional view (above) demonstrates the inner structure of this device with a small oxygen port (light blue) and a larger air intake (left) has several drawbacks. due to the flat design, only one mask can be printed at a time on most desktop printers, limiting throughput. practically, our initial tests demonstrate difficulties folding these masks created using conventional pla filament, with significant gaps along the seams that are difficult to mitigate. if successfully sealed, the mask may provide limited airflow for some users and a second breathing port, achievable by mirrorimaging the port-bearing half of the mask, may need to be added. as a result of multiple limitations, this mask is currently undergoing revisions by the original designer. the hepa mask designed by the thingiverse user kvatthro [11] may be manufactured using most desktop printers. pla filament is suggested due to the possibility of fitting the mask to the individual user after heat exposure, which is important to ensure the best possible air seal in field conditions. the mask comes in male and female variants and allows space for an exchangeable hepa filter insert within a port at the front of the mask (fig. 4) . a similar design has been proposed by the chinese company creality [12], with a different configuration of the filter holder, intended for insertion of layers of folded fabric or filters (fig. 5) . the creality goggles require separately sourcing transparent plastic inserts, which may be obtained from repurposed household items. as with all masks, judicious testing for seal adequacy and experimentation with sizing and materials are required for implementation. the lowell makes mask is a variant of the replaceable front filter design which offers the benefit of printing without supports or adhesion [13] (fig. 6) . the mask is intended to be lined with a foam padding on the inside. while addition of elements such as foam padding to reusable ppe like the lowell makes mask improves user comfort, this may impact the selection of sterilization approaches and must be considered carefully. finally, additional creative designs, such as the "flexible mask valvy" by the thingiverse user iczfirz [14] have demonstrated the feasibility of printing pla masks on a cloth bed platform. this design allows for reusability with dedicated filter inserts. additional variations on personal protective equipment include protective face shields, such as those designed by prusa [15] . these simple devices feature a reusable printable headpiece to which a separately sourced transparent sheet of plastic can be attached to create a face shield, protecting the user's eyes and mouth (fig. 7) . face shield designs completely bypassing 3d printing have also emerged. covid-19 requires meticulous precautions in limiting person-to-person spread via direct contact with objects or surfaces such as door handles. simple interventions limiting such transmission can have far-reaching consequences. transmission from door handles may be problematic in public and in medical centers which usually have a large number of doors designed for patient privacy or ward control, especially during periods of isolation during pandemics. while meticulous and regular surface cleaning partially addresses this issue, modifications of a range of handles to allow alternative mechanisms for opening doors without direct skin-to-surface contact have been recently developed at materialise. these ready to print door handle accessories [16] can be manufactured on most 3d printing platforms (fig. 8) . current cdc guidelines for disinfection and sterilization in healthcare facilities define three major levels of pathogen eradication: cleaning, disinfection, and sterilization [17] . cleaning is defined as removing visible soil and organic material. the definition of disinfection varies based on whether it is low or high level, and refers to removing many or all microorganisms respectively, under optimal conditions. sterilization is defined as assured complete eradication of all microbial life on a given piece of equipment. based on analogy with the established operational parameters for reusable respirators [18], high-level disinfection is likely the most appropriate modality when dealing with reusable 3d printed personal protective equipment. recommended disinfection agents range from concentrated alcohol to quaternary ammonium compounds, and the precise agent selection would likely vary depending on the utilized material and printing technology. initial testing of the preferred/available disinfection mode may be conducted prior to scaling up manufacture, in consultation with local hospital policies and consideration of disinfection material availability. ensuring compatibility with widely available common household chlorine-based or hydrogen peroxide-based compounds may be prudent for individual users. in all cases, consultation with local hospital guidelines regarding the frequency, nature, and acceptability of disinfection and sterilization of reusable equipment should be followed. for devices requiring sterilization, manufacturer specifications for printing materials should be consulted. for example, 3d printed nasal swabs needed to expand testing in the us must not only be safe and provide adequate sample, but also must be sterilized and packaged appropriately for testing and eventual clinical use. where available, limited physical impact methods such as hydrogen peroxide gas plasma or ionizing radiation may be the preferred means of sterilization, since alternative methods such as autoclaving may deform the printed parts. we recommend that 3d printing experts communicate with their local hospital supply chain and potentially with national strategic stockpile holders. a centralized strategic local response to this crisis requires open forms of organized communication. in the united states and canada, local and state/province supply chain experts should relay best information of what is in stock, in transit, or on backorder. medical devices are highly regulated for safety. while dedicated people are responding in unprecedented ways, the 3d printing community must work in parallel to ensure that emergency parts are safe, or at a minimum safer than the alternative of not using them during a pandemic. even with the urgency of the growing covid-19 crisis, standard safety and quality measures of 3d printing labs should continue to be followed. for larger academic medical centers that have partnerships between university-based 3d printing resources and hospitals, this is often already in place; however, appropriate safety protocols should always be reviewed. safe implementation of unregulated parts is essential, and risk/benefit ratios can change very rapidly as medical supplies become unavailable. companies and regulatory bodies are strongly urged to work with the 3d printing community rapidly and efficiently. for hospital systems using internal 3d printing provided by medical or research/biomedical engineering personnel only, there is a concern for liability with 3d printing materials without safety and quality measures in place and these systems should address this concern immediately if not done already. intellectual property remains a concern, particularly for potentially reverse-engineering medical parts that cannot be purchased in a timely fashion during a pandemic. given the gravity of the situation at the time of writing, it is hoped that regulators, legal experts, and policy makers can rapidly come to agreements or allowances to save human lives using the goodwill of established and needed academic-industry partnerships. the concept of 3d printing in medicine started with the goal of improving patient education, diagnosis, and treatment [19] . we hope that this pandemic will inspire global creativity, learning and innovation through collaborative interactions of health professionals and engineers. we hope that 3d printing will be a force for a positive impact on morbidity and mortality in these trying times. going forward, the 3d printable medical model resources described here will likely be expanded in numerous centralized model repositories with new creative open source models, descriptions of intended use, assembly instructions, and target material/printer descriptions. we hope that the readers of 3d printing in medicine will find this discussion useful in addressing the covid-19 challenge and making a positive impact in patients' lives using this transformative technology. covid-19) pandemic planning and provision of ecmo services for severe ards during the covid-19 pandemic and other outbreaks of emerging infectious diseases acute oxygen therapy italian hospital saves covid-19 patients lives by 3d printing valves for reanimation devices respirator-free reanimation venturi's valve (rev. 4) wasp shares open source processes for production of personalized ppe masks and helmets makers guide prusa protective face shield -rc2 guideline for disinfection and sterilization in healthcare facilities cleaning reusable respirators and powered air purifying respirator assemblies stereolithographic (sl) biomodelling in craniofacial surgery publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations authors' contributions rt, fjr, and lc wrote the manuscript. all authors provided text contributions to the manuscript. jmm contributed fig. 1 . lc generated figs. 2, 3, 4, 5, 6 and 8. nw contributed to fig. 3 . the authors read and approved the final manuscript. the authors declare that they have no competing interests. key: cord-316157-7nci4q1q authors: iheduru‐anderson, kechi title: reflections on the lived experience of working with limited personal protective equipment during the covid‐19 crisis date: 2020-10-03 journal: nurs inq doi: 10.1111/nin.12382 sha: doc_id: 316157 cord_uid: 7nci4q1q coronavirus disease 2019 (covid‐19) has placed significant strain on united states’ health care and health care providers. while most americans were sheltering in place, nurses headed to work. many lacked adequate personal protective equipment (ppe), increasing the risk of becoming infected or infecting others. some health care organizations were not transparent with their nurses; many nurses were gagged from speaking up about the conditions in their workplaces. this study used a descriptive phenomenological design to describe the lived experience of acute care nurses working with limited access to ppe during the covid‐19 pandemic. unstructured interviews were conducted with 28 acute care nurses via telephone, webex, and zoom. data were analyzed using thematic analysis. the major theme, emotional roller coaster, describes the varied intense emotions the nurses experienced during the early weeks of the pandemic, encompassing eight subthemes: scared and afraid, sense of isolation, anger, betrayal, overwhelmed and exhausted, grief, helpless and at a loss, and denial. other themes include: self‐care, ‘hoping for the best’, ‘nurses are not invincible’, and ‘i feel lucky’. the high levels of stress and mental assault resulting from the covid‐19 crisis call for early stress assessment of nurses and provision of psychological intervention to mitigate lasting psychological trauma. permitted hospitals to amend their policies, allowing health care workers to reuse ppes and move from patient to patient without changing their gowns or facemasks (cdc, 2020) . although this move appears unprecedented, it is in line with the guidelines for changes in health care delivery during emergencies, when the focus is on saving as many lives as possible, and health care providers including nurses, may be expected to practice outside of the normal scope of their practice (koenig, lim, & tsai, 2011; powell, christ, & birkhead, 2008) . these changes in standards of care were instituted by the agency for healthcare research and quality and the office of the assistant secretary following the 911 terrorist attack, 2001 anthrax letter attacks, and the fears of the avian influenza pandemic in 2004 (agency for healthcare research & quality, 2005 , 2007 . powell et al. (2008) emphasized that during disasters and endemics, health care providers need to discuss any anticipated changes to the standards of care, particularly as it relates to limited resources, such as ventilators. because the community and the public are expected to adjust to the scarcity of resources, powell and colleagues stressed that 'even before a patient comes to the hospital, political leaders and health officials must emphasize publicly that standards of care are and must be different in a public health disaster' (powell et al., 2008, p. 25) . health care providers must do whatever they can with the available resources. in a scarce resource environment, the focus of care shifts from the individual patient to optimizing outcomes for populations of patients (chang, backer, bey, & koenig, 2008; koenig et al., 2011; powell et al., 2008) . veenema and toke (2007, p. 72c) underscored the protection of health care workers during crises, stating that 'giving providers and their families personal protective equipment and instituting other measures such as staff rotation and stress management programs' are essential to preventing burnout. in the context of covid-19, while some hospitals require their staff to wear face masks at all times while onsite (fox, 2020) , others are preventing their workers from wearing face masks brought from home, with some hospital administrations even threatening their staff with disciplinary action, including termination (ault, 2020) . these conflicting policy changes and confusion have posed a different type of challenge for health care workers. there have been several online reports of nurses and other health care providers being intimidated or reprimanded for speaking out about their working condition during the pandemic. this prompted the american nurses association (ana) to respond, calling on occupational safety and health administration (osha) to remind employers that retaliation against health care workers for speaking out and raising concerns about their personal safety while caring for covid-19 patients is illegal (ana, 2020c) . the ana reminded nurses experiencing retaliation from their employers of their right to file a whistleblower complaint online with osha. as many hospitals continue to restrict the use of ppe to preserve their supply in anticipation of growing covid-19 cases with the rapidly evolving outbreak, many health care providers on the frontline believe that the ppe restrictions are impeding their ability to safeguard their welfare (ana, 2020d) . these policy changes presented by health care organizations are in line with the crisis capacity category described by the institute of medicine (2010) and the cdc (2020). 'crisis capacity is defined as adapting spaces, staff, and resources so that … you're doing the best you can with what you have. staff may be asked to practice outside of the scope of their usual expertise. supplies may have to be reused and recycled. in some circumstances, resources may become completely exhausted. family members may be asked to provide basic patient hygiene and other aspects of care that do not require medical expertise' (institute of medicine, 2010, p. 13) . little research has examined the experiences of nurses during global, regional, or national health care crises related to disease outbreaks or natural disasters. existing studies have focused on hospital preparation, availability of resources, and the safety of patients (barbisch & koenig, 2006; karabacak, ozturk, & bahcecik, 2011; ruchlewska et al., 2014; tzeng & yin, 2008) , the education of hospital staff (powers, 2007) , emergency room nurses' description and management during a crisis (vasli and dehghan-nayeri, 2016) , and the psychological impact of disease outbreaks on hospital workers (sun et al., 2020; wu et al., 2009; yin & zeng, 2020) . however, in mass casualty events and disease outbreaks, nurses may experience anxiety and personal loss (sun et al., 2020; veenema & toke, 2007; yin & zeng, 2020) . most studies of nurses' experiences during a disease outbreak were focused on asian countries due to current and previous experiences related to covid-19, middle east respiratory syndrome-coronavirus (mers-cov), and human swine influenza outbreak (khalid, khalid, qabajah, barnard, & qushmaq, 2016; kim, 2018; lam & hung, 2013; su et al., 2007; sun et al., 2020; yin & zeng, 2020) . a study conducted in turkey to determine the crisis management activities and attitudes of hospital nurse managers during times of crisis, such as earthquakes and bomb explosions reported that over '71% percent of the nurse managers surveyed in these hospitals left resolution of crisis to the top hospital management, 64.7% noted they increased the number of the staff members, and 58.1% said they ignored crises' (karabacak et al., 2011, p. 323) . crisis situations such as the one presented by covid-19 are a major barrier in providing optimal care as they have a strong impact on patients, their families, communities, and health care providers. during a crisis, nurses and other health care providers face various moral and ethical conflicts and dilemmas (koenig et al., 2011; tzeng & yin, 2008) . patient care is significantly affected by several factors, such as stress and fatigue, workload, lack of time, demand for expertise (kim, 2018; lam & hung, 2013; mahmoudi, mohmmadi, & ebadi, 2013) , influx of patients, experiences of health care providers, as well as level of managerial support (hagbaghery, salsali, & ahmadi, 2004; healy & tyrrell, 2011; kelley et al., 2004 ). an ana survey of 32,174 nurses working on the frontline during the covid-19 crisis indicated that 74% were concerned about the lack of ppe, 58% feared for their personal safety, and 64% were extremely concerned about the safety of their friends and family (ana, 2020d). considering the sparseness of empirical data on the lived experiences of nurses during crises situations, especially in the united states, this study examined the experiences of frontline nurses during the covid-19 crisis. crisis is defined as an undesirable event or outcome, which includes the element of surprise or disruption of action, and is a threat to the resources and well-being of an individual within the organization. it can have negative consequences, such as increased risk of death, delay in treatment, ignoring medical advice, and putting nurses under pressure (vasli and dehghan-nayeri, 2016) . in crisis situations, important lifesaving resources, such as 'ventilators and components, oxygen and oxygen delivery devices, intensive care unit beds (adequately staffed and equipped), health care providers, medications, etc.) are likely to be scarce' (koenig et al., 2011, p. 3) . similarly, during the covid-19 outbreak, the entire nursing workforce is facing a significant demand, which is anticipated to increase at an alarming rate. the purpose of this study was to describe the lived experience of acute care nurses working with limited access to ppe during the covid-19 pandemic. how do registered nurses describe the lived experience of working with limited ppe during the covid-19 crisis? this qualitative descriptive phenomenological study explored the lived experiences of acute care nurses working on the frontline during the covid-19 disease outbreak. descriptive phenomenology was chosen as the design for the current study because it explored and described the participants' everyday experiences as they lived them while working with limited ppe on the frontline of the 2020 covid-19 crisis. phenomenology as a research method is dedicated to describing the structures of experience as perceived by individuals without recourse to assumptions, judgments, or presuppositions (van manen, 2017a) . it is the search for structure and essence in experience, to form a deeper understanding of the nature and meaning of everyday experience (munhall, 2012) . the focus is on providing rich textured description of the individual experiences as described by those who experience it. the role of the researcher is to describe what people experience and how they experience it (finlay, 1999) , and to understand these experiences as much as possible through the eyes of the research participants. purposive sampling augmented with snowball sampling was used to recruit participants who met the inclusion criteria. to qualify to partake in the study, the participant was required to be a registered nurse, working in an acute care setting, or in units with diagnosed covid-19 patients or . recruitment was done through direct email to nurses working on the frontlines known to the author, via facebook and linkedin posts, posts to nursing support forums, and by wordof-mouth. participants were encouraged to share recruitment flyers with their colleagues to increase the sample size. the study was approved and monitored by the central michigan university institutional review board (irb) for the protection of human subjects in research. the irb-approved informed consent form was emailed to the participants for their review before scheduling the telephone interviews. prior to each interview, verbal consent to participate in the study was audio recorded and transcribed as part of the interview. to ensure confidentiality, each participant was assigned a pseudonym (creswell, 2012) , which was used throughout the research and for data presentation. all raw data were stored in dated folders in a secured network location. phenomenology is focused on lived experiences, aimed at describing, not explaining, how and why meanings arise, without researcher bias (finlay, 1999) . 'phenomenology does not look for 'truth' but for the participants' perceptions of 'their truth'-their own experiences as they perceive them' (sloan & bowe, 2014, p. 1,300) . using thematic analysis as described by burnard, gill, stewart, treasure, and chadwick (2008) , once the audio recording had been transcribed, the author familiarized herself with the data and verified its accuracy by simultaneously reading the transcript and listening to the audio recordings. during this process, any personal information, which may have been erroneously included in the interview, was deleted. all transcripts were line numbered. during the second reading of each transcript, open coding was performed by highlighting sections of the text and entering words and phrases that summarize what is being said in the text into an excel spread sheet created for this purpose. next, all the words and phrases from each individual interview spread sheet were compiled onto a single page. duplicate words and phrases were deleted, and overlapping and similar categories were refined and merged to reduce the number of categories. all the interview data relevant to the research purpose were allocated to the appropriate categories, which formed the final themes and subthemes. the author consulted a colleague not involved in the study to verify the coding process, and solicit unbiased feedback (elo et al., 2014) . finally, a report was written from the information organized in this table of findings. trust in qualitative research findings may be addressed using at least two of eight key strategies developed from lincoln and guba's model of trustworthiness (creswell, 2012) . lincoln and guba (1985) introduced the criteria of credibility, transferability, dependability, and confirmability for the assessment of rigor. for the reader to appraise transferability to other settings or populations, the author has provided justification for the research design, detailed description of the inclusion criteria, sample characteristics, and data collection and analysis methods (hader, 2010; maher, hadfield, hutchings, & de eyto, 2018) . bracketing, which allows one to become less assuming about another's experience, to be open, nonjudgmental and compassionate, and to present data from the perspectives of the participant rather than the researcher (chan, fung, & chien, 2013) was practiced. owing to the unprecedented nature of the covid-19 pandemic and its persistent broadcast on mass media, keeping a reflexive journal was very important for the author. the author chose to explore the experiences of these nurses because as a nurse who no longer worked in acute care setting, i wondered what it must be like to go to work every day during this crisis. it was important to hear directly from the nurses as they reflected on their everyday lived experiences. at times during the study interviews and data analysis, i was sometimes overwhelmed by the experiences described by these nurses. therefore, keeping a journal was very important for me to document and explore these feelings, in order to fully represent the participant experiences rather than mine. the author also engaged with other nurse colleagues to reflect on the overall effects of the pandemic and continued to maintain a reflexive journal to elucidate evolving perceptions throughout the research process (tufford & newman, 2012) . member-checking was ensured by returning to six participants to verify the transcribed audio recordings and clarify statements made during the interviews. a summary of the findings and themes was discussed with four participants in a telephone conference call. they all confirmed that the themes accurately reflected their experiences. this respondent validation is used to ensure the dependability and credibility of qualitative studies (elo et al., 2014; hadi & josé closs, 2016) . the sample comprised of 28 nurses, 21 women and 7 men, aged 28 to 65 years. their level of education ranged from associate degree to master's degree in nursing. all participants worked in acute care hospital, with 22 working in hospital in the northeast, 2 in the southeast, and 4 in midwestern united states (table 1 ). the lived experience of acute care nurses working with limited access to ppe during the covid-19 pandemic has been summarized into four themes. the first main theme is emotional roller coaster, which describes the intensity of the varied emotions the nurses experienced during the early weeks and months of the pandemic, encompassing the following subthemes: scared and afraid, sense of isolation, anger, felt betrayed, overwhelmed and exhausted, grief, helpless and at a loss, denial. other main themes include: self-care, 'hoping for the best', 'nurses are not invincible', and 'i feel lucky'. the themes, subthemes, and participants' exemplar quotes are displayed in table 2 . age range (in years) 28 to 65 experience of nursing practice (in years) 3 to 42 highest level of nursing education associate's degree in nursing (asn) 5 bachelor's degree in nursing (bsn) 17 master's degree in nursing (msn) 6 unit of acute care employment medical-surgical unit (med/surg) 11 emergency department (ed) 6 intensive care unit (icu) 10 'i felt like my employers were too busy covering their butts, that they continued to lie. on television, they tell the public that their main concern is the safety of their employees, but their actions were contradictory'. (nikki) overwhelmed and exhausted 'the barrage of information was too much. i was mentally and emotionally exhausted to take advantage of them. i am still mentally exhausted. i cried a lot. i lose my patience with minimal provocation'. (alexie) 'i was tired all the time. it was very hard getting out of bed, but i pushed myself to get up and go to work. after a very long day of seeing nothing but suffering and death, i feel mentally drained'. (priest) grief 'i used to think that nurses can overcome anything, but the death of that nurse, was devastating for me. i know people die, but…, it just hit home for me, the death of a nurse, someone you work with, and… my heart just aches'. the sense of isolation was profound for some of the nurses. although they went to work and were able to see their coworkers, many were isolated from their loved ones, for fear of unknowingly infecting them with the virus even when they were negative or asymptomatic. because some of these nurses felt like their close relative, who are not health care providers, would be unable to understand their grief, they kept their true feelings to themselves. therefore, close relatives did not know how to offer support, and were sometimes not able to recognize when their actions were perceived as unsupportive. in these situations, the nurses felt isolated and were not able to share their experiences with those who are closest to them. anger intermingled with fear was pervasive throughout the study. interestingly, very few participants (three) discussed being physically exhausted. all of them discussed being 'emotionally and mensome participants discussed being physically overwhelmed by working long hours and several days without days off for rest because nurse coworkers got sick or quit their jobs for fear of contracting the virus. one of the participants discussed being 'overwhelmingly exhausted', but was afraid to call out sick without being covid positive because she had not been on the job for a long time and her manager was very critical of nurses who called out, reminding the nurses that sick calls during the covid crisis will be considered during the annual evaluation. many participants discussed being overwhelmed and 'stressed out' with the volume of information received from work, social media, and television. some reported being short-tempered, cried with minimal provocation, or for 'no apparent reason', and 'not being able to hold it together'. alexie discussed being aware of important stress management strategies but not being able to use them due to mental and physical exhaustion. several nurses talked about their grief. jackie discussed her grief in the following statement: the pain and sorrow you feel when you learn that one of your coworkers has succumbed to this deadly virus. the feelings of helplessness and loss were echoed by many of the robert's concerns were echoed by amber who questioned the information being provided by her employer. least among the nurses' roller coaster of emotions was denial. other nurses were in denial because they were receiving mixed messages from their employers, managers, and the government, and because it was easier to deny the reality. self-care, and the lack thereof, was expressed by more than half of the participants. some described self-care as maintaining connections to other people, family, and friends during the difficult time. for others it meant keeping up with their routines prior to the crisis, like exercising, taking time to rest, and connecting with loved ones. some discussed not being able to 'shut it off' even when away from work. watching excessive television or following the news on social media affected their sleep and increased their anxiety. jane talked about forgetting to care for herself while caring for others. some of the participants used some unhealthy practices, such as increased smoking, alcohol consumption, and overeating or eating 'comfort foods', which were not particularly healthy to deal with increased stress. hoping for the best described what most of the nurses did once they reconciled to not having control over the pandemic or the non-availability of ppe. all the nurses in this study did what they were trained to do and hoped for the best outcome for themselves, their families, and their patients. for instance, kasey stated, just have faith, do your best, and hope for the best. if it is your destiny to die from this virus, whether you go to work or not, you will die from it. it's like a mantra for me. it kept me from screaming out loud and going crazy. i went to work, did what i trained to do, and hoped for the best outcome. flower who has only been employed at her current hospital for a little over four months felt that she did not have a choice but to go to work stating that she did what she needed to do and 'hoped for the best'. kelly also expressed being hopeful stating, we are nurses; we do what needs to be done. it is up to the employers and the government to provide us what we need to do the important work of taking care of patients and saving lives. in the situation we found ourselves with lack of adequate supply of ppe, and other things…sometimes limited iv supplies, we did our best and keep our fingers crossed. while many of these nurses have taken care of patients with various communicable diseases and worked with limited resources before, they expressed never having worked in situations where they lacked appropriate ppe. several of the participants' comments indicated that they felt that they were viewed as invincible, able to continue to operate without proper care. some felt that their employers perceived their lives and well-being as less important than that of their patients. twelve nurses in this study had eventually tested positive for covid-19; seven were symptomatic but did not require hospitalization. in describing their experiences, they compared it to being sui wish they would treat nurses with more care. others were told by their employers that even if they tested positive, but remained asymptomatic, they had to continue working. noah expressed surprise at this instruction from her unit manager, stating, 'nurses are often viewed as machines, unbreakable. we can be expected to be superhumanly resourceful and resilient, but in this crisis, we needed a little more caring'. several of the nurses talked about the need to feel supported and appreciated for what they were doing during the crisis when many around the world were sheltering in place, but they had to go to work. this is evidenced by sophia's statement: i am very grateful that the hospital eventually recognized the important work we were doing, that we too needed caring for. when they started providing safe transportation and meals for us, i was grateful. it made me feel like someone cared. under the circumstances we had to work, it made a difference. the above statement is in contrast to abby's statement about not feeling supported by her employers and managers, comparing herself to hospital equipment, especially during the earlier days of the pandemic. she stated, in the first three weeks of this madness, i just wanted to feel supported, i wanted to feel that my leaders and employers cared about me; i did not feel that… i felt like i was easily dispensable and placed at the same level as the hospital equipment. i seriously considered quitting, but i couldn't do that to my colleagues. nurses just want to be valued as humans… the participants talked about feeling lucky. lucky that they were not sick, were able to work and provide for their families and their this study aimed to describe the lived experience of acute care nurses who had to work with limited access to ppe during the covid-19 pandemic. their experiences denote intense emotional turmoil described under five main themes. the fear, anger, sense of isolation, exhaustion, and helplessness are consistent with feelings described by nurses caring for covid-19 patients in china (sun et al., 2020) . while many americans were following the shelter-inplace orders issued across the country to protect themselves from covid-19, tens of thousands of nurses across the united states were heading to work every day to care for patients affected by covid-19 and others requiring hospitalization for various ailments. the critical shortage of ppe for nurses and other health care workers placed them at risk of contracting the virus, becoming sick, and even dying. the emotional roller coaster was more pronounced during the earlier weeks of the pandemic in the united states, as also reported by sun et al. (2020) . the nurses' negative emotions were more pronounced when they first began taking care of covid-19 patients. o' boyle et al. (2006) reported that nurses were overwhelmed with the workload and longer work hours because some colleagues refused to work during the crisis. the nurses were concerned about exposing their families to the virus, which was also a concern for nurses taking care of patients during the 2003 outbreak of severe acute respiratory syndrome (sars) in taiwan (lee et al., 2005) , and middle east respiratory syndrome-coronavirus (mers-cov) in south korea. the sense of isolation was worsened with the nurses changing their home routine to protect their loved ones as was also reported by nurses caring for ebola virus patients (smith, smith, kratochvil, & schwedhelm, 2017) . physical and mental exhaustion, and the sense of betrayal expressed by the participants has been reported in other studies (lam & hung, 2013; sun et al., 2020) . o'boyle et al. (2006) reported that nurses feared they will be abandoned, have limited access to ppe, be at risk of infection, and have unmanageable numbers of patients to care for in cases of public health emergencies like covid-19. with the care standards and infection control protocols changing frequently during the covid-19 pandemic, the nurses were confused by the conflicting information they received. these changes also created moral and ethical dilemma for the nurses. evidence from public health literature indicates that appropriate communication of information is a major challenge during public health disasters (powell et al., 2008; vasli and dehghan-nayeri, 2016) , and poor communication and inaccurate information can weaken public trust in the government and result higher mortality rates (choi, kim, moon, & kim, 2015) . the nurses in this study struggled to balance their concerns with personal safety with their ethical and moral obligation to provide quality care for their patients. this is in line with the evidence from jiang (2020) study on the psychological impact and coping strategies of frontline medical staff in hunan china during the outbreak of covid-19, as well as kim and choi (2016) these nurses reported that they received conflicting information from their leaders at different levels. this is in conflict with ana warning issued in march 2020 that a lack of ppe will increase the risk of nurses becoming ill themselves, and more equipment was necessary to mitigate potential staff shortages caused by illness and quarantines (ana, 2020c). as reported by some of the nurses in this study, many health care organizations were not transparent with their nurses, many nurses were gagged from speaking up about the conditions in their workplaces. several of the nurses discussed self-care activities, such as exercise, meditation, and listening to podcasts, used to cope with the stress of dealing with the crisis. some mentioned avoiding watching the news. previous studies of nurses working with patients during severe disease outbreaks have highlighted the importance of selfcare activities to improve psychological well-being (sun et al., 2020; yin & zeng, 2020) . appropriate and supportive care for nurses is critical to prevent adverse short-and long-term outcomes for them and their families. studies indicate that perceived support is an important factor for mitigating prolonged and complicated grief (hutti et al., 2017; kim, 2018) . in taiwan the nurses in this study did not report experiencing any stigma from the community as disease carriers. which is in conflict with report from other studies where nurses and other health care providers reported being perceived as disease carriers and a threat to the safety of others (maben & bridges, 2020; sun et al., 2020) . nurses in this study reported being angry for several reasons. maben and bridges (2020, p. 2,743) reported that a 'failure to protect nursing staff adequately is causing anger and frustration, making nurses feel unsafe at work, while they are risking their own health and fearful of transmission to their families'. another source of anger rose from the focus of inadequate access to ppe in acute and intensive care settings, making it seem that the lives of nurses and care providers in non-acute care settings appear to matter less. overall, the high levels of stress and mental assault resulting from the covid-19 crisis calls for early stress assessment of nurses and providing psychological intervention to mitigate lasting psychological trauma. the author engaged in continued telephone communications with the two nurses who expressed wanting to hurt themselves during the interview for several weeks until they were able to secure professional psychological help. further, it is critical for nurse leaders and health care administrators to understand the impact of grief on the nurses. while most nurses will experience normal grief reactions in response to the covid-19 crisis, others may have significant, sustained, extremely intense, complex grief responses, which may negatively affect their physical and psychological well-being. those battered by stress may be the last to recognize it and stigma can be an obstacle to asking for help. as expressed by one of the participants, some of the nurses may not want to appear weak, put pressure on their peers, or they may fear of letting down their teams. therefore, nurse leaders must monitor their nurses for signs of complicated grieving, such as anxiety, depressive symptoms, and signs of post-traumatic stress disorders. the sense of betrayal expressed by these nurses should not be brushed off. it must be addressed. there is still time for employers and nurse leaders to redeem and repair lost trust of some of their nurses. nurse leaders and employers must respond to the needs of their nurses by using scientific evidence. ongoing honest communication of facts and compassionate responses for the nurse's experiences must be ensured. instead of protecting the institution, leaders must be transparent and lead with heart. policies related to the covid-19 must consider the many facets of the complex issues facing the nurses instead of taking a one-size-fits-all approach. the existing stigma of mental illness has not dissipated because of covid-19; therefore employers must do whatever they can to ensure that nurses who need help get it. there are several limitations to this study. first, the qualitative nature of the study limits the generalization of the findings. all the interviews were conducted from a distance through telephone or audio-visual means, and therefor, there was limited observation of body language beyond the tone of voice. although the study examined the lived experience of working with limited ppe during the covid-19 crisis, the crisis is still ongoing and many of the nurses were working in less than ideal conditions. future studies must examine the experiences of the nurses several months and years after the crisis is under control. the experiences of others working in health care during this crisis should also be explored. the covid-19 crisis is unprecedented. the degree to which nurses were exposed to death and experienced grief is alarming. although there were weeks of warning of impending pandemic, health care organizations and the u.s. government failed in their duty to provide for and protect their health care workers. while many americans socially isolated in their homes to avoid contracting the covid-19, nurses were heading to work, willingly exposing themselves and in some cases their families. the findings of this study indicate that many nurses across the united states now need their employers and the organizations to be present for them. although not explicitly named in some cases, many are suffering from trauma, and sustained mental and emotional stress. they need support for their mental and emotional health. it should not be assumed that nurses would seek help if needed. employers and leaders should preemptively offer support and in some cases should mandate that nurses speak to counselors or psychologists to promote mental and emotional well-being. this is an important opportunity to fully recognize that nurses are invaluable but finite assets, for generations they bear inherent emotional strain on behalf of society. to mitigate the loss of currently practicing nurses which will likely worsen the projected nursing shortage, the nursing profession and health care leaders must do all they can to support the welfare of nurses during this crisis and beyond. the author wishes to acknowledge all the nurses who took part in this study and the central michigan university, especially the college of health professions for providing the time release for the completion of this study. kechi iheduru-anderson https://orcid. org/0000-0003-2353-0410 coronavirus disease 2019 (covid-19) altered standards of care in sass casualty events: bioterrorism and other public health emergencies (no. 290-04-0010; bioterrorism and other public health emergencies) ana disturbed by reports of retaliation against nurses for raising concerns about covid-19 safety amid ppe shortage, clinicians face harassment, firing for selfcare understanding surge capacity: essential elements guidance for planners of the psychological response to stress experienced by hospital staff associated with covid: early interventions. covid trauma response working group rapid guidance analysing and presenting qualitative data bracketing in phenomenology: only undertaken in the data collection and analysis process? maximizing medical and health outcomes after a catastrophic disaster: defining a new mental health care for medical staff in china during the covid-19 outbreak public health crisis response and establishment of a crisis communication system in south korea: lessons learned from the mers outbreak qualitative inquiry and research design: choosing among five approaches qualitative content analysis: a focus on trustworthiness predictors of maternal grief in the year after a newborn death applying phenomenology in research: problems, principles and practice all partners healthcare employees now required to wear masks while on duty nurse leaders: a closer look ensuring rigour and trustworthiness of qualitative research in clinical pharmacy the factors facilitating and inhibiting effective clinical decision-making in nursing: a qualitative study stress in emergency departments: experiences of nurses and doctors predicting grief intensity after recent perinatal loss forum on medical and public health preparedness for catastrophic events psychological impact and coping strategies of frontline medical staff in hunan between crisis management: the activities of nurse managers in turkey the critical care crisis in the united states healthcare workers emotions, perceived stressors and coping strategies during a mers-cov outbreak factors influencing emergency nurses' burnout during an outbreak of middle east respiratory syndrome coronavirus in korea nurses' experiences of care for patients with middle east respiratory syndrome-coronavirus in south korea crisis standard of care: refocusing health care goals during catastrophic disasters and emergencies perceptions of emergency nurses during the human swine influenza outbreak: a qualitative study facing sars: psychological impacts on sars team nurses and psychiatric services in a taiwan general hospital naturalistic inquiry covid-19: supporting nurses' psychological and mental health ensuring rigor in qualitative data analysis: a design research approach to coding combining nvivo with traditional material methods barriers to nursing care in emergency wards a phenomenological method nurses' beliefs about public health emergencies: fear of abandonment allocation of ventilators in a public health disaster evaluation of hospital-based disaster education effect of crisis plans on admissions and emergency visits: a randomized controlled trial phenomenology and hermeneutic phenomenology: the philosophy, the methodologies, and using hermeneutic phenomenology to investigate lecturers' experiences of curriculum design the psychosocial challenges of caring for patients with ebola virus disease prevalence of psychiatric morbidity and psychological adaptation of the nurses in a structured sars caring unit during outbreak: a prospective and periodic assessment study in taiwan a qualitative study on the psychological experience of caregivers of covid-19 patients bracketing in qualitative research crisis management systems: staff nurses demand more support from their supervisors phenomenology and meaning attribution but is it phenomenology? qualitative health research emergency nurses' experience of crisis: a qualitative study when standards of care change in mass-casualty events the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perception, and altruistic acceptance of risk a study on the psychological needs of nurses caring for patients with coronavirus disease 2019 from the perspective of the existence, relatedness, and growth theory key: cord-331978-y4uo7o8g authors: maxwell, daniel n; perl, trish m; cutrell, james b title: “the art of war” in the era of coronavirus disease 2019 (covid-19) date: 2020-03-04 journal: clin infect dis doi: 10.1093/cid/ciaa229 sha: doc_id: 331978 cord_uid: y4uo7o8g nan novel coronavirus disease (covid-19) caused by the virus sars-cov-2, began in wuhan, china, and has spread worldwide, with over 101,700 cases and 3,461 deaths in more than 75 countries. with rapidly increasing cases and local community transmission in multiple countries outside of china, including the united states, the outbreak has entered a new phase, which requires a shift in primary battle strategy from a focus on containment in china to international mitigation. what will be required to fight this novel virus as it travels the globe? the metaphor of war is often used in the infectious diseases field, with its interspecies fight for survival. military strategies can be applied to outbreak management, and advice from one of the oldest and bestknown military sages -china's own sun tzu discusses the importance of preparation in the art of war. sun notes that victory is achieved before any fighting begins and that those headed toward failure look for victory only after the battle has already begun 1 . so again, how do we prepare to fight covid-19? as cases of covid-19 explode internationally, a strategic shift is required away from primarily containment, keeping the virus "out there", to home-based mitigation and public health responses. the task of healthcare systems is no longer screening and treating small numbers of infected returning travelers in highly specialized units with expert teams. now, the task is bearing the burden of identifying, isolating, triaging and managing the rising number of cases, necessitating total engagement of the medical community, public health sector, governments and society as a whole. for the medical and public health communities, this enormous task requires approaches that are both rapidly scalable and sustainable. we need to use existing teams and resources efficiently and to build capacity where it is lacking. two reports in this issue of clinical infectious diseases shed light on possible steps forward. first, we must learn from our own and others' battles. marchand-senecal et. al. 2 report on the successful management of the first hospitalized case of covid-19 in canada. they draw on and highlight lessons from the 2003 sars experience in toronto. notably, while they utilized airborne, contact, and droplet precautions in a negative pressure room, no advanced personal protective equipment (ppe) such as powered air-purifying respirators (paprs) was used. the rationale was simple. prior research demonstrates that using unfamiliar or increasingly complex ppe increases the risk of selfcontamination 3 . consequently, training for healthcare workers (hcw) focused on ensuring proper donning and doffing techniques with familiar, well-rehearsed ppe procedures. as sun tzu noted, "if in training soldiers' commands are habitually enforced, the army will be well-disciplined." 1 the authors also highlight improvements in infection prevention and control (ipc) infrastructure, administrative controls, and public health coordination compared to their 2003 sars experience. standard staffing models rather than a dedicated covid-19 team were used safely. strategies that focus on maintaining the workforce by requiring sufficient training for all staff offer potential for more sustainable, scalable hcw capacity in these extraordinary settings. still, these authors note the paucity of evidence-based guidance for initial triage and discharge timing decisions in hospitalized covid-19 patients. second, we must train the way we intend to fight. as illustrated by the canadian report, the allure and novelty of ppe "maximalism" should be avoided in favor of proven strategies that hcw have practiced and conduct with a high-degree of fidelity without self-contamination. regarding triage, bryson-cahn 4 and colleagues in washington state present a novel framework for home screening and evaluation of persons under investigation (puis) based on prior preparation for ebola community screening in 2014. their experience describes nine community-based assessment visits during which teams screened puis in a variety of community settings after the ipc team determined a home assessment was appropriate. detailed protocols are given for how a hcw team, with appropriate training and required supplies, can safely perform a focused assessment and collection of screening samples outside the healthcare setting. this approach avoids unnecessary exposures and resource utilization for those who otherwise are safe to remain at home. their explicit protocols provide a framework for other healthcare and public health systems to weigh along with cost-effectiveness and scalability. both papers highlight the power of collaborative partnerships and communication between public health and healthcare facilities required in these events. finally, we must identify our weaknesses and vulnerabilities the "enemy" can exploit. as sun tzu exhorted, "carefully compare the opposing army with your own, so that you may know where strength is superabundant and where it is deficient." 1 we want to highlight four critical vulnerabilities at present within the united states context but with global applicability. first, a paramount vulnerability that must be rapidly addressed is the limited diagnostic testing capacity for sars-cov-2 in the clinical arena. at this stage where screening must expand from narrow geographic-based criteria to syndromic surveillance, rapid and validated testing at scale must be available to help inform clinicians and public health officials for isolation, triage and care of patients. fortunately, fda emergency use authorization regulatory requirements have been relaxed to allow more laboratory developed tests to come online even as the cdc races to expand testing capacity in the public health sector. these efforts must be given utmost priority to define the scope of current community transmission and to allow proactive, rather than reactionary, public health responses. second, aggressive supply chain management during periods of increased demand is critical. public panic and fear can create or exacerbate real supply shortages, especially in an era of social media and just-in-time supply chain management. the world health organization and others have issued helpful guidance on the rational use of ppe for covid-19, aimed at optimizing hcw safety while mitigating disruptions in the global ppe supply chain. 5 rapid scalability in the supply of pharmaceuticals and ppe must be considered a public health imperative. moreover, preventing rushes on the public market through measured risk communication with the public can help safeguard needed supplies. finally, we must consider strategies to decrease less urgent use of ppe and identify situations where we can use different types of protection, where elements of ppe can be reused, or where the use of ppe is not supported by evidence-based practice. third, efforts to build and leverage margin and flexibility within healthcare staff capacity must be prioritized. marchand-senecal et. al. point out that specialized, dedicated teams in an outbreak, while attractive, could be quickly overwhelmed as cases increase. moreover, longer shifts and increased work intensity may lead to hcw fatigue and lapses in ppe techniques, driving nosocomial transmission, a painful reminder from the battle with sars. initial reports indicate about 4% of chinese hcw caring for covid-19 patients were infected, with 15% classified as severe or critical disease. 6 transmission to hcws, a feature seen with sars and mers, is devastating as it simultaneously diverts resources, depletes hcw capacity, saps morale, and drives public fear. to mitigate this, healthcare systems experiencing a surge in cases should consider all measures to liberate resources and staff, including telemedicine triage, drive-thru testing, and preparations to reschedule elective medical care. fourth, and finally, our national and global commitments to funding for public health and epidemic preparedness must be expanded and sustained. rather than the current "boom and bust" funding roller-coaster responsive to the latest outbreak, governments must provide expanded, stable funding levels to improve disease surveillance and response and to build technical capacity for rapid deployment of diagnostics, vaccine development, and clinical trials of pharmaceuticals for this outbreak and the next. 7 the folly of short-sighted cuts to public health and research funding is manifest in the significant costs associated with a lack of preparedness and threatens global health and security. as the battle against covid-19 ramps up worldwide, it is imperative that the entire global community join together in solidarity, apply the hard-fought lessons of this and prior epidemics, and move rapidly to implement proven public health and ipc principles to turn the tide against this foe. quoting sun tzu one final time, "he who knows these things, and in fighting puts his knowledge into practice, will win his battles." none of the authors has any conflicts of interest. the art of war, circa 6 th century b.c.e, translation by lionel giles diagnosis and management of first case of covid-19 in canada: lessons applied from sars common behaviors and faults when doffing personal protective equipment for patients with serious communicable diseases clinical infectious diseases 5. who. rational use of personal protective equipment for coronavirus disease 2019 (covid-19): interim guidance characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72314 cases from the chinese center for disease control and prevention responding to covid-19-a once-in-a-century pandemic? key: cord-305503-j5e6fp61 authors: choi, gordon y.s.; wan, winnie t.p.; chan, albert k.m.; tong, sau k.; poon, shing t.; joynt, gavin m. title: preparedness for covid-19: in situ simulation to enhance infection control systems in the intensive care unit date: 2020-04-10 journal: br j anaesth doi: 10.1016/j.bja.2020.04.001 sha: doc_id: 305503 cord_uid: j5e6fp61 nan editordhealthcare simulation has been defined as a tool, device, and/or environment that mimics an aspect of clinical care. 1 although routinely used for enhancing medical education, recently its value to inform improvement in healthcare systems and processes has been recognised. 2 specifically, in situ simulation uses structured scenarios within environments that closely replicate real-world clinical situations, to produce information that can be used to improve systems and processes. 3 this approach is especially useful when approaching situations that would otherwise be difficult to study in the actual clinical setting because of practical constraints or inherent dangers to patients or healthcare workers (hcws), such as preparing the response to an outbreak. discovering that an infection control protocol is inadequate, or impractical to implement, in the real-world setting of a contagious patient during an infectious outbreak can have potentially severe consequences. coronavirus disease 2019 (covid-19) is already known to be associated with a high risk of transmission of disease to hcws, 4 and is likely to be more transmissible than severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers). 5 within the icu, potentially aerosol generating procedures such as manual ventilation and tracheal intubation are known to enhance transmission of respiratory viral disease to hcws, 6 and therefore introducing robust infection control processes as soon as possible is of paramount importance. although several expert opinion pieces have been written regarding appropriate standards for infection control and prevention of transmission of covid-19,7à9 few address operational issues, particularly the practical aspects of implementation, such as the ability to achieve an efficient, practical, and reproducible workflow in specific clinical settings. to examine system and operational issues related to our infection control guidelines, we designed and implemented a high-fidelity in situ clinical simulation to replicate admission, including tracheal intubation, of a patient with suspected or known covid-19 infection. the main objective of the simulation was to test the ability of the hcw team to effectively implement use of personal protective equipment (ppe), and the practicality of the intubation protocol and preliminary outbreak infection control guidelines. participants were a clinical team including volunteer doctors and nurses who underwent an in situ high-fidelity simulation. additional supporting staff participants were also available to enter the simulation when requested by doctor or nurse participants. the simulation was managed by one experienced simulation manager outside the isolation room observing though a glass observation panel, and one within. the simulation was conducted in a fully appointed but unused and disinfected airborne infection isolation room (aiir) with an anteroom and interlocking doors. a specified clean area located outside the anteroom was used for donning ppe. doffing ppe took place at a station within the anteroom. a simman 3g (laerdal medical ltd, orpington, uk) was used to simulate a patient with clinical covid-19 associated severe hypoxaemic respiratory failure and moderate arterial hypotension being admitted to the icu. tracheal intubation and placement of a central intravenous catheter was required. workflow and processes were critically observed throughout by the simulation managers. table 1 observed safety threats recorded during debriefing and response actions taken to eliminate or minimise the specific safety threat identified. aiir, airborne infection isolation room; hcw, healthcare workers; ppe, personal protective equipment. improper donning technique cuffs of waterproof gowns frequently not tucked securely under the gloves backs of gowns not secured leaving large exposed clothing areas personal belongings (pens and mobile phones) carried into aiir and removed from room without cleansing response illustrated step-by-step guide with 'hot tips' at each donning post provision of on-duty 'patrol' nurse to monitor the donning process buddy checking: personnel encouraged to check each other's ppe integrity extra dedicated hospital mobile phone available inside and outside the aiir, with use of speakerphone to allow easy communication and forwarded calls guideline amendment to not take personal belongings into aiir observation before intubation connections between the bag valve mask (bvm) resuscitator, peep valve, mainstream co 2 monitor, bacterial/viral filter, and face mask were frequently incorrectly placed repeated need to dis-/reconnect circuitry between intubation completion and connection to mechanical ventilator inability to rapidly provide key drugs or equipment for urgent use in the aiir, particularly those requiring patient identification, special registration, or both failure to clearly communicate explicit backup intubation plans and role assignments to key team members response guideline amendment stating that, before use, a doctor and a nurse must cross-check circuit component placement, function and security additional mainstream end-tidal co 2 sensor made available for use in ventilator circuit accompanied by guideline amendment guideline amendment that additional gowned personnel, airway equipment, and drugs should be immediately available in the anteroom standardised medication set developed for intubation: induction agent, muscle blocking agent, pre-prepared vasopressor, and sedative/analgesia infusion pumps a pre-intubation checklist developed and prominently displayed in intubator's line of vision, specifically including requirement for airway backup plan (fig. 1 a pre-designed management focused feedback rubric was used to debrief the participants at the end of the simulation. the domains for feedback and discussion included the following key events in chronological order: donning ppe, preintubation check, intubation procedure, and doffing ppe. participants were encouraged to provide feedback and suggestions that may enhance the effectiveness of the protocol and improve clinical workflow. after each debriefing and critical review, changes to improve the guideline and workflow were instituted, and the revised protocol was tested in the subsequent simulation. we completed 11 individual simulations involving 44 participants (11 doctors and 33 nurses/supporting staff). each simulation lasted 20e30 min and debriefing lasted 30 min. based on the observations of the simulation facilitators and the structured debriefing, several infection control-related workflow problems were observed (table 1 and fig. 1) . observed safety threats, and those recorded during debriefing, addressed the following key domains: donning and doffing of ppe, advance preparation of intubation and ventilation strategies, technical understanding of circuit setup, environmental protection measures, communication difficulty, and accessibility of key drugs and equipment. responses to eliminate or minimise the observed safety threats resulted in both guideline changes, modifications to the environment, and implementation of methods to improve workflow and ability of staff to follow infection control guidelines (table 1) . repeated simulations resulted in no additional changes after the eighth simulation. we recommend in situ simulation methodology as a valuable tool to evaluate and improve system performance, in this case infection control guidelines before the occurrence of an anticipated real event. repeated simulations appear useful as new simulations yielded meaningful system/process deficits up to the seventh simulation. this meant that within 2 days relevant guideline modifications and workflow improvements could be fully evaluated and implemented. anticipating the rapid progression of the covid-19 pandemic, a potentially fatal respiratory disease, it is especially important to be prepared in the icu to protect staff from transmission during high-risk procedures such as tracheal intubation. with the use of in situ simulation as described, we were able to create a workable guideline, visual aids, and workflow that allowed proper implementation of infection control in a real clinical setting. in situ simulation answers the questions 'what could be done better?' and 'what is working well?'. 2 to answer these questions, key components of simulation are: 1) simulation should take place in situ (within the real workplace with normally available equipment and drugs) to re-create the work environment accurately; 2) participants should be working hcws reflecting the makeup of the clinical environment (doctors, nurses, and supporting staff); 3) scenario should recreate a meaningful clinical event; 4) structured debriefing should be done by a combination of simulation experts and senior management staff to focus on the evaluation of guidelines, systems and workflow (in addition to providing for education of participants); and 5) should be repeated until further useful system observations cease to occur. 10 it is clear that our reported infection control protocol and improvements may not be directly applicable to other icus, as systems and processes should be specific to individual institutions and local practices. this report is limited in that the time constraints of an imminent outbreak did not allow a more formal evaluation of methodology, nor provide evidence that the intervention described improved actual practice, or contributed to the actual reduction of transmission to hcws. nevertheless, we believe in situ simulation provides a potentially useful tool to rehearse the safe care of patients in anticipation of treating an emerging infectious disease such as covid-19. technology-enhanced simulation for health professions education: a systematic review and meta-analysis simulation for systems integration in pediatric emergency medicine the study of factors affecting human and systems performance in healthcare using simulation characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention rigidity of the outer shell predicted by a protein intrinsic disorder model sheds light on the covid-19 (wuhan-2019-ncov) infectivity aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-ncov) patients covid-19: a critical care perspective informed by lessons learnt from other viral epidemics outbreak of a new coronavirus: what anaesthetists should know in situ simulation: detection of safety threats and teamwork training in a high risk emergency department the authors declare that they have no conflicts of interest. key: cord-330870-l0ryikhv authors: eubanks, allison; thomson, brook; marko, emily; auguste, tamika; peterson, logan; goffman, dena; deering, shad title: obstetric simulation for a pandemic date: 2020-07-23 journal: semin perinatol doi: 10.1016/j.semperi.2020.151294 sha: doc_id: 330870 cord_uid: l0ryikhv objective: in the middle of the covid-19 pandemic, guidelines and recommendations are rapidly evolving. providers strive to provide safe high-quality care for their patients in the already high-risk specialty of obstetrics while also considering the risk that this virus adds to their patients and themselves. from other pandemics, evidence exists that simulation is the most effective way to prepare teams, build understanding and confidence, and increase patient and provider safety. finding: practicing in-situ multidisciplinary simulations in the hospital setting has illustrated key opportunities for improvement that should be considered when caring for a patient with possible covid-19. conclusion: in the current covid-19 pandemic, simulating obstetrical patient care from presentation to the hospital triage through postpartum care can prepare teams for even the most complicated patients while increasing their ability to protect themselves and their patients. objective: in the middle of the covid-19 pandemic, guidelines and recommendations are rapidly evolving. providers strive to provide safe high-quality care for their patients in the already high-risk specialty of obstetrics while also considering the risk that this virus adds to their patients and themselves. from other pandemics, evidence exists that simulation is the most effective way to prepare teams, build understanding and confidence, and increase patient and provider safety. finding: practicing in-situ multidisciplinary simulations in the hospital setting has illustrated key opportunities for improvement that should be considered when caring for a patient with possible covid-19. conclusion: in the current covid-19 pandemic, simulating obstetrical patient care from presentation to the hospital triage through postpartum care can prepare teams for even the most complicated patients while increasing their ability to protect themselves and their patients. the current covid-19 pandemic has completely changed our lives and the healthcare environment we practice in. it is estimated that over 3.65 million patients have already tested positive and more than 250,000 people have died from the virus worldwide and these numbers continue to increase daily 1 medicine are providing non-intensive care unit providers with courses to help prepare them to care for critically ill patients and top medical colleges are providing updated guidance and algorithms as more becomes known about this fatal disease. this situation is highly dynamic, and providers are forced to learn, adapt, and change protocols quickly as more information emerges with each passing hour. from prior pandemics and disasters, it is evident that simulation is one of the most effective ways to practice new protocols and identify gaps in knowledge and preparation [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] . communication, teamwork, and process efficiency are dramatically increased with simulations, which is why they are quickly being adapted as an essential part of medical training for small team events like codes and postpartum hemorrhages and large-scale, multi-hospital emergencies, disasters, and pandemics. medical simulation improves performance of medical teams and optimizes patient care by building a sense of control and understanding in an otherwise chaotic setting 13 . a large review of simulation studies demonstrated that these benefits resulted in improved patient safety by decreasing time to recognition and intervention in critical events 13 . the ebola outbreak in 2014-2016 was the most recent event that demonstrated a need for pandemic and disaster preparedness throughout the country, as hospitals quickly realized they did not have plans for admitting, transporting, and caring for these highly contagious patients 6, 8, 15, 16 . this was also one of the first times that simulations focused on protecting the providers from disease and not just improving patient care. simulations initially focused only on donning and doffing personal protective equipment (ppe), as this was noted to be one of the most critical aspects of readiness for this threat 16 . while the lessons learned in preparation for the ebola outbreak were important to manage patients with a highly infectious virus, the virus never reached pandemic level in the united states and hospitals quickly returned to normal operating procedures. now, facing a true global pandemic with covid-19, it is essential to prepare healthcare teams across the country for a large-scale influx of complex and challenging patients, while protecting teams and non-infected patients from a highly contagious disease. key components for pandemic simulation for covid-19 include the following areas: given the highly infectious nature of covid-19, simulation-based training should initiate with the arrival of the patient to the hospital. hospitals need to be prepared to triage patients and identify all patients under investigation (pui) as quickly as possible, isolating them and donning appropriate ppe while they undergo evaluation. ppe has been a significant hurdle in this pandemic as many locations are facing shortages of ppe. therefore, understanding protocols for extended use and reuse of ppe is critical to maintaining adequate protective measures. identifying ways to store n-95 masks or understanding the process for reprocessing them may be invaluable as a way to save resources when the supply chain is interrupted. further, in these simulations, ppe use must either be simulated or items recycled to ensure valuable ppe is saved for use with patients only. incorporation of up-to-date screening questions for when patients present to the healthcare facility should be drilled and even scripted as these questions are the first line of protection for our staff and patients. these questions are constantly changing and frequently asked by those with little or no medical training. once a pui is identified, this patient needs to be isolated and potentially separated from their visitor, spouse, or partner depending on the institution's visitor policy. immediately ensuring the staff and patient are in appropriate ppe is a priority. most hospitals have designated screening areas and limited entry points. therefore, the safest transportation method and route for a covid positive/pui patient from those specific points to labor and delivery should be identified early and practiced. as each hospital will have their own plan for alerting the necessary staff and teams of a new pui, details about which members of the patient's care team make those calls should be clearly identified and included in all simulations. the process of moving the patient to a pre-identified room should be carefully developed to decrease exposure to other patients and staff. working through safely moving multiple patients at one time should also be practiced in case of mass presentation with a focus on protecting staff and patients from exposure. one important consideration is to have a "runner" who moves in advance of the transportation team to clear hallways of patients, visitors, and providers. the runner also opens and closes all doors allowing the "contaminated" personnel to touch nothing along the route. a covid-19 designated room should have limited quantities of ppe and relevant triage and labor and delivery supplies within the room to decrease providers entering and exiting the room and sharing of supplies between patients. however, plans should include limiting storage of supplies in these rooms as all room contents will have to be thrown away if an aerosolizing event occurs with a covid/pui patient. hospitals must balance appropriate stocking of rooms with what is absolutely necessary. it is a fact that all supplies in the room will have to be wasted or terminally cleaned when the patient leaves this room. prepackaged essential supply kits for specific tasks (triage, delivery) that can be taken into a room stocked with only essential singleuse items may be incorporated into simulations. storage of ppe and methods for safe donning and doffing are of the upmost importance for teams to protect themselves and patients. the second stage of delivery, is highly debated as a potentially aerosolizing event, making this possibly a high-risk for the spread of covid-19 1 . discussion about which personnel are in the room with the patient and which personnel are on stand-by should be outlined and practiced. all providers in the room should have full ppe for the delivery. additional team members (anesthesiology, advanced pediatrics, an additional obstetrician) may wait outside the room ready to don ppe and enter if required. the process for acquiring additional supplies or personnel should be simulated to identify any concerns. additional simulations for contingency plans should be outlined and practiced, including emergency cesarean delivery with and without intubation/extubation, transfer of a patient to the icu (including who and how to notify the receiving team), and management of a postpartum hemorrhage including procuring medications, potential transfer to or, transport of blood from the blood bank, and transfer of specimen handling if necessary. a multidisciplinary approach should be taken to incorporate pediatric, anesthesia, and icu protocols into the care of these patients and their babies. institutional protocols for handling mom and baby interactions should be included in the simulation. if mother and baby interaction will be handled through distancing, masking and careful hygiene the simulation should ensure room set up, supplies and equipment to facilitate this approach. should the guidance be to separate mom and baby, and the patient agrees to that, it is vital to understand when and how this separation would occur and how to fully care for the baby in the postpartum period with this separation. labor and delivery management inherently involves high-risk situations with rapidly changing events that must still be addressed during the covid-19 pandemic. in obstetric team training, algorithms are heavily relied upon to care for patients in emergency situations and therefore, simulating these emergencies while incorporating the new protocols for caring for pui and covid-positive patients must be practiced. finally, as soon as possible after each simulation and each actual patient encounter with the new protocols, a formal, multidisciplinary debrief should take place to review processes that are working well, areas for improvement, and concerns from the team. specific action items to improve the process moving forward should be identified, assigned to individuals to work on, and implemented. in the current situation, guidance is changing rapidly, and teams will have to adapt and change quickly. excellent patient care should always be the top priority which must not be changed by the covid-19 pandemic. while using the least amount of personnel and interventions possible is desirable, it is important to continuously consider what is safest for the covid-positive patient, the providers, and the other patients. in order to provide resources for conducting obstetric covid-19 simulation, the acog simulation working group created a standardized simulation instruction manual which is available online at: https://www.acog.org/education-and-events/simulations/covid-19-obstetricpreparedness-manual 17 . this manual includes general instructions as well as four standardized simulation exercises that involve the following scenarios: a. all providers and patients must be educated on any policy developed to divert symptomatic patients to be screened and tested. all patients with planned visits (required/non-telehealth appointments) and planned admissions may be called the day prior to their appointment or admission and screened over the phone. they should be given updates on new guidance and a way to ask questions should they develop concerns before their planned arrival. b. it also became clear that patients were arriving to the hospital with their own masks and those without one were given one by the hospital. this can be reviewed in the pre-screening phone calls. c. the pre-screening phone calls were also the opportunity to educate the patients on the visitor policies for labor and delivery a. it is vital to involve anesthesiology, pediatrics, infectious diseases, and critical care in all planning and simulations as these specialties have quickly changing guidelines, as well. it was also clear that there were smaller, but still important gaps, in planning that simulation revealed: b. pediatric considerations: i. the use of simulation was found to be highly effective for planning of handoff for the newborn. guidelines from national organizations such as acog provides information regarding the suspension of common practices such as the use of late-preterm maternal steroids, oxygen administration for nonreassuring fetal heart tracings, delayed cord-clamping, and skin-to-skin maternal-infant bonding. simulation debriefing provided for sharing of information regarding these guidelines and for establishing institutional policies with interdisciplinary teams. for the pediatric teams, simulation provided for workflow refining of infant resuscitations either in the or or in an isolation room outside of the or given that these infants are puis or that resuscitative efforts may be aerosolizing. safe donning and doffing of pediatric teams was achieved through practice provided through simulation. a. simulation demonstrated the importance of workflow for these units for covid positive or puis. preparing a "covid cart" with ppe as well as a list of designated covid team members trained and fitted for specialized ppe was essential. ideally negative pressure labor and delivery rooms should be allocated and if these are not available then planning for isolation of these patients from other laboring patients is essential. as well, preparing a designated operating room for cesarean sections by removing all extra supplies or equipment, covering or plastic wrapping all keyboards and equipment necessary for the pediatrics, anesthesia and obstetrical teams to prevent needless contamination. assignment of clearly labeled donning and doffing areas with sufficient supplies of ppe, hand sanitizer, disinfecting wipes and containers as well as designated "dofficers" for assisting healthcare workers were found to be essential. assigning runners outside of the or with direct communication with the or personnel helped prevent breach of isolation. designating a pacu room with negative pressure was found to be ideal, however if these are not available then designating a pacu strategically based on the institution was important in the planning process. clear communication between the or and pacu should be established. optimally planning for maximizing the use of regional anesthesia for cesarean sections (whether planned or urgent) should be initiated. the greatest risk to healthcare workers occurs during the intubation and extubation procedures when a general anesthetic becomes necessary. simulation was found to be invaluable for this preparation in order to minimalize healthcare worker exposure. institutions have various protocols for these procedures, and it is essential for obstetric teams to work with their anesthesia colleagues regarding ppe and process for these events (especially if unplanned general anesthesia needs to take place intraoperatively). active management of the third stage is essential in all patients, but particularly in patients with covid to ensure that fluid shifts and bleeding patterns are safely monitored. b. missing materials/equipment in patient rooms i. while usually, leaving the room to grab an extra cord for an intrauterine pressure catheter (iupc) would not normally be a problem, to limit entry and exiting the room and limit amount of ppe used, it can be convenient to have kits of just essential supplies in the room. however, equipment that is exposed to covid patient and not used increases waste and therefore keeping excess supplies like extra iupc and monitoring cords, saline flushes, suture and lidocaine for repairs, forceps, vacuums, and extra delivery kits ensured ease of access while limiting waste. ii. this can be expanded to include making kits to use for deliveries or care on other units. in some settings, multidisciplinary drills to teach the collaborating units where these were located, and what they contained which increased preparation and eased anxiety. a. patient flow from the or to the pacu was established through simulation workflow processes. institutions will be able to allocate specific areas for these patients to recover. the logistics involved during doffing of each team member required multiple simulations in order for these members to become comfortable with these vital steps when healthcare workers are at greatest risk for self-contamination. in order to prevent a "bottleneck" of healthcare members doffing at the same time we established several doffing stations with "dofficers". as well as our pacu teams, we worked with our critical care and icu teams to prepare for the event that a pregnant covid patient should need to deliver in the icu or recover there. b. management and handling of the placenta i. in many of our initial simulations, we found there was no plan for management of a placenta from a pui/covid patient that we desired to have the pathology department evaluate. in some institutions practicing these simulations, a sterile processing plan, along with the ability to notify the receiving pathology team of the specimen, was developed to send some or all placentas for research analysis or pathologic evaluation. while in other institutions, made a blanket rule to discard all placentas in hazardous waste. c. management of scrubs after an aerosolizing event with a covid patient i. while a plan for changing scrubs was outlined early in this process, simulation demonstrated that there was no plan for safely disposing of soiled scrubs that did not put the housekeeping/laundry team at risk. organization of a separate bin for covid soiled scrubs with a decontamination process should be considered. d. transport and storage of breastmilk for an isolated mother and baby i. should a mother agree to be separated from her infant but desire to pump for her baby, lactation desired a safe collection and storage process for this breast milk. a separate pump and refrigerator for these patients can be placed in respective rooms. summary: pregnancy and birth are defining moments for a woman and her family. they can also be one of the most stressful events in a woman's life. in the middle of a new pandemic, women and their practitioners are frequently in uncharted territory and plans that have been made are having to be altered in ways most could never have foreseen. it is vital that practitioners are prepared to care for their patients' physical and emotional needs with the highest level of care while remaining current on ever-changing new information on the disease, protocols, patient safety practices and personal protection strategies. simulation allows for continuous practice that builds confidence and teamwork and increases patient safety. given the unknowns that accompany this pandemic, protocols are rapidly changing, and recurring simulation events allow for incorporation of new guidelines and hospital-wide changes. facing this pandemic with the maximum preparation and knowledge is vital to the care for our patients and ourselves. resources available: https://www.acog.org/education-and-events/simulations/covid-19obstetric-preparedness-manual management of critically ill adults with covid-19 icu readiness assessment: we are not prepared for covid-19 society for critical care medicine. critical care for non-icu clinicians using simulation for disaster preparedness advancing preparedness for highly hazardous contagious diseases: admitting 10 simulated patients with mers-cov. health security designing and conducting tabletop exercises to assess public health preparedness for manmade and naturally occurring biological threats beyond the ebola battle-winning the war against future epidemics mass casualty education for undergraduate nursing students in australia what is the impact of multidisciplinary team simulation training on team performance and efficiency of patient care? an integrative review postpartum magnesium sulfate overdose: a multidisciplinary and interprofessional simulation scenario anticipation and response: pandemic influenza in malawi impact of crisis resource management simulation-based training for interprofessional and interdisciplinary teams: a systematic review immersive simulation education: a novel approach to pandemic preparedness and response simulation as a critical resource in the response to ebola virus disease intensive care medical procedures are more complicated, more stressful, and less comfortable with ebola personal protective equipment: a simulation study covid-19 obstetric preparedness manual key: cord-306770-hjzlj8k3 authors: mick, paul; murphy, russell title: aerosol-generating otolaryngology procedures and the need for enhanced ppe during the covid-19 pandemic: a literature review date: 2020-05-11 journal: j otolaryngol head neck surg doi: 10.1186/s40463-020-00424-7 sha: doc_id: 306770 cord_uid: hjzlj8k3 background: adequate personal protective equipment is needed to reduce the rate of transmission of covid-19 to health care workers. otolaryngology groups are recommending a higher level of personal protective equipment for aerosol-generating procedures than public health agencies. the objective of the review was to provide evidence that a.) demonstrates which otolaryngology procedures are aerosol-generating, and that b.) clarifies whether the higher level of ppe advocated by otolaryngology groups is justified. main body: health care workers in china who performed tracheotomy during the sars-cov-1 epidemic had 4.15 times greater odds of contracting the virus than controls who did not perform tracheotomy (95% ci 2.75–7.54). no other studies provide direct epidemiological evidence of increased aerosolized transmission of viruses during otolaryngology procedures. experimental evidence has shown that electrocautery, advanced energy devices, open suctioning, and drilling can create aerosolized biological particles. the viral load of covid-19 is highest in the upper aerodigestive tract, increasing the likelihood that aerosols generated during procedures of the upper aerodigestive tract of infected patients would carry viral material. cough and normal breathing create aerosols which may increase the risk of transmission during outpatient procedures. a significant proportion of individuals infected with covid-19 may not have symptoms, raising the likelihood of transmission of the disease to inadequately protected health care workers from patients who do not have probable or confirmed infection. powered air purifying respirators, if used properly, provide a greater level of filtration than n95 masks and thus may reduce the risk of transmission. conclusion: direct and indirect evidence suggests that a large number of otolaryngology-head and neck surgery procedures are aerosol generating. otolaryngologists are likely at high risk of contracting covid-19 during aerosol generating procedures because they are likely exposed to high viral loads in patients infected with the virus. based on the precautionary principle, even though the evidence is not definitive, adopting enhanced personal protective equipment protocols is reasonable based on the evidence. further research is needed to clarify the risk associated with performing various procedures during the covid-19 pandemic, and the degree to which various personal protective equipment reduces the risk. during the coronavirus disease 2019 (covid-19) pandemic, personal protective equipment (ppe) worn by health care workers is critical for reducing transmission of the infection in health care settings, particularly when aerosol-generating medical procedures (agmp) are being performed. an aerosol is a suspension of fine solid particles or liquid droplets in air or another gas. within an aerosol, viral droplet nuclei can travel long distances and remain in the air for long periods of time. aerosols are not as effectively filtered by surgical masks, and can be breathed directly into the lungs. for transmission to occur, it is not enough for viral material to exist in droplet nuclei; the virus must remain viable. whether or not covid-19 remains viable in aerosols (and for how long) is still being investigated, but the balance of evidence indicates that betacoronaviradae such as the 2003 sars coronavirus (sars-cov-1) are viable in aerosols [1] . many otolaryngology procedures are thought to be aerosolgenerating [2] . when healthcare workers are at risk of transmission of infection from aerosols, "airborne" (rather than droplet) precautions are required [3] . otolaryngologists who are susceptible to being infected with covid-19 and who are working in close proximity to infected tissues for lengthy periods may be exposed to large infectious doses. covid-19 infects the upper aerodigestive tract with the highest viral loads occurring in the nasal cavities [4] . the surgeon's nose, throat, and conjunctiva (all potential routes of transmission) [1, 5] are typically within 30-60 cm of the patient's upper respiratory mucosa. during agmp, as a surgeon gets closer to the source of the aerosol, particle density increases exponentially according to principles of diffusion [6] . the association between infectious dose and disease severity has not yet been determined. analogous novel viral respiratory viruses, however, may provide a degree of evidence. the basic reproductive numbers (the expected number of cases directly generated by one individual in a population where all individuals are susceptible) for sars-cov-1 and covid-19 appear to be similar and thus comparisons are reasonable [7, 8] . in animal studies, increasing the initial exposure to sars-cov-1 increased the risk that mice developed the infection [9] . greater initial exposures to sars-cov-1 [10] , mers coronavirus [11] and influenza [12] resulted in more severe disease. in at least one recent study, a higher concentration of covid-19 in the nasal passages (i.e., higher viral load) was associated with increased risk of more severe disease and death [13] . viral load, however, is measured after the onset of infection and thus is not a proxy for infective dose. during the pandemic, health care agencies such as the world health organization, u.s. centers for disease control and the public health agency of canada [3, 14, 15] are responsible for defining agmp and rationing ppe when demand is greater than supply. the lists of agmp often do not specifically include otolaryngology procedures. national otolaryngology organizations and other ent groups [16] have published otolaryngology-specific agmp lists and ppe guidelines that call for a greater levels of protection than the public health agencies. for example, givi et al and the canadian society of otolaryngology-head and neck surgery [2] call for airborne precautions when performing agmp on patients for whom the index of suspicion for covid-19 infection is not high, whereas the world health organization, the u.s. centers for disease control, and the public health agency of canada do not [3, 14, 15] . givi et al also suggest that health care workers use powered air purifying respirators (paprs) when available for agmp performed on patients with probable or confirmed covid-19, in contrast to public health agencies that are either silent on the issue or suggest paprs are not needed [17] . we are members of the division of otolaryngology in saskatoon, saskatchewan. we were invited by the local health authority to provide evidence that a.) demonstrates which otolaryngology procedures are aerosolgenerating, and that b.) clarifies whether the higher level of ppe advocated by otolaryngology groups is justified. the following serves as a summary of our submission. part 1: aerosol-generating otolaryngology procedures is covid-19 transmitted via aerosols? respiratory aerosols typically consist of droplet nuclei less than 5 μm in size [18] . droplets fall to the ground at rates inversely proportional to their size. a 10 μm diameter particle settles in 8.2 min, compared to 1.5 h for a 3 μm diameter particle, and 12 h for a 1 μm particle [19] . thus, unless rooms are well ventilated, aerosolized droplets can become more concentrated over time. for an infection to be transmitted via aerosol, the organism must be able to survive within the droplet nuclei until it is deposited onto the mucous membrane of a susceptible individual either via inhalation or direct contact. the world health organization has cautioned that more studies are needed to confirm if covid-19 is transmitted via aerosols [20] , however an april 1, 2020 report from the u.s. national academies of science, engineering and medicine suggests it is likely [21] . the letter cites studies in which covid-19 rna was detected in air samples in hospital rooms of patients with covid-19 [22] . a widely cited experimental study indicates that covid-19 can remain viable in aerosols for hours [5] , but has been criticized since the methods used to aerosol the virus in the experiment are not reflective of agmp or natural cough [20] . a case report of a trans-nasal pituitary adenoma excision performed in china before widespread introduction of strict ppe provides anecdotal evidence of aerosolized transmission of covid-19. during the case, fourteen chinese health care workers were reportedly infected by the patient (who was mildly symptomatic pre-operatively), who was later confirmed to have covid-19. transmission occurred to workers who were both inside and outside the operating room [23] . during the sars-cov-1 epidemic, the largest nosocomial outbreak in hong kong occurred with a clear spatial pattern of infection that matched ventilatory patterns of the hospital floor, suggesting aerosolized transmission was likely [24] . a similar study showed that the pattern of spread of a large community outbreak of sars-cov-1 matched the ventilatory pathways from the apartment of the index case [25] . research about agmp has arisen from and been motivated by the need to protect health care workers during previous pandemics. cohort and case-control studies comparing the rates of transmission from patients to health care workers who perform certain procedures versus health care workers who do not provide direct evidence of the risk conferred by the procedures. experiments demonstrating that various procedures generate aerosols provide more limited evidence since they do not prove that transmission occurs via the airborne route. after the aids epidemic of the 1980s there was concern regarding the transmission of blood-borne viral illnesses during surgery. experiments showed that electrocautery, bone drilling, ultrasonically activated (harmonic) devices, and suction irrigation create aerosolized blood droplets and tissue particles [26] [27] [28] [29] . there is no epidemiological evidence, however, that the human immunodeficiency virus can be transmitted via aerosolized blood droplet nuclei [30] . experiments have also shown that intranasal and temporal bone drilling aerosolizes bone, blood and mucosa [26, 28, 31] . workman et al applied fluorescein inside the nasal cavity of cadaveric specimens, performed various surgical procedures, and measured aerosol spread outside of the nostrils using a blue-light filter and digital image processing. intranasal drilling but not cold instrumentation or microdebriding produced fluorescein aerosols that could be detected up to 60 cm from the nostrils [31] . during temporal bone drilling the spread of particles might be greater since the walls of the nasal cavity likely prevent the spread of some material. it is not known if the respiratory mucosa lining the middle ear and mastoid air cell system is involved in covid-19, but because the rest of the airway is involved, it appears likely that the lining of the eustachian tube, middle ear, and mastoid air cell system are also contaminated [32, 33] . .for these reasons, the use of use of high speed drills during mastoidectomy should be considered an agmp during covid-19. during the sars-cov-1 epidemic, it was initially thought that transmission occurred primarily via contact or large respiratory droplets. it was observed, however, that transmission to health care workers occurred despite the use of contact and droplet precautions, particularly during procedures suspected to be aerosolgenerating such as endotracheal intubation [34, 35] . a meta-analysis of observational studies evaluating the risk of transmission of sars-cov-1 during the epidemic showed that health care workers performing endotracheal intubation, non-invasive ventilation, tracheotomy and manual ventilation before intubation were significantly more likely than health care workers not involved in these procedures to contract the disease [36] . only one case-control study of front-line health care workers caring for sars-cov-1 patients in china contributed to the "meta-analysis" of tracheotomy [37] . in the univariate analysis, 6/85 cases (who had igg against sars-cov-1) versus 11/646 controls (who did not have igg against sars-cov-1) had performed tracheotomies during the epidemic (odds ratio 4.15, 95% ci 2.75, 7.54). the odds ratio for bronchoscopy, on the other hand, did not reach significance (pooled or 1.3, 95% ci 0.5, 14.2). many public health agencies and professional organizations [38] , however, list bronchoscopy as an aerosol generating procedure. the world health organization appears to classify bronchoscopy [39] as an agmp based on a study comparing the rate of tuberculin skin test conversion among pulmonology and infectious diseases fellows graduating in 1983 during a resurgence of tuberculosis in the united states. seven of 62 (11%) pulmonology fellows versus one of 42 (2.4%) infectious diseases fellows reported having converted tuberculin skin tests during their fellowships [40] . it was not clear that the pulmonology fellows were infected as a result of performing bronchoscopies. a 2009 study during the h1n1 influenza outbreak measured the amount of viral rna in the air in the vicinity of h1n1 positive patients undergoing bronchoscopy and other procedures, compared to controls. the concentration of viral rna was not significantly increased during bronchoscopy or any other procedure studied. the authors wrote that their study may have been underpowered to detect small differences in aerosol concentrations [41] . if bronchoscopy is aerosol-generating, it may be due to the suctioning usually involved with the procedure. air currents moving across the surface of a film of liquid generate droplets at the air-liquid interface, with the size of the droplets inversely proportional to the velocity of the air [39] . it is for this reason that any procedure that involve open suctioning of the airway is usually classified as aerosol-generating. there do not appear to be any studies that directly assess whether diagnostic nasopharyngoscopy produces aerosols in patients infected with respiratory viruses, and/or if it is associated with increased risk of airborne transmission of respiratory viruses to healthcare workers. workman et al performed an experiment in which they pushed an atomizer device from the cranium of a cadaver through the cribriform plate and into the nasal cavity, plunged the syringe "at maximal pressure" to inject aerosolized fluorescein into the nasal cavity, then performed intra-nasal endoscopy and measured the spread of fluorescein out the nostrils. various masks that were modified to allow passage of the endoscope were placed on the cadaver head in front of the nostrils. it is not known whether their methods accurately mimic the situation in patients with covid-19. they did find, however, that the masks reduced the spread of fluorescein outside the nostris [31] . despite the lack of evidence, in the covid-19 era diagnostic endoscopy of the upper airways is often listed as an agmp by health care agencies, likely because of its perceived similarities to bronchoscopy and because the endoscope travels through tissues with high covid-19 viral loads [2, 42] . in contrast to bronchoscopy, however, many endoscopic procedures of the upper aerodigestive tract do not require suctioning. further evidence is needed to understand the degree to which endoscopy of the upper aerodigestive tract generates aerosols. generation of aerosols during cough, pursed lip breathing and normal breathing: implications for outpatient procedures most ent outpatient procedures induce coughing due to deep instrumentation and/or excessive mucous or blood that triggers the cough reflex. the jet of droplets and aerosols expelled by a cough can hit nearby health care workers at high volume and velocity, and at close range. the frequency of cough is higher in a patient infected with covid-19, since it is a symptom of the infection [43] . the world health organization considers cough to be aerosol-generating [44] , a position that is supported by a number of studies [45] [46] [47] [48] [49] [50] . the average distribution of droplet sizes expelled during cough ranges on average between 0.58-5.42 μm, with multimodal peaks at 1, 2 and 8 μm. larger droplets may partially evaporate during the jet expulsion from the mouth to produce smaller droplet nuclei [45] . aerosols are also generated by "pursed lip" breathing methods, often adopted by patients who have epistaxis to avoid aspirating blood trickling posteriorly and into the throat [51] . aerosols can be produced by normal breathing as air passes over respiratory mucosa [52] [53] [54] , through the reopening of closed small airways to form small airborne droplets [55] , and/or through fluid film rupture in the bronchioles [56] . during normal breathing, the lungs filter out most larger droplets from being exhaled [53] . as might be expected, coughing produces more aerosolized droplets than normal breathing or talking [53] . breathing rate and age are both positively correlated with breath aerosol concentration, but do not completely explain the variability observed between individuals [56] . head and neck physical examinations and the collection of nasopharyngeal swab samples are not typically classified as agmp [17] . the fact that aerosols are produced during normal breathing combined with the close proximity required to perform these procedures do, however, provide support for recommendations from otolaryngology groups that airborne precautions should be taken by health care workers performing head and neck examinations in patients who have suspected or known covid-19 [16] . part 2: evidence clarifying if enhanced ppe are needed for otolaryngology agmp givi et al and the canadian society of otolaryngology-head and neck surgery suggest adhering to airborne precautions when performing agmp on patients whose covid-19 status is unknown or who have low risk of infection during the pandemic [2, 16] . they also recommend paprs (if available) to perform agmp on patients with probable or confirmed covid-19 [2, 16] . the world health organization [57] , cdc [14] and public health agency of canada [15] do not make these recommendations. occupational health professionals are often tasked with determining the type of ppe needed in novel circumstances arising in various industries. the cdc through the national institute for occupational safety and health (niosh) [58] and the canadian center for occupational safety and health [59] recommend "control banding" as a qualitative or semi-qualitative technique used to guide the implementation of workplace control measures. in control banding assessments, the potential for harm is determined by 1.) the consequences of exposure; 2.) the concentration of toxin; and 3.) the risk of exposure. operations that expose workers to a greater potential for harm demand more stringent control measures. the consequences of covid-19 infection to individuals are well described elsewhere [43] but range from mild illness to death. if health care workers become sick they can pass the infection to others, propagating the pandemic, and are no longer available to assist on the front lines. the increased risk of exposure to high concentrations of aerosols during otolaryngology agmp has already been discussed. thus, the following section focuses on the third element, the risk of exposure to covid-19, and the likelihood that the different ppe recommended by the different groups alters the risk. the risk of exposure to covid-19 when a patient's covid-19 status is unknown a significant proportion of individuals infected with covid-19 are either pre-symptomatic (they have not developed symptoms yet) or asymptomatic (they never develop symptoms). the mean incubation of covid-19 period is 5-6 days, with a range of 1-14 days [43] . a well-known study of 3063 passengers on the quarantined diamond princess cruise ship showed that 52% of 634 persons who tested positive for covid-19 had no symptoms at the time of testing [60] . on march 31, 2020, the director of the u.s. centers for disease control (cdc) stated that the percentage of people in the general population who have covid-19 but do not have symptoms is 25% [61] . this estimate ranges from 12.6% in china [62] to 50% in iceland, where a very high proportion of the population (5%) has been tested for covid-19 and thus the results may be more reflective of reality [63] . pre-symptomatic carriers can transmit disease. on april 1, the cdc reported the results of an investigation of all 243 cases of covid-19 reported in singapore between january 23 and march 16. seven clusters of cases were identified in which pre-symptomatic transmission was the most likely cause of secondary cases [64] . it is estimated that 44% of transmission could occur before the first symptoms [65] . the true number of cases of covid-19 in the population is unknown but is assuredly much higher than the number of cases confirmed by testing and reported to government agencies due to limitations in population sampling and test sensitivity [66] . it is therefore likely that a significant proportion of patients presenting to the health care system for various reasons but who do not complain of symptoms of covid-19 will be infected with the virus and can transmit it to health care workers for many months to come. the sensitivity and specificity of commonly performed covid-19 diagnostic tests has not been definitively determined in part because a safe "gold standard" comparator has yet to be developed. variability in sampling due to technical difficulties swabbing the nasopharynx or because of changes in the viral load throughout the course of illness may affect the sensitivity of the test. a negative result thus does not necessarily rule out infection. if the test is positive, it is likely correct, although it is possible that though cross-contamination from other patients or lab workers could result in false positive results [66] . the positive-and negative-predictive values of the test depend in part on the local true prevalence of covid-19. for the reasons stated above, recommendations for airborne precautions for agmp performed on patients whose covid-19 status is unknown during the pandemic appear to be reasonable according to the precautionary principle [67] . it is not clear when such precautions should be rescinded. published epidemiological projections suggest that similar to previous pandemics, even after the current wave of new cases subsides, outbreaks will recur throughout the world over at least the next year until herd immunity and/or an effective vaccination program is established [68] . the risk of exposure of covid-19 using powered airpurifying respirators, reusable elastomeric respirators and filtering facepiece respirators (n95 masks) powered air-purifying respirators (paprs), reusable elastomeric respirators and filtering facepiece respirators (e.g., n95 masks) represent different methods of filtering out aerosols in the air. a papr, which costs about usd 1400, contains a battery-powered high-efficiency particulate air filter that delivers clean air into a hood or a full face mask, and blows off exhaled air. the hood is either hard and tight-fitting or loose. the risk of leakage with paprs is negligible and, unlike reusable elastomeric respirators and n95 masks, there is no need for a fit test or additional eye protection since the head is completely enclosed within the system [69] . this feature of the papr benefits individuals who fail fit tests and those whose religious beliefs prevent them from shaving. decontamination protocols for paprs must be in place and adhered to meticulously before they are re-used [69] . resuable elastomeric respirators, which typically cost <usd 100, are used more commonly in heavy industry than health care. such devices are made to meet national institute for occupational safety and health (niosh) standards, and are defined by the ability of the device to filter out oil or non-oil particulate. they may either cover the lower half of the face (and require additional eye protection) or cover the entire face. respirators are classified according to their particulate filtration efficiency; both reusable elastomeric respirators and filtering facepiece respirators come in p100 (99.97% filtration efficiency) and n95 (95% filtration efficiency) varieties [70] . the familiar n95 mask costs usd 1.50 and can thus be more widely distributed during a pandemic. no studies exist that directly compare the different respirators' abilities to prevent transmission of viral illness in the health care setting. such studies would need to incorporate doffing and reprocessing procedures in the experimental design, since there is high risk of transmission if doffing is performed incorrectly, and the risk may be modified by the type of ppe used [71] . .experimental studies in the occupational health literature have been performed that compare how well different respirators filter aerosols (typically sodium chloride aerosols) in simulated industrial environments. the protection factor is a measure of the ratio of airborne contaminant inside and outside the respirator. the u.s. occupational health and safety administration reports that the assigned protection factor (i.e., the workplace level of respiratory protection that a respirator is expected to provide to employees in the context of a "continuing, effective respiratory protection program") for paprs ranges between 25 and 10,000, versus 10 for filtering facepiece respirators, 10 for half mask elastomeric respirators, and 50 for full facepiece elastomeric respirators [72] . other reports similarly demonstrate the superior performance of paprs or elastomeric respirators in simulated workplace environments compared to n95 filtering facepiece respirators [73, 74] . a major risk with filtering facepiece respirators and reusable elastomeric respirators is that the air tight seal can leak during a procedure, compromising their performance. in a study of 8 subjects each tested on six different n95 masks, thermal imaging showed that leakage (mainly in the nasal and malar region) occurred in all failed leak tests [13] and the majority (26 of 35) passed fit tests [75] . the risk of leakage would be expected to increase with the length of time the n95 mask is worn, for example during long otolaryngology cases. there is concern that the unfiltered exhaust from paprs may increase the risk of transmission of virus particles to patients from users who are unknowingly infected with covid-19, but this risk would likely be diminished if papr users wore surgical masks [76] . paprs may be cumbersome to use, may fog up, and prevent the use of headlights, but these concerns are also true of masks, face shields and goggles. the balance of evidence suggests that paprs and full facepiece elastomeric respirators, when properly used, doffed and reprocessed, would be expected to reduce the risk of transmission of infection and/or severity of illness by reducing exposure to covid-19 during high risk otolaryngology cases, compared to n95 masks. costeffectiveness studies comparing different respirator types have not been performed but it may be feasible for hospitals to acquire a limited number of suits for use during high risk procedures. a 2010-2012 survey across six american states that included 98 hospitals indicated that 85% of the hospitals had paprs available [77] . the prevalence of paprs in canadian hospitals is unknown. as initial outbreaks of covid-19 diminish there is an opportunity for hospitals to acquire paprs and develop protocols for their use in preparation for future covid-19 cases and outbreaks. given the shortages of disposable n95 filtering facepiece respirators worldwide, there has been emphasis on their reuse. for example, givi et al state that it may be appropriate to reuse n95 masks after agmps performed on patients at low risk of having covid-19 [16] . experimental models show that virus survival on n95 masks depends on time elapsed and relative humidity [78] . sars-cov-1 can survive for up to 28 days on medical equipment in low temperature and low humidity environments [79] . there has been no published research on experiments involving covid-19. a variety of decontamination methods have been proposed, from using heat and steam, hydrogen peroxide vapor, uv light, and letting the mask sit for days before repeat usage [80] [81] [82] . the use of ultraviolet light (uv-c) has been proposed owing to its ability to penetrate the materials found in n95 masks [83] . using a surrogate virus, fisher and shaffer described that a minimum dose of 1000 j m − 2 of uv-c is required to cause a 3 log reduction in a surrogate virus [84] . vaporized hydrogen peroxide has also been suggested as method useful for decontaminating materials, and has been demonstrated to reduce infectious titers of mammalian viruses to less than ten 50% tissue culture infective doses (tcid 50 ) [85] . the cdc has provided statement that decontamination with either uvc, vaporized hydrogen peroxide, or moist heat could be considered by health care institutions in an emergency [86] . of the myriad of different procedures performed by otolaryngologists, only tracheotomy has specifically been found to pose an increased risk of airborne viral transmission to health care workers, in a study examining exposure to agmp performed on patients with sars-cov-1 [36] . a large amount of indirect evidence, however, demonstrates that most surgical procedures of the upper aerodigestive tract create aerosolized biological particles through the use of suction, cautery, and other powered instrumentation. in patients infected with covid-19, aerosolized particles would likely contain viral material because of high viral loads in the upper aerodigestive tract. cough, pursed lip-and natural breathing also produce aerosols. the close proximity of a physician performing outpatient ent procedures to an infected patient's mouth and nose adds further hazard. emerging evidence suggests that covid-19 is viable in aerosolized droplet nuclei and that a larger infective dose (which may result from prolonged exposures during long procedures) may increase the severity of disease. at any given time, a significant proportion of patients infected with covid-19 will not have symptoms. negative covid-19 test results may not be accurate. travel history will no longer be an important predictor of disease as border restrictions severely reduce the frequency of travel. it is thus reasonable, based on the precautionary principle, for health care workers performing agmp during the pandemic to observe airborne precautions regardless of whether a patient is known to have covid-19 or not. otolaryngology groups have advocated for the use of respirators with greater filtration capabilities than n95 masks, when available. experimental studies conclude that paprs and reusable elastomeric respirators have greater filtration capabilities when used, doffed and reprocessed properly. studies have not been performed that compare rates of transmission and costeffectiveness between different types of respirators in the real-world circumstance of a pandemic. paprs are significantly more expensive than other types of respirators but the investment appears to be reasonable for lengthy high risk procedures. local institutional recommendations and regionspecific epidemic characteristics must be taken into account when determining ppe use. otolaryngology-head and neck surgery is a relatively small specialty and institutional pandemic planning committees may be unaware of the level of ppe required for otolaryngology procedures. otolaryngologists should participate in or communicate with ppe planning committees so that their viewpoints are reflected in institutional protocols. regional epidemic characteristics (e.g., the prevalence of cases and trend of the epidemic curve) should also be considered when determining the level of ppe required, especially when a patient's covid-19 status is unknown. patients who do not have a diagnosis of covid-19 are obviously more likely to be asymptomatic or pre-symptomatic carriers if they live in regions where the prevalence is high. the reported prevalence, however, may underestimate the true value especially in jurisdictions where the rate of screening testing is low. furthermore, even if the epidemic curve shows signs of flattening or diminishing, recurrent outbreaks may occur suddenly and without warning, especially if physical distancing and/or other public health measures are not being effectively followed [87] . the most cautious approach, if possible, would therefore be to adhere to a higher standard of ppe until the pandemic is over. there is an opportunity to perform research to quantify the risk of covid-19 transmission from patients to health care workers performing aerosol-generating otolaryngology procedures during the covid-19 pandemic. the most important studies would be cohort studies that aim to estimate the risk of developing covid-19 from performing otolaryngology agmps, and whether different types of ppe, training and/or doffing procedures modify the outcomes. measuring the level of aerosolized viral particles in rooms where agmps are being performed on patients with covid-19 would provide indirect evidence of the degree to which these procedures put health care workers at risk of aerosolized transmission, and whether exposure concentration affects risk of infection and/or severity of disease. aerosol transmission of infectious disease guideline for healthcare workers performing aerosol-generating medical procedures during the covid-19 pandemic infection prevention and control during health care when covid-19 is suspected. interim guidance sars-cov-2 viral load in upper respiratory specimens of infected patients aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 graham's laws of diffusion and effusion early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia different epidemic curves for severe acute respiratory syndrome reveal similar impacts of control measures development of a dose-response model for sars coronavirus viral loads in clinical specimens and sars manifestations viral load kinetics of mers coronavirus infection influenza infectious dose may explain the high mortality of the second and third wave of 1918-1919 influenza pandemic viral dynamics in mild and severe cases of covid-19 covid-19) cdc_aa_refval=https%3a%2f%2fwww.cdc. gov%2fcoronavirus%2f2019-ncov%2finfection-control%2fcontrol-recommendations infection prevention and control for coronavirus disease (covid-19): interim guidance for acute healthcare settings safety recommendations for evaluation and surgery of the head and neck during the covid-19 pandemic public health ontario. ipac recommendations for use of personal protective equipment for care of individuals with suspect or confirmed covid-19 modes of transmission of virus causing covid-19: implications for ipc precaution recommendations generation and behaviour of airborne particles (aerosols) modes of transmission of virus causing covid-19: implications for ipc precaution recommendations rapid expert consultation on the possibility of bioaerosol spread of sars-cov-2 for the covid-19 pandemic transmission potential of sars-cov-2 in viral shedding observed at the university of precautions for endoscopic trans-nasal skull base surgery during the covid-19 pandemic role of air distribution in sars transmission during the largest nosocomial outbreak in hong kong evidence of airborne transmission of the severe acute respiratory syndrome virus blood containing aerosols generated by surgical techniques: a possible infectious hazard characterization of aerosols produced during surgical procedures in hospitals mastoidectomy and trans-corneal viral transmission aerosol exposure from an ultrasonically activated (harmonic) device human immunodeficiency virus transmission in health care settings: risk and risk reduction endonasal instrumentation and aerosolization risk in the era of covid-19: simulation, literature review, and proposed mitigation strategies. int forum allergy rhinol detection of rhinovirus, respiratory syncytial virus, and coronavirus infections in acute otitis media by reverse transcriptase polymerase chain reaction prevalence of various respiratory viruses in the middle ear during acute otitis media possible sars coronavirus transmission during cardiopulmonary resuscitation transmission of severe acute respiratory syndrome during intubation and mechanical ventilation aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review which preventive measures might protect health care workers from sars? american college of chest physicians and american association for bronchology [corrected] consensus statement: prevention of flexible bronchoscopy-associated infection infection prevention and control of epidemicand pandemic-prone acute respiratory diseases in health care; who interim guidelines. geneva occupational tuberculous infections among pulmonary physicians in training influenza aerosols in uk hospitals during the h1n1 (2009) pandemic -the risk of aerosol generation during medical procedures e56278. available from infection prevention and control best practices guideline. vancouver; 2020 report of the who-china joint mission on coronavirus disease 2019 (covid-19) infection prevention and control of epidemic and pandemic prone acute respiratory infections in health care: who guidelines. geneva study on transport characteristics of saliva droplets produced by coughing in a calm indoor environment influenza virus in human exhaled breath: an observational study size distribution and sites of origin of droplets expelled from the human respiratory tract during expiratory activities exhalation of respiratory viruses by breathing, coughing, and talking measurements of airborne influenza virus in aerosol particles from human coughs variability of infectious aerosols produced during coughing by patients with pulmonary tuberculosis protection from epistaxis blood aerosol contamination: a novel use of a surgical facemask particle concentration in exhaled breath the size distribution of droplets in the exhaled breath of healthy human subjects flow-induced instabilities of a mucus-serous bilayer clearance of mucus by simulated cough the mechanism of breath aerosol formation rational use of personal protective equipment (ppe) for coronavirus disease (covid-19); interim guidance control and prevention: the national institute for occupational safety and health (niosh) canadian centre for occupational health and safety. osh answers fact sheet: control banding estimating the asymptomatic proportion of coronavirus disease 2019 (covid-19) cases on board the diamond princess cruise ship infected but feeling fine: the unwitting coronavirus spreaders serial interval of covid-19 among publicly reported confirmed cases free coronavirus tests reveal 50% of cases show no symptoms presymptomatic transmission of sars-cov-2 -singapore temporal dynamics in viral shedding and transmissibility of covid-19. medrxiv report from the american society for microbiology covid-19 international summit, 23 march 2020: value of diagnostic testing for sars-cov-2/covid-19 the precautionary principle: in action for public health public health agency of canada. covid-19 in canada: using data and modelling to inform public health action. technical briefing for canadians board on health sciences policy; institute of medicine. the use and effectiveness of powered air purifying respirators in health care: workshop summary niosh-approved particulate filtering facepiece respirators selfcontamination during doffing of personal protective equipment by healthcare workers to prevent ebola transmission assigned protection factors for the revised respiratory protection standard; osha 3352-02 comparison of performance of three different types of respiratory protection devices respirator performance against nanoparticles under simulated workplace activities infrared imaging for leak detection of n95 filtering facepiece respirators: a pilot study practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-ncov) patients tt -directives concrètes à l'intention des équipes de soins intensifs et d'anesthésiologie prenant soin de patients atteints du corona hospital respiratory protection practices in 6 u.s. states: a public health evaluation study survival of a surrogate virus on n95 respirator material coronavirus survival on healthcare personal protective equipment hydrogen peroxide vapor sterilization of n95 respirators for reuse. medrxiv rapid evidence summary on sars-cov-2 survivorship and disinfection, and a reusable ppe protocol using a double-hit process. medrxiv n95 respiratory masks for covid-19: a review of the literature to inform local responses to global shortages comparison of uv c light and chemicals for disinfection of surfaces in hospital isolation units a method to determine the available uv-c dose for the decontamination of filtering facepiece respirators efficacy of vaporized hydrogen peroxide against exotic animal viruses decontamination and reuse of filtering facepiece respirators covid-19 : where we are. considerations for next steps springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations not applicable. authors' contributions pm conceived the review, conducted a literature review, wrote and edited the manuscript. rm conceived the review, conducted a literature review, wrote and edited the manuscript. the author(s) read and approved the final manuscript. none.availability of data and materials not applicable.ethics approval and consent to participate not applicable. not applicable. the authors declare that they have no competing interests. received: 16 april 2020 accepted: 28 april 2020 key: cord-297704-70nbsrl4 authors: ananda-rajah, m.; veness, b.; berkovic, d.; parker, c.; kelly, g.; ayton, d. title: hearing the voices of australian healthcare workers during the covid-19 pandemic date: 2020-09-27 journal: nan doi: 10.1101/2020.09.25.20197061 sha: doc_id: 297704 cord_uid: 70nbsrl4 background: the statistics of healthcare worker (hcw) covid-19 infections do not convey the lived experience of hcws during the pandemic. this study explores the working conditions and issues faced by australian hcws. methods: qualitative analysis of free-text responses from australian hcws from 3 august to 5 august 2020 from an open letter calling for better respiratory protection for hcws, transparent reporting of hcw covid-19 infections and diversity in national infection control policy development. the open letter was sent to an email list of 23,000 hcws from a previous campaign and promoted on social media. results: among 2,733 hcws who signed the open letter during the study period, 407 free-text responses were analysed. doctors and nurses accounted for 58% and 35% of respondents, respectively. most respondents came from victoria (48%); new south wales (18%); queensland (12%) or western australia (12%). dominant themes included concerns about: work health and safety standards; guidelines on respiratory protection including the omission of fit-testing of p2/n95 respirators; deficiencies in the availability, quality, appropriateness and training of personal protective equipment; a top-down workplace culture that enabled bullying in response to concerns about safety that culminated a loss of trust in leadership, self-reported covid-19 infections in some respondents and moral injury. conclusion: occupational moral injury in hcws is the consequence of lapses in leadership at policy-making and organisational levels that have violated the normative expectations of hcws. the challenge for healthcare leaders is to address workplace culture, consultation and engagement with hcws in order to prevent this hidden pandemic from spreading throughout the health system. compared to many developed countries, australia was relatively spared the impacts of covid19 . total case numbers were 7,767 until 30 june 2020 but increased when victoria, a state with a population of >6 million, experienced a resurgence in early july 2020 accounting for 19,574 (75%) of a total of 26,207 infections by 6 september 2020 (1) . this resurgence was associated with a sharp increase in healthcare worker (hcw) infections in victoria (national data unavailable) from 388 on 16 july (2) to 3,206 by 3 september with one death reported in april 2020 (3) . there are parallels between the australian and international experience with hcws disproportionately infected with covid-19 compared to the general community. by 16 september 2020, an estimated three million hcws globally had been infected (4) and as of 16 july 2020 over 3000 had died (5) . the prevalence of covid-19 in hcws from the united states and the united kingdom is 2,747 cases per 100,000 hcws, compared with 242 cases per 100,000 people in the general community (6) . at least 1,000 hcws have died in the usa (7) and 600 in the uk (5), with hcws from non-caucasian backgrounds comprising nearly two-thirds of deaths (8) . while many jurisdictions have struggled to prevent hcw infections, some have effectively protected their hcws, with china (9), singapore (10) and taiwan (11) the notable exceptions. statistics however, do not convey the lived experience of hcws. in australia, the media and professional societies have highlighted some of the issues faced by hcws, who have reported workplace bullying (12) , concerns about personal protective equipment (ppe) (13) and mental health morbidity (14) . hcws have turned to the media to help broadcast their concerns (15) in response to a lack of progress using conventional channels. the aim of this analysis was to give voice to hcws about the challenges they have faced during the covid-19 pandemic. . cc-by-nc-nd 4.0 international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 27, 2020. . https://doi.org/10.1101/2020.09.25.20197061 doi: medrxiv preprint on 2 august 2020, a letter signed by 23 doctors was sent to the australian minister for health. the letter was shared via email to 23,000 hcws who had responded to earlier campaigns, with an invitation to add their name in support. it garnered over 2,700 signatures by the morning of 5 august 2020. an optional question was included for respondents to share concerns about their occupational safety. the open letter was signed by 2,733 hcws with 407 free-text contributions. the majority (48%) of respondents were from victoria (vic); followed by new south wales (nsw) (18%); and similar representation from queensland (qld) and western australia (wa) (12%). doctors and nurses accounted for 93% of responses, with remaining respondents from paramedicine, allied health, and clerical backgrounds (table 1) . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint "we don't want to be heroes. we just want protection in line with ohs standards (gp, victoria)" -policies/guidelines and work health and safety obligations. hcws felt that they deserve "the same occupational health and safety demanded in any other industry" (anaesthetist, vic) and that "with community transmission rates climbing, subpar ppe is just unacceptable." (trainee doctor, vic). hcws highlighted the mining and asbestos removal industry where "no worker can work without the appropriate respirator" (nurse, wa). hcws perceived guidelines derived from the world health organization to be "woefully inadequate… [with] studies showing the virus to be airborne since march, whereas who only got on board in july." (gp, qld). this who position gave "managers and hospital executives an excuse to lower the standard of ppe to a surgical mask, face shield, and apron" (nurse, wa) with hcws noting "very poor leadership from executive" (doctor, vic). many perceived that guidelines were "dictated by resources and not staff safety" (nurse, qld) and that australia has "waited until our own staff got sick and intubated before we very gradually changed the ppe quality supplied to staff in australia." (doctor, vic). hcws decried that "staff becoming sick is unacceptable" (nurse, tas) and "having any fellow hcws at the same health network with confirmed covid is far too many" (doctor, vic). they asked, "since when was it acceptable for miners to die from preventable ohs accidents? never -so don't make it acceptable for hcws" (doctor, vic) noting that "we give everything for our patients, but we don't expect to have to give our lives" (nurse, tas). the approach to occupational safety was, "reactive not proactive as numbers began to grow" (nurse, vic). is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 27, 2020. . https://doi.org/10.1101/2020.09.25.20197061 doi: medrxiv preprint vic), policies dismissed precaution and were "dragging their heels … adopting the cheapest ppe instead of the most suitable." (paramedic, vic). respondents drew a comparison to sars, where "respiratory protection was upgraded well before the evidence-based studies regarding respiratory protection 'proved' that aerosol spread was occurring which saved hundreds of hcw lives" (physician, tas). opportunities had been squandered given, "australia had so much time to learn from the experiences overseas" (nurse, tas). instead we "lost valuable time to prepare for this pandemic due to government and department effective obstructiveness" and did not consult broadly enough, "occupational medicine doctors should have been involved in expert groups from start to prevent workplace outbreaks." (occupational medicine physician, wa). hcws recognised the threat to health system functionality where asymptomatic patients who had "moved across many areas of the hospital" could cause an outbreak "affecting hospital flow and productivity." (midwife, vic) "protect us properly so we can protect you!" (nurse, western australia)-lack of access to ppe, issues with quality and appropriateness. despite hcws being "essential", a lack of or limited supply of ppe was reported across australia. respondents emphasised that they "need ppe in our practice consult rooms, not in a 'national stockpile' thousands of kilometres away!" (doctor, qld). the lack of availability of ppe had led to rationing, with ppe being "locked in cupboards" (doctor, nsw) and respondents being "directed to store surgical masks in a plastic bag and reuse them for the same patient on multiple occasions" (doctor, nsw). ppe had quality issues with "gowns that tear easily, surgical mask quality is often poor" (nurse, wa), masks that "often require a tremendous amount of "macguyver-ing" but still "slid down, exposing my nose" (trainee doctor, vic), "poorly fitting ear loop ones" which affected critical manoeuvres where "several colleagues had to remove eye protection as they kept fogging up." (surgeon, nsw). is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 27, 2020. . https://doi.org/10.1101/2020.09.25.20197061 doi: medrxiv preprint hcws were angered by a lack of internal support: "my hospital's chief medical officer has been silent on this issue, even when it was raised in a public forum." (trainee doctor, vic), citing that the inadequacy of ppe "runs contrary to oh&s regulations in every other facet of working life" (trainee doctor, qld). the lack of representation in policy-making meant that, "general practice is under-represented in the decision-making process and the allocation of ppe, despite our high profile in the early presentations"." (nurse, wa). consequently, hcws are "purchasing their own masks, at extreme cost" (nurse, sa) including non-approved items such as "an elastomeric p3 filter mask but i would be disciplined if i wore it to work despite it likely being superior to a non-fit tested n95/p2 respirator." (doctor, vic). the provision of respirators is not a one-size-fits-all matter. respiratory protection is only effective if hcws "have quantitative fit testing" (anaesthetist, vic) "to ensure that they provide an adequate seal. without proper fitting, these masks provide no additional protection over and above a standard surgical mask." (anaesthetist, nsw). one surgeon recounted how they "had to apply strips of micropore tape around the mask to achieve an adequate seal. … it beggars belief that hcws are expected to jury-rig n95 masks to achieve a life-protecting air-tight seal" (surgeon, wa). in-house fit-testing was occurring, with alarming results, where "around 40% of women failed a quantitative fit test on the disposable p2/n95 masks" (anaesthetist, nsw), noting that "women and non-caucasian faces appear at greatest risk of failure. they also appear to be disproportionately the hcws exposed and dying in the uk." (anaesthetist, qld). arranging fit-testing was not easy, with hcws having to "fight to even be fit-tested for n95 masks", and having to "to pay for that fit-testing myself before the hospital relented and tested the rest of the department." (doctor, tas). hcws were bewildered as to "why certain industry sectors make it mandatory for their workers to have such rigorous testing performed and others such as healthcare, where lives matter just as much, do not seem to be implementing this" (anaesthetist, vic). "supply . cc-by-nc-nd 4.0 international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 27, 2020. . https://doi.org/10.1101/2020.09.25.20197061 doi: medrxiv preprint issues" was the reason cited for organisational resistance to fit-testing even when there were "multiple hcw infections despite adhering to the current policy for ppe" (ed doctor, vic). reusable respirators such as powered air-purifying respirators (paprs) were seen as viable alternatives to disposable respirators "as it provides superior protection in those who cannot achieve adequate seal with n95 or p2 masks" (anaesthetist, wa) and had a proven track record in safety during sars: fit for purpose ppe was important particularly for first responders where they "do not function in a controlled environment" and "face wind, weather, manual handling of infected patients, difficult extrications, patient lifts, carries, and sit centimetres from patients in confined spaces". gowns were prone "to billowing in the wind, spreading droplets, contaminating faces and surfaces, as well as providing no protection to legs when bending, lifting, sitting" (paramedic wa). proceduralists encountered ppe failures, "on a patient who had suffered a cardiac arrest, the mask developed a major leak and fogged up the face shield which meant i was exposed to viral aerosol and had poor visibility." (anaesthetist, vic). even anaesthetists, who are at high risk due to intubation responsibilities are being asked "to use cheap n95 duckbill masks without formal fit testing… intubators' face shields are fogging so badly that it is almost impossible to see. full face respirators must be made available." (anaesthetist, vic). guideline variability resulted in mask confusion with the need "to juggle between different masks based on the interventions we use to treat patients" where "we are not able to predict these decisions until we are already on scene" (paramedic, nsw). in addition to fit testing, ppe training was required. "donning and doffing correctly, needs education and compliance monitoring! i've seen so many nurses do it incorrectly" (surgical nurse, vic). there were calls . cc-by-nc-nd 4.0 international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 27, 2020. hcws described being bullied and victimised in their workplaces, being told they were "not a team player" (ed doctor, nsw) and "face shaming tactics from colleagues" (gp, wa), in a workplace that "has actively tried to silence me" (allied health, qld) for expressing concerns about their safety. hcws were "threatened to be stood down for requesting an n95 mask" (paediatrician, nsw), having "n95 masks taken out of our hands before going into see positive covid patients." (physician, vic) and of being "bullied by admin staff who don't want us to ask for appropriate ppe, and lied to" (anaesthetist, qld). senior managers had told staff that they "need to toughen up" (ed doctor, qld) while infection control nurses were "chastising front-line ed nurses caring for suspected covid-19 patients for wearing n95s, saying they should only use surgical masks" (trainee doctor, tas). requests for use of personal higher-grade ppe was discouraged by infectious diseases experts as it may "'set a precedent and that the optics of not following the [department of health and human services] guidelines were not good." (nurse, vic). infection control were "very poor in backing up the hcws" and preferred to "toe the executive line rather than evidence-based practice." (ed physician, nsw), creating "a very bad taste in our department" (ed physician, nsw). hcws were angry that infectious diseases experts "had determined n95 masks were only needed for aerosol generating procedures in covid19 patients" and who expressed "hubris when they were asked about hcw infections" implying "that the high rate of hcw infections and deaths was due to incorrect donning and doffing rather than the grade of the ppe itself" (physician, vic). is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 27, 2020. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 27, 2020. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 27, 2020. . https://doi.org/10.1101/2020.09.25.20197061 doi: medrxiv preprint this study is a clarion call for organisational leaders, managers and policy makers to acknowledge and address the barriers to work, health and safety that have violated the normative expectations of healthcare workers. the hcw respondents in this study expect to feel safe at work but find themselves in the opposite situation due in a large part, to leadership not meeting their expectations at national, state and local service levels. themes inductively identified from the data spanned the system, organisational and personal impacts of covid-19 with lapses in leadership cross cutting all of them. policies on respiratory protection were perceived to have disregarded the precautionary principle that is implicit within work health and safety policy (16) . issues regarding access to ppe, its appropriateness and quality; a lack of respirator fit-testing within a respiratory protection program; and a command-and-control culture in the workplace that suppressed respondent concerns, was felt to have contributed to self-reported workplace acquisitions of covid-19. respondents were critical of leadership, at all jurisdictional levels, which has resulted in a loss of trust that threatens to endure for years to come. the moral injury to hcws would appear to be the "hidden pandemic", resulting in emerging mental health issues including anxiety, sleeplessness, withdrawal, resentment and anger. respondents reported being in the untenable position of needing to deliver patient care while facing unacceptably high risks to themselves in a workplace failing to protect them (17, 18). the list of injurious events started with concerns about national guidelines on respiratory protection endorsing the surgical mask for routine care of covid-19 patients rather than fit-tested p2/n95 respirators or above. to respondents, academic arguments of disease transmission referencing the aerosol versus droplet dichotomy (19) were resolved early in the pandemic. instead, they felt forced to follow policies at odds with their own assessment of personal risk. raising legitimate concerns appeared to have invited bullying, victimisation and censure within their organisations. respondents cited a disregard of work health and safety obligations bordering on hubris by is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 27, 2020. . https://doi.org/10.1101/2020.09.25.20197061 doi: medrxiv preprint organisational leaders and infection control/infectious diseases experts, who were unfortunately perceived as being more intent on enforcing guidelines rather than meaningful engagement with frontline staff. as a result, several hcws took matters into their own hands, organising in-house fit-testing or the purchase of reusable respirators. during this pandemic, moral injury has referred to challenging decisions involving patient care that conflict with provider values (20) . the concept originated in the military (21) and was extended by litz et al. to "perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations" (22) . a complementary variant has emerged from the social sciences in reference to healthcare where "it arises from sources that include injustice, cruelty, status degradation and profound breaches of moral expectations" (23). it is not a mental illness, but rather a violation of an individual's moral or ethical code that results in psychological distress (20) . the voices of the respondents clearly point to an established moral injury where they feel like they are being treated as "expendable" rather than essential to the pandemic response. reversing occupational moral injury is not easy once established but this is the challenge healthcare leadership must rise to. shale, in a seminal and timely commentary, presents a practical roadmap for moral repair (23) . this framework prefaces each of the seven actions with acknowledgment: of the injured party as a moral equal, of shared norms, of testimony in a climate of safety, of the responsibility of leaders which is not equivalent to directing blame at them, of remediation to rectify the issues, of negative feelings and finally, of authentic acknowledgement of sorrow and regret that are not rehearsed apologies (23) . the high degree of engagement required for reparation stands in contrast to the limited consultation experienced by many respondents on matters relating to their safety at work. inadequate consultation has been a missed opportunity that also . cc-by-nc-nd 4.0 international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 27, 2020. . https://doi.org/10.1101/2020.09.25.20197061 doi: medrxiv preprint contravenes australian work health and safety legislation designed to address the power imbalance between management, who issue directives, and workers placed in the risk zone (16) . this study has several limitations. the purpose of the open letter was primarily to advocate for increased protection for hcws, and thus the methodology was not designed to optimally probe hcw perspectives. the study may not be representative of all hcws as the response rate was 12% at 48 hours and it did not capture all types of hcws including a large sample of nurses, administrative or support staff. occupational moral injury has not been well described in healthcare and deserves further research to better understand its root causes, preventative strategies and evidence based remediation. response and non-response bias common to survey methodology may be operating and these findings require confirmation in studies from other jurisdictions. finally, there was no 'check' to ensure that respondents were indeed hcws, however the consistency of themes would argue otherwise. constructive engagement with hcws that also addresses their moral injury presents the challenge for healthcare leaders during this pandemic and beyond. this process should be seen as an opportunity to harness the resourcefulness of hcws that many respondents felt had been sidelined, with the wealth of governance and operational experience among healthcare leaders, policy makers and government in order to fast track solutions. achieving shared goals necessarily starts with better consultation and a dose of courage in all actors. not doing so risks the contagion described in this report spreading throughout australia's healthcare system with implications for other jurisdictions. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 27, 2020. . https://doi.org/10.1101/2020.09.25.20197061 doi: medrxiv preprint is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 27, 2020. . https://doi.org/10.1101/2020.09.25.20197061 doi: medrxiv preprint johns hopkins coronavirus resource centre. victoria -covid-19 data dashboard 2020 coronavirus update for victoria department of health and human services. coronavirus/latest news and data/updates 2020 governments not 'prioritising nurses' as covid-19 death toll surpasses 1 global: health workers silenced risk of covid-19 among front-line health-care workers and the general community: a prospective cohort study lost on the frontline 2020 covid-19: two thirds of healthcare workers who have died were from ethnic minorities use of personal protective equipment against coronavirus disease 2019 by healthcare professionals in wuhan, china: cross sectional study the fight against covid-19: disinfection protocol and turning over of cleanspace((r)) halo in a singapore hospital protecting healthcare workers during the coronavirus disease 2019 (covid-19) outbreak: lessons from taiwan's severe acute respiratory syndrome response doctors 'bullied' by hospital administration for asking to wear masks the royal australasian college of physicians. racp survey: 10 percent of physicians in public hospitals sourcing their own ppe -calls for greater transparency on government stockpile 2020 healthcare workers struggling with mental well being during the pandemic are you a healthcare worker concerned about covid-19? tell us your story 2020 protecting our healthcare workers current guidelines for respiratory protection of australian health care workers against covid-19 are not adequate and national reporting of health worker infections is required airborne transmission of covid-19 managing mental health challenges faced by healthcare workers during covid-19 pandemic odysseus in america: combat trauma and the trials of homecoming moral injury and moral repair in war veterans: a preliminary model and intervention strategy moral injury and the covid-19 pandemic: reframing what it is, who it affects and how care leaders can manage it key: cord-308100-tvk47fd7 authors: soetikno, roy; teoh, anthony yb.; kaltenbach, tonya; lau, james yw.; asokkumar, ravishankar; cabral-prodigalidad, patricia; shergill, amandeep title: considerations in performing endoscopy during the covid-19 pandemic date: 2020-03-27 journal: gastrointest endosc doi: 10.1016/j.gie.2020.03.3758 sha: doc_id: 308100 cord_uid: tvk47fd7 nan based on experiences and the literature, our objective is to provide practical suggestions for performing endoscopy in the setting of covid-19 pandemic. sars-cov-2/novel coronavirus-19 has become a global pandemic. human-to-human transmission occurs through respiratory secretions, aerosols, feces, and contaminated environmental surfaces. 1, 2 transmission can occur in both symptomatic and asymptomatic individuals. 3 viable virus particles can be detected in aerosols up to 3 hours after aerosolization and up to 3 days on surfaces. 4 a recent publication suggests that undocumented infections were the source of a substantial majority of documented cases. 5 the risk of infection to healthcare workers is significant: in one of the earliest documentations of infection in wuhan, 29% of patients (40 out of 138) were healthcare workers. 6 it is unknown how much of the risk was related to the direct care of infected patients or to the inadequate use of personal protective equipment (ppe). when performing endoscopy, it seems inevitable that healthcare providers (hcp) will be exposed to either respiratory or gastrointestinal fluids from patients. thus, adequate protection of hcp is now critical. the world endoscopy organization has recently released a recommendation on infection prevention and control in digestive endoscopy based on experiences from china. 7 similarly, an italian group has provided recommendations regarding the performance of endoscopy during the covid -19 outbreak. 8 based on their experiences with a similar coronavirus, which caused sars 17 years ago, hong kong adopted measures similar to those aforementioned immediately upon the first news of covid-19 outbreak in late january. 9 with numbers of covid-19 cases continuing to rise in north america and europe, we aim to provide practical suggestions to potentially avoid the transmissions of covid-19 in the endoscopy unit. the virus characteristics and its transmission make endoscopy a potential route for infection. possible routes of sars-cov-2 transmission include (1) person-to-person, (2) respiratory droplets, (3) aerosols generated during endoscopy, and (4) contact with contaminated surroundings and body fluids. 1,10 additional care must be instituted when handling blood samples or specimens because the virus has been detected in the blood of covid-19 patients. lei pan et al 10 demonstrated that 48.5% of the patients presented with gi symptoms, including anorexia (83.8%), diarrhea (29.3%), and vomiting (0.8%), with the severity increasing as the disease progressed. with the detection of the virus in the feces, the centers for disease control and prevention (cdc) has suggested the use of separate bathrooms in cases of suspected covid19. 11 in line with these recommendations, extensive precautions need to be adopted to avoid potential oral-fecal transmission. importantly, staff with a travel history to covid-19-affected areas or a history of exposure to covid-19-affected individuals should first self-quarantine for 14 days, to eliminate risk of transmission. is endoscopy an aerosol-generating procedure? all endoscopic procedures should be considered aerosol-generating procedures (agp). coughing and retching can occur during upper endoscopy, generating aerosols. likewise, patients undergoing colonoscopy may pass flatus, which is also known to disseminate bacteria to nearby surroundings. 12 a prospective study has demonstrated unrecognized endoscopist exposure to infectious particles during gi procedures. 13 recently, the world health organization (who) has published an extensive guideline on the rational use of personal protective equipment (ppe) for covid-19 and provided specific instructions for healthcare workers performing agp on patients with covid-19. 14 these include the use of a respirator (n95, ffp2 standard, or equivalent), gown, gloves, eye protection, and apron although aprons are not usually not used in the united states. their use should be immediately and strictly adopted in practice, if at all possible. 13 patient-contaminated fluids often splatter when inserting or removing an accessory from the endoscope's working channel, adjusting the air/water button, retrieving tissue from a biopsy bottle, and while performing precleaning. patients' saliva can contaminate the pillow or the bed, and stool mixed with water often drips to the bed during colonoscopy. extensive environmental contamination can occur even from patients with mild covid-19 upper respiratory symptoms. ong and colleagues 15 the goal is to attain zero percent infection rates among hcp while providing essential services to patients. for the gi community, the key element will be to prevent exposure during any endoscopic procedure. as the outbreaks continue to occur, masks and personal protective equipment (ppe) may become scarce in quantity. an early inventory of what is available to the institute is essential to formulate a plan for ppe usage. conservation of ppe is important and should be planned. management 1. prepare. plan. test. practice. repeat. ready the team. being well prepared is the best we can do to reach our zero-contamination goal. 2. staff management is an integral part of performing endoscopy during the covid pandemic. 3. establishment of a rapid response communication channel using smart phone apps, email, and video conferences to distribute information across the entire unit. to stay updated on the development of the infection and discuss a unified plan. 1. ensure performance of fit testing for n95 respiratory masks for all hcp. during the course of the outbreak, some masks may run out of stock and hcp will need to plan for alternatives. protection, however, may be achievable even without n95 through the use of medical masks. 17 note that as an agp, endoscopy of pui/covid patients requires the use of respiratory protection. the powered air purifying respirator (papr) is a desirable alternative that does not require fit testing and can be used by employees with facial hair who would otherwise not achieve a good seal with the n95. most units, however, are not stocked to have an adequate supply of papr. 5. familiarize staff with the correct method of hand hygiene. an excellent review has been published. 18 compliance with correct hand hygiene practices is low; thus, a practice, review, and compliance check is necessary. 6. follow the who recommendations for ppe (table 1 ). 14 familiarize staff with the correct sequence of gowning up (donning) and down (doffing) through teaching videos and diagrams (table 1) 19 . note that there is poor correlation between selfperceived proficiency in ppe use and its appropriate use. 17 repetitive training and demonstrated competency are necessary. use a buddy system, where another colleague observes the gown up and down procedures to advise on any breach of protocol (table 2 ). inform to conserve the use of masks and ppe. 9. set up a designated area for donning ppe that is easily accessible and near the room. doffing of ppe ideally occurs in an anteroom or a doffing area that is separate from the procedure room. 20 10 equally important, staff should take additional precautions to prevent contamination among providers. work at individual working stations using a designated phone, computer, and chair, and stay at least 6 feet from any other coworkers while at work to the extent possible, recognizing that this will be difficult in some situations. avoid sharing workstation items and equipment. wipe workstations before and after use with virucide, following instructions on the virucide exactly as recommended. 11 create a workflow to provide a clear job description and designation of authority with backup plans. separate the workflow to minimize cross-contamination. for example, consider dividing the clinical workforce into 2 teams, alternating roles at predefined intervals (such as weekly). one team is on-site and providing direct clinical care. the second team is coordinating clinical care off-site, minimizing risk of exposure and providing back-up coverage if an on-site provider were to become ill or require quarantine. 12 in the staff lounge/eating area, we allow sitting in one direction, thus preventing infection from face-to-face transmission. 13 the bathroom is a potential site of transmission. ideally patient and staff bathrooms are separated and disinfected frequently. in the epidemic area, the indications include management of upper gastrointestinal bleeding, acute cholangitis, foreign body, and obstructions. 7 care (initial diagnosis, biopsy, staging, palliation of biliary and luminal obstruction) of cancer patients may also be considered urgent. reschedule nonurgent endoscopy services. this measure is aimed at reducing the risk of spreading infection from asymptomatic patients, reducing the risk of cross-infection among patients, reducing use of ppe, and reducing unnecessary admissions to free up hospital resources. in the setting of substantial community spread of covid-19: 1. require all staff to have daily measurements of temperature before starting work. all febrile staff should not be allowed to work, and they should be evaluated according to local protocols to screen for potential covid-19 infections. 2. cdc mitigation strategies in the setting of substantial community spread include requiring all hcp to wear a face mask when in the facility, depending on supply. 21 there is a high viral load in the upper respiratory tract, and there is a significant potential for asymptomatic persons to shed and transmit virus. 22 data showing the prolonged stability of the virus on surfaces may have significant potential implications for use of staff' ppe in the general area. 23 3. require staff to perform work using individual stations: use the same phone, computer, and chair. do not share. do not answer phones elsewhere other than in your own station and disinfect your working space regularly. 4 . limit the number of hcp in the endoscopy suite to those essential for performance of the procedures (see below regarding trainees). off-duty workers should stay at home as much as possible. 5. for hcp directly involved in the procedures, use the hospital-issued scrubs and dedicated endoscopy shoes. leave these at work. 6 . although these continue to evolve, current covid-19 screening guidelines include assessing patient's symptoms (such as fever and/or symptoms of acute respiratory illness) and potential contact with a suspected or laboratory-confirmed covid-19 patient. the decision to quarantine should be made at that time ( fig. 1 ). 7 . with the availability of rna testing against covid, point-of-care testing in patients presenting for endoscopy may facilitate more accurate risk stratification. before the procedure: outpatients 1. screen for symptoms, signs, and exposure to sars-cov-2 (contact and travel history). measure their temperature to risk stratify (fig. 1 ). 2. test all suspected patients for covid-19 whenever possible using rt-pcr. 24 if possible, wait until the test results have been received before proceeding. 3 . suspected or confirmed patients should be provided a mask while being triaged, and should be isolated or separated from other patients by at least 6 feet. alternately, they should be placed in a negative pressure room. 4 . patients should be advised to minimize movements while waiting for the procedure to minimize facility contamination. in-patients 1. evaluate for covid-19 status and reassess for symptoms suspicious for covid-19 in all patients referred for endoscopy and triage accordingly. 2. ensure that a ppe supply is available before entering the procedure room. c. contact asymptomatic patients within 14 days to assess their progress after procedure. reprocessing reusable medical equipment. we are not aware of a change in the rme protocol. note that the most significant hcp contamination occurs during precleaning of the endoscope in the procedure room due to splashing from the air/water button. follow the protocol to turn off the processor when replacing the air/water button with the credit card button. sars-cov-2 is deactivated by commonly used disinfectants such as alcohol or chlorine-based solutions. the cdc cleaning and disinfection recommendation can be adopted. please see table 2 for the recommended attire for the personnel cleaning the unit. personnel cleaning the endoscopy unit must also undergo repeated practice and have their proficiency documented. trainees are an integral part of most academic endoscopic units. with the potential surge in covid-19 infection, the role of a trainee in endoscopy procedures requires reevaluation. because there is too much uncertainty with regard to its transmissible potential and associated morbidity and mortality, we recommend the following plan of actions in managing trainees during endoscopy: 1. they master the prevention of transmission described previously through repeated practice and documented proficiency. 2. fellows' involvement increases procedure time, and thus increases the potential for exposure. our practice is to preserve critical resources and minimize the risk of exposure; thus, we limit trainees' involvement during endoscopic procedures. 25 as board-certified internists, however, fellows may provide essential physician support in a time of crisis, such as during a surge. they may contribute to the covid-19 management workforce. 3. at many institutions, fellows cover multiple clinical sites as part of their on-call duties or for acgme required continuity clinics. in the absence of point-of-care testing, we suggest that fellows be stationed at one hospital to avoid inadvertent spread of infection across multiple sites. our guidance is based on our practical experience, observations, and published literature. note that present understanding of sars-cov-2, however, is still rapidly evolving. the success of preventing endoscopy unit transmission of sars-cov-2 is contingent upon the compliance of every member of the team. we must cooperate and collaborate in order to adhere to the prevention steps the best we can and prevent transmissions. place over face and eyes to adjust fit. extend to cover the wrist of isolation gown how to remove ppe (example 1) grasp palm area of the other gloved hand and peel off first glove. hold removed glove in gloved hand. slide fingers under the glove at the wrist and peel off the second glove over the first. lift headband or earpiece from the back to remove goggles or face shield. unfasten gown ties while ensuring the sleeves do not contact your body. pull the gown away from the neck by touching the inside of the gown only. turn inside out and roll into a bundle to discard. grasp bottom and top ties of the mask. remove ties without contacting the front of the mask. how to remove ppe (example 2) grasp gown in the front and pull away from your body so the ties break. touch outside of the gown only with gloved hands. while removing the gown, roll it inside-out into a bundle and peel your gloves off at the same time. lift headband or earpiece from the back to remove goggles or face shield. grasp bottom and top ties of the mask. remove ties without contacting the front of the mask. patients without respiratory symptoms. no ppe required covid-19-new insights on a rapidly changing epidemic evidence for gastrointestinal infection of sars-cov-2. gastroenterology presumed asymptomatic carrier transmission of covid-19 aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov2). science clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan suggestions of infection prevention and control in digestive endoscopy during current 2019-ncov pneumonia outbreak in wuhan covid-19) outbreak: what the department of endoscopy should know recommendations for the prevention of transmission of sars during gi endoscopy clinical characteristics of covid-19 patients with digestive symptoms in hubei, china: a descriptive, cross-sectional, multicenter study. :23. 11. 10 things you can do to manage covid-19 at home. cdc; 2020 hot air? risk of bacterial exposure to the endoscopist's face during endoscopy geneva: world health organization surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) from a symptomatic patient bioaerosol concentrations generated from toilet flushing in a hospital-based patient care setting supporting the health care workforce during the covid-19 global epidemic isolation precautions | guidelines library | infection control | cdc putting on and removing personal protective equipment implementation of mitigation strategies for communities with local covid-19 transmission clinical presentation and virological assessment of hospitalized cases of coronavirus disease 2019 in a travel-associated transmission cluster. infectious diseases (except hiv/aids) aerosol and surface stability of hcov-19 (sars-cov-2) compared to sars-cov-1. infectious diseases (except hiv/aids) cdc 2019-novel coronavirus (2019-ncov) real-time rt-pcr diagnostic panel. instructions for use covid-19 clinical insights for our community of gastroenterologists and gastroenterology care providers key: cord-270781-f9nra823 authors: gulia, ashish; tiwari, akshay; arora, ramandeep singh; gupta, srinath; raja, anand title: sarcoma care practice in india during covid pandemic: a nationwide survey date: 2020-07-31 journal: indian j orthop doi: 10.1007/s43465-020-00206-3 sha: doc_id: 270781 cord_uid: f9nra823 background: amidst the covid-19 pandemic, management of cancer has been one of the most intensely debated topics across the globe. we conducted an online survey to determine the consistency/or the lack of it, in the management of sarcoma patients between centres and the changes in policies. methods: a twenty-five question online survey was conducted among practicing physicians over a period of 10 days using online portal (surveymonkey.com). it was followed by a critical analysis based on responses to each question. results: of 194 medical professionals who participated, 80% were surgeons and 53% were working in government institutes. most respondents (81%) continued their practice with some modifications. in op majority (67%) relied only on symptom, contact enquiry and temperature recording for screening. covid-19 testing was done more (43%) in ip patients. most of institutes (83%) followed rotational policy to reduce the number of staff at risk while 57% offered an alternate accommodation. 52.3% continued chemotherapy for all patients while radiotherapy for all was offered by 45%. in metastatic cases, majority preferred either no treatment or non-surgical intervention (71%).84.5% believed in adapting changes (42%—avoid supra major surgeries, 27%—operating only emergency cases and 15.5%—high grade sarcomas with curative intent) in surgical management of sarcomas. for benign bone tumors, majority (71%) agreed on adapting changes while 25% agreed on deferring all cases. 69% preferred teleconsultations for follow-up. complete ppe were being used for all aerosol generating procedures by 44%. only two thirds agreed with their institutes policy of ppe usage and covid-19 testing. conclusion: this survey has highlighted disparity on covid-19 screening and management in various institutes across the country. this will act as a reference point for tracking future trends in bone and soft tissue tumor management guidelines, as the covid-19 scenario unfolds globally and particularly in india. amidst the covid-19 pandemic, management of cancer has been one of the most intensely debated topics across the globe [1, 2] . most of the attention, resources and priorities of the healthcare systems have been directed towards containing the pandemic. this, coupled with delayed presentation of patients (both from fear of going out and from a lack of means of travel during the lockdown) is likely to lead to a delayed diagnosis and stage migration of a large number of cancer patients [3] . even for patients who do manage to reach the right centre, prioritising their treatment while containing covid-19 transmission among both the healthcare staff and patients themselves has been a difficult balancing act for oncologists across the world [4] . this becomes particularly relevant given that healthcare workers and cancer patients are a higher risk group for morbidity and mortality due to covid-19 infection [4, 5] . management of bone and soft tissue sarcomas is no exception to this dilemma [6] . delay in the treatment of these rare cancers is a threat to both limb and life, and there is no consensus on how to prioritise their management in the times of this pandemic. in the presence of ever evolving guidelines that change within and between countries, the pattern of care offered for bone and soft tissue sarcomas is bound to vary between centres. we conducted a survey amongst oncologists across india who are involved in the management of bone and soft tissue sarcomas, to analyse the patterns of screening, prioritising, and managing these patients within the constraints of resources and policies available with them. the purpose of this survey was to determine the consistency, or the lack of it, in the patterns of care offered to sarcoma patients between centres and the policies followed. this would provide a much-needed insight of how the management of bone and soft tissue sarcomas is going to unfold in the coming times and beyond. a valuable outcome of this survey would be to formulate future strategies in the management of sarcomas in india, suggest ways to remove bottlenecks and propose modifications in sarcoma management in covid times. these precious inputs by sarcoma experts across india could also form the basis of research looking at modifications in the diagnosis, management and follow-up of these patients even beyond the covid-19 pandemic, having been tested in covid times. the author group conducted a comprehensive literature review on available data and practices in management of musculoskeletal tumors. a 24-item questionnaire was developed after deliberation within the study team (table 1) . this survey covered three main domains (a) participants speciality and working environment (b) institutes' policies related general covid-19 prevention and management (c) practices related to musculoskeletal tumor management in covid-19 pandemic. the electronic version was designed and created table 1 questionnaire on management of musculoskeletal tumors in covid-19 pandemic using the surveymonkey platform (surveymonkey inc. san mateo, california, usa). the survey was piloted by seven experts, who were not from the study team (fig. 1) . this helped us to check the content, its relevance and validity. we conducted the survey over duration of 10 days from 21st april 2020 to 30th april 2020. the survey was circulated to medical professionals involved in evaluation and management of musculoskeletal tumors. these included professionals from orthopedics, surgical oncology, medical oncology, radiation oncology and other allied fields such as anesthesiology, palliative medicine and physiotherapy. we utilized various online platforms for circulation of survey, these included emails, whatsapp groups and telegram messenger services. the introductory note explained the purpose of our survey. the embedded link helped participants to take the online survey via the website of the survey platform. two reminders were staged on day 5 and day 8 of survey. to further increase the sample size, we posted the survey link during our online classes. the data collection was closed on 30th april, 2020 and was analyzed. the results were collated, and descriptive analysis was done. a total of 194 medical professionals took part in the survey. these were 52% orthopedic surgeons, 28% oncological surgeons, 5.1% medical oncologists, 2.6% radiation oncologists and the rest of them were anesthesiologists, pathologists, palliative medicine and physiotherapists. 53% of the participants were working in government institutes, 33.5% in hospitals in the private sector, and the remaining 13.5% belonged to non-teaching government institutes and selfowned nursing homes/clinics (fig. 2) . we have had respondents all across india (25 states including union territories) and 14 of them from international centres. of these, 6 states had more than 1000 cases, 7 states had 200-1000 cases and most respondents (81%) were continuing their practice with some modifications, while in 10% practice was running as usual and in 9% there were no outpatient (op) or interventional services (fig. 3) . the modifications included providing emergency services and op to new patients only in 36%, emergencies only in 33% and other modifications in the remaining (fig. 3 ). in op, 10% were screened by symptom and contact enquiry, 57% had additional temperature recording while 30% also had covid-19 testing (fig. 3 ). in inpatient services (ip), the proportion being tested for covid-19 was higher at 43% (fig. 3) . 38% of the participants disagreed with the current policies of their institutes. they were of the opinion of inclusion of covid-19 testing for operative cases, inpatients (31%) and those undergoing noninvasive procedures (14%) while 27% felt it has to be done for all patients visiting the hospital. 83% of them said that their institute was following rotational policy to reduce the number of staff at risk (fig. 2) . 57% of them have been offered an alternate accommodation option. for follow-up, 69% are doing teleconsultations via phone and advising patients to come back after the restrictions subside, 14% were continuing follow-up (fu) as usual while 11% had ceased all fu (fig. 4) . 20% believed this practice teleconsultations will continue even after the pandemic while 60% were going to end it after the pandemic (fig. 4) . 32% believed the current restrictions will continue for 2 more months while 29% were of the opinion the current pattern of work is essential for the next 6 months. 52.3% said they were continuing chemotherapy for all patients while 31% said they were not enrolling new patients while continuing chemotherapy for those who are already receiving it, in 5.7% all chemotherapy delivery had been discontinued and with modifications in 11% (fig. 5) . specifically, for patients with metastatic disease, 28% offered only best supportive care, 37% offered sarcoma-directed treatment but preferred stereotactic body radiation therapy (sbrt) over surgery for pulmonary metastasis. curative treatment including pulmonary metastectomy for select group of patients was being offered only in 29%. surgical management of sarcomas was as per usual only in 15.5% of respondents, with the rest adapting, including 42% who were avoiding procedures requiring long duration and blood loss, 27% were operating only emergency cases, while in 15.5% surgery was done only in high grade sarcomas with curative intent (fig. 5) . in contrast for benign bone tumors, surgical management of benign bone tumors was as per usual only in 3% of respondents, with the rest adapting (41% operate only for surgery, 20% for locally aggressive lesions, 11% others) and in 25% surgeries were completely deferred (fig. 5 ). 45% were administering radiotherapy for all sarcoma cases as indicated, while 23% were not taking up new patients and 20% were administering it only in emergency and definitive treatment scenarios (fig. 5 ). for those with palliative care need, only 13% were offering usual palliative care service. modified practice included home-based care only in 27%, op-based oral medication only in 9%, and chemotherapy and/or radiotherapy but not surgical treatment in the remaining. complete ppe (jumpsuits, n95 mask, face shield, double gloves, shoe covers) are being used for only proven covid-19 patients in 31% of the institutes while 44% were using it for all aerosol generating procedures in addition to use during treating a known case of covid-19 (fig. 4) . as an alternate to complete ppe, partial protection in the form of n95 masks were used in 20% of the institutes while n95 + face shields were used mandatorily during all interventional procedures in 28% (fig. 4) . only two thirds agreed with their institutes' policy of ppe usage selection and supported the use of ppe for all non covid-19 cases undergoing aerosol generating procedures. covid-19 has been a pandemic with an unprecedented impact for several reasons. firstly, it can spread and infect a large number of people and cause morbidity and mortaility in a small fraction. secondly, it can affect healthcare providers thus interrupting delivery of healthcare workers. lastly, the lockdown initiated by the covid-19 pandemic as an intervention to slow the spread and prepare services, has had an unparalleled detrimental effect on patient's ability to access healthcare in india. these challenges become particularly relevant in the care of patients with cancer and specially sarcomas which require multidisplinary timely management to achieve optimal outcomes. this survey was conducted to understand the delivery of care for sarcomas by oncologists across india. surgeons are usually the first point of contact for sarcoma and hence were predominant (80%) amongst respondents (fig. 2) . the results of our survey highlighted significant disruptions in delivery of cancer care. covid-19 has placed an enormous strain on medical facilities and most institutions have brought about dramatic changes in practice. less than 10% of respondents have continued to deliver their practice with no changes. most of them have adapted op, ip and fu services while 9% have completely shut down delivery of sarcoma-directed services. there was encouraging use of 80% of respondents for tele consults, with 20% stating their intent to continued use beyond the pandemic (fig. 4) . this could become a study model to test its utility during non covid-19 times. treatment of cancer is a delicate balance between preventing up-staging and avoiding attendant morbidity/mortality. expectedly, majority of the respondents were of the opinion that emergencies and newly diagnosed cases should not be denied treatment for sarcoma, without compromising on the safety of health care workers (hcw), patients, and their attendants. this is in alignment with the limited opinions available in the literature [6, 7] . the french sarcoma group issued recommendations that encourage maintaining neoadjuvant and adjuvant chemotherapy and radiotherapy for all patients who are not suspected to have a covid-19 infection, and advised provisions for adequate post-operative resuscitation capacities for high-risk surgeries [6] . similar guidelines have been published us keeping an indian perspective in mind [7] but, approximately half the respondents in our survey stated that chemotherapy and radiotherapy were no longer available for new patients. radiation oncology clinics have unique issues [8] . most patients are outpatients and need travel. difficulties in isolating patients, shared machine time, pre-existing disease states and immunocompromised status add to the prospects of delivering safe and effective radiotherapy. denial of treatment for patients already on treatment may wreak havoc with radiation treatment planning. practices for delivery of radiation varied widely which can be a result of lack on clarity and consensus on ideal practices and we believe this will improve over a period. surgery forms the mainstay of sarcoma treatment. respondents were sensitive to the risks of exposure and difficulty in operating prolonged surgeries with full ppe. 82 (42%) respondents operated only on high grade sarcomas with curative intent, but avoid major surgeries like internal hemipelvectomies, free flaps, etc. and 52 respondents (27%) operated only emergencies (fig. 5) . these policies are also likely to change/evolve over time as the availability of healthcare infrastructure and hcw improves. as benign bone conditions are not life-threatening, there was a broad consensus to defer elective surgery for these patients and operate only on patients with emergencies or locally aggressive lesions by 48 and 39 respondents, respectively. 22 respondents offered alternate non-surgical modalities (fig. 5) . ppe is resource-constrained and rational use is obligatory. ministry of health and family welfare, govt of india recommends full complement of ppe use by hcws for (a) intensive care unit (icu)/critical care patients, (b) emergency severely ill patients of severe acute respiratory infection (sari) (c) during transport of sari patients (d) sample collection, transport and testing and (e) autopsy [9] . we found that there was wide variation in use of full ppe. the false-negative covid-19 reports might be a reason for respondents to use full ppe even in patients who are negative for covid-19. for respondents not using full ppe, components of full ppe were used in multiple combinations which differed widely. this heterogeneity might reflect ppe availability across institutes depending on resources. our survey highlights that staffing is a huge challenge. availability of hcw is key in delivery of care. rotational staffing policies ensure limitation of exposure and ensures continuity of care. 161 respondents (83%) were following this policy. isolation of hcw by providing alternative accommodation at hospitals is ideal to prevent both, exposure of hcw and exposure by hcw in the community. 83 respondents (43%) were not provided alternate accommodation. 80% of our respondents anticipate that current working pattern might need to be extended between 2 and 6 months. in the absence of guidelines by societies and associations, it is upon the individuals to take the call and strike a balance between continuing care and ensuring safety as of now. non-uniform availability of resources, differential hospital setups, multitude of "guidelines", limited hospital capacity, including icu and lack of point-of-care testing and seroprevalence data adds to the difficulty [10] . we expect to have more robust policies in near future, as both the covid-19 pandemic and the outcome of sarcoma care evolves over time. the global approach to covid-19 testing has been nonuniform [11] . the incidence of asymptomatic carriers is unknown and is reflected in differential screening patterns across institutions. in our survey, non-uniform screening procedures were practiced. in op, 10% were screened by symptom and contact enquiry, 57% had additional temperature recording while 30% also had covid-19 testing (fig. 3) . in ip, the proportion being tested for covid-19 was higher at 43% (fig. 3) . not surprisingly, 38% of respondents disagreed with their screening policy. indian council of medical research (icmr) guidelines for testing for covid-19 have evolved since the declaration of pandemic in march 2020 to may 2020 and that has impacted on indvidual hospitals practices of testing [12, 13] . palliative care services are under-resourced at the best of times [14] . as health systems become strained under covid-19, providing safe and effective palliative care, including end-of-life care, becomes especially vital and especially difficult. palliative treatment was offered by 141 (73%) respondents. palliative surgery was generally not recommended in this survey. pharmacological interventions/ radiation/chemotherapy were used alone or in combination. metastatic disease though low on priority during triage were not ignored with 56 respondents (29%) offering definite curative therapy including metastasectomy for select group of patients with good prognosis (oligometastatic disease) and 71 respondents (37%) offered nonsurgical treatment (sbrt) for the metastasis. even in covid-19 era, cancer remains top priority for treatment-timely treatment is vital. there is significant disruption to providing care to sarcoma patients with approximately half the respondents in our survey stated that chemotherapy and radiotherapy were no longer available for new patients. almost all, emergency and most routine patients with high risk are being offered treatment. wide variations exist on the use of ppe but might become more uniform as availability and cost improves. telemedicine has made a big change. palliative treatment is not being neglected. this survey brings to light changes of practice in most institutions, some of which are here to stay. having picked up some good lessons from the modifications this pandemic has forced upon us, treatment of sarcomas post the pandemic might not be the same ever again. this survey will act as a reference point for tracking future trends in bone and soft tissue tumor management guidelines, as the covid-19 scenario unfolds globally and particularly in india. what is your specialty? how will you describe your practice during lockdown? how are you/your institution screening your opd patients for covid-19? how has your policy changed during the covid-19 pandemic for op? how are you/your institution screening your ip patients for covid-19? do you agree with current covid-19 testing policies at your institution? what is your policy on managing benign bone tumors during covid-19 pandemic? 15. what is your policy on radiation therapy for sarcomas during covid-19 pandemic? 16. how is complete ppe (jumpsuits, n95 mask, face shield, double gloves, shoe covers) being used in your setup? 17. if not using complete ppe, what is being used at your institution? 18. do you agree with current policies for use of ppe at your institution? 19. if "no", what should be the correct policy? 20. what is your current policy for routine follow-up of sarcoma patients during covid-19 pandemic? 21. are you using formal tele consults/virtual consults during covid-19 pandemic? 22. what do you think about palliative treatment for sarcomas during covid-19 pandemic? 23. how are you treating sarcoma with metastatic disease during covid-19 pandemic 24. how long do you believe we will need to continue with the current pattern of working? references 1 implications of sars-cov-2 infection and covid-19 crisis on clinical cancer care guidance for management of cancer surgery during the covid-19 pandemic cancer patients in sars-cov-2 infection: a nationwide analysis in china covid-19 in pediatric oncology from french pediatric oncology and hematology centers: high risk of severe forms? french sarcoma group proposals for management of sarcoma patients during the covid-19 outbreak adapting management of sarcomas in covid-19: an evidence-based review the impact of covid-19 on radiation oncology clinics and patients with cancer in the united states ministry of health and family welfare directorate general of health services challenges faced by medical journals during the covid-19 pandemic testing individuals for coronavirus disease 2019 (covid-19) the lancet commission on palliative care and pain relief-findings, recommendations, and future directions conflict of interest the authors declare that they have no conflict of interest. key: cord-310944-tfn0ltrz authors: peck, jessica l. title: covid 19: impacts and implications for pediatric practice date: 2020-07-09 journal: j pediatr health care doi: 10.1016/j.pedhc.2020.07.004 sha: doc_id: 310944 cord_uid: tfn0ltrz since the rapid emergence of the novel coronavirus in december of 2019 and subsequent development of a global pandemic, clinicians around the world have struggled to understand and respond effectively and efficiently. with global response encompassing social, political, organizational, and economic realms, world leaders are struggling to keep pace with the rapid changes. challenges within global healthcare system and the healthcare profession itself include rationing supplies and services within health care systems, many of which were stretched to the brink before this latest viral outbreak (american hospital association, 2020). leaders are making policy decisions while balancing the slow and precise nature of science with the rapid and pressing need for life-saving information (altmann, douek, & boyton, 2020). shortcuts on research are occurring, including publishing papers with lack of peer review. social media and lurid reporting bolster feelings of mistrust and panic-buying while burgeoning conspiracy theories commandeer national dialogue. this is a time in history to prioritize global health and thoughtful pandemic preparedness (lancet, 2020). pediatric nurse practitioners (pnps) are ideally situated to be a trusted source of accurate health information for children. this continuing education article summarizes the latest evidence-based information on the rapidly developing coronavirus pandemic; equipping pnps for clinical preparation and response. 1.. distinguish risk factors for covid-19-related morbidity and mortality and identify modes of transmission. 2.. appraise appropriate covid-19 testing parameters and procedures for children. 3.. compare pediatric clinical presentation to adults with covid-19 infection and recommend appropriate treatment measures. 4.. state appropriate infection-control measures to reduce transmission. 5.. describe measures to reduce the risk of infection spread, mitigate adverse health effects in high-risk children, and to promote general health through preventive care. media and lurid reporting bolster feelings of mistrust and panic-buying while burgeoning conspiracy theories commandeer national dialogue. this is a time in history to prioritize global health and thoughtful pandemic preparedness (lancet, 2020) . pediatric nurse practitioners (pnps) are ideally situated to be a trusted source of accurate health information for children. this continuing education article summarizes the latest evidence-based information on the rapidly developing coronavirus pandemic; equipping pnps for clinical preparation and response. severe acute respiratory syndrome (sars) family and is also referred to as sars-cov-2. covid-19 is a zoonotic, enveloped, single-stranded ribonucleic acid (rna) virus that can quickly mutate and recombine, creating novel virus strains that spread from animals to human. there are currently four strains of coronavirus circulating in humans, all thought to originate in bats. covid-19 was first reported in wuhan, china; with controversial and unsubstantiated reports on the nature of its origin. coronaviruses are known for causing severe respiratory distress and respiratory failure along with coagulopathies, multi-system organ failure, and death (zimmerman & curtis, 2020) . the timeline (see figure 1 ) of the covid-19 outbreak is astonishing, as china first reported a cluster of cases of pneumonia in wuhan on december 31, 2019. just a month later the world health organization (who) declared a public health emergency of international concern and by march 11 th , assessed the crisis as a global pandemic (who, 2020) . response in the united states (us) evolved rapidly as president trump declared a state of national emergency under the stafford act on march 13 th . six days later, california became the first state to issue a statewide stay-at-home order. the following week, the u.s. national guard was activated in all fifty states. by the end of march, new york city emerged as the epicenter in the us and by the end of april, the us reported more than one million cases, the highest number in the world (kantis, kiernan, & bardi, 2020) . declaration of a public health emergency has directed the entire healthcare system to initiate population-based triage, the management of massive numbers of individuals seeking care. tasks in this strategy include providing crisis leadership, sustaining organizational response, and achieving disease containment. triage-based categories include addressing susceptible, exposed, infectious, removed, and/or vaccinated populations, usually through an incident command system. goals are divided into two phases (see table 1 ). phase one addresses broad generic interventions based on best public health practices, while phase two management decisions are surge-dependent and specific to the five aforementioned triage categories (burkle, 2008) . children are a population who have been spared significant burden of severe illness. to date, two studies (n= 2,143 and n= 171) have described similar covid-19 findings in pediatric patients. boys are more commonly affected than girls and most children were either asymptomatic or mildly symptomatic. children younger than three years of age and those with congenital heart disease seem to be disproportionately impacted (yagnik et al., 2020) . social determinants of health are emerging as a predictor of health disparity in covid-19, many of which impact pediatric populations. essential workers are less likely to be able to work from home and financially tolerate furlough. persons with crowded housing, inconsistent access to care, chronic conditions, and high stress levels impacting immune function are more susceptible to adverse outcomes as are those who experience racial or ethnic prejudice and/or discrimination (golden, 2020) . people of color, particularly african americans, experience more serious covid-19-related morbidity and mortality. while african americans make up 13% of the us population, they account for approximately 30% of deaths, and up to 75% of covid-19related deaths in chicago. asian americans show similar disparity at 18% of the us population and 23% of covid-19 deaths (golden, 2020) . other populations at significant risk include older adults (> 65 years of age), persons with underlying medical conditions (e.g., asthma, cardiovascular disease, kidney disease), persons with immunocompromise, persons with severe obesity (body mass index >40), persons with diabetes, persons undergoing dialysis, and persons residing in long-term care or nursing homes (cdc, 2020c) . care must be taken to ensure equitable, transparent provision of services during this pandemic. covid-19 is thought to spread mainly from person-to-person, primarily through close contact and droplet exposure from distances of six feet or less (zimmerman & curtis, 2020). children carry the covid-19 virus in the upper respiratory tract, making it easier to spread in childcare centers, schools, and homes; where pediatric respiratory hygiene is inconsistent and problematic (zimmerman & curtis, 2020). r 0 (pronounced r-naught) is the average number of secondary cases attributable to an index case. in other words, it is the average number of persons someone with covid-19 is predicted to infect. r 0 estimates for covid-19 range from 2.0-5.7. experts project 82% of the population needs immunity (antibody induced or vaccine acquired) to stop transmission and achieve herd immunity (ramirez, 2020) . early analysis suggests active public health surveillance, contact tracing, quarantine implementation, and coordinated social distancing efforts are critical in stopping the spread of covid-19 (sanche et al., 2020) . as of june 25, 2020, there were no confirmed cases of covid-19 intrauterine transmission, although there were concerns over possible correlation to miscarriage, intrauterine growth restriction and preterm delivery (zimmerman & curtis, 2020) . in the weeks following this report, however; there is growing evidence maternal-fetal transmission is occurring (alzamora et al., 2020) . unlike earlier outbreaks of sars, covid-19 yields fewer maternal mortalities (schwartz, 2020) . covid-19 outcomes of pregnant women are similar to women who are not pregnant, including the need for intensive care. as of may 1, seven maternal deaths have been reported (d'ambrosio, 2020). there is currently no evidence to suggest covid-19 transmission is foodborne, although early reports indicate the virus can live up to 24 hours on cardboard and paper (i.e. food packaging containers) and up to three days on harder surfaces (cdc, 2020h) . current advice to reduce transmission associated with grocery shopping or take-out food includes handwashing before and after handling food packaging, removing packaging prior to eating, limiting trips to the grocery store, and ensuring food preparers (including grocers and restaurants) are complying with health guidance such as wearing masks and screening workers for illness (cdc, 2020h) . there are currently no reports of domestic pets as vectors, although one tiger at a new york city zoo tested positive (cdc, 2020e). if persons are ill with known or suspected covid-19, it is wise to self-isolate from pets if possible. to lower risk of transmission, dogs should be walked on a leash, keeping a six-foot distance from other people and animals. crowds should be avoided, and pet-owners should not allow strangers to pet their animals. if a pet shows signs of illness, the veterinarian should be called for further instruction as opposed to arriving unannounced at an animal clinic (cdc, 2020e). pediatric healthcare providers have always demonstrated expertise in promoting general holistic health, and now that task is more critical than ever as persons with pre-existing medical conditions are disproportionately affected by adverse outcomes from covid-19. table 2 offers strategies for targeted health interventions to optimize health and mitigate potential serious and life-threatening outcomes associated with covid-19 infections. non-pharmaceutical interventions (npis) are actions, apart from immunization and medication administration, people and communities can take to help slow the spread of illness. the goals of npis are to prevent and/or minimize morbidity and mortality while minimizing social disruption and economic effects. timing is crucial to ensure npis are applied with the least restrictive measures which provide the greatest public health benefit (banholzer et al., 2020) . the challenge of npis is that evidence of efficacy is always retrospective. evidence concerning npis implemented to mitigate the spread of covid-19 in the us is to date, inconclusive, although early analysis conducted by banholzer et al., (2020) is promising (table 3 ). social distancing (e.g. maintaining a physical distance in public at a minimum of six feet from persons not living together in the same household) has emerged as a critical npi to slow the spread of covid-19 (messonier, lipsitch, stripling, & markel, 2020) . families can be equipped by healthcare providers who emphasize the importance of promoting adherence. role modeling from parents and other adults in the home is an effective way to encourage children to adhere to public health guidelines. parents should emphasize personal responsibility, especially with adolescents, by establishing clear expectations and firm guidelines with instruction including ways in which lack of personal responsibility can adversely impact the lives of others. families should also consider postponing visits to see older family members or grandparents and consider use of technology to maintain emotional and relational connections (inouye, schuchat, aiello, galea, & nuzzo, 2020). on april 3, 2020, the cdc made a departure from previously issued guidance with a broad recommendation for anyone over two years of age to wear face masks or coverings while in public. this does not replace recommendations for social distancing or personal hygiene measures to control the spread of covid-19 (cdc, 2020b). persons excluded from mask usage include babies less than two years of age, and persons who have trouble breathing, are incapacitated or are unable to remove a mask without assistance. mask use is more effective in protecting others from spread of viral pathogens than protecting the wearer from infection. ideal fabrics for do-it-yourself masks include denim, canvas, and paper towels, with scarves as a last resort. layering adds potential protection, but also can decrease ability to breathe easily (cdc 2020b). in general, surgical masks and n-95 respirators should be reserved for healthcare workers and other first responders. in healthcare settings, n-95 masks should be reserved for high-risk aerosolizing procedures such as intubation and endotracheal suction and high-risk healthcare workers including those with a history of asthma. the use of expired n-95 masks may be acceptable in some circumstances. fit-testing and seal-check is recommended for all n-95 mask use, expired or not (mcmillan & rebman, 2020) . the straps and bridge of the nose are usually the first areas to break down and should be visually inspected before use. to preserve masks and maximize usage, longer usage is preferred over re-usage. a face shield used over a mask is preferred and may help extend the life of the mask (mcmillan & rebman, 2020). lack of adequate personal protective equipment (ppe) has been a widely publicized and broadly discussed concern of healthcare providers, first responders, and essential workers. ideal ppe when caring for a patient with known or suspected covid-19 infection includes: a new n-95 mask, gown, medical grade gloves, and eye covers and/or a face shield (cdc, 2020b). proper donning and doffing of ppe are essential to prevent viral spread. institutions should take care to implement protocols and training to adequately equip personnel. hand hygiene should be performed before and after removal and masks should be removed by the straps and handled with gloves. if there is limited or no ppe in a health care setting, usage should be reserved for high-risk persons (e.g. persons > 60 years of age, with chronic medical conditions, or pregnant) or those performing high-risk aerosolizing procedures such as intubation, endotracheal suction, or cardiopulmonary resuscitation. limiting visitors in the healthcare setting can be a measure to reduce ppe usage (mcmillan et al., 2020) . the cdc has issued guidelines for reuse of surgical gloves, masks, and other ppe should new items not be available. homemade ppe should be used a last resort. the cdc has a ppe burn rate calculator tool available online to help estimate usage and ordering needs for healthcare settings (cdc, 2020b). frontline personnel and essential workers are concerned about covid-19 transmission to family members and household contacts. self-quarantine should be considered, particularly if there are persons in the home at high-risk for adverse outcomes from covid-19 (little et al., 2020) . several hotel chains are offering free lodging to frontline personnel, and many other community efforts include donation of vacation homes or recreational vehicle use. if selfisolation is not possible, a separate room and bathroom is ideal if available for symptomatic persons, with delivery of meals using disposable plates and utensils. frontline workers should remove all clothing and shower at their place of employment if possible. alternatively, stripping clothing in the garage or designated entry spot of the home while placing soiled clothing in a garbage bag for laundering is preferred. shoes should be removed and placed in a plastic bin at the home entrance. cleaning soles of shoes with bleach is not recommended, as it may increase risk of exposure. frontline workers should regularly self-monitor for symptoms including temperature and promptly report any potential signs of illness (charbonneau, 2020). evidence is still emerging on efficacy of these efforts, but early results point to handwashing, disinfecting carefully, avoiding sharing rooms and surfaces, managing home deliveries with caution, and ensuring adequate ventilation as most efficacious. healthcare providers can help families plan for modifications of behavior and factors in the home environment with assistance in problem solving to overcome barriers (little et al., 2020) . in addition to consideration in the home setting, careful attention should be given to measures within the healthcare setting to minimize the risk of nosocomial infection (table 4) . the gold standard of diagnosis for covid-19 remains the reverse transcriptasepolymerase chain reaction (rt-pcr) using a nasopharyngeal swab, which demonstrates greater reliability over salivary or oropharyngeal specimen analysis (sethuraman, jeremiah, & ryo, 2020) . rt-pcr positivity is estimated to persist approximately three weeks beyond the onset of illness, indicating only the detection of viral rna and not necessarily viable transmittable virus (sethuraman, jeremiah, & ryo, 2020) . at the end of may 2020, the us is performing approximately 150,000 tests per day with a daily goal of 500,000. nationally, the positive rate is around 20% while germany is reporting 6% and south korea 3%. positive rates of more than 10% indicate less than ideal conditions and inadequate testing (relman, taylor, & benjamin, 2020) . currently there are approximately 70 assays commercially available with wide variability in length of testing and significant supply chain issues affecting availability of cotton swabs, reagents, and other items necessary to complete testing. as rapid point-of-care tests emerge on the market (currently there are three), they arrive with a disadvantage of threats of inconsistency in reporting, creating more challenges with contact tracing. sensitivity and specificity currently vary widely and need further investigation (relman et al., 2020) . in clinical cases with a high index of suspicion and an initial negative nasopharyngeal rt-pcr, repeat testing should be pursued (zimmerman & curtis, 2020). testing of children is variable by region related to state and county guidelines, testing availability and accessibility, and community prevalence. time estimations of rt-pcr positivity and seroconversion are still unknown in children because largely adult populations have been studied to date. some concern has emerged after reports of persistent pcr in stool specimens, suggesting possible implications for high-risk caregivers of children who need assistance with elimination needs (sethuraman et al., 2020) . serology testing for covid-19 antibodies is rapidly emerging to explore individual immunity as well as the use of convalescent plasma in therapy for persons with active infection. the food and drug administration (fda) issued rapidly changing guidance on antibody testing, initially waiving the need to apply for an emergency use authorization (eua) but later requiring application within ten days of appearance on the commercial market. if the test does not meet fda standards, testing must be suspended (shah & shuren, 2020) . experts advocate for a thoughtful, deliberate approach to ensure the utmost standards of scientific rigor and safety to guide high-stakes policy decisions (altmann, douek, & boyton, 2020) . barriers to testing are influenced by social determinants of health. although the federal government passed legislation to cover cost of covid-19 testing, cost of care associated with the diagnostic test may not be covered. locations of testing centers should be accessible to the community and drive-through testing centers should make accommodations for those who do not have a car (relman et al., 2020) . testing times should provide flexibility in consideration of employment hours of essential workers. efforts should be made to eliminate racial or ethnic discrimination while providing reassurance and anticipatory guidance to counter fear of stigma resulting from a positive test. many primary care systems are severely impaired, and many overwhelmed emergency centers may turn patients away. there is much work to be done to ensure equitable access for all to covid-19 related care (relman et al., 2020) . it appears children present with similar symptoms described in adults with active covid-19 infection, although most are either asymptomatic or mildly symptomatic. in late april 2020, the cdc added six symptoms now believed to be associated with covid-19 including: chills, shivering, muscle aches, headache, sore throat, and a loss of taste and/or smell (neuman, 2020). these were added to previously identified symptoms of fever (91-100%), cough (43-80%) and rhinitis (33-60%); 50-80% of reported cases reported an ill family contact and 30% reported nosocomial contact (zimmerman & curtis, 2020). although much has been discussed in the media concerning gastrointestinal symptoms as a pediatric presentation, the reported study referenced had five subjects, leaving much to be discovered (feder, 2020) . emerging characteristics of serology and radiologic findings are listed in table 5 . recent developments include concern of what is being called "covid-toes." initially, dermatologists had concern for children with pre-existing skin conditions, particularly those taking biologics or immunomodulators, who might be at increased risk for covid-19-associated morbidity and mortality. anecdotal reports were channeled to a registry development with the global rheumatology alliance where more organized reports of pernio-like lesions on the toes began to coalesce. these lesions are characteristic of chilblains, but without any cold exposure. children report a burning sensation, pain, and/or tenderness lasting approximately two weeks. there is no correlation currently between dermatologic manifestation and severity of illness (forand, 2020) . as skin eruptions are common with viral illnesses of childhood, it is important to reassure parents covid-toes seem to be an uncommon occurrence and to seek care with any health concerns (cleveland clinic, 2020). concerned providers may report possible cases to www.aad.org/covidregistry. also, of concern are reports of a kawasaki-like syndrome (referred to by the cdc as multisystem inflammatory syndrome in children (mis-c) in fifteen children aged 2-15 years hospitalized in new york city (hester, 2020) . while none of these children have died related to mis-c, five have required ventilator support and six have died from other covid-19 complications. reports of misc-c in europe include 20 cases in italy, 20 in paris, and 12 in britain (goldstein, 2020) . some children appear to have signs of initial recovery followed by a secondary inflammatory response. clinical implications include increased vigilance of potential manifestations of systemic vasculitis with appropriate clinical assessment and public health reporting for covid-19 (hester, 2020) . parents can be reassured mis-c still appears quite rare as a complication and in and of itself is not contagious (steenhuysen, 2020) . other vascular complications include higher than previously indicated coagulopathies, possibly initiated by a cytokine storm. retrospective autopsy findings suggest mortality related to undiagnosed deep vein thrombosis. further exploration is needed to investigate the molecular mechanism, incidence, and clinical implications of these findings (bandyopadhyay et al., 2020). the national institute for health (nih) published the first covid-19 treatment guidelines in may of 2020. there are some special considerations for pediatric populations, but the majority of guidance includes statements iterating insufficient data exists for or against use of pharmacologic therapies to treat covid-19 infections in children (nih, 2020). treatment mainly consists of supportive care with provision of sufficient fluid and calorie intake along with oxygen supplementation and airway support. most cases appear to be mild and can be treated at home following clinician determination of minor illness with appropriate anticipatory guidance and evaluation of available resources. vitamin d supplementation may play a role in reducing the risk of covid-19 infections, but there is insufficient evidence to support universal recommendation for children (grant et al, 2020) . children who are ill enough to require hospitalization need observation for progression of respiratory distress, multi-system organ failure, and development of secondary nosocomial infections (zimmerman & curtis, 2020). other covid-19 pharmacologic treatment explorations include monoclonal antibodies, protease inhibitors, and rna synthesis inhibitors (zimmerman & curtis, 2020). chloroquine in particular has been widely publicized and publicly debated. emerging recommendations include prioritizing available supply for rigorous, scientific clinical trials, preventing treatment interruptions for those on chloroquine for chronic rheumatic diseases, and provision of clear messages with transparent and accurate interpretation of available data concerning covid-19 treatment (yazdany & kim, 2020) . if a child has a laboratory confirmed or clinically suspected case of covid-19, isolation should be initiated. discontinuing isolation can be test-based with two or more negative tests (with eua approval from the fda) more than 24 hours apart and meeting requirements for symptom-based strategy. if testing is not available, isolation may be discontinued solely with a symptom-based strategy after a minimum of ten days from the onset of symptoms and more than three days from recovery (defined as a minimum of 72 hours afebrile without antipyretics and improvement in respiratory symptoms cdc, 2020f). the world is waiting with bated breath for a covid-19 vaccine. with more than 100 potential vaccines in development, safety and scientific rigor in the process will need to take highest priority (altmann et al., 2020) . many approaches are being studied including liveattenuated, inactivated, subunit, recombinant, viral vector, and dna vaccines (zimmerman & curtis, 2020) . vaccine development is a process which customarily takes 20+ years, but in the case of covid-19, is being attempted in 12-18 months. comparatively, other vaccines for children have gone through rigorous clinical trials with more than 70,000 subjects studied over four years or more, a difficult bar to clear in these conditions. in biologics, the process is the product, and it is essential the process is the same for every dose (offit, 2020). on may 4, 2020, the national institute of allergy and infectious disease announced the human epidemiology and response to sars-cov2 (heros) study. more than 6,000 children in 2,000 families currently enrolled in nih-funded pediatric research in 11 cities will participate in the effort to provide answers as to why most children with acute covid-19 infection are not seriously ill. families will be studied remotely with caregiver collection of specimens. questions to be addressed include: 1) do infection rates differ in children with asthma? 2) how many children infected with covid-19 develop symptoms? and 3) are children resistant to covid-19 infection? (nih, 2020). primary care access has been severely disrupted by restrictions implemented to prevent covid-19 transmission. challenges include limited ppe, limited availability of covid-19 tests, patient workflow disruptions with closed waiting rooms and drive-through services, dramatic patient census drops and revenue shortfalls, and parental fears resulting in hesitance to present for care. in addition, rapid changes in telehealth in the last two months have exceeded changes made in the last two decades, with many practices quickly adapting from little-to-no telehealth to a majority of services being delivered remotely (mostashari, 2020) . long-term health impacts and outcomes remain to be seen. many pnps have been called upon to care for young adults, converting inpatient critical care units to house persons aged into their 30s (philips et al., 2020; renke et al., 2020) . in times of emergency, this may be necessary. the national association of pediatric nurse practitioners (napnap) asserted this is appropriate in certain circumstances but clarified certain conditions for consideration including: 1) individual state nurse practice acts should be consulted and followed, 2) the pnp has education and training to give appropriate care to the assigned patient, 3) safe harbor protections are in place to protect the pnp from being forced to accept unsafe assignment, and 4) care will transition to an adult provider as soon as possible (napnap, 2020a). early estimates suggest measles vaccination rates have fallen up to 60% since onset of the covid-19 pandemic (dunleavy, 2020) . pnps play an important role in promoting vaccination by encouraging and equipping families to stay on schedule to avoid vaccinepreventable illness (goza, 2020) . napnap recommends innovative solutions to provide safe opportunities to keep vaccination schedules on time including: 1) separating well and sick visit hours, 2) staggering appointment times, 3) closing waiting rooms, 4) reminding families about upcoming vaccines, 5) using every patient encounter as an opportunity to administer vaccines, and 6) administering as many simultaneous vaccines as possible (napnap, 2020b) . the world has changed on a 9/11 type of scale in the weeks following rapid spread of covid-19. this is likely to change society in several ways with long-term implications still largely unknown. professional experts in science, medicine, nursing, economics, business, journalism, and others are offering professional opinions of their expectations of world changes and paradigm shifts (politico, 2020). schools are struggling to adapt rapidly, making high-stakes decisions with little information available. the american academy of pediatrics issued guidance regarding return to school to shape conversations around holistic health and equity (hester, 2020) . napnap (2020c) issued a position statement concerning child health and wellness during covid-19. recommendations for families include: 1) supporting children as they ask questions about the pandemic, 2) close monitoring of child health and well-being with prompt contact of primary healthcare providers if changes are noticed, and 3) continuing to seek care in-person or using telehealth to maintain well visits and immunization schedules while receiving anticipatory guidance and necessary screenings. recommendations for providers include: 1) increasing utilization of telehealth and telemedicine, 2) designing office experiences to support social distancing in a developmentally appropriate way, 3) increasing access to hand sanitation, 4) providing masks as indicated, 5) ensuring ppe is available for all staff, 6) advocating for mental health awareness and connection to resources, 6) referring families to credible sources of health information, 7) reminding families to present for well care, and 8) considering participation in research efforts. pnps will need to continue to be active learners, adaptive and flexible while serving as trusted sources of information for families with children who concerned about immediate and long-term impacts and implications of covid-19. 1. which statement is most accurate concerning covid-19 morbidity and mortality in the pediatric population? a. children have been disproportionately affected, with high rates of morbidity and mortality b. children have lower rates of infection, but higher rates of death than adult populations c. children with covid-19 infection are mostly asymptomatic or mildly symptomatic d. children are at much higher risk for acquiring covid-19 than adult populations 2. which of the following statements are true about non-pharmaceutical interventions (npis)? select all that apply. a. the goal of npis is to eliminate all mortality associated with covid-19 b. timing is critical to ensure least restrictive measures with greatest public health benefit c. social distancing is the least effective measure to prevent the spread of covid-19 d. healthcare providers should emphasize personal accountability by establishing clear expectations and firm guidelines e. school closures are one of the most effective npis in helping slow the spread of covid-19 3. which of the following represents most appropriate mask usage according to cdc guidelines? a. cloth face coverings for infants less than two years of age b. surgical grade masks for school-aged children when in public c. do-it-yourself masks with scarves and coffee filters for primary care providers d. n-95 mask use for a pediatric nurse practitioner with a personal history of asthma 4. what actions should be taken to preserve ppe supplies for healthcare workers? select all that apply. a. use expired 3m n-95 masks for low-risk exposures* b. removal, disinfection, and reuse of ppe is preferred over extended single periods of use c. ideal ppe for covid-19 care includes a new n-95 mask, gown, medical grade surgical gloves, and eye covers and/or a face shield* d. visitors to the healthcare setting should be limited* e. mask removal should be preceded and followed by strict hand hygiene* 5. what should healthcare or essential workers do to help prevent transmission of covid-19 to household contacts? a. all essential or frontline workers should remain in self-quarantine for 30 days after providing care b. soles of shoes worn in healthcare setting should be cleaned with bleach after removing c. self-isolation at home should ideally occur in a separate room with private bathroom* d. n-95 masks and ppe gowns should be worn at home 6. if a child presents to the clinical setting with symptoms of covid-19 compatible illness, what test should the pediatric provider order? a. rt-pcr nasopharyngeal swab b. serology for covid-19 antibodies c. chest ct without contrast d. home-testing kit with saliva collection 7. which of the following clinical presentation scenarios is most concerning for possible covid-19? a. 6-year-old with one episode of diarrhea, two episodes non-bilious emesis, and no ill contacts b. 18-year-old with a bmi >40 and prior history of type ii diabetes mellitus who presents with cough, chills, fever, and loss of smell* c. 12-year-old with sore throat, lymphadenopathy, and nausea d. 1-year-old with maculopapular rash to the hands, feet, and buccal mucosa 8. what is the most appropriate response to parental concerns over multisystem inflammatory syndrome in children (mis-c)? a. this is a life-threatening illness becoming common in children b. this is a rare and usually treatable complication from a viral illness c. this is a contagious illness that can easily spread from child-to-child d. kantis, c., kiernan, s., and bardi, j.s., 2020, think global health (https://www.thinkglobalhealth.org/article/updatedtimeline-coronavirus) . "who timeline covid-19, by the world health organization, 2020 (https://www.who.int/news-room/detail/27-04-2020-who-timeline---covid-19). what policy makers need to know about covid-19 protective immunity. the lancet. advance online publication severe covid-19 during pregnancy and possible vertical transmission hospitals and health systems face unprecedented financial pressures due to covid-19 covid-19 pandemic: cardiovascular complications and future implications impact of non-pharmaceutical interventions on documented cases of covid-19. medrxiv. advance online publication autopsies of covid-19 patients reveal clotting concerns population-based triage management in response to surge-capacity requirements during a large-scale bioevent disaster strategies for optimizing the supply of facemasks discontinuation of transmission-based precautions and disposition of patient with covid-19 in healthcare settings are covid toes and rashes common symptoms of the coronavirus? why are we hearing so much about them these days? cleveland clinic miscarriage and maternal mortality in pregnant patients measles vaccinations in u.s. children fall up to 60 percent since pandemic, cdc says digestive issues were an early symptom of coronavirus for 5 children who needed hospital treatment, a study says dermatology expert weighs in on 'covid toes,' tracking dermatologic symptoms of covid-19 evidence that vitamin d supplementation could reduce risk of influenza and covid-19 infections and deaths coronavirus in african americans and other people of color 15 children are hospitalized with mysterious illness possibly tied to covid-19. the new york times aap statement on new data showing declines in childhood immunizations promoting healthy movement behaviours among children during the covid-19 pandemic. the lancet child & adolescent health aap offers guidance for reopening schools the science of social distancing updated: timeline of the coronavirus. a frequently updated tracker of emerging developments from the beginning of the novel coronavirus outbreak reducing risks from coronavirus transmission in the home-the role of the viral load be confident protecting yourself and providing the best care to your patients during this covid-19 pandemic american nurses association the science of social distancing collapse national association of pediatric nurse practitioners [napnap]. (2020a, april) study to determine incidence of novel coronavirus infection in u.s. children begins covid-19 vaccine update: will we have the vaccine any time soon? is the immune system induced by the vaccine really protective? rapid implementation of an adult covid-19 unit in a children's hospital. the journal of pediatrics coronavirus will change the world permanently. here's how what is r 0 ? gauging contagious infections. healthline covid-19 testing: possibilities, challenges, and ensuring equity utilization of pediatric nurse practitioners as adult critical care providers during the covid-19 pandemic: a novel approach high contagiousness and rapid spread of severe acute respiratory syndrome coronavirus 2 an analysis of 38 pregnant women with covid-19, their newborn infants, and maternal-fetal transmission of sars-cov-2: maternal coronavirus infections and pregnancy outcomes. archives of pathology and laboratory medicine interpreting diagnostic tests for sars-cov-2 insight into fda's revised policy on antibody tests: prioritizing access and accuracy three u.s. children with covid-18 have rare inflammatory syndrome who timeline-covid-19 pediatric characteristics of 2019 novel coronavirus: review of available use of hydroxychloroquine and chloroquine during the covid-19 pandemic: what every clinician should know. annals of internal medicine coronavirus infection in children including covid-19: an overview of the epidemiology, clinical features, diagnosis, treatment and prevention options in children key: cord-309324-vatugz84 authors: sorbello, massimiliano; el-boghdadly, kariem; schumacher, jan; ahmad, imran title: personal protective equipment, airway management and systematic reviews. comment on br j anaesth 2020 date: 2020-06-30 journal: br j anaesth doi: 10.1016/j.bja.2020.06.038 sha: doc_id: 309324 cord_uid: vatugz84 nan editor -we read with interest the paper by sanfilippo and colleagues 1 pandemic. airway management with ppe carries significant challenges, including restricted movement, limited communication, impaired vision, loss of tactile sensitivity, and wearer discomfort. we thus agree with the need for a systematic review in this subject, however we wish to highlight some concerns regarding this study. firstly, the search reported by sanfilippo and colleagues 1 appears to have missed some relevant and critically important studies. although sanfilippo and colleagues located only a single study examining anaesthetists as subjects, five other studies, all authored by and including anaesthetists, met inclusion criteria and would have been expected to be included in their analysis, three of which focused on the covid-19 pandemic. these include two randomised crossover trials, 2-3 one crossover trial, 4 and two observational studies. [5] [6] a further study in a cardiac arrest setting might have been included also. 7 these omissions could reflect an incomplete search strategy, inadequate screening, or unclear inclusion criteria, and significantly undermine the validity and reliability of the results and interpretation. secondly, for the outcome metrics sought, success rate and time to successful tracheal intubation, critical operator chracteristics were not considered. in particular, the background and experience of airway operators must be factored in as different levels of experience can cause poor performance 8 rather than the ppe itself. the authors did not examine or report this key element of the included studies. thirdly, the authors compared a highly variable and diverse ppe baseline (in diverse population studies). for example, one study compared outcomes after tracheal intubation of a manikin with either a glidescope or a macintosh laryngoscope with participants wearing hazmat ppe, 9 and another examined the airwayscope with participants wearing "chemical, biological, radiation and nuclear ppe". 10 in the first study a complete hazmat suit with papr was used by 1 st -3 rd year emergency medicine residents, whereas in the second a group of 19 volunteers with "some prior experience of tracheal intubations on human patients using a macintosh laryngoscope (mean number of intubations, 1.13+/-1.31)" was using "nylon shirt and pants, antigas mask, gloves and rubber boots", which are intuitively less cumbersome compared with a full hazmat suit. this variation is emphasised in the legend of table 1 in sanfilippo and colleagues' paper, 1 which reveals the diversity of the included ppe, ranging from respirator masks to powered air-purifying respirators (paprs), which would have significant differences in their influence on technical performance. the importance of simulation and training in airway management, particularly in combination with the physical and cognitive challenges imposed by ppe has been reported elsewhere. [11] [12] [13] [14] we agree with the authors that training is of utmost importance; on the other hand, we want to emphasize other priority factors such as the need to identify dedicated airway teams and intubation spots, 15 and the need for team preparedness and pre-procedural planning (including cognitive aids and airway management and ppe donning/doffing checklists), [12] [13] [14] and the need for clear indications for correct ppe and operative instructions to improve user compliance and acceptance. 16 we cannot underestimate the additional mental workload imposed by the clinical scenario and by the fear of self-infection which could never be reproduced even in the highest fidelity simulation. it is encouraging that sanfilippo and colleagues have attempted to synthesise data on this practice. however significant limitations in their data hamper our ability to interpret the evidence base, but their data do highlight that the real concern is not measuring how limited airway management is by ppe, but rather the need for better understanding of ppe diversity, correct use of ppe and development and training in new techniques, protocols and devices to overcome such difficulties. otherwise, as with the chinese proverb, when the wise points the moon, the fool looks at the finger. systematic review of simulated airway management whilst wearing personal protective equipment a randomised crossover simulation study comparing the impact of chemical, biological, radiological or nuclear substance personal protection equipment on the performance of advanced life support interventions the impact of respiratory protective equipment on difficult airway management: a randomised, crossover, simulation study the aerosol box for intubation in coronavirus disease 2019 patients: an in-situ simulation crossover study use of in situ simulation to evaluate the operational readiness of a high-consequence infectious disease intensive care unit comparison of three tracheal intubation methods for reducing droplet spread for use in covid-19 patients comparison of powered and conventional air-purifying respirators during simulated resuscitation of casualties contaminated with hazardous substances device or target? a paradigm shift in airway management: implications for guidelines, clinical practice and teaching intubation efficiency and perceived ease of use of video laryngoscopy vs direct laryngoscopy while wearing hazmat ppe: a preliminary high-fidelity mannequin study utility of the pentax-aws in performing tracheal intubation while wearing chemical, biological, radiation and nuclear personal protective equipment: a randomised crossover trial using a manikin the italian coronavirus disease 2019 outbreak: recommendations from clinical practice consensus guidelines for managing the airway in patients with covid-19: guidelines from the difficult airway society, the association of anaesthetists the intensive care society, the faculty of intensive care medicine and the royal college of anaesthetists outbreak of a new coronavirus: what anaesthetists should know consensus statement: safe airway society principles of airway management and tracheal intubation specific to the covid-19 adult patient group covid-19: intubation kit, intubation team or intubation spots? barriers and facilitators to healthcare workers' adherence with infection prevention and control (ipc) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis key: cord-299592-ymurfkbs authors: bhattacharya, sudip; hossain, md mahbub; singh, amarjeet title: addressing the shortage of personal protective equipment during the covid-19 pandemic in india-a public health perspective date: 2020-04-15 journal: aims public health doi: 10.3934/publichealth.2020019 sha: doc_id: 299592 cord_uid: ymurfkbs nan such resources in the state or national level can be useful so that equipment are not being used can be mobilized with other institutions experiencing scarcity. such approaches may foster collaborative efforts against covid-19 ensuring efficient use of resources at the systems level. nonetheless, it is only possible to address covid-19 if we can flatten the epidemic curve by classical intervention measures like lockdown and social distancing processes, which may give lead time to many health care systems to arrange further management of the outbreak. but during exponential phase of pandemic as rapid increase in covid-19 patients it is very challenging to provide adequate ppes to the health workers of any country. to solve this problem, i.e., to optimize the use of face masks during the pandemic, the centers for disease control and prevention (cdc) identifies 3 levels of operational status: conventional, contingency, and crisis [1]. during normal times, face masks are used in conventional ways to protect hcws from splashes and sprays. when health care systems become stressed and enter the contingency mode, cdc recommends conserving resources by selectively cancelling nonemergency procedures, cancelling outpatient encounters which might require face masks/ppes. when face masks are unavailable, the cdc recommends use of face shields without masks, taking clinicians at high risk for covid-19 complications out of clinical service, staffing services with convalescent hcws presumably immune to sars-cov-2 (severe acute respiratory syndrome coronavirus 2), and use of homemade/handmade masks, perhaps from bandanas or scarves if necessary [2] . many communities in the india and globally are rapidly entering ppe crisis mode. recently news are circulating about the unconventional solutions for ppe at local hospitals, such as plastic garbage bags for gowns and plastic water bottle cut outs for eye protection [3] . shortage of sanitizer can be solved by using handmade sanitizer having 90% concentration of alcohol, this type of ideas/news/decisions are facing many continued criticism from medical fraternity as they are perceiving as mockery/knee jerk response. plans for resupply through the repurposing of existing industrial capacity are welcome but seem unlikely to solve the shortage quickly enough as supply chains become affected in the pandemic [4]. the task force to combat covid-19 was created to solve precisely this problem, but its inventory is not transparent and news reports suggest its supplies are being distributed unevenly or are insufficient to meet demand [5] . hcws need supplies and solutions for these shortages now, and for that reason, the journal of american medical association (jama) issued a call for ideas for how to address the impending ppe shortage [6]. there were many proposals (table 1) . . sterilization of used ppe with agents ranging from ethylene oxide, uv or gamma irradiation, ozone, and alcohol was identified as common proposal. there were also novel proposals such as mask-fiber impregnation with copper or sodium chloride, these ideas are not unscientific they were field tested after prior viral epidemics to determine the feasibility of sterilizing ppe [7] . although scientists acknowledged that the uncertainty about the effects of these sterilizing agents on the structural integrity of ppe, and there is some evidence the fibers in masks and respirators that filter viral particles can degrade and lose their efficacy with ppe reprocessing [7] . some of the other idea was to reduce patient contact so most of the private clinics remains closed and most of the clinicians doing teleconsultations. alter staffing is also considered as important step, health department of india gave directives to the medical colleges that the all health care workers will work on a rotation basis for minimizing the contact risk [8] . home delivery of online groceries are another option. in india, a company named "big-bazaar" is already providing online groceries to the peoples who are confined in their homes due to lockdown [9]. however, such technology-based services are contingent on the availability and accessibility of those services in different countries. in india and other low and middle-income countries, innovative technological interventions should be devised and deployed to ensure timely and efficient distribution of goods and services. such socioeconomic approaches may not only reduce the risks of covid-19 transmission but also ensure daily necessities of the citizens are met adequately. other measures are like appointing the healthy staffs to the service area and the staffs who have medical conditions are exempted from service delivery. other than that, using government services like relaxing importing rules, use of police forces, converting railway coaches as isolations are also important and innovative steps. legislative steps like mandatory social distancing, curfew, can help the crisis period by flattening the epidemic curve [10] . these are the short-term conventional solutions. here we propose few more which is out of the box thinking like-production of sanitizer at mass scale by the alcohol industry during covid-19 crisis period, in india is happening right now [11] . similarly, in india, the textile industry and hardware industry is producing bulk masks, gowns, caps, protective shields etc instead of producing clothes [12] . moreover, the automobile industry can make ventilators instead of producing vehicles at this critical period. in india, the mahindra group came out with a prototype ventilator and soon they will start producing [13] . besides this, global evidence on managing the shortage of ppe can be useful to inform future strategies. for example, taiwan experienced a critical shortage at the beginning of the covid-19 crisis. implemented this issue was mitigated by several strategies including rapid production and distribution of ppe to prioritized centres resulting in a declined shortage of ppe. these strategies used a 3-tier personal protective equipment (ppe) stockpiling framework that could maintain a minimum stockpile for the surge demand of ppe in the early stage of a pandemic [14] . some of these strategies include export prohibition, rationing, and increase production through either mandates or voluntary productions [15] . we believe many lessons can be learnt from countries like these. these countries provide real-time examples that can be copied by others with similar healthcare systems. such local and global innovations should be evaluated and adopted ensuring patient compliance during covid-19 to improve health outcomes. in our opinion smart questions need smart answers, in the era of emerging and re-emerging disease outbreaks like covid-19, besides the conventional approach we must think differently and implement the success stories of similar countries in india. while health systems in most of the countries are struggling to fight covid-19, the operational challenges including safety of the health workforce and prevention of transmission is much higher in resource-constrained contexts. it is essential to prioritize these health issues and adopt best practices to ensure the availability, accessibility, and utility of ppe and other resources in an efficient way. multilevel policy interventions with user-level quality assurance may help in mitigating those issues. perhaps, more importantly, we have to extend our support to each other, act together for our survival, without blaming each other. world health organization (2020) coronavirus disease (covid-19) line rajasthan govt directs private liquor companies to manufacture hand sanitizers the economic times (2020) coronavirus impact on textile industries: indian textile and apparel industry to be affected due to coronavirus attack in china: cmai. available from mahindra's ventilator for coronavirus patients to cost less than rs 7,500; designed in 48 hours stockpile model of personal protective equipment in taiwan its response to the crisis shows that swift action and widespread healthcare can prevent an outbreak all authors declare no conflicts of interest in this paper. (2020) key: cord-284640-tl9nmvog authors: tabah, alexis; ramanan, mahesh; laupland, kevin b.; buetti, niccolò; cortegiani, andrea; mellinghoff, johannes; morris, andrew conway; camporota, luigi; zappella, nathalie; elhadi, muhammed; povoa, pedro; amrein, karin; vidal, gabriela; derde, lennie; bassetti, matteo; francois, guy; kai, nathalie s.s.i.y.a.n.; de waele, jan j. title: personal protective equipment and intensive care unit healthcare worker safety in the covid-19 era (ppe-safe): an international survey date: 2020-06-13 journal: j crit care doi: 10.1016/j.jcrc.2020.06.005 sha: doc_id: 284640 cord_uid: tl9nmvog purpose: to survey healthcare workers (hcw) on availability and use of personal protective equipment (ppe) caring for covid-19 patients in the intensive care unit (icu). materials and method: a web-based survey distributed worldwide in april 2020. results: we received 2711 responses from 1797 (67%) physicians, 744 (27%) nurses, and 170 (6%) allied hcw. for routine care, most (1557, 58%) reportedly used ffp2/n95 masks, waterproof long sleeve gowns (1623; 67%), and face shields/visors (1574; 62%). powered air-purifying respirators were used routinely and for intubation only by 184 (7%) and 254 (13%) respondents, respectively. surgical masks were used for routine care by 289 (15%) and 47 (2%) for intubations. at least one piece of standard ppe was unavailable for 1402 (52%), and 817 (30%) reported reusing single-use ppe. ppe was worn for a median of 4 h (iqr 2, 5). adverse effects of ppe were associated with longer shift durations and included heat (1266, 51%), thirst (1174, 47%), pressure areas (1088, 44%), headaches (696, 28%), inability to use the bathroom (661, 27%) and extreme exhaustion (492, 20%). conclusions: hcws reported widespread shortages, frequent reuse of, and adverse effects related to ppe. urgent action by healthcare administrators, policymakers, governments and industry is warranted. the sars-cov-2 virus and the disease it causes (coronavirus disease 2019; covid-19) has created a global public health emergency following its first appearance in december 2019 (1) . as of early june 2020 there had been more than 6.4 million confirmed cases and 385,000 deaths reported worldwide (2). this highly contagious virus poses a significant but largely preventable risk to healthcare workers (hcw) (3) . in some areas, hcw have comprised up to 11 % of all confirmed covid-19 cases with an increasing number of occupationally attributed deaths being reported (4, 5) . use of personal protective equipment (ppe) can markedly reduce the infection risk associated with caring for covid-19 patients (6, 7) . while there is little evidence to which ppe offers the best protection, training in donning and doffing, simulation and face to face instructions are likely beneficial (8) . as a result of adequacy of instruction, availability of fit-testing, and supply limitations (9) , hcw may not be utilizing ppe as per recommended guidelines (6, 10, 11) . reports of ppe scarcity and unavailability are emerging worldwide. hcws report on social media and the general press resorting to reusing ppe or using household and self-made items in place of ppe. while limited evidence exists on the effectiveness of these practices, it has sometimes been done on the advice of their employers or health organisations (12, 13) . pictures of hcws' faces bruised by wearing masks for extended periods have been used to illustrate the extreme work conditions when caring for such patients. while pain, heat stress and fluid loss with using powered air-purifying respirators (papr) were predicted by experimental data (14) , there are no real-life reports of this issue when using ppe that is available to hcws. the objective of this study was to describe the current reported practices, availability, training, confidence in the use and adverse effects due to extended use of ppe by hcws from around the world caring for covid-19 patients who require icu management. a web-based survey was conducted in order to elicit hcw reports surrounding ppe related to the covid-19 pandemic. participation was voluntary and anonymous. this study was approved and granted a waiver of signed individual informed consent by the royal brisbane and women's hospital human research ethics committee (lnr/2020/qrbw/63041), brisbane, australia. the survey target population was all hcw of any discipline or training background or level who are directly involved in the management of covid-19 patients in a critical care setting. a 2-part studyspecific survey was designed (see electronic supplement). in the first part, questions surrounding basic demographic, training experience, and institutional work characteristics were elicited. no specific identifying data (i.e. name, date of birth) was requested the second part comprised of a series of questions regarding the usual practices and availability of ppe, along with perceptions of its adequacy in terms of supply and training in the workplace as well as adverse effects of wearing ppe on the hcw. questions were developed and the survey pre-tested for ease of administration, flow, and content by management committee members and by experienced clinician volunteers. following iterative revisions, the final survey was developed. an english language version was prepared then translated in the french, spanish and italian languages. the survey started with a binary question: if the respondent declared directly caring for covid-19 patients in the icu setting the survey was continued and the response categorized as valid. in the opposite case the survey was terminated, and the response categorized as invalid. the final survey was prepared using the surveymonkey® online platform (svmk inc., san mateo, usa) and posted at https://www.surveymonkey.com/r/ppe-safe. the survey was planned to be open for 2 weeks starting march 30. only the english language version was initially available with the others implemented as of april 7, 2020. duration of the survey was subsequently extended and we report data collected between march 30 and april 20, 2020. subjects were invited to participate through several venues including email invitations using mailing lists of the european society of intensive care medicine, australia and new zealand intensive care society, australian college of critical care nurses, and the european society of clinical microbiology and infectious diseases. in addition, ad hoc emails and advertisements were made via personal networks and social media accounts of management committee members. survey results were exported to and analysed using stata 15.1 (stata corp, college station, usa). means with standard deviations (sd) and medians with interquartile ranges (iqr) were used to describe normally and non-normally distributed continuous variables, respectively. differences in grouped means and medians were tested using the t-test and wilcoxon rank-sum test, respectively. categorical data were compared using the chi-square or fisher exact tests. a p-value less than 0.05 was deemed to represent significance for all comparisons. we performed univariate logistic regression to test the effect of ppe-clad shift duration, modelled as a continuous variable, on adverse effects. we used a separate univariate model for each adverse effect, and for any adverse effect. valid responses were received from 2711of 4879 (56%) individuals who accessed the survey. of which 1797 (67%) were physicians, 744 (27%) were nurses, and 170 (6%) were allied hcw (table 1 and figure e-sup 1). the median age was 41 (iqr, 34-49), 1254 (46%) were female. as detailed in the electronic supplement, respondents worked in 90 different countries, mostly from europe (1666; 61%) followed by asia (437; 16%), and north america (224;8%). most (1585; 58%) respondents worked in a covid-19 dedicated icu, including 281 (10%) in another area re-purposed as a covid-19 icu. one third (924; 34%) of subjects reported working in an icu that contained patients with and without covid-19, and 201 (7%) worked in other areas. as shown in table 1 , several characteristics were different among those working in covid-19 dedicated or repurposed icus as compared to mixed or other icus. in the routine care of patients with covid-19 most respondents reported use of ffp2/n95 masks (1557; 58%), surgical masks were reportedly used for routine care in 289 (15%) cases but infrequently (47, 2%) for intubations. waterproof long sleeve gowns (1623; 67%), and face j o u r n a l p r e -p r o o f shields/visor (1574; 62%). use of papr was infrequent with routine care (184; 7%) or intubation (254, 13%). their use was more frequent in asian and north american countries compared with oceania and europe but was not associated with the type of icu, it's capacity or current workload. variations between countries were wide and shown in the electronic supplementary tables 3. a comparison of ppe usage between professions is shown in the electronic supplementary table 2 . comparisons should be interpreted with caution as due to the nature of the survey it is unknown if differences between respondents may is due to their institution or profession. a comparison of the ppe used in routine care and for intubation among the respondents is shown in figure 1 . six hundred and twenty-eight (23%) subjects reported use of different mask for intubation compared to routine care. the corresponding numbers for gown and eye protection are 284 (12%) and 495 (20%). (table 2) ppe availability more than half of respondents (1402, 52%) reported at least one piece of the standard ppe as not available, and 817 (30%) reported that at least a piece of single-use ppe was being reused or washed as a result of shortages ( table 2 ). the distribution of ppe that was reportedly not available or being reused is shown in table 2 . overall few respondents indicated that no additional ppe should be provided. among the 1184 (44%) respondents that detailed additional need, this was most commonly hazmat suits and paprs. homemade solutions to ppe shortages included 3d printed face shields (529, 20%), homemade gowns (163, 5%), and homemade masks (145, 5%). there were wide variations between countries, with some reporting up to 19% of some items missing and others up to 39% being reused (tables electronic supplement 2). most of the respondents (2245, 83%) reported that they had formal training in the use of ppe. that included training at commencement in the institution (336, 13%) and within the last 2 months due to the covid-19 pandemic (1509, 60%). most reported they would benefit from additional training, this included simulation (1224, 49%) or demonstration by infection control specialists (478, 19%), and didactic teaching (220, 9%). less than half reported having formalized mask fit testing at any time (1243, 49%). a two-person technique was reportedly used for donning (193, 8%), doffing (159, 6%), or both (643, 26%), sometimes (881, 35%) but never in almost one-quarter (639, 25%) of respondents. there was a strong association between reporting never use of a 2 persons technique and never receiving ppe training, fit testing, and low confidence in using recommended ppe (p<0.001 for all comparisons) almost half (1211, 45%) reported being very or confident with their technique in using the available ppe and 138 (5%) were not confident at all. confidence in the adequacy of protection was reported by 1187 (44%), while 376 (14%) were not confident at all. this was similar for doctors, nurses and allied health (p=0.93). there was a strong association between confidence in protection and the absence of ppe shortage and confidence in technique (p<0.001 for both comparisons). the median duration of a shift while wearing ppe without the ability to take a break (ppe-shift) as 4 hours (iqr 2, 5 hours). this was similar for nurses (median 4, iqr 2, 6 hours) and doctors (median 4, iqr 3,5 hours). adverse effects were reported by 80%, including heat (1266, 51%), thirst (1174, 47%), pressure areas (1088, 44%), headaches (696, 28%), inability to use the bathroom (661, 27%) and extreme exhaustion (4924, 20%) ( table 3) . they were all associated with longer duration of shifts wearing ppe (table 4 ). this survey provides a snapshot of the reported availability, perceived adequacy of training and provided protection, adverse effects and usage of ppe among hcw managing covid-19 patients in critical care environments from across the globe. it is important to note that these responses are likely influenced by how burdened hcw are, the safety culture, and the baseline resources in their institutions. while these data do not prove adequacy or inadequacy of ppe per se, they do lend important insights into what hcw are experiencing in this novel pandemic situation. it is important to recognize that information on human-to-human covid-19 transmission is still emerging. while respiratory droplets are considered as the main route of transmission, airborne transmission resulting from aerosol-generating procedures likely is a mode (15) . surface contamination with transmission using contact means is another route of infection transfer (16) . recommendations for ppe vary significantly both between and within countries. as an example, airborne precautions are recommended only for high-risk procedures in some countries whereas this is routinely in others (6, 10, 11, 17) . furthermore, shortages of ppe equipment has led to practices to reduce, reuse, or substitute lesser or non-approved products in an attempt to address inadequate supply of ppe (18) . variability in knowledge, training and technique, such as the formal fit testing of respirators or the use of a 2 persons technique for donning and doffing ppe are correlated with confidence and likely impact safety of hcws managing icu patients infected with covid-19. these factors contribute to a sense of uncertainty and lack of confidence in a safe workplace among hcw (9, 19) . access to appropriate ppe was the first of 8 sources of anxiety in a group of hcws interviewing during the first week of the pandemic (20) . this is likely further exacerbated by frequent changes in guidelines and public health messages. those may be secondary to epidemiological changes, the rapidly accumulating knowledge but also by the scarcity of the resource, further increasing anxiety and distrust from hcws. the shortages and concerns surrounding provision of adequate ppe represents a major issue from a supply chain perspective. this further raises serious concerns about equity and justice related to provision for those most in need. at local levels, reports of ppe being stolen from healthcare institutions, misappropriated, or hoarded have occurred such that this equipment may not be available to those at highest risk (18) . at subnational and national levels this has also become a concern as bidding wars and re-direction of orders has occurred. recent examples of countries threatening to block export shipments of ppe to other countries has further exacerbated concerns by hcw around access to appropriate ppe. while it is likely that innovative approaches and ramp-up of domestic manufacturing processes may help to meet demand, it is a serious risk for low income countries who may ultimately suffer the greatest adverse effects of lack of ppe. confirming social media and widely distributed photos of hcws bruised faces, most respondents have reported adverse effects from ppe. this question the safety of currently available ppe when it is worn for an extended duration. most of the available ppe was designed and manufactured for single-use and brief duration of use. these findings call for urgent design and manufacture of ppe j o u r n a l p r e -p r o o f that can be safely worn and remains effective for extended durations. it also reinforces the need for recruitment of an increased health care workforce. this would allow for surge capacity whilst minimizing harm to frontline staff. there are some limitations of this study that must be noted. first, it is a voluntary survey and responses reflect opinions and perceptions alone. they may not necessarily reflect actual practices as these are not confirmed through audit. second, we did not use a systematic sampling strategy but rather made the survey broadly available and accordingly there is no denominator to establish a response rate. therefore, our results may reflect a small portion and potentially biased reflection of the true opinions of all hcw. by using scientific society mailing lists we may have skewed the sampling towards the geographical location of their members. however, we elected to pursue this study approach in order to obtain a contemporary view. given the time frame and rapid changes related to this pandemic, we therefore elected to pursue this study without subsequent formalized sampling strategy. this allowed the identification of trends in reported use of ppe rather than real time data. third, the study has an over-representation by physicians which may underestimate the burden of adverse effects caused by ppe. fourth, there is an underrepresentation of low-and middle-income countries, which may have skewed the results. finally, we only offered the survey in english, french, spanish and italian. this may have been a barrier for some hcw to participate and may have resulted in a selection of respondents that may be different had we included options for other languages. in summary this survey study provides a snapshot of reported ppe practices availability, and confidence in adequacy to provide protection among hcws at the frontlines of the covid-19 pandemic. respondents report widespread shortages and reuse of single-use ppe items. half of the respondents had never had fit-testing of masks. adverse effects from ppe usage frequently reported and mostly associated with ppe-clad shift duration. urgent action by healthcare administrators, policymakers, governments and industry is warranted to address these issues. this study was endorsed by, and communications were sent to the members of: a novel coronavirus from patients with pneumonia in china association of public health interventions with the epidemiology of the covid-19 outbreak in wuhan coronavirus disease 2019 (covid-19): situation report doctors, nurses, porters, volunteers: the uk health workers who have died from covid-19 2020 surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (covid-19). intensive care medicine personal protective equipment during the covid-19 pandemic -a narrative review personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff covid-19: the crisis of personal protective equipment in the us infection prevention and control during health care when covid-19 is suspected: interim guidance covid-19 personal protective equipment (ppe) considerations for acute personal protective equipment (ppe) shortages 2020 recommended guidance for extended use and limited reuse of n95 filtering facepiece respirators in healthcare settings limiting factors for wearing personal protective equipment (ppe) in a health care environment evaluated in a randomised study aerosol and surface distribution of severe acute respiratory syndrome coronavirus 2 in hospital wards aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-ncov) patients critical supply shortages -the need for ventilators and personal protective equipment during the covid-19 pandemic protect our healthcare workers understanding and addressing sources of anxiety among health care professionals during the covid-19 pandemic n95/ffp2 maks 1557, (57%) 127, (8%) 267, (17%) ffp3 mask 649 face shield or visor 1574, (58%) 131, (8%) 820, (52%) cover 1636, (60%) 43, (3%) 41, (3%) balaclava reported as missing denoted ppe that would normally be used but is not available. none reported denotes respondents that did not report using any equipment in that category of ppe. washed or reused denotes single use ppe that is washed or reused due to stock or availability issues. papr shown as mask and head protection as includes a hood and shown as n/a for reuse as they are reusable by design extreme exhaustion 77, (12%) 187, (20%) 116, (27%) 32, (31%) inability to use the bathroom 61, (9%) 261, (28%) 176, (41%) 47, (45%) headaches 118, (18%) 297, (31%) 137, (32%) 36, (35%) thirst 216 footer: ppe-shift duration denotes the amount of time in hours that the hcw is wearing ppe without the ability to take a break j o u r n a l p r e -p r o o f key: cord-290653-48swl1aq authors: teng, margaret; tang, si ying; koh, calvin jianyi title: endoscopy during covid-19 pandemic: an overview of infection control measures and practical application date: 2020-09-16 journal: world j gastrointest endosc doi: 10.4253/wjge.v12.i9.256 sha: doc_id: 290653 cord_uid: 48swl1aq the novel severe acute respiratory syndrome coronavirus 2 (sars-cov-2) has resulted in coronavirus disease 2019 (covid-19) which has affected more than 4.5 million people in 213 countries, and has been declared a pandemic by world health organization on march 11, 2020. the transmission of sars-cov-2 has been reported to occur primarily through direct contact or droplets. there have also been reports that sars-cov-2 can be detected in biopsy and stool specimens, and it has been postulated that there is potential for fecal–oral transmission as well. gastrointestinal symptoms have been reported in 17.6% of covid-19 patients and transmission can potentially occur through gastrointestinal secretions in this group of patients. furthermore, transmission can also occur in asymptomatic carriers or patients with viral shedding during the incubation period. endoscopic procedures hence may pose significant risks of transmission (even for those not directly involving confirmed covid-19 cases) as endoscopists and endoscopy staff are in close contact with patients during these aerosol generating procedures. this could result in inadvertent transmission of infection at time of endoscopy. numerous organizations and societies worldwide have come up with guidelines, recommendations or position statements to optimize the practice of endoscopy during the coronavirus disease 2019 (covid-19) pandemic [1] [2] [3] [4] [5] [6] [7] [8] [9] . in addition, various centers have described their experiences regarding endoscopy in covid-19 [10, 11] . the guidelines by leading organizations in the united states, canada, europe, united kingdom, australia, asia and japan are summarized in table 1 . we aim to compare practices regarding endoscopy during covid-19 between countries and share our experience in devising and implementing infection prevention and control measures to mitigate risk of transmission during endoscopy. all organizations agree with the broad principle that elective cases should be individually assessed and reviewed, and elective non-urgent cases should be deferred. depending on risk assessment, cases deemed to be of higher priority like those with suspected time-sensitive diagnosis e.g. malignancy should still proceed with endoscopic evaluation as delay may result in deleterious effect on patient outcomes. it is not a straightforward dichotomy, and the rationale underlying this approach is the need to balance medical urgency of procedure (as delay in procedure may have consequent delay in diagnosis and appropriate treatment, possibly leading to complications of disease or disease progression) with the risk of infection and utilization of potentially scarce resources. however, the definition of an elective case which should proceed differs considerably between various organizations and societies -it reflects that different areas have different incidences of covid-19 and hence varying capacities for the performance of semi-urgent endoscopy. our practice is that emergent cases are performed whereas outpatient elective cases are reviewed on a case-by-case basis and may be rescheduled. direct-access endoscopy is suspended during this period. examples of emergent procedures which should be done: upper or lower gastrointestinal (gi) bleeding (bsg further recommends for upper gi bleeding to risk stratify to only for patients predicted to require endoscopic therapy, and for lower gi bleeding to limit to patients in whom interventional radiology is not possible or unsuccessful). foreign body removal; pancreatobiliary: cholangitis; gi obstruction requiring palliation; examples of elective procedures which should be deferred: screening and surveillance oesophagogastroduodenoscopy (ogd) or colonoscopy in asymptomatic patients. evaluation of non-urgent symptoms. therapeutic endoscopy in benign disease. of note, bsg recommends that if procedures are deferred for urgent referrals, the cases should be listed on a separate urgent deferred waiting list to ensure appropriate follow-up and to prioritize endoscopy when normal activities resume. our experience is also that there are many patients who do not fit clearly into either emergent or elective categories, for example, patients with symptomatic irondeficiency anemia who are not actively bleeding, but for whom delay until normal endoscopic services resume might be life threatening or have prognostic implications due to undiagnosed peptic ulcer disease or gi malignancy. after clinical review, numerous such patients would still be considered to proceed with endoscopy. despite utilizing this approach, we have reduced the total endoscopy case load to less than 40% of the usual load in our center. at our center, prior to endoscopy, patients are pre-screened for symptoms (fever, upper respiratory tract symptoms) and significant contact and travel history. on arrival at the endoscopy center, patients are screened again for symptoms, and patients' temperatures are checked. after passing through screening and temperature taking, patients will enter the waiting area. all patients should be wearing at least a surgical mask and should maintain adequate physical distance of 1-2 m from others. asian pacific society for digestive endoscopy and esge suggest that no caregivers or relatives should be allowed to enter the endoscopy center. we have devised a simple algorithm to aid decision making regarding timing of procedures ( figure 1 ). september 16, 2020 volume 12 issue 9 all organizations concur that for all procedures, all members of the endoscopy team should wear appropriate personal protection equipment (ppe) -usually consisting of n95 or surgical mask, eye shield/goggles, face shield, water-resistant gown and gloves. aga and asge advise the use of n95 mask for all procedures. in contrast, esge, cag and gesa limit the use of n95 mask for high-risk procedures only. aga also specifies that 2 sets of gloves (rather than 1 set) should be used in all procedures, whereas cag and esge suggest that 2 sets of gloves be used in high-risk procedures only. this minimizes contamination by reducing risk of transferring viral organisms from ppe to clothes or the rest of the body during removal of ppe. these differences probably reflect variable availability and practical rationing to conserve limited ppe resources amidst competing needs. endoscopy staff should be trained in donning and removing ppe, and hand hygiene practices must be observed strictly. in our center, we have enhanced our universal precautions, to n95 mask, eye goggles, water resistant gown and gloves for endoscopy in all patients. in addition, for confirmed or suspected covid-19 cases, the endoscopist and assisting nurses wear all ppe with the addition of powered air-purifying respirators (papr) as an additional barrier. all confirmed or suspected covid-19 cases should have been admitted to hospital. suspected cases are defined as per guidance from our ministry of health [12] usually suspected if they have clinical signs and symptoms suggestive of acute respiratory illness, and covid-19 cases are confirmed with syndrome coronavirus 2 (sars-cov-2) polymerase chain reaction test of respiratory or nasopharyngeal swabs. in our center, endoscopy staff are assessed daily for symptoms and signs suggestive of covid-19 infection-temperature is checked twice a day. staff are grouped into teams of 2-3 which are segregated into separate endoscopy rooms and remain together for the whole day. this is to minimize concomitant exposure to infection and prevent potential spread of infection between teams. the number of endoscopy staff should be curbed with only essential staff (senior endoscopist +/-trainee, maximum of 2-3 assisting nurses) allowed in the room during procedures. particular mention should be made of different perspectives of the involvement of trainees in procedures. aga and bsg have recommended to review and consider limiting their participation in procedures in view of constraints in ppe supply and concerns of increased procedural time. gesa has adopted a more nuanced approach and suggested that trainees should be restricted from participating in procedures involving confirmed covid-19 cases or cases at high risk of covid-19 but should be allowed to do procedures involving cases at low risk of covid-19. our center adopts this stance, valuing trainee participation in standard endoscopy but limiting their exposure to covid-19 confirmed or suspected cases. in our center, for confirmed or suspected patients with covid-19, endoscopic procedures should be done in negative pressure rooms if fluoroscopy is not required, or in a designated operating theatre with negative pressure if fluoroscopy is required. in limited resource settings where negative pressure rooms are not available, aga advises portable industrial-grade high-efficiency particulate air filters as an alternative, in line with centers for disease control and prevention guidelines. our center has a total of 6 available endoscopy rooms-all inpatient cases are consolidated in 1-2 specified rooms, and outpatient cases are done in other available rooms. this ensures no cross-contamination between patients. standard cleaning and disinfection of endoscopy rooms and endoscopy equipment should continue. endoscopes and endoscopic accessories are reprocessed with standardized reprocessing procedures. our center's practice is in line with the united states multi-society guidelines [13] . endoscopes are cleaned manually-endoscope components are disassembled, and endoscope and their components are immersed in detergent which is compatible with the endoscope. all available channels are flushed and brushed to remove any residue. endoscopes and their components are subsequently subjected to high-level disinfection with an automated endoscope reprocessing unit. for confirmed or suspected covid-19 cases, used endoscopes and endoscopic equipment will be cleaned on site with disinfectant. used scopes will then be placed in biohazard bags (double bagged) into a container and transported back to the endoscopy centre for further cleaning and reprocessing, which will be done separately from other endoscopic equipment. all endoscopy staff involved in disinfection and reprocessing of endoscopes and endoscopic equipment should be wearing ppe. patients can be contacted at 7-d and 14-d post-procedure to ask about new diagnosis of covid-19 or development of symptoms of covid-19 infection. this is suggested by the united states joint gi society and esge but not routinely practiced elsewhere. our center conducts routine follow-up calls as per our patient feedback process but not specifically for covid-19. we have formulated a proposed workflow incorporating the above measures which can enhance safety of endoscopy in this period (table 2) . with numerous countries employing strategies such as social distancing to decrease rates of sars-cov-2 infection, the peak of the covid-19 pandemic may have passed and attention now turns to how best to re-introduce normal activities and services safely. aga and digestive health physicians association (dhpa), asge, and bsg have recently published guidelines on resumption of endoscopy during the covid-19 pandemic [14] [15] [16] . timing of resuming elective procedures should be guided by incidence of covid-19 cases in the local community, and availability of equipment and manpower. aga/dhpa propose to resume elective endoscopic procedures when inpatient urgent cases are done on a case-to-case basis; outpatient elective non-urgent cases are reviewed by physician in charge -proceed with cases with suspected significant or time-specific diagnosis, reschedule all other cases; direct access endoscopy is suspended; prior to endoscopy: pre-screen patients for history of fever or upper respiratory tract symptoms (cough, sore throat, rhinorrhea), significant contact and travel history, or if they have been issued a home quarantine order or stay home notice; this includes patients who have family members or close contact with suspected or confirmed covid-19 case, and patients with recent travel to high risk countries in the past 14 d. on day of endoscopy: check patient's body temperature on arrival and ensure patients are at least 2 m apart in the endoscopy centre. all patients and staff wear surgical masks while in the endoscopy centre. hand hygiene is performed before and after patient contact; only 1 visitor per patient will be allowed to enter the endoscopy centre. personal protection equipment (ppe) all members of the endoscopy team wear ppe consisting of n95 mask, face shield, eye shield/goggles, long-sleeved surgical gown and gloves; for confirmed covid-19 cases; the transfer team will wear ppe while transporting patients to and from the ward; the endoscopist and assisting nurses will wear ppe with powered air-purifying respirators (papr) (eye shield/goggles are not required with a papr) before entering the room; all endoscopy staff are trained to don and remove ppe accurately; hand hygiene is performed before wearing and after removing ppe. wearing of ppe follows these steps: gown is worn first, followed by n95 mask and eye shield/goggles, then face shield, and finally gloves. removal of ppe follows these steps: remove gloves and gown first inside the room, then remove papr and n95 mask outside the room or in ante-room (if available). endoscopy staff are grouped into teams and segregated into separate endoscopy rooms. endoscopy staff are advised to minimise personal contact and interaction with staff from other groups. for confirmed or suspected patients with covid-19, endoscopic procedures are done in negative pressure rooms. if fluoroscopy is not required, endoscopy is done at bedside in negative pressure isolation room in the ward. if fluoroscopy is required, endoscopy is done in a designated major operating theatre room. the endoscopy team prepares all necessary equipment and scopes on a clean trolley before proceeding to the location. all other inpatient cases are consolidated in a specified room in the endoscopy centre. if this is not possible, the inpatient case will be scheduled as last case in the room. outpatient elective cases are performed in other available rooms. post procedure standard cleaning and disinfection of endoscopy rooms continue. all surfaces in endoscopy rooms are cleaned, followed by disinfection. for confirmed covid-19 cases. used equipment will be wiped down on site with disinfectant, placed in a labeled "dirty" trolley and brought back to endoscopy centre for further cleaning and disinfection. used scopes will be wiped down on site with disinfectant, placed in a biohazard bag (double bagged), and placed in a rigid container with lid for transportation back to the endoscopy centre for reprocessing. there is a sustained decrease in rate of new covid-19 cases in the community for at least 14 d, and the decision to resume should also take into consideration availability of resources required to ensure the safety of both healthcare staff and patients. resumption of elective endoscopic procedures should be done cautiously and gradually in a phased manner. both aga/dhpa and asge recommend additional measures for pre-procedure patient screening. aga/dhpa suggest conducting sars-cov-2 pcr testing within 48 h before procedure; if unable to do so, to consider asking patients to keep daily temperature logs for 10 d before procedure. on the day of procedure, a symptom questionnaire will be administered to patients and their temperatures will be checked. asge suggests doing pre-screening with a questionnaire on symptoms, contact history, travel history, and occupational exposure within 72 h before procedure. responses to the questionnaire should be updated on the day of procedure. the rest of the infection prevention and control measures discussed above should continue to be implemented and observed. additionally, asge mentions that patients should be followed up and surveyed 1-2 wk postprocedure -they are advised to inform the endoscopy centre if they develop symptoms or are diagnosed with covid-19 within 14 d of procedure. the covid-19 pandemic has united the world in taking enhanced measures in endoscopy to limit the spread of disease. however, different approaches to these measures highlight system differences in approach to care and logistic limitations. guidelines and recommendations on endoscopy during covid-19 are not exhaustive and not inflexible. of note, many of these guidelines were released consecutively as the pandemic evolved in individual countries and might not necessarily reflect the current state of practice. in these challenging and rapidly evolving times, there is constant emergence of new information, and new innovations in testing and treatment. we should hence be prepared to continually adapt our practices to improve quality and safety of endoscopy during the pandemic. electronic address: ewilson@gastro.org. aga institute rapid recommendations for gastrointestinal procedures during the covid-19 pandemic dinis-ribeiro m. esge and esgena position statement on gastrointestinal endoscopy and the covid-19 pandemic covid-19: advice from the canadian association of gastroenterology for endoscopy facilities, as of march 16 updated advice on preventative measures during gastrointestinal (gi) endoscopic procedures during the covid-19 pandemic practice of endoscopy during covid-19 pandemic: position statements of the asian pacific society for digestive endoscopy (apsde-covid statements) gastrointestinal endoscopy in the era of the acute pandemic of coronavirus disease covid-19) outbreak: what the department of endoscopy should know considerations in performing endoscopy during the covid-19 pandemic revision of suspect case definition for coronavirus disease 2019 (covid-19) multisociety guideline on reprocessing flexible gi endoscopes: 2016 update recommendations for resumption of elective endoscopy during the covid-19 pandemic guidance for resuming gi endoscopy and practice operations after the covid-19 pandemic bsg guidance on recommencing gi endoscopy in the deceleration early recovery phases of the covid-19 pandemic key: cord-273303-g86w0xt5 authors: latz, christopher a.; boitano, laura t.; png, c. y. maximilian; tanious, adam; kibrik, pavel; conrad, mark; eagleton, matthew; dua, anahita title: early vascular surgery response to the covid-19 pandemic: results of a nationwide survey date: 2020-05-23 journal: j vasc surg doi: 10.1016/j.jvs.2020.05.032 sha: doc_id: 273303 cord_uid: g86w0xt5 objectives: the covid-19 pandemic has had major implications for the united states healthcare system. this survey study sought to identify practice changes, understand current personal protection equipment (ppe) use, and determine how caring for patients with covid-19 differs for vascular surgeons practicing in states with high covid-19 case numbers versus low case numbers. methods: a fourteen-question online survey regarding the effect of the covid-19 pandemic on vascular surgeons’ current practice was sent to 365 vascular surgeons across the country via redcap from 4/14/2020 to 4/21/2020 with responses closed on 4/23/2020. the survey response was analyzed with descriptive statistics. further analyses were performed to evaluate whether responses from states with the highest number of covid-19 cases (new york, new jersey, massachusetts, pennsylvania and california) differed from those with lower case numbers (all other states). results: a total of 121 vascular surgeon responded (30.6%) to the survey. all high-volume states were represented. the majority of vascular surgeons are reusing ppe the majority of respondents worked in an academic setting (81.5%) and were performing only urgent and emergent cases (80.5%) during preparation for the surge. this did not differ between high case and low covid case states (p=0.285). high case states were less likely to perform a lower extremity intervention for critical limb ischemia (60.8% vs. 77.5%, p=0.046), but otherwise case types did not differ. most attendings work with residents (90.8%) and limited their exposure to procedures on suspected/confirmed covid-19 cases (56.0%). thirty-eight percent of attendings have been redeployed within the hospital to a vascular access service, and/or other service outside of vascular surgery. this was more frequent in high case volume states compared to low case volume states (p=0.039). the majority of vascular surgeons are reusing ppe (71.4%) and n95 masks (86.4%), and 21% of vascular surgeons feel that they do not have adequate ppe to perform clinical their duties. conclusion: the initial response to the covid-19 pandemic has resulted in reduced elective cases with primarily only urgent and emergent cases being performed. a minority of vascular surgeons have been redeployed outside of their specialty, however, this is more common among states with high case numbers. adequate ppe remains an issue for almost a quarter of vascular surgeons who responded to this survey. involvement in covid-19 positive cases, 38% of attendings have been redeployed to services 1 other than traditional vascular surgery, such as the icu and vascular access service, and 71% are 2 reusing personal protective equipment (ppe). twenty-one percent of vascular surgeons do not 3 feel they have adequate access to ppe. twenty-one percent did not feel they have adequate access to ppe. responses from states with the highest number of covid-19 cases (new york, new jersey, 1 massachusetts, pennsylvania and california) differed from those with lower case numbers (all 2 other states). 3 results: a total of 121 vascular surgeon responded (30.6%) to the survey. all high-volume 4 states were represented. the majority of vascular surgeons are reusing ppe the majority of 5 respondents worked in an academic setting (81.5%) and were performing only urgent and 6 emergent cases (80.5%) during preparation for the surge. this did not differ between high case 7 and low covid case states (p=0.285). high case states were less likely to perform a lower 8 extremity intervention for critical limb ischemia (60.8% vs. 77.5%, p=0.046), but otherwise case 9 types did not differ. most attendings work with residents (90.8%) and limited their exposure to 10 procedures on suspected/confirmed covid-19 cases (56.0%). thirty-eight percent of attendings 11 have been redeployed within the hospital to a vascular access service, and/or other service 12 outside of vascular surgery. this was more frequent in high case volume states compared to low 13 case volume states (p=0.039). the covid-19 pandemic is impacting the entire united states in unprecedented ways. this is especially true of the healthcare system as certain hospitals are amid an overwhelming 4 surge of patients, while other hospitals are actively preparing for predicted surges. issues for 5 surgeons are wide-reaching as practices are shut down and patient care is delayed. in addition, 6 there are increased levels of stress and anxiety amongst surgical staff as a significant portion of 7 the worldwide cases have involved healthcare workers. 1-4 8 there have been major changes to most surgical practices in preparation for the pandemic. 5 as 9 operative caseloads dwindle, and new consults are deferred indefinitely, new issues arise. these 10 include the possibility of redeployment from traditional roles, threats of decreased 11 reimbursement, and a potential decrease in case volume and learning opportunities for trainees. of the 365 physicians contacted to complete this survey 121 replied for a 30.6% response rate. thirty-three states were represented including all high volume covid-19 states (figure 2). the 7 majority of respondents were from california (13.2%), massachusetts (9.9%), and new york 8 (11.6%) but these states still represented less than 50% of respondents (n=51, 42.1%). seventy 9 respondents (57.9%) were from low volume covid-19 states. the majority of physicians who answered this survey practice in an academic setting (81.5%), 11 followed by a large community practice (14.3%). small community practices were not well 12 represented in this survey, comprising only 4.2% of respondents (figure 3). 13 practice changes have been instituted with 80.5% of vascular surgeon respondents limiting their survey are modifying their practice to limit trainee exposure. this practice may also be partially 20 driven by ppe shortages, but likely also reflects a desire to protect our trainees from 21 unnecessarily exposure. the majority of vascular surgeon respondents were also being asked to 22 reuse ppe, a common practice throughout the united states during the pandemic. 18 it is unclear how many institutions have instituted re-sterilization protocols. 19 resources should be directed at 1 improving access to ppe for all healthcare providers to ensure those providing essential duties 2 are not at an increased risk of contracting delay in cases seems common, whether it is occurring while waiting for a covid-19 4 rule out test or waiting to enter the operating room until a sufficient amount of time has passed 5 after intubation on covid-19 positive or suspected cases. the impact this has on outcomes is 6 currently unknown but given the many time-sensitive interventions that vascular surgeons 7 provide, this may be problematic. even in negative pressure rooms, it takes 30 minutes for 8 99.99% of the aerosolized particles to be removed; waiting for these rooms to clear of 9 aerosolized particles can cause fatal delays in treating ruptured aneurysms or cause undue 10 ischemia time in cases where tourniquets are applied for extremity hemorrhage. it was outside 11 the scope of this project to determine the impact this operative delay may have on patient 12 outcomes. an even greater impact than the delay in cases is the transition of cases from all elective, 14 urgent and emergent operations to primarily only vascular urgencies and emergencies which are 15 life and limb saving. these include symptomatic/ruptured aaa, type b dissection with 16 malperfusion, wet gangrene, acute limb ischemia, acute mesenteric ischemia, symptomatic 17 carotid artery disease, and revision/removal of nonfunctional or infected dialysis access. it is 18 likely that the centers not performing the above cases are transferring patients with these 19 diagnoses to higher levels of care as opposed to opting for non-operative management. the fact 20 that less than 5% of respondents are still performing elective cases shows the far-reaching 21 implications of the pandemic on vascular surgery daily practice, as well and adherence to 22 recommended protocols from both the surgeon general and vascular surgery specific 23 recommendations. 20 furthermore, the downstream effects of not treating vascular disease that is 1 considered elective has yet to be determined. it will be important to understand how the health of 2 the vascular surgery patient population is affected by this shift toward urgent and emergent 3 cases. at our large, tertiary institution, which is both a high-volume vascular center and within a 5 high volume covid-19 state, we have altered practice to manage our vascular services 6 optimally. in our initial response (early march 2020), vascular trainees were not involved in 7 covid-19 cases and attendings saw these patients alone (both to protect our trainees and to 8 limit use of ppe). all elective surgeries and clinics were canceled, and patients were tracked on a 9 master list managed by the division chief to ensure appropriate follow up. patients admitted to 10 the hospital were not allowed to have visitors. the division created a combined list of surgical 11 cases, and each attending determined individually if their patient could be rescheduled or 12 required an urgent procedure. as the pandemic evolved, so did the response from our division; by the end of march into 14 mid-april the vascular service had been restructured such that teams of two attendings were 15 covering call week to week and served as each other's back up. the rationale was to limit 16 exposure, and in the event that one team contracted covid-19, a back-up team would be readily 17 available. the team that was "on call" for the week also would see any clinic patients of their 18 partners that were deemed necessary for an in-patient visit. once our hospital established an 19 appropriate supply of ppe, our vascular trainees were involved in cases and patient care once 20 again. over the last month, our group has evolved further; hospital-wide initiatives included 1 strengths inherent to this study include the novel data provided regarding attending vascular 2 surgeon sentiment and practice patterns during the covid-19 pandemic and the reasonably high 3 response rate obtained over a short period of time. these data can be used to inform other crises 4 by highlighting trends in practice and surgeon sentiment, and hopefully this will inform 5 expectations and lead to a more streamlined response during the next crisis. because there was 6 only a one-week period over which responses were collected, there was unlikely to be much 7 evolution and the practice and systems issues addressed in the survey. the covid-19 pandemic has resulted in practice changes for the survey respondents including a 2 shift to only operating for urgent and emergent indications. this has led many untreated vascular 3 patients, the effect of which has yet to be determined. a minority of vascular surgeons have 4 been redeployed outside their specialty, however, this is more frequent among states with high 5 covid-19 case numbers. reuse of ppe and n95 masks are common. however, adequate ppe 6 remains an issue for 21% of vascular surgeons who responded to this survey. pandemic-time-to-act-is-long-past-due/. rapid 17 response of an academic surgical department to the covid-19 pandemic: implications for 18 the 20 importance of the minimum dosage necessary for uvc decontamination of n95 respirators covid-19 survey 1 key: cord-344262-5yk1keg3 authors: evans, lauran k.; shinagawa, austin; sutton, sarah; calvo, lisa title: covid-19 drive-through point of screening and testing (post) system: a safe, efficient, and adaptable model for nasopharyngeal swab collection date: 2020-09-02 journal: disaster medicine and public health preparedness doi: 10.1017/dmp.2020.313 sha: doc_id: 344262 cord_uid: 5yk1keg3 objective: the authors aim to demonstrate that the current drive-through testing model at a health district was improved in certain parameters compared with a previous testing protocol, and to provide the methodology of the current model for other coronavirus disease (covid-19) testing sites to potentially emulate. methods: initially, a small drive-through site was constructed at a converted tuberculosis clinic, but due to an increase in testing needs, an expanded point of screening and testing (post) system was developed in an event center parking lot to administer tests to a higher volume of patients. results: an average of 51.1 patients was tested each day (2.0 tests per personnel in personal protective equipment [ppe] per hour) at the initial tuberculosis clinic drive-through site, which increased to 217.8 patients tested each day (5.9 tests per personnel in ppe per hour) with the new drive-through post system (p < 0.001). mean testing time was 3.4 minutes and the total time on-site averaged 14.4 minutes. conclusions: this post drive-through system serves as an efficient, safe, and adaptable model for high volume covid-19 nasopharyngeal swabbing that the authors recommend other covid-19 testing sites nationwide consider adopting for their own use. t he novel severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is the pathogen responsible for a pandemic beginning in 2020, which was declared an emergency by nearly every state in the united states. 1, 2 one of the challenges that health care providers are facing during this pandemic is inadequate access to diagnostic tests for patients. 3 this not only presents the problem of the inability to confirm whether potential patients are positive for coronavirus disease (covid-19), which could facilitate its spread, 4 but it also distorts public opinion on the severity of this situation. 5 in addition, patients with a confirmed diagnosis are more likely to adhere to selfquarantine orders, 6 further preventing the spread of disease. increased testing also allows for public health officials to have a better understanding of this pandemic's impact on the public. as the number of tests increases, so does the accuracy of statistical measures. 7 an inadequate perspective on the prevalence of covid-19 in communities could lead to the premature discontinuation of social distancing orders or recommendations, which then could cause a secondary peak in incidence rates. this trend was seen in st. louis during the 1918 influenza pandemic, 8 which outlines the importance of both accurate public perception of the pandemic's severity and construction of strong epidemiological models. for these reasons, adequate availability and administration of diagnostic testing for covid-19 are paramount for reducing further pandemic-related morbidity and mortality. specific sites for covid-19 testing in several communities are necessary due to the scale of this pandemic. emergency departments (eds) in the united states, which are often already functioning near capacity under normal conditions, 9 could be easily overwhelmed should patients present solely for covid-19 testing purposes. additionally, this could preclude social distancing, particularly in waiting rooms, and deplete personal protective equipment (ppe) and other resources in the hospital. 9,10 therefore, the installation of a specific testing program for covid-19 could dramatically alleviate the burden of this pandemic on eds. the current gold standard diagnostic test is a reverse transcription polymerase chain reaction (rt-pcr), which detects viral rna in respiratory secretions. 11 one model described in the literature for the administration of this test, which typically uses nasopharyngeal and/or oropharyngeal swabs, 11 is a drive-through site. this drivethrough model, implemented at testing centers in several countries, allows for each patient's automobile to function as an isolation compartment, preventing person-to-person spread at the site. [6] [7] [8] 13 in april 2020, the washoe county health district (wchd) implemented a drive-through covid-19 point of screening and testing (post) system for the reno-sparks area community and surrounding rural areas, accounting for a total population of about 471 000. the post system, which operates in the parking lot of an event center in reno, nevada, allows for the administration of hundreds of rt-pcr tests performed per testing day, at no cost to patients. this was developed to address limitations in daily test capacity, as well as inefficiencies at a previous testing station, which was converted from a pre-existing tuberculosis (tb) clinic. 10 the authors hypothesize that this model is more successful in several parameters, such as total testing capacity and the number of tests completed at the drive-through, per tester in ppe per hour, compared with the previous testing center at the tb clinic. the authors also believe that the wchd post system, similar to those previously reported in the literature, represents a particularly efficient, safe, and adaptable model for covid-19 testing, and recommend that other covid-19 testing sites nationwide consider adopting it for their own purposes. samples were obtained initially via both nasopharyngeal and oropharyngeal swabs in phase 1 and nasopharyngeal swabs alone in the latter part of phase 1 and throughout phase 2. the cdc 2019-ncov real-time rt-pcr diagnostic panel was used for the detection of covid-19 when samples were sent to the state laboratory. starting march 6, 2020, the wchd implemented phase 1 of their testing protocol for potential covid-19 patients. patients were initially asked a series of questions relating to exposure, work environment, and symptoms by an assessment administered over the telephone through the wchd covid-19 community triage line. based on these questions, appointments were scheduled for patients deemed to be at high risk for infection. patients with an appointment at this stage were likely receiving their first test; however, the differentiation between initial and follow-up testing for each patient was not recorded in the study. testing during phase 1 occurred at wchd's tb clinic, which was converted to a covid-19 testing center. testing occurred 6 days per week for 8 hours each day, from 9:00 am to 5:00 pm, with a variable number of patient appointments scheduled at each 60-minute interval. swabs were obtained by a rotating group of 2 to 4 personnel in full ppe, while 1 staff member in partial ppe completed paperwork required for testing and prepared the specimens for shipment. full ppe at this site entailed n95 masks, disposable gowns, disposable and reusable face shields, and nitrile gloves. partial ppe entailed an n95 mask and gloves. the tb clinic functioned as a testing site for 21 days. on april 1, 2020, the wchd implemented phase 2 of their testing protocol, which consisted of the new post system, located at the adjacent event center. appointments were similarly determined by the phone triage line, so patients at highest risk were prioritized for testing. testing in phase 2 was conducted on mondays, wednesdays, fridays, and saturdays from 9:00 am to 1:00 pm with patients scheduled at each 15-minute interval. workers in ppe generally arrived and exited the facility within 45-60 minutes of testing start and stop, for proper donning and doffing. workers not in ppe usually arrived and exited the facility within 15-45 minutes of testing start and stop, for site setup and cleanup. the post system is composed of multiple checkpoints that each automobile must progress through in sequential order. the specific layout of the wchd post system is detailed in figure 1 . patients determined to be high risk were scheduled via the wchd covid-19 community triage line and provided the date and time of their drive-through appointment. the patients were instructed at this time to keep their windows fully closed when driving through the testing site, unless specifically directed otherwise by staff. the number of patients in each car ranged from 1-5 with most cars containing 1-2 patients. on the day of testing, automobiles that enter the site are directed to checkpoint a. at this point, the automobile driver is instructed to display identification, through the window, for the person(s) receiving the test. staff at checkpoint a then confirm the appointment by matching the person(s) name and date of birth (dob) to a list of scheduled tests for the day. if confirmed, an adhesive note with the patient's "number," assigned at the time of scheduling, is placed on the windshield (secured under the windshield wiper, if possible), and the patient is then directed to drive to checkpoint b. if the appointment is not confirmed, the patient is provided a number to contact at the wchd and is directed to leave the site through an alternative exit (see figure 1 ). there is a significant amount of distance delineated at the wchd post system from checkpoint a to checkpoint b (571 meters), allowing automobiles to line up while awaiting testing without disrupting the check-in process at checkpoint a. staff at checkpoint b communicate the patient number on each windshield to an organizer located near the checkpoint. the organizer references this number to find the corresponding covid-19 drive-through point of screening and testing (post) system file containing a completed laboratory slip, consent form (online data supplement 1), and stickers with the patient's information. a clipboard containing these documents is handed to another staff member driving a golf cart, who will lead the patient to the appropriate testing station. each golf cart, carrying the clipboards for 2 automobiles, leads these automobiles to 1 of 3 swabbing stations as soon as a station is available, before transferring the clipboard to the personnel involved in the swabbing. the automobile drivers are instructed to park their vehicles in the 2 designated parking spaces in front of each station. checkpoint c consists of the 3 swabbing stations covered by canopy tents, each staffed by 3 personnel wearing full ppe. two of these personnel, labeled as "swabbers," are each responsible for swabbing the patient(s) requiring testing in a single automobile. the third personnel in ppe acts as a "clerk," whose responsibilities are recording the time of testing and which staff member swabbed which patient, preparing testing kits for the swabbers, attaching patient stickers to test tubes, and placing lab slips in the specimen bag. once the 2 swab personnel each receive the appropriate clipboard from the golf cart driver, both hand the lab slip and stickers to the clerk before adding a new pen and covid-19 informational sheet (online data supplement 2) to the clipboard. then, swabbers approach their corresponding automobile with the clipboard and instruct the patients to open their window, which should have remained closed on the site prior to this point. the swabber verbally confirms the patient's name and dob and obtains the patient's informed consent (online data supplement 1) with signature following an explanation of the swabbing procedure. the patient is asked to keep the pen and informational sheet, while the clipboard containing the consent form is brought back to the station. swabbers then obtain a testing kit from the clerk and again approach their respective vehicles. this testing kit contains a labeled test tube, nasopharyngeal swab, tissues, a paper cup, and hand sanitizer. swabbers instruct patients to blow their nose and dispose of the tissue in the paper cup. next, the swabber performs the nasopharyngeal swab in both nares before placing the sample in the test tube. the patient is given hand sanitizer, provided once the 2 automobiles leave a station, the golf cart driver is signaled to lead the next pair of cars to that same station. during this transition, the swabber drops the sealed test tube into the appropriate specimen bag, held open by the clerk, who places the bag into an ice chest. swabbers then change their gloves following every test to avoid cross-contamination. the ice chest containing patient specimens is transported to a nearby state health laboratory at 2-hour intervals during each shift by a health district employee. the wchd call center or contact tracing staff notify the patients of their test results via phone or e-mail at approximately 48-72 hours after testing, answer any questions, and arrange for the next appropriate steps should the test be positive, including extensive contact tracing. all personnel donning ppe at this location use a reusable heavy suit and hood powered air purifying respirator (papr), which are thoroughly sprayed before doffing with highconcentration ethanol solution (with or without bleach), following each shift, in the decontamination area (see figure 1 ). some other staff members also opted to use ppe while on-site, although this was not required. data collection ceased on april 27, 2020, for preparation of the current manuscript, although covid-19 testing continues to be administered at this site. the following parameters were collected from the wchd: covid-19 tests performed each day, number of required staff and their responsibilities, positive covid-19 tests per week, ppe use per shift, distances of the post system route via measurement wheel, and safety concerns. the time intervals for individual automobiles driving through the site were recorded in a single day (april 27, 2020), although the researchers caution that the wchd modified the testing hours from this day onward to decrease heat exposure for the workers. all other parameters this day were consistent with the rest of the post system data set. the specific time intervals, measured in minutes, recorded for each automobile, included the exit from checkpoint a, arrival at checkpoint c, and exit from checkpoint c. descriptive statistics and 2-tailed independent sample t-tests were completed, comparing parameters at the tb clinic to those at the post system. swab personnel during phase 1 who donned ppe consisted of wchd registered nurses, per-diem nurses, third-or fourthyear medical students, and physicians. phase 2 included the exact same swab personnel plus military medics, due to later involvement of the u.s. military. all swabbers in both phases each day of testing at the tb clinic (phase 1) required 4-8 personnel in full ppe (2-4 per half-day shift), averaging 6.14 personnel in full ppe per day. other staff at the tb clinic included 1 clerk in partial ppe, 1-3 "flaggers" directing traffic, and 1 administrator handling paperwork. the ppe used at the tb clinic during each shift involved 1-2 n95 masks, 1-2 disposable gowns, and 1-2 disposable (or reusable) face shields per testing personnel. one to 2 pairs of nitrile gloves were used for each patient tested. the clerk in partial ppe used 1 n95 mask and approximately 10 pairs of gloves per shift. at the post system (phase 2), there was an average of 9.23 personnel in full ppe per day. other staff spread over the event center lot included 8-11 "flaggers" directing traffic, 5 golf cart drivers, 4-7 administrators handling paperwork, 1 safety officer, and 1-3 emts. the ppe at the post system involved a total of 10 hood paprs, which were reused for the duration of the month; heavy suits for all testing personnel, replaced weekly; and 1-2 pairs of nitrile gloves per patient tested. on april 27, 2020, patients in 136 automobiles were tested for covid-19 during a 2-hour shift. the "total time on site," defined as completion at checkpoint a to completion at checkpoint c, ranged from 8 to 20 minutes, with an average of 14.4 minutes. the "check-in time," defined as checkpoint a exit to checkpoint c arrival, ranged from 4 to 17 minutes with an average of 11.0 minutes. the "testing time," defined as checkpoint c arrival to checkpoint c exit, ranged from 2 to 6 minutes, 3.4 minutes on average. these time intervals are outlined in table 1 . the entire distance of the driving route through the wchd post system measured 999 meters (0.62 miles). there were 2 instances reported of a mismatched lab slip and test tube vial arriving at the laboratory during phase 2. no instances were reported of a break in ppe or accidental contagion exposures among the staff. the largest safety concern at the post system was the amount of time spent wearing the papr and heavy suit, considering the progressively increasing outdoor temperatures in reno, particularly near the end of each shift at 1:00 pm. emts and safety officers were on-site at all times to address the safety of the patients and staff. automobile safety was encouraged by advising personnel to walk behind vehicles and through constant communication with automobile drivers by "flaggers" and golf cart drivers. check-in time represents the exit from checkpoint a (near entrance) to arrival to checkpoint c (testing area). testing time represents the arrival at checkpoint c to the exit from checkpoint c. total time on-site represents the summation of the check-in time and testing time. all data were recorded on a single selected day of covid-19 testing at the health district post during phase 2. time was measured in whole minutes (mins) and distance in meters. sd = standard deviation. disaster medicine and public health preparedness this drive-through post system at a health department in the united states, which operates as a unified and efficient testing site available to both urban and rural populations, is an alternative to similar covid-19 drive-through testing models previously reported in the literature. [6] [7] [8] 13 key distinct features of the post system are a clear and efficient layout with the capacity to test thousands daily, the implementation of a strict protocol for all staff on-site, and the use of trained professionals for obtainment of nasopharyngeal swabs. the post system referenced in the current study was already able to accommodate a large volume of patients in a short time span, with up to 283 samples collected in 4 hours. this is comparable to the model averaging 192 patients per day reported by ton et al., 6 as well as the model in south korea, which could accommodate around 100 tests per day. 13 however, the authors believe that the post system is amenable to even further expansion. recruitment of additional staff, parallel driving lanes, increased swabbing stations, longer site hours, and more testing days are all measures that could realistically expand the capacity of the post system to thousands of patient tests per day. the efficiency of the post system should be highlighted as well. two of the main limitations in the administration of high-volume covid-19 testing are the availability of qualified personnel for swabbing (eg, nurses, medical students, and physicians) and the nationwide ppe shortage. 14, 15 therefore, the authors measured the efficiency of both testing systems (phases 1 and 2) through calculating the number of tests conducted in 1 hour by 1 personnel donned in full ppe. results revealed 2 tests/ppe/hour for the tb clinic in phase 1 and nearly 6 tests/ppe/hour in phase 2. the authors did not identify a similar metric in the current literature for covid-19 testing models and suggested that "covid-19 tests/ppe/hour" could be used as an objective measure of testing model efficiency. nevertheless, the authors believe that a single worker in ppe conducting nearly 6 tests per hour (or about 1 test per 10 minutes) is a satisfactory level of efficiency for a drive-through testing station. additionally, the shortage of ppe was addressed in the wchd post system by the use of a papr and heavy suit. the papr allowed for~100% efficiency at filtering air, which is more protective than the n95 masks used in other models. 14 the reusable nature of both the papr and suit following decontamination significantly reduced the burden of this testing site in terms of ppe use relative to other models. 6 another set of metrics suggestive of the high efficiency of the post system is the time intervals recorded throughout 1 day of testing. the total time on-site averaged around 14 minutes, consisting of about 11 minutes for check-in and 3 minutes for swabbing. these numbers are comparable to the model in south korea, which references a specimen collection time of 2 minutes and total time of < 15 minutes. 7 these short-time intervals not only considerably contribute to the efficiency and capacity of the post system, but also reduce the associated time burden on patients' schedules. the authors also posit that the post system is highly adaptable to communities in the united states, including areas with a larger or smaller population than the reno-sparks area. this model could be implemented in any comparably sized lot, although event centers are especially applicable due to their probable disuse for regular activity during this pandemic. the identification of patients at high risk for infection over a telephone triage line allows for the remote assessment of patients by physicians or epidemiologists, increasing the applicability of the post system to rural areas, provided that a laboratory is within acceptable distance. however, patients should be strongly cautioned that serious symptoms should preclude testing through the post system and instead prompt an in-person visit with a physician. one obvious limitation of the post system is that it is only available to patients with access to an automobile. patients might also forego social distancing to access an automobile for testing purposes, such as asking a friend to drive them through the testing site. to accommodate patients without a car, the wchd launched a mobile testing program with local emergency medical services. patients requiring in-person testing were able to make appointments, via phone, for testing to be brought to their place of dwelling through this initiative. however, risk assessment was only available through online or telephone, and in-person referral was completed through other community testing sites, and not the currently described system. another limitation includes the lack of a physician present on-site in the case of a medical emergency among staff or patients (eg, heat stroke or respiratory failure); however, a safety officer, emergency medical technicians, military medics, and registered nurses were all on-site who could help address potential emergencies. because the stations in the post system were covered by canopy tents, the swabbers were exposed to outside weather conditions. the testing schedule at the wchd site was transitioned to start 1 hour earlier and remain open for 3 hours each day (after cessation of patient testing data collection), with the addition of a fourth testing station, to address concerns of heat and dehydration among swabbers. similar problems were reported in the drive-through model in south korea. 13 this limitation might be alleviated by more protective tents or similar structures. serum covid-19 antibody testing via antecubital venipuncture or finger prick could also be integrated into the post system if such tests become widely available and are clinically indicated. 3 antibody drive-through testing may not necessitate the same degree of ppe as the nasopharyngeal swab, considering the decreased droplet and airborne risk. additional considerations are inclusive of phlebotomists or further training of personnel, patient positioning for obtainment of covid-19 drive-through point of screening and testing (post) system serum sample in an automobile, the risk of bloodborne pathogen exposure, and the requirement for additional supplies. previous processes from the current post system that could transition effectively to antibody sample collection include specimen labeling, storage, and transport, as well as the telephone assessment and subsequent patient scheduling. translating this protocol for drive-through covid-19 testing to other sites nationwide could significantly improve testing efficiency and reduce consumption of ppe for testing purposes. the authors believe that the post system is an effective model for high-volume, safe, and efficient testing that is adaptable to most communities in the united states, and that it should be emulated in areas with inadequate testing programs. the post system described in the present study improves on a prior testing center used by the health district, and represents a particularly efficient, safe, and adaptable model for covid-19 testing. although the limitations of this model should be considered before implementation, the authors recommend that other covid-19 testing sites nationwide consider adopting it for their own purposes. proclamation on declaring a national emergency concerning the novel coronavirus disease (covid-19) outbreak. united states: the white house united states: national conference of state legislatures. state action on coronavirus covid-19: testing times substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov-2) excess mortality from covid-19: lessons learned from the italian experience. 2020;epub covid-19 drive through testing: an effective strategy for conserving personal protective equipment innovative screening tests for covid-19 in south korea drawing on israel's experience organizing volunteers to operationalize drive-through coronavirus testing centers system c on the f of ec in the ush. hospital-based emergency care: at the breaking point drive-through medicine: a novel proposal for rapid evaluation of patients during an influenza pandemic forecasting the impact of the first wave of the covid-19 pandemic on hospital demand and deaths for the usa and european economic area countries. medrxiv. 2020;epub google maps, maxar technologies drive-through screening center for covid-19: a safe and efficient screening system against massive community outbreak sourcing personal protective equipment during the covid-19 pandemic understanding and addressing sources of anxiety among health care professionals during the covid-19 pandemic covid-19 drive-through point of screening and testing (post) system disaster medicine and public health preparedness no funding was sought in the publication of this manuscript. however, the authors would like to acknowledge the wchd for their tremendous support in the development of the testing system demonstrated in the current study, as well as data collection and manuscript preparation, including contributions by lisa lottritz, angela penny, heather kerwin, james english, and kevin dick. other support for the covid-19 drive-through testing center came from the washoe county sheriff's office, reno fire department, team rubicon, army and air force reserves, and silver state barricade and sign. the authors have no conflicts of interest to declare. key: cord-322382-p46slvka authors: wesemann, christian; pieralli, stefano; fretwurst, tobias; nold, julian; nelson, katja; schmelzeisen, rainer; hellwig, elmar; spies, benedikt christopher title: 3-d printed protective equipment during covid-19 pandemic date: 2020-04-24 journal: materials (basel) doi: 10.3390/ma13081997 sha: doc_id: 322382 cord_uid: p46slvka while the number of coronavirus cases from 2019 continues to grow, hospitals are reporting shortages of personal protective equipment (ppe) for frontline healthcare workers. furthermore, ppe for the eyes and mouth, such as face shields, allow for additional protection when working with aerosols. 3-d printing enables the easy and rapid production of lightweight plastic frameworks based on open-source data. the practicality and clinical suitability of four face shields printed using a fused deposition modeling printer were examined. the weight, printing time, and required tools for assembly were evaluated. to assess the clinical suitability, each face shield was worn for one hour by 10 clinicians and rated using a visual analogue scale. the filament weight (21–42 g) and printing time (1:40–3:17 h) differed significantly between the four frames. likewise, the fit, wearing comfort, space for additional ppe, and protection varied between the designs. for clinical suitability, a chosen design should allow sufficient space for goggles and n95 respirators as well as maximum coverage of the facial area. consequently, two datasets are recommended. for the final selection of the ideal dataset to be used for printing, scalability and economic efficiency need to be carefully balanced with an acceptable degree of protection. the coronavirus (covid-19) pandemic is challenging healthcare systems worldwide. by the end of january 2020, it was declared an international "public-health emergency" by the world health organization (who) [1] , with the number of covid-19 patients increasing daily. to ensure the protection of the healthcare workers (hcws) treating these patients, personal protective equipment (ppe) is imperative. however, the widespread shortage of ppe is well known, which requires a degree of ingenuity to tap into other meaningful resources [2] and to close the gap between the need for and the availability of ppe. the u.s. centers for disease control and prevention has itself considered the use of nonmedical devices in crisis situations [3] . the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) has been extensively analyzed, showing that it is sustained in aerosols for up to 3 hours and for up to 72 h on plastic and stainless steel surfaces after contamination. even though research shows an exponential decay in the virus titer in all experimental settings [4] , it also reveals that high viral loads in the upper respiratory tract might be a factor in its epidemiologic characteristics. furthermore, the potential for people infected with sars-cov-2 to transmit the virus while asymptomatic [5, 6] , the mode of transmission, and the aerosol and surface stability of sars-cov-2 require a specific focus on preventive measures [7] , which may vary depending on the activities that hcws perform [8] . there is currently no universal standard for face/eye protection from biological hazards, which is reflected in the diversity of public health care guidelines [8] [9] [10] . face shields in combination with additional ppe (goggles and mouth/nose mask) have been shown to reduce the risk of inhalational exposure, especially when performing activities with aerosol formation [9, 11] . hcws, particularly those prone to contact with potentially infected aerosols, are at high risk of exposure to an increased viral load and should be provided with the appropriate ppe to prevent infection and avoid possible nosocomial spreading routes [12] . face shields are ppe devices used by many workers (e.g., medical, dental, and veterinary personnel) for protection of the facial area from splashes, sprays, or the spatter of body fluids. however, face shields should be used with other protective equipment and, as such, are classified as adjunctive ppes [9] . recommendations on face shield use differ depending on the setting but the essential use of ppes in the population during a pandemic has led the who to appeal for an increase in their production [13] . supplementary ppes are recommended for high-risk hcws in particular, including goggles for eye protection and face shields to avoid contamination of the facial area. due to their proximity to patients and subsequent potential exposure to infected airborne particles or aerosols [14, 15] , the presence of oral fluids, and the use of sharp instruments, hcws are at increased risk of sars-cov-2 infection [16] . the quest to find alternative resources and solutions to overcome the shortage of ppe also suggests a relaxation of the less essential regulatory requirements. face shields are considered class i medical devices, exempt from food and drug administration (fda) pre-market notification (form 510 [k]) [9] , which can be manufactured using materials that have been classified harmless when in contact with skin or food. therefore, to provide hcws with sufficient ppes to increase facial protection, face shields could be 3-d printed. 3-d printers are in widespread use for professional and private purposes. despite not being as fast as injection molding processes, this method of production allows the at-home, on-demand manufacture of face shields by a broad spectrum of users. this study evaluates the utilization of 3-d printers, which are otherwise used for dental purposes, to produce face shields using open-source design data and investigates their clinical suitability. four popular open-source standard tessellation language (stl) datasets for the frameworks of four face shields were selected ( the data sets for the face shields were downloaded as standard tessellation language (stl) files and imported into a slicing software application (prusa slicer, prusa research; holešovice, czech republic). a biodegradable material (din en iso 14855) with a melting temperature of >190 • c and a vicat softening temperature (vst) of 160 • c was used as the filament for printing (greentec pro, 1.75 mm, extrudr, lauterbach, austria) with a fused deposition modeling printer (prusa i3 mk3s, prusa research, holešovice, czech republic). printing was performed on a powder-coated print bed at a printing temperature of 220 • c, a printing bed temperature of 60 • c, a printing speed of 40 mm/s, a nozzle size of 0.4 mm, 20% infill, and a layer height of 0.2 mm. each face shield was printed individually. for completion, a 0.1-mm thick polyethylene terephthalate (pet) din a4 (210 × 297 mm) transparent foil (laser foils, dots office products, kansas city, mo, usa) was prepared and mounted to the frame as described: for the rc1, rc2, and v3 face shields, four holes were made in the visor at the intended locations using a din a4 perforator and then pressed onto the four pins for retention. for the easy 3d face shield, the foil was clamped into a dedicated slot. at the posterior end of each frame, an elastic strap (0.6 mm, polyester, available by the meter) was attached. after downloading and 3-d printing the stl datasets, the filament weight, total weight, printing time, and the necessary tools for assembling the framework were determined. for clinical assessment, 10 dental clinicians and/or intensive care nurses wore each face shield (n = 4) for one hour when performing dental treatment or intensive care. the clinical parameters examined were rated on a 10-cm visual analogue scale (vas) ranging from 0 = "not acceptable" to 100 = "excellent" and measured with a ruler for subsequent evaluation. the parameters included the following: (1) the contact of the headframe with the forehead (fit), (2) comfort during usage, e.g., pressure on the head and slipping of the device (comfort), (3) sufficient space for additional protective devices, e.g., goggles or glasses and oronasal mask (space), (4) sealing of the forehead and lateral coverage of the cheeks and temporal/zygomatic area and the chin (protection), and (5) overall evaluation (overall). for analysis, the mean values and standard deviations were determined. to verify the normal distribution of the five parameters, the shapiro-wilk test was applied. subsequently, a one-way analysis of variance (anova) was applied, incorporating the five dependent variables (fit, comfort, space, protection, and overall), with the post-hoc tukey test. the significance level was set at α = 0.05. the statistical analysis was performed using a statistical software (ibm spss statistics, ver. 22.0, ibm corp, armonk, ny, us). the shapiro-wilk test revealed no significant differences (p ≥ 0.168). therefore, normal distribution of the data was assumed. by contrast, one-way anova showed significant differences for all five parameters (p = 0.001) (figure 2 ). the fit was rated significantly better for rc1 (82 ± 8) and rc2 (86 ± 5) compared to that for easy 3d (63 ± 6) (p = 0.001) and budmen v3 (40 ± 8) (p = 0.001) ( table 1) . conversely, easy 3d (83 ± 7) and rc2 (78 ± 7) displayed the highest wearing comfort compared to rc1 (56 ± 7) and budmen v3 (48 ± 8) with significantly lower scores (p = 0.001). the space for additional protective devices was rated highest for rc2 (85 ± 5), showed no difference between budmen v3 (80 ± 5) and easy 3d (80 ± 4) (p = 0.997), and was rated significantly lower for rc1 (42 ± 8) (p = 0.001). in terms of protection, easy 3d (84 ± 4) received the best rating, followed by rc1 (70 ± 6) and rc2 (69 ± 7), and, lastly, budmen v3 (65 ± 6). overall, easy 3d (87 ± 4) and rc2 (81 ± 5) received the highest scores, which differed significantly from those for rc1 (63 ± 6) and budmen v3 (56 ± 4) (p = 0.001). the printing was possible without support structures, but the limited contact area with the print bed may cause detachment of the object during the printing process. the size and the distance between the four integrated point attachments are designed to match the spacing of a perforator (din a4 standard), which makes assembly easy. an additional printed reinforcement with an incorporated slot helps keep the curvature of the foil on the lowermost side (shield curvature aid). the headframe has a clamp fit. however, this can become uncomfortable when worn for an extended period of time due to the pressure it exerts. the lateral expansion covers the cheeks and most of the zygomatic area. however, the space between the headband and the visor is limited. consequently, eye and oronasal protective devices may interfere with the visor (figure 3) . furthermore, the open space between the headframe and the visor frame does not provide protection against aerosols from above. reinforcement of the lowermost side of the foil can be prone to error during printing (the narrow slot caused failures at high printing speeds or when using stereolithography-based printers) and may detach during treatments. similar to rc1, the printing of rc2 is possible without support structures, but the limited contact area with the print bed may cause detachment of the object during the printing process. rc2 is equipped with additional printed reinforcement at the lowermost side of the foil, as described for rc1. the rc2 model does not have a clamp fit for the headframe, which increases the wearing comfort. however, the fit (the intimacy of the headframe contact with the forehead) remains similar to that with rc1. the increased space between the face and visor is sufficient for essential eye and mouth-nose protective equipment, but, at the same time, lateral protection against aerosols when using pre-fabricated din a4 foils is reduced. for some clinicians, the weight of the framework and the missing sealing between the headframe and visor (as with rc1) may be a disadvantage. the budmen v3 face shield offers a simplified geometry with a higher contact area with the print bed, which minimizes printing failures and shortens the printing time. the assembly is comparable to that of rc1 and rc2 (designed to match the spacing of a perforator of din a4 standard). the space available for additional ppe is comparable to that with rc2. the lateral expansion and complete sealing of the forehead provide more protection from above and laterally. the headband is rigid due to its one-piece construction impairing its completely intimate adaption to the head and minimizing its fit. the rigidity of the face shield reduces wearing comfort and fit compared to rc2. the contact area with the print bed is large, which makes detachment during printing unlikely. this process shortens the printing time. conversely, the printing of the narrow visor slot might pose problems at high printing speeds, and the delicate design might be more prone to breakage. after printing, the visor is pushed into a small continuous slot with clamping retention. this eliminates the need for additional steps, such as perforations. furthermore, the visor remains stable and can be changed easily. the lower weight of the easy 3d makes it comfortable to wear. the space beneath the visor is less than that with rc2 but more than that with rc1. the headframe fits snuggly to the forehead and offers good protection from aerosols since the forehead is sealed, and the lateral extension of the visor covers the cheek and the zygomatic areas. the present article is based on the belief that documentation and transparency [17] using open-source data will help identify ways to combat the spread of sars-cov-2 infection. the rationale of the present investigation was to remove the necessity of time-consuming testing procedures with respect to printing time, ease of assembly, printability, and the comfort of using open-access data to print face shields in situations of scarcity. similar in design to commercially available face shields, the samples presented in this study represent a simplified design that allows for on-demand manufacturing of face shields and assembly using common house-hold items. for effective and efficient manufacturing of the face shields presented in this study, fused deposition modeling (fdm) was preferred due to its increased printing capability and minimal post-processing requirements. by contrast, stereolithography (sla) printers require uncured resin to be removed from the finished print using cleaning or washing procedures prior to additional light-curing [18, 19] . while both printing techniques require support structures in non-supported areas, fdm-based techniques will generally require fewer support structures. thus, this process further decreases the time needed for post-processing. moreover, some design features such as the clamping slot of the easy 3d face shield or the shield curvature aid of the rc2 can result in failures when using sla-techniques due to the non-removable support structures in non-accessible gaps or fissures. besides the previously mentioned considerations regarding printing technology, printer selection for present purposes depends on the print volume requirement needed to meet the size of the printed dataset (table 1 ). in the present case, the prusa rc2 design was selected as a reference, requiring a width of 144 mm, a length of 191 mm, and a height of 20 mm. the prusa i3 mks3 sample used in the present study features a print bed with a width of 210 mm, a length of 210 mm, and a maximum printing height of 250 mm. the sample is, therefore, suitable for printing all of the face shields evaluated. other printers, e.g., form 3 (formlabs, somerville, massachusetts, usa) do not offer the printing volume needed. in order to print the rc2 design, the dataset would have to be scaled to 95% and/or the printing direction changed to fit onto the printing platform. changing the size may result in an improved or diminished fit of the face shield. moreover, the benefit of a support-structure free design is no longer present when longer printing times are needed due to having to change the printing direction. acrylonitrile butadiene styrene (abs) features good strength but not biodegradability. in addition, abs has to be printed at higher temperatures (240-250 • c) compared to polylactide (pla, 180-220 • c) and is, therefore, more susceptible to shrinkage during cooling. as a consequence, abs is considered to be more prone to failures during the printing process. polyethylene terephthalate (petg) combines both the high fracture strength of abs and the reduced susceptibility to failure of pla. however, again, it lacks biodegradability. the material used in the present study is based on lignin (greentec pro) and combines the previously mentioned attributes [20] . visors can be manufactured from several types of materials that include polycarbonate, propionate, acetate, poly(vinylchloride), and petg [9] . since pla and petg are known to show volume change during sterilization processes [21] , one-time use of the visor is recommended, whereas a study showed that sterilized 3-d printed surgical splints using filaments based on lignin (green-tec pro) remained dimensionally stable [22] . the sterilization of the frame might be possible, but was not tested in this study. therefore, a recommendation regarding sterializability cannot be made. the biodegradation of the material, documented according to the en 13432 standard, will minimize the impact of plastic on the environment. the lack of requirement for a din a4 perforator can be considered to be a major advantage of the easy 3d face shield design, allowing assembly without the need for further region-specific (din a4) tools. the small radius of curvature of the easy 3d visor compared to that of the rc1/rc2/v3 models enables both the space for expansive ppe, such as goggles, as well as extended lateral protection against aerosols. however, even though the lateral extension of the visor was rated best compared to that of the other frames, the recommendation of extension to the ear was still not met [9] . this can be overcome by customizing the size of the pet foil. mass production using non-industrial in-office 3-d printers might be limited due to their printing times, which were greater than 1.40 h. in a more recent version of the rc2 design, print files with four frames stacked on top of one another were provided by the developers (rc3). stacking frames may be an easy method for overnight printing in a private, non-industrial setting. other frames evaluated in the current study, such as the easy 3d face shield, cannot be stacked in the same way without additional support structures due to the closed one-piece design with a protruding frontlet. thus, its cost-effectiveness remains debatable. from a scalability point of view, the rc3 is recommended for mass production in non-industrial environments. however, the easy 3d frame is a viable option for small scale in-house production. in general, open-source data with a limited need for support structures are preferred due to their printing speed and economic efficiency (waste of material) [23] . most of the available online datasets, such as that for the production of ppe including respirators, were not specifically designed for additive manufacturing. such datasets might be used for the private production of prototypes but cannot be recommended for large-scale production during times of material shortages. easy to use and self-sustaining face shield production using one's own printing capabilities in combination with sufficiently available, commercial goods, such as the laser copy foils in the current study, can be considered to help protect hcws from aerosol or accidental hand-to-face contamination during their daily clinical routines. pet foils for visors should be individually sized to full facepiece length that extends below the chin and offers sufficient width to reach at least the point of the ear for more peripheral protection. customization of the available datasets for face shield production on the basis of factors such as 3-d face scans might improve wearing comfort, fit, and sealing capacity and increase protection. however, this may require time-consuming individual adaptation of the datasets. in general, the ongoing pandemic might result in the rethinking of material supply for healthcare institutions. in particular, increased efforts in realizing real-time, on-demand in-campus production allows for independence from external suppliers and a decreased need for stock-piling [24] . this will increase flexibility in daily clinical routines and autonomy in emergency situations but will introduce new regulatory challenges [25] . printing ready-to-use sterile parts using specific cleanroom printing devices will enable further optimization of just-in-time production in the near future and further broaden the application range of additively manufactured goods in hospitals [26] . though the face shields produced for the current study can reduce the viral load on the facial area from aerosol penetration, they should not be used as solitary face/eye protection, but rather as an adjunct to other ppe such as protective eye/nose masks and goggles. 3-d printing of the frame of a face shield was possible using open-source data and biodegradable material. when printing face shields, the printing ability and printing time need to be considered and may vary depending on the design. for clinical suitability, a design should be chosen to allow sufficient space for goggles and n95 respirators as well as maximum coverage of the facial area. due to its printability, ease of assembly, space for additional ppe, and protection, the easy 3d face shield was shown to be the most effective. however, it lacks scalability potential (stacking) in non-industrial environments. if large-scale production is a priority, the rc2 should be the preferred option due to the availability of a stacked dataset. transmission dynamics and evolutionary history of 2019-ncov critical supply shortages-the need for ventilators and personal protective equipment during the covid-19 pandemic aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 presumed asymptomatic carrier transmission of covid-19 sars-cov-2 viral load in upper respiratory specimens of infected patients covid-19, a worldwide public health emergency rational use of personal protective equipment for coronavirus disease ( covid-19): interim guidance face shields for infection control: a review american national standard for occupational and educational personal eye and face protection devices efficacy of face shields against cough aerosol droplets from a cough simulator protecting chinese healthcare workers while combating the 2019 novel coronavirus rational use of face masks in the covid-19 pandemic novel coronavirus disease 2019 (covid-19): the importance of recognising possible early ocular manifestation and using protective eyewear precautions in ophthalmic practice in a hospital with a major acute sars outbreak: an experience from hong kong transmission routes of 2019-ncov and controls in dental practice a systematic risk-based strategy to select personal protective equipment for infectious diseases mechanical properties of fdm and sla low-cost 3-d prints the influence of printing parameters on selected mechanical properties of fdm/fff 3d-printed parts one year evaluation of material properties changes of polylactide parts in various hydrolytic degradation conditions how to sterilize 3d printed objects for surgical use? an evaluation of the volumetric deformation of 3d-printed genioplasty guide in pla and petg after sterilization by low-temperature hydrogen peroxide gas plasma accuracy of a workflow using sleeveless 3d printed surgical guides made from a cost-effective and biodegradable material: an in vitro study support structure constrained topology optimization for additive manufacturing three-dimensional printing surgical instruments: are we there yet? regulatory considerations in the design and manufacturing of implantable 3d-printed medical devices on the intrinsic sterility of 3d printing acknowledgments: developers of the referring open-access datasets are highly acknowledged for their efforts in providing data for individual printing of ppe. the authors declare no conflict of interest. key: cord-307697-ds4uw7y1 authors: ahmed, jawad; malik, farheen; bin arif, taha; majid, zainab; chaudhary, muhammad a; ahmad, junaid; malik, mehreen; khan, taj m; khalid, muhammad title: availability of personal protective equipment (ppe) among us and pakistani doctors in covid-19 pandemic date: 2020-06-10 journal: cureus doi: 10.7759/cureus.8550 sha: doc_id: 307697 cord_uid: ds4uw7y1 background the coronavirus disease (covid-19) pandemic has put an excessive strain on healthcare systems across the globe, causing a shortage of personal protective equipment (ppe). ppe is a precious commodity for health personnel to protect them against infections. we investigated the availability of ppe among doctors in the united states (us) and pakistan. methods a cross-sectional study, including doctors from the us and pakistan, was carried out from april 8 to may 5, 2020. an online self-administered questionnaire was distributed to doctors working in hospitals in the us and pakistan after a small pilot study. all analysis was done using statistical package for social science (spss) version 23.0 (ibm corp., armonk, ny). results after informed consent, 574 doctors (60.6% from pakistan and 39.4% from the us) were included in the analysis. the majority of the participants were females (53.3%), and the mean age of the participants was 35.3 ± 10.3 years. most doctors (47.7%) were from medicine and allied fields. among the participants, 87.6% of doctors from the us reported having access to masks/n95 respirators, 79.6% to gloves, 77.9% to face-shields or goggles, and 50.4% to full-suit/gown. whereas, doctors in pakistan reported to have poor availability of ppe with only 37.4% having access to masks/n95 respirator, 34.5% to gloves, 13.8% to face-shields or goggles, and 12.9% to full-suit/gown. the reuse of ppe was reported by 80.5% and 60.3% physicians from the us and pakistan, respectively. more doctors from pakistan (50.6%) reported that they had been forced to work without ppe compared to doctors in the us (7.1%). conclusion there is a lack of different forms of ppe in the us and pakistan. doctors from both countries reported that they had been forced to work without ppe. compared to the us, more doctors from pakistan reported having faced discrimination in receiving ppe. after informed consent, 574 doctors (60.6% from pakistan and 39.4% from the us) were included in the analysis. the majority of the participants were females (53.3%), and the mean age of the participants was 35.3 ± 10.3 years. most doctors (47.7%) were from medicine and allied fields. among the participants, 87.6% of doctors from the us reported having access to masks/n95 respirators, 79.6% to gloves, 77.9% to face-shields or goggles, and 50.4% to fullsuit/gown. whereas, doctors in pakistan reported to have poor availability of ppe with only 37.4% having access to masks/n95 respirator, 34.5% to gloves, 13.8% to face-shields or goggles, and 12.9% to full-suit/gown. the reuse of ppe was reported by 80.5% and 60.3% physicians from the us and pakistan, respectively. more doctors from pakistan (50.6%) reported that they had been forced to work without ppe compared to doctors in the us (7.1%). there is a lack of different forms of ppe in the us and pakistan. doctors from both countries reported that they had been forced to work without ppe. compared to the us, more doctors from pakistan reported having faced discrimination in receiving ppe. the novel coronavirus, initially originating from the hubei province of china, has spread to nearly every continent, overwhelming and straining even the most sophisticated healthcare systems [1] . the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is transmitted through inhalation or contact with infectious droplets. it may be asymptomatic early on in the course or present with mild respiratory symptoms, headache, fever, fatigue, nausea, vomiting, in addition to some reports describing hematological and cardiac involvement [2] . healthcare workers (hcws) or individuals who tend to coronavirus disease patients are at highest risk of contracting the infection. the prevention of the spread of infection to and from medical personnel solely lies in the effective use of personal protective equipment (ppe), including gloves, face masks, airpurifying respirators, goggles, face shields, respirators, and gowns. the rampant nature of covid-19 has created a shortage of ppe in high demand areas. the abrupt increase in the demand for ppe has to be met with an accelerated manufacturing and supply of ppe. many healthcare systems are failing to provide ppe due to financial or time constraints. there have been multiple reports of hcws protesting about the lack of appropriate ppe, and instances of doctors and other healthcare staff being forced into working without this precious commodity [3, 4] . the healthcare system of the united states (us) is known all over the world for its innovative and highly specialized patient care. the us spends a significant amount (17.1%) of the country's gross domestic product (gdp) on health care, which is far more on health care as a percentage of its economy than any other developed nation [5] . nonetheless, the us has the highest number of cases (1,432,265 cases and 87,180 deaths; may 18, 2020) of covid-19, and despite being the pinnacle of modern medicine, the healthcare system is strained and stretched to its very limits [6] . as expected, the situation in developing countries, with weaker healthcare infrastructure, is even direr. the covid-19 pandemic was confirmed to have reached pakistan on february 26, 2020 [6] . in pakistan, 42,125 cases have been reported with 903 deaths till may 18, 2020 [6] . consequently, the already struggling health care system of pakistan is not equipped for large pouring in of potentially infectious patients seeking testing and care [7] . resources are stretched thin, and the number of hcws being infected is rising every day. in this context, we sought to examine the availability of ppe in pakistan (a resource-constraint country) and the us (resource-rich country) as well as draw a comparison between the two in terms of availability, discrimination in distribution and perceived reasons for the shortage of ppe. a cross-sectional study was carried out among doctors in the us and pakistan using convenience sampling. the study duration was from april 8 to may 5, 2020. a self-administered questionnaire was made using google forms and was distributed to doctors in the us and pakistan via emails and social media platforms. the bias of receiving irrelevant (non-doctors) responses was reduced by posting the questionnaire on doctor/physician-only groups. the credibility of social media groups was ensured that they only admit licensed doctors after confirming their registration numbers and affiliations. the inclusion criteria consisted of three points, (1) a practicing doctor, (2) work in a hospital, and (3) currently working in pakistan or the us. responses of doctors working in private clinics were excluded from the study. explanation of the study's aim, as well as the informed consent form was present at the start of the questionnaire, permitting us to collect the data. a structured questionnaire consisting of four major parts was designed by authors (see appendices section). the initial draft of the questionnaire was sent to multiple senior doctors for evaluation, and all appropriate suggestions were incorporated in the questionnaire. the first part consisted of a brief explanation of the study, informed consent statement, and demographic variables such as country name, age, gender, the specialty of work, and hospital type (private or public). the second part consisted of questions to assess the availability of different forms of ppe, including n95 respirator, masks, gloves, eye protection (goggles or face shield), and full-suit/gown. the third part consisted of questions to assess any discrimination in ppe distribution, perceived reasons for its shortage, the extent of reuse of ppe, and to identify if doctors had been forced to work without ppe. the last part consisted of questions about the likelihood of quitting the job if adequate ppe was not provided and feelings of doctors working in the pandemic situation. in total, the questionnaire consisted of 33 items. a small pilot study was carried out among 10 doctors from each country (pakistan and the us) to ensure that no ambiguity exists in the questionnaire. recent contact with covid-19 patients was defined as a contact within the last three days of filling the questionnaire. all the data were entered and analyzed through statistical package for the social sciences software (spss version 23.0; ibm corporation, armonk, ny, us). results were drawn through descriptive statistics, and means with standard deviation were presented for continuous variables such as age and amount of money spent on purchasing ppe. categorical variables were reported as frequencies with percentages. chi-squared and independent sample t-tests were used to find statistical significance, and a p-value of <0.05 was considered significant for all analyses. a total of 574 doctors (268; 46.7% males) from both countries (60.6%; n = 348 from pakistan and 39.4%; n = 226 from the us) were included in the analysis. the mean age of participants was 35.3 ± 10.3 years, and most of the respondents (47.7%; n = 274) were from medicine and allied fields. the demographics of the participants are noted in table 1 ppe availability was reported significantly more (p < 0.001) among doctors in the us than doctors in pakistan. in the us, 53.1% (n = 120) doctors reported having access to all forms of ppes (including n95 respirators/masks, gloves, gowns/full-suits, and face-shields or goggles) in their hospitals, whereas only 12.6% (n = 44) of doctors in pakistan reported having this privilege. among the participants, 87.6% (n = 198) of doctors from the us reported having access to masks/n95 respirator, 79.6% (n = 180) to gloves, 77.9% (n = 176) to face-shields or goggles, and 50.4% (n = 114) to full-suit/gown. in contrast, doctors in pakistan reported to have poor availability of ppe with only 37.4% (n = 130) having access to masks/n95 respirator, 34.5% (n = 120) to gloves, 13.8% (n = 48) to face-shields or goggles, and 12.9% (n = 44) to full-suit/gown. more than half (58.4%; n = 132) of n95 respirator users in the us reported to have size-fitted masks, whereas only a quarter (25.9%; n = 90) of participants from pakistan reported sizefitting for their n95 respirator in pakistan. in our analysis, 80.5% (n = 182) and 60.3% (n = 210) doctors from the us and pakistan reported reusing ppe, respectively. the details of the frequency of reusing ppe for the us and pakistan are graphically presented in figure 1 . chi-squared test and independent sample t-test were used to find statistical significance between the variables. in the absence of ppe, significantly higher (p < 0.001) number of doctors in pakistan (81.0%; n = 282) reported to have kept working in contrast to doctors form the us (14.2%; n = 32). moreover, a significantly higher (p < 0.001) number of doctors from pakistan (49.4%; n = 172) reported that they had been "bullied into working" without ppe as opposed to the us doctors (7.1%; n = 16). shortage of supply (68.3%; n = 392) and inadequate/poor distribution management (41.1%; n = 236) were reported as the most common reasons for the lack of ppe ( table 2 ). other reasons reported by doctors from the us and pakistan are given in figure 2 . a total of 140 (24.4%) doctors, with 98 (28.2%) from pakistan and 42 (18.6%) from the us reported that they would "likely quit" their job and 32 (5.6%) doctors (the us = 8; pakistan = 24) proclaimed that they would "definitely quit" if they do not receive proper ppe in the future ( table 2) . almost three-fourth (73%; n = 254) doctors from pakistan and 58.4% (n = 132) from the us reported that hcws in their hospitals had been infected by covid-19. half of the respondents from the us (50.4%; n = 114) and pakistan (50.0%; n = 174) expressed that they felt scared working in a pandemic situation ( table 2) . almost one-third (31.6%; n = 110) doctors from pakistan and one-fourth (23%; n = 52) doctors from the us reported that they felt purposeful and proud of themselves for working in the pandemic (figure 3 ). the summarized results of the study and responses of doctors from both countries are presented in table 2 and table 3 . chi-squared test and independent sample t-test were used to find statistical significance between the variables. one of the most substantial strategies to protect both patients and hcws from transmittable pathogens is the adequate use of ppe. in our study, the availability of ppe was reported to be better among the us doctors as compared to pakistani doctors. more doctors in pakistan faced discrimination in receiving ppe, and the reuse of ppe was reported by the doctors from both countries. according to the world health organization (who), the essential supplies of ppe include gowns, gloves, masks or respirators, goggles, face shields, head cover, and rubber boots. since covid-19 is primarily transmitted by contact or droplet and its definite cure has not been discovered yet, the only significant and emotive subject for the hcws is ppe. the types of protection required to combat the specific mode of transmission include (1) gloves and aprons as contact precautions, (2) gloves, aprons, fluid-resistant surgical masks with or without eye protection (goggles or a visor) for droplet transmissions, and (3) gloves, fluid repellant longsleeved gowns, eye protection, and filtering facepiece 2/3 (ffp2/3) mask or n95 respirator during aerosol-generating procedures [8] . our study population comprised of doctors from two countries having a vastly different landscape of healthcare and helped us in comparing the difficulties faced by both countries in the face of a pandemic. a comparison of ppe availability in the us and pakistan with reports from the uk is shown in table 4 . our results are consistent with reports from the uk that some protective equipment such as gowns/full-suits and eye protection are scarce [4] . almost three-quarters of the doctors from pakistan reported that they were not size fitted for their n95 respirator. these results are alarming as the improper fitting of the n95 respirator reduces its efficacy and can make doctors susceptible to infection [9] . in our study, doctors from the us reported to have comparatively better access to ppes, however, they too, are struggling to maintain adequate ppe supply in light of the overwhelming influx of cases, and are not out of danger to get infected. for the worst-hit cities like new york and san francisco, donations were called for from the locals, to ease the state of desperation [1] . the strategic national stockpile (sns), which was responsible for making ppes available during epidemics of ebola virus and h1n1 influenza, is currently making an effort to balance between a quick distribution and restocking [1] . part of the problem could be attributed to the unpreparedness of the authorities despite multiple warnings of a possible influenza pandemic in the near future [10] . furthermore, the us had decreased its production of masks, gowns, and gloves and hugely relied on imports from countries like china [10] . in our study, more than one-third of the doctors from pakistan (35%) reported reusing one ppe for more than one week, while most of the doctors in the us (44%) reported reusing one ppe for two days. in times of extreme shortages and the rapidly increasing cases, the health and safety executive (hse) recently issued guidance that recommended reusing ppes, which followed a skeptical response by the hcws of england [11] . the guidance stated reusing water-resistant equipment and promoted the use of sealable bags for storage, whereas washable gowns or similar long-sleeved articles of clothing were advised as replacements for medical gowns [11] . in literature, several methods of disinfection have been described, which include the use of hydrogen peroxide vapors, ultraviolet (uv) radiation, moist heat, dry heat, and ozone gas, with hydrogen peroxide vapors being the most widely suggested technique [12] . reuse of ffp after appropriate measures has been considered a suitable alternative; however, it is uncertain to state the same for surgical masks [12] . although our study reported that a large majority of physicians from the us and pakistan reusing their pieces of equipment, the exact method of decontamination being administered is beyond the scope of this study and needs further evaluation. the dire shortage of protective gear does not seem to be the only concern of hcws worldwide as the biased distribution and supply further add to the trouble. analysis of our data showed that doctors from pakistan faced greater discrimination in receiving ppe, with one of the main reasons being lack of seniority in position, which is surprising since a large workforce in tertiary care hospitals comprises of junior training doctors. our study showed that 49.4% and 7.1% of doctors from pakistan and the us, respectively, were forced to work without ppe. when compared to the reports from the uk, where 56% of doctors felt pressurized to work despite inadequate ppe, our figures are lower, but they cannot be ignored [4] . news of doctor being arrested for demanding ppe in pakistan has also been reported [13] . several factors have contributed to the shortage of ppes on a global scale. one reason is the psychological 'fear of uncertainty' among masses, giving rise to panic buying and hoarding of masks and gloves along with other essential products. in the current era of globalization, the supply of any product is dependent on its demand; however, with the advent of this sudden calamity, the demand has escalated multiple folds in a short duration, leaving the suppliers struggling to keep up. disruption in the supply and demand graph has resulted in a higher equilibrium price, and certain opportunists are trading the life-saving essentials at staggering rates. another major aspect contributing to the crisis is the travel/export restrictions halting china's trade, which produces and supplies nearly 50% of the worldwide face masks along with other types of safety equipment [14] . the shortage of supplies on a global scale has not only rendered several nations to improvise and innovate but also highlighted the significance of national self-dependency. who, at the beginning of march 2020, advised the relevant industries and governments to ramp up the manufacturing of ppes by 40% to curb the ever-increasing demand [15] . regardless of the efforts of several non-governmental organizations (ngos) in pakistan to distribute ppes among doctors and donation of supplies from china as a gesture of goodwill, the level of protection of pakistan's hcws is nowhere near satisfactory. in the us, however, the role of ngos in contributing to ppe supply or healthcare system is limited, the reason being the notable difference in the socioeconomic status and spendings of both countries on their respective health budgets. even before the pandemic, the government-run tertiary-care hospitals of pakistan highly relied on the interventions from ngos and overseas donors, with the dependency increasing now more than ever. the majority of doctors in our study reported being scared of the current situation and feared that they might transmit the infection to their loved ones. the feeling is synchronous among doctors globally, particularly emergency room physicians, working in direct contact with the infected patients, and performing the intubation [16] . the fear of infecting loved ones was responded positively by the vast majority of both pakistani and the us doctors, with 98.9% and 97.3% responses, respectively. the figure is comparatively greater than that found in a survey performed by royal college of physicians (rcp), stating that 61% of respondents worrying about spreading the disease to family members [17] . almost 50% of participants of our study, from the us and pakistan, described feeling scared while working in a global pandemic. the study from rcp reported similar data, with 48% of their respondents feeling concerned about working in the current situation [17] . the fear among hcws is real and justified as the infectivity and mortality due to covid-19 is increasing every day. similarly, a study on the effect of the sars outbreak (2002-2009) on hcws described a significant sense of threat to life, vulnerability, along with the somatic and cognitive impact [18] . in our study, about 160 (46%) pakistani participants felt like quitting their job due to lack of ppe, which was higher than the response from the us doctors, 72 (31.9%) of which responded affirmatively. however, this figure is not in line with a study from greece published during the a/h1n1 influenza pandemic in 2009, where only 4.3% of hcws reported opting for leave to avoid contracting the virus [19] . even a recent article from the same country (greece) reported the willingness of hcws to work during the current pandemic to be unaffected [20] . the readiness to work, in turn, may be dependent on the socioeconomic status of a state, the trust of its service workers on government, and the severity of the situation. other factors may include but are not limited to gender, childcare responsibilities, personal safety, and protective measures [21] . in our study, 73% of doctors from pakistan and 58.4% from the us reported that hcws in their hospitals had been infected with covid-19. in china, an estimated 3,300 hcws were infected, and 22 expired due to "insufficient protective equipment" [22] . these statistics are alarming, for the war against covid-19 is yet to be over. as the number of infected/dead hcw rises, the anxiety and reluctance of other hcws to work will also increase [23] . the general public should be made aware of the fact that ppe is crucial for hcws on the frontline and n95 respirators, full-suits/gowns or eye protection are not required for daily life uses. it is suggested to introduce a proper surveillance system for the distribution of ppe among doctors in a healthcare setting. social media spreading unauthentic information and promoting black marketing to escalate prices should be banned. the shortage of ppe can cripple the healthcare system. as more healthcare personnel will get infected with covid-19, the workforce fighting against pandemic will decrease. a recent study conducted in a resourcelimited setting found that ward assistants have not been adequately educated about hygiene protocols [24] . educating ward assistants is equally important regarding the proper use of hand disinfectants and ppe, so they do not act as a vector for transmitting infections to healthy patients in this time of covid-19 pandemic. alternative methods for the conservation of these limited and indispensable commodities need to be employed. at present, some healthcare systems are disinfecting or reprocessing ppes using appropriate techniques reported by who or using telemedicine tools for performing medical exams as a form of electronic-ppe [25, 26] . furthermore, recommendations of reprocessing n95 respirators using hydrogen peroxide vapors or uv light have surfaced. although resourceful, these methods lack standardized protocols, and the efficacy of the disinfection process is still uncertain [25] . our study is limited by its online-survey nature, small sample size, and reporting bias, as some responses may be driven by personal emotions of doctors. to conclude, there is a shortage of ppe in hospitals of the us and pakistan due to covid-19 and doctors are feeling scared working without adequate protection in the pandemic situation. some doctors even reported that they are likely to quit their job if they do not receive proper ppe in the future. adequate ppe is crucial in the battle against covid-19, and radical steps need to be taken by hospital administrations and governments to make ppe more accessible to doctors and other hcws. there is a need to educate the general population regarding ppe usage and make them realize that doctors and other hcws are the ones that need them the most. further research is required on this topic that includes other healthcare personnel, and a need to study the opinion of the general population regarding ppe usage is suggested. availability of personal protective equipment (ppe) is a pressing issue for doctors working in covid-19 pandemic. the study aims to assess the availability of ppe to all doctors currently working. the data will be kept confidential and no names and institution details are required. if you meet the following criteria, only then please fill the form (1) are a practicing doctor, (2) work in a hospital (if you work in a private clinic you are ineligible to fill the questionnaire), and (3) working in pakistan or united states. by filling the questionnaire you agree to be part of the study and agree to provide information to the best of your knowledge. the study data will be used for publication in any journal. thank you for taking part in the study. your response has been recorded. human subjects: consent was obtained by all participants in this study. animal subjects: all authors have confirmed that this study did not involve animal subjects or tissue. conflicts of interest: in compliance with the icmje uniform disclosure form, all authors declare the following: payment/services info: all authors have declared that no financial support was received from any organization for the submitted work. financial relationships: all authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. other relationships: all authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work. covid-19: the crisis of personal protective equipment in the us cardiac manifestations of coronavirus disease 2019 (covid-19): a comprehensive review. cureus. 2020 healthcare workers protest for vital protection equipment doctors lacking ppe "bullied" into treating covid-19 patients world health organization: united states of america world health organization: novel coronavirus (covid-19) situation reports drugs ther perspect. 2020 personal protective equipment during the covid-19 pandemic -a narrative review comparing the protective performances of 3 types of n95 filtering facepiece respirators during chest compressions: a randomized simulation study why america ran out of protective masks -and what can be done about it rimmer a: covid-19: experts question guidance to reuse ppe disposable masks: disinfection and sterilization for reuse, and non-certified manufacturing, in the face of shortages during the covid-19 pandemic pakistan doctors beaten by police as they despair of 'untreatable' pandemic china makes them, but has been hoarding them world health organization: shortage of personal protective equipment endangering health workers worldwide as coronavirus spreads, doctors fear for themselves -and their families nearly half of doctors fear for their health -survey psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital general hospital staff worries, perceived sufficiency of information and associated psychological distress during the a/h1n1 influenza pandemic covid-19 pandemic and its impact on mental health of healthcare professionals healthcare workers' willingness to work during an influenza pandemic: a systematic review and meta-analysis. influenza other respir viruses what hospitals and health care workers need to fight coronavirus protecting health care workers during the covid-19 outbreak: lessons from taiwan's sars response (epub only) compliance and knowledge of healthcare workers regarding hand hygiene and use of disinfectants: a study based in karachi world health organization: rational use of personal protective equipment for coronavirus disease ( covid-19) and considerations during severe shortages electronic personal protective equipment: a strategy to protect emergency department providers in the age of covid-19 key: cord-269826-l44xbgok authors: wills, timothy t.; zuelzer, wilhelm a.; tran, bryant w. title: utilization of an orthopedic hood as personal protective equipment for intubation of coronavirus patients: a brief technical report date: 2020-06-02 journal: geriatr orthop surg rehabil doi: 10.1177/2151459320930554 sha: doc_id: 269826 cord_uid: l44xbgok background: the novel coronavirus disease (covid-19) has afflicted millions of people worldwide since its first case was reported in december 2019. personal protective equipment (ppe) has been tailored accordingly, but as of april 2020, close to 10 000 health care workers in the united states have contracted covid-19 despite wearing recommended ppe. as such, standard guidelines for ppe may be inadequate for the health care worker performing high-risk aerosolizing procedures such as endotracheal intubation. in this brief technical report, we describe the integration of an orthopedic hood cover as an item for full barrier protection against covid-19 transmission. technical description: the coronavirus airway task force at virginia commonwealth university medical center approved this initiative and went live with the full barrier suit during the last week of march 2020. the ppe described in this report includes a stryker t4 hood, normally used in conjunction with the stryker steri-shield t4 helmet. instead of the helmet, the hood is secured to the head via a baseball cap and binder clip. this head covering apparatus is to be used as an accessory to other ppe items that include an n95 mask, waterproof gown, and disposable gloves. the motor ventilation system is not used in order to prevent airborne viral entry into the hood. discussion: an advantage of the full barrier suit is an additional layer of droplet protection during intubation. the most notable disadvantage is the absence of a ventilation system within the hood covering. conclusion: modification of existing ppe may provide protection for health care workers during high-risk aerosolizing procedures such as endotracheal intubation. although the integration of this medical equipment meets the immediate needs of an escalating crisis, further innovation is on the horizon. more research is needed to confirm the safety of modified ppe. the novel coronavirus disease (covid-19) was first reported in wuhan, china, in december 2019. 1, 2 since that time, the disease has afflicted millions of people worldwide. 3 with a mortality rate between 2.7% and 27.3% of the geriatric population in the united states, it has been more than 20 times more deadly than this season's influenza. 4 the primary route of viral transmission appears to be through respiratory droplets, although viral particles found within the path of hospital ventilation systems suggests that aerosolization of these particles makes covid-19 even more contagious. 5 only low-quality evidence exists regarding both covid-19 transmission and the necessary personal protective equipment (ppe) to protect health care workers from infection. 6 in fact, in a 2-month period between february and april 2020, close to 10 000 health care workers in the united states have contracted covid-19 despite wearing recommended ppe. 7 during endotracheal intubation, the risk of viral transmission through respiratory droplets increases by almost 7-fold. 8 a recent model demonstrated direct contamination of, among other surfaces, the laryngoscopist's neck and ears by droplet and aerosolized particles following a simulated patient cough. 9 as such, standard guidelines for ppe may be inadequate for the health care worker performing this procedure. we describe in a brief technical report the integration of an orthopedic hood cover as an item for full barrier protection against covid-19 transmission during endotracheal intubation. this project was initiated by the department of anesthesiology and department of orthopedic surgery at virginia commonwealth university medical center. after passing qualitative standards with a saccharin spray test, the institution's coronavirus airway task force approved its use and went live with the full barrier suit during the last week of march 2020. standard ppe for airborne precautions at our institution includes the following items ( in this brief technical report, we describe the redistribution of perioperative equipment to enhance the safety of health care workers during the covid-19 crisis. limited medical supplies have required physicians to provide innovative ideas at an unprecedented pace. an advantage of this full barrier suit is an additional layer of droplet protection during endotracheal intubation of coronavirus patients. moreover, ease of implementation was extremely important due to the exponential increase in intubation case volume. the absence of electronic or technological equipment allowed for timely acquisition of supplies. lastly, this outfit is intended for disposable single use only. this eliminates the need for a decontamination protocol associated with reused equipment. with the binder clip in place, the baseball hat is doffed easily and safely along with the hood. because of the outfit's simplicity, the most notable disadvantage of this full barrier equipment is the absence of a ventilation system within the orthopedic hood covering. as a result, body heat causes condensation in the clear hood window, and visibility can be reduced during an intubation procedure. accumulation of carbon dioxide within the hood is possible when worn for long periods of time. in normal circumstances, the hood covering can be comfortably worn for the duration of joint replacement surgery due to the movement of air provided by the fans within the stryker steri-shield t4 helmet apparatus. the ventilation system is not recommended in a covid-19 laden environment due to the lack of viral filtration when air is blown into the hood. moreover, the fan component cannot be reliably sterilized for reuse. an adapter using 3-dimensional printing technology may allow for the addition of a high-efficiency particulate air filter to the t4 helmet. data are currently being collected regarding the use of the described full barrier ppe. to date, this remains the anesthesiologists' "first-choice" for ppe at our institution and is being used for all covid-19 patients who require intubation from acute hypoxic respiratory failure. although there is theoretical concern for inadequate ventilation in the absence of a helmet and fan, our team consistently performs successful intubations in the hood covering without experiencing dizziness or shortness of breath. the addition of an orthopedic hood covering to standard ppe may provide protection for health care workers during highrisk aerosolizing procedures such as endotracheal intubation. although the integration of this medical equipment meets the immediate needs of an escalating crisis, there is certainly room for further innovation and improved versions of protective equipment. the implications of coronavirus disease management will be relevant for years to come and more research is needed to confirm the safety of modified ppe. a novel coronavirus from patients with pneumonia in china a novel coronavirus outbreak of global health concern world health organization. who (covid-19) homepage. 2020. covid19.who.int cdc covid-19 response team. severe outcomes among patients with coronavirus disease 2019 (covid-19)-united states transmission potential of sars-cov-2 in viral shedding observed at the university of nebraska medical center interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings. 2020. cdc.gov characteristics of health care personnel with covid-19-united states aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review barrier enclosure during endotracheal intubation authors' note t.t.w. designed, planned, and helped implement the personal protective equipment described in the report. he helped write and edit the manuscript. w.a.z. helped write and edit the manuscript. b.w.t. designed, planned, and utilized the personal protective equipment described in the report. he helped write and edit the manuscript. the author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: b.w.t. is a member of the editorial board for the geriatric orthopaedic surgery and rehabilitation journal. the author(s) received no financial support for the research, authorship, and/or publication of this article. timothy t. wills, md https://orcid.org/0000-0002-2379-5171 bryant w. tran, md https://orcid.org/0000-0002-1231-5611 key: cord-284374-sqxlnk9e authors: park, jiyeon; yoo, seung yeon; ko, jae-hoon; lee, sangmin m.; chung, yoon joo; lee, jong-hwan; peck, kyong ran; min, jeong jin title: infection prevention measures for surgical procedures during a middle east respiratory syndrome outbreak in a tertiary care hospital in south korea date: 2020-01-15 journal: sci rep doi: 10.1038/s41598-019-57216-x sha: doc_id: 284374 cord_uid: sqxlnk9e in 2015, we experienced the largest in-hospital middle east respiratory syndrome (mers) outbreak outside the arabian peninsula. we share the infection prevention measures for surgical procedures during the unexpected outbreak at our hospital. we reviewed all forms of related documents and collected information through interviews with healthcare workers of our hospital. after the onset of outbreak, a multidisciplinary team devised institutional mers-control guidelines. two standard operating rooms were converted to temporary negative-pressure rooms by physically decreasing the inflow air volume (−4.7 pa in the main room and −1.2 pa in the anteroom). healthcare workers were equipped with standard or enhanced personal protective equipment according to the mers-related patient’s profile and symptoms. six mers-related patients underwent emergency surgery, including four mers-exposed and two mers-confirmed patients. negative conversion of mers-cov polymerase chain reaction tests was noticed for mers-confirmed patients before surgery. mers-exposed patients were also tested twice preoperatively, all of which were negative. all operative procedures in mers-related patients were performed without specific adverse events or perioperative mers transmission. our experience with setting up a temporary negative-pressure operation room and our conservative approach for managing mers-related patients can be referred in cases of future unexpected mers outbreaks in non-endemic countries. high-volume healthcare facility, which is how the previous south korea outbreak occurred 11 . moreover, there may be very few hospitals that are prepared to provide perioperative care for mers patients. therefore, herein, we share our experience of providing infection prevention and control measures for surgeries for mers-related patients in our hospital. during the mers outbreak in our hospital, six mers-related patients underwent surgery including three possibly exposed patients, one directly exposed patient, and two mers-confirmed patients who recovered from the disease. all patients were negative during two preoperative mers screenings using real-time reverse transcription polymerase chain reaction (rrt-pcr) 14 . figure 1 shows the total number of surgeries performed during the outbreak period at our hospital and the distribution of mers-related patients undergoing surgery. temporary set-up of a negative-pressure operating room. the operating rooms in our hospital were generally positive-pressure environments, and we had no permanent negative-pressure operating rooms. because a negative-pressure operating room is the optimal environment to prevent airborne virus spreading to adjacent areas 13 , two of our 25 operating rooms in the main operating suite of the hospital were temporarily converted into negative-pressure operating rooms to perform surgical procedures on mers-related patients. operating rooms no. 16 and 17 were selected because they were connected to each other, but each room had separate atmospheric air inlets and exhaust systems. they also had separate air-conditioning and humidification systems. of the two connected rooms, one was used as the main operating room and the other was used as the anteroom where healthcare workers (hcws) applied and removed the personal protective equipment (ppe). in each room, fresh air was supplied from an inlet duct and discharged outside through the exhaust duct (fig. 2) . because a constant exhausting air volume was maintained through the outlet duct, negative pressure in the operating room was achieved by decreasing the inflow air volume that entered through the inlet duct. first, the blades of the air volume control damper in the inlet duct were closed as much as possible (fig. 2) . however, because the damper was not intended to be air-tight, the inflow volume to the operating room did not decrease sufficiently. second, as an additional measure to decrease the inflow volume, we opened the access hole in the inlet duct, which was originally used for duct inspection purposes (fig. 2) . finally, a smoke test was carried out to ensure negative pressure. the room pressure was maintained at −4.7 pa in the main operating room and at −1.2 pa in the anteroom (fig. 3) ; −4.7 pa is below the negative pressure room standard of −2.5 pa 15 . www.nature.com/scientificreports www.nature.com/scientificreports/ airflow in both rooms reached 14-18 air exchanges per hour, according to airflow velocity measurements with an anemometer (ebt731 balometer; tsi alnor ® , minnesota, united states). in this environment, removing airborne contaminants requires 18 minutes for 99% efficiency and 28 minutes for 99.9% efficiency 16 . therefore, 30 minutes of room ventilation was required after aerosol forming high-risk procedures, such as endotracheal intubation or extubation 12, 17 . the cleanliness level of each room was also measured using a particle counter (tsi 9310; tsi, united states): main operating room = 2,604 and the anteroom = 2,540, which were much lower than the institutional target level of <10,000 for general surgery (fig. 3) . cleanliness level was defined as the number of particles smaller than 0.5 µm in 0.3048 m 3 . equipment preparation and disinfection. all built-in instruments such as computers, telephones, and ventilators were covered with plastic paper. sufficient amounts of drugs, fluids, and other equipment were prepared in the operating room before surgery, and other unnecessary equipment was moved out. additionally, we used disposable equipment, when possible. high efficiency particulate air (hepa) filters were installed in the breathing circuits, both on the inspiratory and expiratory limbs of the ventilators and at the patient's site that connected to endotracheal tube. after operations with mers-exposed patients, 30 minutes of room ventilation was followed by surface disinfection with diluted chlorine bleach (500 ppm) 18, 19 . cleaners wore standard ppe while disinfecting surfaces. for mers-confirmed patients, surface disinfection was performed twice. institutional guidelines for perioperative management of mers-related patients. during the mers outbreak, we set the following principles for perioperative management of mers-related patients: all elective surgeries for mers-confirmed patients were postponed to reduce the risk of potential in-hospital transmission. for mers-exposed patients, surgical procedures were delayed until after the potential incubation period of 14 days 20 . when a mers-related patient required an urgent or emergency operation, mers-cov pcr tests were performed twice with distinct specimens preoperatively, to account for asymptomatic mers patients or delayed positive conversion in symptomatic mers-exposed patients. for patients with ambiguous pcr results or without a pcr test, operations were performed according to the management guidelines for mers-confirmed patients. all the surgical procedures for mers-related patients were performed in the last order of the day as possible. perioperative protection level for hcws. when an operation for a mers-related patient was scheduled, the division of infectious diseases and infection control department confirmed the protection level of the hcws, according to institutional guidelines (table 1 ). in principle, standard ppe was applied to hcws who cared for asymptomatic mers-exposed patients. standard ppe includes surgical gloves, surgical gowns, eye shields, and n95 respirators. while managing mers-confirmed or mers-exposed patients with mers-associated symptoms including fever, myalgia, respiratory symptoms, or diarrhea, hcws implemented enhanced ppe, which included coverall clothes with head cover, shoe covers, goggles, two pairs of surgical gloves, and powered air purifying respirator (papr) or n95 respirators. although we performed preoperative mers-cov pcr screening, enhanced ppe was still recommended when managing symptomatic mers-exposed patients regardless of their pcr results. anesthesiologists were recommended to apply enhanced ppe (including papr from the middle of the outbreak) when managing all mers-related patients because they were most directly exposed to the aerosol-producing high-risk procedures, such as endotracheal intubation and extubation. only minimal numbers of hcws were present in the operating room. institutional education regarding the precise use of ppe was provided to the all associated hcws and they were assisted by skilled nurses in the operating room during the ppe donning and doffing processes. patient transfer for operation. mers-related patients were transferred directly to the negative-pressure main operating room through an exclusive path and elevator by a physician wearing proper ppe. the walls and the floor of the passageways and the elevator were covered with plastic paper. mers-related patients wore a www.nature.com/scientificreports www.nature.com/scientificreports/ surgical mask during transfer. because only anesthesiologists wore enhanced ppe when in proximity to asymptomatic mers-exposed patients, 30 minutes of room ventilation was performed after anesthetic induction, including endotracheal intubation. the surgical team then entered the main operating room through the anteroom. in the cases of symptomatic mers-exposed patients or mers-confirmed cases, all hcws wore enhanced ppe and the 30-minute ventilation time was not required. after completion of operation procedures, patients who were moved to the general ward recovered in the main operating room without going through the post-anesthesia care unit. thirty minutes of room ventilation was performed after tracheal extubation. a physician in the main operating room sent the patient into the corridor, while the other physician outside the main operating room wearing ppe took over and transferred the patient to the general ward directly through the exclusive pathway (fig. 4) . patients moving to the intensive care unit (icu) were transferred while remaining intubated. before transfers, we injected patients with a sufficient amount of intravenous muscle relaxant and sedative drugs to prevent coughing or movement and we applied a portable ventilator or bag-valve mask with a hepa filter to the patient. operations for six mers-related patients. the details of the six mers-related patients undergoing surgery are presented in table 2 . two patients had operations during phase 1 and four patients during phase 2 of the outbreak (fig. 1) . the negative-pressure operating room was set up to be used from phase 2. regarding ppe levels for the hcws attending these six patients, standard ppe was applied during management of patient a (asymptomatic mers-exposed patient), while anesthesiologists wore enhanced ppe for high-risk procedures (tracheal intubation). enhanced ppe was applied to hcws for patient b because the patient was symptomatic and still within the two-week incubation period, even though both pcr results were negative. enhanced ppe, including papr to reduce risk of mers-transmission, was applied for patient c who underwent surgery in the middle of the outbreak (phase 2). papr provides more perfect sealing and protection of the head surface. patients d and e had documented mers-cov infection and their recovery was confirmed with symptom resolution and two negative mers-cov pcr tests. however, enhanced ppe with papr was applied to hcws because the infection risk could not be eliminated during exposure to a large amount of body fluid, especially during cesarean section (patient d). after spinal anesthesia, she recovered in the main operating room and was transferred directly to the general ward. patient f had a history of exposure to a mers patient in the emergency room and was isolated due to a fever. enhanced ppe was applied to the hcws for patient f and she underwent surgery with only one set of negative pcr results because of her emergency condition. mers, as well as sars, is associated with coronaviruses, both of which have high affinity for the lower repiratory tract and easily produce severe pneumonia [21] [22] [23] [24] [25] . although mers has lower human-to-human transmission potential and has resulted in fewer large outbreaks than sars, there may be occasional amplification of clusters in healthcare settings [21] [22] [23] . moreover, mers case fatalities are reported to be much higher than sars (35-45% for mers and 10-15% for sars) 12, 17, 23, 24, 26 . unlike sars, ongoing small and large mers outbreaks in the arabian peninsula foster potential future mers outbreaks in non-endemic countries. however, there is likely to be a very limited number of hospitals that are prepared with negative-pressure operating rooms, except for a few hospitals in hong kong that experienced the 2003 sars outbreak 13 . almost all hospitals generally have positive-pressure operating rooms and they may experience an outbreak without facilities that are prepared for perioperative management of mers patients, as our hospital did in 2015. one of the highlights of our experience during the outbreak was the temporary set-up of a negative-pressure operation room with an adequate pressure gradient (≥2.5 pa) by modifying two connected operating rooms according to us centers for disease control and prevention (cdc) guidelines 15 . continuous negative pressure was maintained in the main operating room (−4.7 pa) and the anteroom (−1.2 pa). this temporary setting was possible because the two adjacent rooms had separate atmospheric air inlets and exhaust systems. although we could not measure the airflow pattern or dispersion of infectious particles directly 27 , the cleanliness levels in both operating rooms were 2,500 particles, well below the institutional target cleanliness for general surgery (<10,000 particles). although the precise route of mers-virus transmission is currently not clearly understood 21 , mers, as well as sars, is known to spread by direct contact with infectious material, such as large respiratory droplets, and also by airborne routes 28, 29 . touching contaminated objects may also be a source of transmission; this is different from tuberculosis, which is transmitted by airborne routes 19, 29 . therefore, when performing procedures that generate aerosols, such as endotracheal intubation, in patients with mers or sars, hcws must wear enhanced ppe, including gloves, a gown, either a face-shield that fully covers the front and sides of the face or goggles, and respiratory protection at least as protective as an n95 filtering face piece respirator 19, 28, 30 . when removing ppe, care should also be taken not to contact contaminated materials. considering potential aerosol generation in operating rooms and the transmission risk of mers-cov while changing ppe, the temporary modification of an operating room to a negative-pressure room with an anteroom should provide suitable protection for hcws participating in operations on mers-related patients 5 . a second highlight of our experience is the highly conservative application of ppe to hcws. at the time of the outbreak, there were no specific guidelines for perioperative management 31 . therefore, we used a conservative approach based on our experience and previous reports. first, although the previous guidelines recommended that asymptomatic mers-exposed patients be managed as general patients undergoing surgery, we applied standard ppe to hcws and we performed mers-cov pcr screening twice. although mers progressed gradually after symptom onset 32 , we could not exclude the possibility that asymptomatic mers-exposed patients had the potential to develop symptomatic disease perioperatively. moreover, we observed development of mers after the known incubation period of 14 days in an immunocompromised host 10, 33 ; thus, the possibility of exceptional cases could be considered. furthermore, a certain proportion of asymptomatic mers-exposed patients could actually be asymptomatic mers-infected patients. approximately 21% of laboratory confirmed mers patients have been classified as asymptomatic or having nonspecific mild symptoms at the time of testing 34 . the potential for transmission from asymptomatic mers-cov pcr-positive person is currently unknown, but there are reports about prolonged viral rna detection in the upper respiratory tract in asymptomatic pcr-positive person 9 . considering these points, it would be reasonable to prepare more conservatively than the existing guidelines call for. www.nature.com/scientificreports www.nature.com/scientificreports/ another point on which our preparations differed from the guidelines was the application of enhanced ppe, which emphasizes full protection of the body surface with a hooded coverall. during the outbreak in our hospital, mers transmission events occurred among hcws who were equipped with standard ppe, including n95 masks. transmission may have occurred after possible contamination of uncovered head or face surfaces 35 . therefore, if a patient with a mers contact history had mers-associated symptoms, applying enhanced ppe (either a n95 respirator or papr) during surgery would be appropriate for hcws because numerous droplets and aerosols may be produced during airway interventions. because the n95 may fit inadequately if worn for a long time or after movement during surgery, wearing papr will be more beneficial. however, unlike hcws dealing with ebola virus, impermeable and fluid-resistant gowns are not required because body fluids are not infectious as with ebola virus diseases 9, 28, 35, 36 . our experience was limited in that, as a mers outbreak outside the endemic country, we did not have an opportunity to perform surgical procedures in actively virus-shedding mers-infected patients. additionally, our infection-prevention protocols would be too conservative to apply in mers-endemic situations. however, considering the potential risk of infected hcws, preventing mers transmission is extremely important in the management of a mers outbreak. importantly, our experience can be generalized to other non-endemic countries for managing potential outbreaks of emerging respiratory diseases. in the era of globalization, a mers outbreak can occur in any country outside the middle east. a very limited number of hospitals are equipped with negative-pressure operating rooms, and therefore, most hospitals are likely to experience a mers or other outbreak in an unprepared circumstance. we hope that this report will help other hospitals in preparing for future mers outbreaks and infection control in unexpected conditions. this study was based on all available data at the samsung medical center from the mers outbreak and on interviews with hcws associated with the outbreak. the study was approved by samsung medical center institutional review board. the documents for review included electronic medical records of mers-related patients who underwent operative procedures and institutional guidelines for perioperative management of mers-related surgical patients. the mers guidelines were prepared through multidisciplinary team discussions that were held by our hospital's infection control department during and after the mers outbreak. the records about the temporary set-up of a negative-pressure operating room were also reviewed. we also collected data through interviews with hcws who participated in surgery and anesthesia for mers-related patients. we defined mers-related patients as those who were possibly or directly exposed to mers or who had a previously confirmed mers diagnosis 10 . in brief, patients who had a potential but unconfirmed close contact history with a mers patient were defined as possibly exposed patients, and they were allowed to continue their normal activities until mers-like symptoms developed. directly exposed patients included those who had close contact with a known mers patient and who did not wear proper ppe; these patients were isolated in their homes or in private negative-pressure rooms at our hospital. because the number of mers-infected patients continuously increased at our hospital, we partially closed the hospital on june 13 10 , at which point outpatient-care clinics were closed and the emergency department was only available for life-threatening emergencies. all elective surgeries were postponed if possible 10 . we defined the early phase of the outbreak (before june 13) as phase 1 and the middle phase of the outbreak (from june 13) as phase 2. for mers-cov pcr tests, either sputum or nasopharyngeal swab samples were collected and sputum samples were preferred if available 14 . sputum was collected directly into a sterile, leak-proof, screw-capped sputum collection sterile container and nasopharyngeal swab was collected with an eswab (482 c, copan diagnostics inc., murrieta, ca, usa). clinical samples were screened by rrt-pcr testing with amplification targeting the upstream e region (upe) and confirmed by subsequent amplification of the open reading frame (orf)1a using powerchek ™ mers real-time pcr kits (kogene biotech, seoul, korea). all rrt-pcr reactions were performed using the 7500 fast real-time pcr system (applied biosystems, foster city, ca, usa). the pcr reaction was performed in a total volume of 20 μl (15 μl pcr reaction mixture and 5 μl template rna). thermocycling conditions included a step at 50 °c for 30 min, followed by 95 °c for 10 min and then 40 cycles of 15 s at 95 °c and 60 s at 60 °c. positive viral template control and no-template control were included in each run. the glyceraldehyde-3-phosphate dehydrogenase (gapdh) gene was amplified simultaneously as a heterologous internal control to monitor pcr inhibition. a positive test result was defined as a well-defined exponential fluorescence curve that crossed the cycle threshold (ct) < 35 cycles for both upe and orf1a. a sample was considered "equivocal" if the upe result was positive but the ct value for orf1a was >35 and <40. we interpreted the result as "indeterminate" if (1) the upe result was positive but the ct value for orf1a was undetected or if (2) the ct value for upe was >35 and <40. institutional review board statement. the study was performed in accordance with the declaration of helsinki and experimental protocols were revised and approved by irb at samsung medical center. (irb no. smc 2016-08-156-002). informed consent statement. irb at samsung medical center has approved the waiver of patient consent form because of the retrospective nature of this study. patient confidentiality is maintained at all time in accordance with samsung medical center policies. middle east respiratory syndrome: new disease, old lessons isolation of a novel coronavirus from a man with pneumonia in saudi arabia contact investigation for imported case of middle east respiratory syndrome enhanced mers coronavirus surveillance of travelers from the middle east to england laboratory-confirmed case of middle east respiratory syndrome coronavirus (mers-cov) infection in malaysia: preparedness and response first confirmed cases of middle east respiratory syndrome coronavirus (mers-cov) infection in the united states, updated information on the epidemiology of mers-cov infection, and guidance for the public, clinicians, and public health authorities family cluster of middle east respiratory syndrome coronavirus infections euro surveillance: bull. europeen sur les. maladies transmissibles = european communicable dis ebola virus disease: an update for anesthesiologists and intensivists control of an outbreak of middle east respiratory syndrome in a tertiary hospital in korea mers-cov outbreak following a single patient exposure in an emergency room in south korea: an epidemiological outbreak study infection control measures for operative procedures in severe acute respiratory syndrome-related patients conversion of operating theatre from positive to negative pressure environment importance of specimen type and quality in diagnosing middle east respiratory syndrome guidelines for environmental infection control in health-care facilities. recommendations of cdc and the healthcare infection control practices advisory committee (hicpac) guidelines for preventing the transmission of mycobacterium tuberculosis in health-care settings infection control and anesthesia: lessons learned from the toronto sars outbreak effects of environmental disinfection on the isolation of vancomycin-resistant enterococcus after a hospital-associated outbreak of middle east respiratory syndrome middle east respiratory syndrome infection control and prevention guideline for healthcare facilities surveillance for human infection with middle east respiratory syndrome coronavirus (mers-cov), interim guidance severe acute respiratory syndrome vs. the middle east respiratory syndrome mers coronavirus: diagnostics, epidemiology and transmission transmission characteristics of mers and sars in the healthcare setting: a comparative study middle east respiratory syndrome lung pathology of severe acute respiratory syndrome (sars): a study of 8 autopsy cases from singapore middle east respiratory syndrome coronavirus in healthcare settings infection prevention and control of epidemic-and pandemic-prone acute respiratory infections in health care, who guidelines guidance on personal protective equipment (ppe) to be used by healthcare workers during management of patients with confirmed ebola or persons under investigation (puis) for ebola who are clinically unstable or have bleeding, vomiting, or diarrhea in u.s. hospitals, including procedures for donning and doffing ppe, page last reviewed on august 30 guidelines for preventing the transmission of mycobacterium tuberculosis in healthcare settings infection prevention and control during health care for probable or confirmed cases of middle east respiratory syndrome coronavirus (mers-cov) infection, interim guidance predictive factors for pneumonia development and progression to respiratory failure in mers-cov infected patients atypical presentations of mers-cov infection in immunocompromised hosts management of asymptomatic persons who are rtpcr positive for middle east respiratory syndrome coronavirus (mers-cov), interim guidance serologic evaluation of mers screening strategy for healthcare personnel during a hospital-associated outbreak surgical protocol for possible or confirmed ebola cases anesthetic implications of ebola patient management: a review of the literature and policies j.p. this author helped with data collection, data analysis, writing of the first draft and revision of the manuscript, and archiving of the study files. s.y.y. this author helped with data analysis, discussion of results, writing and revision of the manuscript, archiving of the study files and approval of final version. j. the authors declare no competing interests. correspondence and requests for materials should be addressed to k.r.p. or j.j.m. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons license, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/. key: cord-318944-13zk6cco authors: bizzoca, maria eleonora; campisi, giuseppina; lo muzio, lorenzo title: covid-19 pandemic: what changes for dentists and oral medicine experts? a narrative review and novel approaches to infection containment date: 2020-05-27 journal: int j environ res public health doi: 10.3390/ijerph17113793 sha: doc_id: 318944 cord_uid: 13zk6cco the authors performed a narrative review on severe acute respiratory syndromecoronavirus-2 ( sars-cov-2) and all infectious agents with the primary endpoints to illustrate the most accepted models of safety protocols in dentistry and oral medicine, and to propose an easy view of the problem and a comparison (prevs post-covid19) for the most common dental procedures. the outcome is forecast to help dentists to individuate for a given procedure the differences in terms of safety protocols to avoid infectious contagion (by sars-cov-2 and others dangerous agents). an investigation was performed on the online databases pubmed and scopus using a combination of free words and medical subject headings (mesh) terms: “dentist” or “oral health” and “covid-19” or “sars-cov-2” or “coronavirus-19”. after a brief excursus on all infectious agents transmittable at the dental chair, the authors described all the personal protective equipment (ppe) actually on the market and their indications, and on the basis of the literature, they compared (before and after covid-19 onset) the correct safety procedures for each dental practice studied, underlining the danger of underestimating, in general, dental cross-infections. the authors have highlighted the importance of knowing exactly the risk of infections in the dental practice, and to modulate correctly the use of ppe, in order to invest adequate financial resources and to avoid exposing both the dental team and patients to preventable risks. the era of corona-virus-disease-19 is an important historical period from various points of view, from the world health to the huge cascade of socio-economic implications. everyday habits have been turned upside down, and the way of life of people all over the globe, engaged in all activities, especially in the health sector, will be involved in this necessary change. dentists, being in close contact with the patient's droplets and aerosols generated, have to revise the operating protocols to protect the team and the patients from the risk of infectious diseases. unfortunately, the pandemic covid-19 will not stop immediately and everyone will have to face each other very long working and social recovery times of the population. in this time, a large part of the population will avoid dental treatment other than those imposed by pain or urgency, both due to money issues and, principally, for a psychological reason: it will not be easy to overcome the fear of infection. for many, the dental practice is a source of possible infections, considering that the first person at risk is the dentist himself. the scenario in dental practices is very complex and several problems can arise which are dangerous for the dental practice [1] [2] [3] [4] [5] [6] [7] [8] [9] . for an infection to emerge, it is necessary that an adequate number of specific microorganisms can infect a person or groups. the classic contamination paths clearly incorporate all the dental unit (team and patient): body fluids in direct contact with the wound site during operation, injuries of the skin and the mucosa with sharp objects, body fluids and contaminated material contact with eyes, aerosols arising during the operation with air produced by turbine and ultrasonic devices, contamination via droplet, and surgical smoke formed during electro-cautery or laser applications [10, 11] . the first problem raised with respect to covid-19, is related to the easy spread of viral agents in the air during dental procedures [12] [13] [14] [15] . hence, aerosol is the most aggressive source of covid-19 as well as other viral infections, placing dentists and their collaborators at the first line of the exposure to risk scale within the context of healthy personnel [10, 16] . the second problem is related to the persistence of the biological agent in operating rooms. the aerosol produced by high rotation instruments and ultrasound could remain for several hours in the air and on the surfaces [17, 18] . although it can save the operator, if well protected, during the therapeutic acts, it means that the air will be contaminated, thus presenting a risk for operators after removing the ppe (personal protective equipment) and for the next patients. this covid-19 pandemic has shown that several people can be positive and spread the viral agents around without any symptoms or signs of biological agents. so, the dental team, a part performing the double triage [1] , should consider each patient as sars-cov-2 positive until proven otherwise and use protective equipment in order to preserve their own health and the health of all patients as attending the dental office. for these reasons, it is necessary to use rigid and precise operating protocols capable of classifying dental procedures based on risks for the team as well as for the patients. this study was born from the awareness of a necessary change in decision making processes. it involves a rereading of relevant literature in order to build protocols addressed to dentists, to assess and modulate the risks of contagion in the dental practice. moreover, it proposes, on the basis of information from literature, a classification of dental procedures based on the risk of contagion of infectious agents, showing what will change for the dentist and the oral medicine expert. an investigation was performed on the online databases pubmed and scopus using a combination of free words and mesh terms: "dentist" and "covid-19" or "sars-cov-2" or "coronavirus-19", and "oral health" and "covid-19" or "sars-cov-2" or "coronavirus-19". only studies fulfilling the following inclusion criteria were considered eligible for inclusion in this study: (i) performed on human subjects, (ii) written in the english language, and (iii) published in 2019-2020. the manuscript titles list was highlighted to exclude irrelevant publications and search errors. the final selection was performed by reading the full texts of the papers in order to approve each study's eligibility based on sars-cov-2 and other infective agents involved in dentistry. data selection and revision was performed by two independent reviewers (meb, university of foggia and gc, university of palermo). they singularly analysed the papers, and in agreement, included 142 papers in this narrative review. the authors, in consideration of the importance of the emerging topic, decided to include also guidelines, online documents, reviews, experts' opinions, renouncing the prisma-related design of regular systematic reviews ( figure 1 ). after a brief excursus on all possible infectious agents, the authors described, on the basis of the literature selected, all personal protective equipment (ppe) actually on the market and their indications. then, they compared (before vs after covid-19 era) the correct safety procedures for each dental practice selected, underlining the danger of underestimating, in general, dental cross infections, if focused only on the newest sars-cov-2. results are summarised in tables 1-8. different classes of bacteria, viruses, and fungi can cause human infections. three factors are important for the transmission of these infectious agents: an infectious agent, a receptive subject and a transmission mode. the pathogens involved in infections during health care mainly derive from staff, from patients (and possible careers), but also from inanimate environmental sources ( figure 2 ). these human sources can: 1) have active infections, 2) be asymptomatic or in an incubation period, or 3) be colonized transiently or chronically with pathogen microorganisms. the infection is the consequence of the contact between a contagious agent and a potential host. moreover, the same characteristics of the host can influence the onset and the severity of the infectious disease. however, several other factors can modify the virulence and behavior of infectious disease such as the number of infectious agents, the transmission way and the pathogenicity [19] . predictors of the disease evolution in a specific subject could be: immune status at exposition time, age, comorbidity, and virulence of the agent [20] . there are two main ways of infective transmission, namely vertical (from mother to fetus: transplacental, during vaginal birth or breast feeding) and horizontal (sexual and non-sexual). in a dental setting, infectious agents are transmitted in the horizontal, non-sexual route [21] . in the non-sexual horizontal transmission, direct or indirect contact (e.g., herpes simplex virus, respiratory syncytial virus, s. aureus), droplets (e.g., influenza virus, b. pertussis) or airways (e.g., m. tuberculosis) are possible routes. other viruses can be transmitted by the blood (e.g., hepatitis b and c viruses and hiv) via percutaneous or mucous membrane exposure [3, 4, 14, 22] . in synthesis, the three main routes of the transmission are [23] : contact transmission: contact transmission can be through direct contact and indirect contact. during direct contact transmission, pathogens are transmitted from an infected person to another subject without an intermediate object or person (for example, mucous membrane or breaks contact blood or other blood-containing body fluids infected, or contact hsv lesion without gloves) [3, 4, 14, 15, 18, 22, 24, 25] . during indirect contact transmission, pathogens are transmitted to the host through objects or human body carrying those pathogens [17, 18, 22, [26] [27] [28] [29] [30] . moreover, all the personal protective equipment (ppe), such as uniforms or isolation gowns, can be contaminated by infectious agents during the treatment of a patient colonized or infected. • droplet transmission: some infectious agents can reach the host through the direct and indirect contact routes or through droplets [3, 15, [31] [32] [33] . droplets can carry infectious pathogens travelling for short distances directly from the respiratory tract of the infectious subjects to host reaching susceptible mucosal surfaces [3, 15, [31] [32] [33] . respiratory droplets are produced during coughs, sneezes, or talks [34] or by airway health procedures. the nasal mucosa, conjunctivae, and mouth are good portals for respiratory viruses [35] . to date, the maximum distance that a droplet can reach is not known, even if pathogens transmitted by a droplet do not run across long distances [19] . the size of droplets has traditionally been defined as being >5 µm [19] . several types of droplets, including those with diameters of 30 µm or greater, can remain suspended in the air [36] . the sizes of the droplets can determine the maximum distance reached: largest droplets, between 60 and 100 microns, totally evaporate before spontaneously falling 2 m away [37] . for respiratory exhalation flows, the critical factor is the exhalation air velocity: these droplets are carried more than 6 m away by exhaled air at a velocity of 50 m/s (sneezing), more than 2 m away at a velocity of 10 m/s (coughing), and less than 1 m away at a velocity of 1 m/s (breathing) [37] . airborne transmission: this means of transmission consists of dissemination of airborne droplet or small particles containing infectious pathogens that remain infective over time and distance (e.g., spores of aspergillus spp., and m. tuberculosis) [31, 33, [38] [39] [40] [41] [42] . several infectious agents can involve dentist and his team [10] (table 1) . • sars-cov-2 determines covid-19 (coronavirus disease 2019), an infectious disease characterized by several important systemic problems such as coronavirus associated pneumonia. the principal symptoms are fever, cough, and breathing difficulties; the most patients have mild symptoms, some progress to severe pneumonia [43] . the diagnosis is performed with the identification of the virus in swabs of patient throat and nose. covid-19 can involve the respiratory tract determining a mild or highly acute respiratory syndrome due to the production of pro-inflammatory cytokines, such as interleukin (il)-1beta and il-6 [44] . one mechanism that can make the coronavirus lethal is the induction of interstitial pneumonia linked to an over-production of il-6 [44, 45] . based on this principle, several researchers have started to use an anti-arthritis drug, tocilizumab, for its anti-il-6 action [46] [47] [48] [49] . herpes simplex virus (hsv) can determine a primary infection with minor, ulcerative lymphadenopathy gingivostomatitis [50] and a recurrent infection with cold sores. herpetic whitlow, an hsv infection of the fingers is usually caused by direct contact of the same fingers with infected saliva or a herpetic lesion [51] [52] [53] . skin, mucosal lesions, and secretions such as saliva can determine the transmission [54, 55] . lesions are usually characterized by vesicles and sequent crusting. acyclovir can be used for the treatment of the diseases. it is sufficient to wear gloves in order to avoid the herpetic whitlow when the clinician treats patients with hsv lesions [10, 56] . • varicella zoster virus (vzv) can determine chickenpox (primary disease), usually in children, and shingles, which is very painful (secondary disease), for the reactivation of a virus residing in sensory ganglia during the latency period [57] [58] [59] . chickenpox disease is highly contagious and spreads via-airborne routes [60] [61] [62] . the virus can infect nonimmune dental team via inhalation of aerosols from a patient incubating the disease. masks and gloves can be not sufficient for complete protection of the healthcare workers [10] . [77] . it is present in saliva and could infect susceptible subjects via direct contact or aerosols [78] . human t-lymphotropic virus is involved in adult t cell leukaemia and spastic paraparesis. this virus can be transmitted through blood [79] [80] [81] [82] and, in a dental setting, it can infect via sharp instruments injuries [10] . hepatitis b virus (hbv) causes acute hepatitis and it is an important risk-agent for the health care staff [83, 84] . the possible ways of transmission are sexual intercourse, through blood, contaminated material injuries, and perinatal way [85] [86] [87] [88] . so, all operators of the dental team should be vaccinated [10, 89] . hepatitis c virus (hcv) causes "non-a" and "non-b" hepatitis and it is transmitted like hbv [85] [86] [87] 90] . the primary infection is often asymptomatic and the most of infected subjects become carriers of the virus with risk of development of chronic liver disease that could evolve in hepatocellular carcinoma [10] . human immunodeficiency virus (hiv) infects the immune system of susceptible subjects, t-helper cells particularly. it can be transmitted like hbv (sexual intercourse, blood borne and perinatal ways) [91, 92] . moreover, this infection have oral manifestations that can help in diagnosis: e.g., oral candidiasis, oral hairy leukoplakia, oral necrotising ulcerative gingivitis and oral kaposi's sarcoma [10, [93] [94] [95] [96] . • cytomegalovirus (cmv) is part of the herpes virus family and can cause diseases with several manifestations [97] . mumps virus is part of the paramyxoviridae group. this pathogen often affects the parotid glands, and the consequently characteristic symptom is swelling of these salivary glands [98] . moreover, this virus can cause inflammation of the ovaries, testis, pancreas or meninges with several complications. after the introduction of the vaccine against measles, mumps, and rubella (mmr), mumps incidence has decreased, even if several mumps cases have recently been reported [99] . • mycobacterium tuberculosis causes tuberculosis and is a bacterium transmitted by inhalation, ingestion and inoculation. the main symptoms are cervical lymphadenitis and lung infections. in order to prevent infection, the dental team should be adequately vaccinated and wear ppe [100] [101] [102] [103] [104] [105] . this bacterium is resistant to chemicals and, for this reason, sterilization and disinfection protocols must be rigorously performed [10] . • legionella spp. is a gram-negative bacterium that causes legionellosis and generally it resides in water tanks. legionellosis occurs with pneumonia, sometimes lethal in older people. since this pathogen lives in water, it can be easily transmitted during dental procedures through aerosols from incorrectly disinfected water circuits [106, 107] . in fact, water circuits that remain unused for long periods of time should be checked regularly to prevent legionella bacteria from residing [106, 107] . • treponema pallidum causes syphilis and dental team must wear gloves in order to adequate protect themselves [10, 108] . meningococcal spp. are gram-negative bacteria. they are located on the nasopharyngeal mucosa and their presence is generally asymptomatic. the bacterium is easily transmitted, especially during adolescence, when people get together. as already mentioned, colonization of the nasopharynx is common, and while the resulting disease is rare, at times, it can cause death or permanent disability [109, 110] . staphylococcus aureus is an important agent involved in nosocomial infections. this bacterium causes a wide range of diseases that can be mild or life-threatening (e.g., bacteraemia, pneumonia, and surgical site infection [111] ). in addition, s. aureus can easily have antimicrobial resistance. this bacterium principally resides on the epithelium of the anterior nares in human beings [112] . group a streptococcus (gas) is a gram-positive, beta-haemolytic bacterium. this pathogen is responsible for several diseases in human beings, such as acute pharyngitis, impetigo and cellulitis. it can also cause serious invasive diseases such as necrotizing fasciitis and toxic shock syndrome (tss) [113] [114] [115] . the bacterium mainly resides in human nose, throat and on skin and it is often transmitted without symptoms [116] [117] [118] . obviously, asymptomatic subjects are less contagious than the symptomatic carriers of this bacterium. gas is transmitted through respiratory droplets spread in the air, for example during coughing, sneezing and nasal secretions [117, 118] . in addition, this bacterium can spread through close interpersonal contact during a kiss, using the same dishes and sharing the same cigarette. streptococci mutans mainly colonize dental surfaces after tooth eruption and is associated to the development of caries [119] . this bacterium may be transmitted horizontally between children during the initial phases of the s. mutans colonization in nursery environments [120] . there is scientific evidence of vertical transmission of s. mutans from mother to child [121] . • some periodontal bacteria (e.g., a. actinomycetemcomitans, p. gingivalis) are considered person-to-person transmitted, but it is still unclear if transmission is governed only by domestic pathways, without definitive implications for the dental office. vertical transmission of a. actinomycetemcomitans is between 30% and 60%, while that of p. gingivalis is rarely observed. horizontal transmission ranges from 14% to 60% for a. actinomycetemcomitans and between 30% and 75% for p. gingivalis [122] . certainly, by understanding the spread mechanisms of these bacteria, it would also be possible to prevent a number of systemic diseases [123] . the dental team must adapt several precautions to avoid these infections; an adequate training and information of the personnel is mandatory in order to control infections in the dental office. the individual protection methods include a series of enforcement with the aim to reduce the risks of contamination, unfortunately without being able to eliminate them. the basic principle of infection control is to approach to each patient as if he was an infected patient (by one of the main microbes listed above) and to correctly carry out the protection methods [124] . adequate personal protective equipment (ppe) must be selected based on a risk assessment and the procedure to be performed. the precautions for infection control require wearing gloves, aprons, as well as eye and mouth protection (goggles and mask, such as medical masks and filtering face piece or fpp) for each procedure involving direct contact with the patient body fluids. whenever possible "single use" or "disposable" equipment should be used [10] (table 2) . if the necessary precautions are not taken, it is inevitable that operators can become infected through contact of the mucous membranes with blood, saliva, and aerosols from a potentially infective patient [10] . in healthcare setting, masks are used in order to: protect personnel from contact with patient infectious material; 2. protect patients from infectious agents carried by healthcare workers; 3. limit the potential spread of infectious respiratory aerosol between patients [19] . masks can be worn with goggles in order to protect mouth, nose and eyes, or with a face shield to provide more complete face protection. we must distinguish masks from particle respirators that are used to prevent inhalation of small particles which may contain infectious agents transmitted through the respiratory tract. the mouth, nose, and eyes are sensitive portals to the entry of infective pathogens, such as skin cuts. medical masks: • could be flat or pleated (some are like cups) and fixed to the head with straps or elastic bands; • does not offer complete protection against small particle aerosols (droplet nuclei) and should not be used during contact with patients with diseases caused by airborne pathogens; • they are not designed to isolate the face and therefore cannot prevent inhalation by the health personnel wearing them; • they must be replaced if wet or dirty. there are no standards that evaluate the efficiency of the medical mask filter. aorn (association of peri-operative registered nurses) recommends that medical (surgical) masks filter at least 0.3 µ particles or have a bacterial filtration efficiency of 90%-95% [126] . surgical masks (sm) are used to prevent that large particles (such as droplets, sprays or splashes), containing pathogens, could reach nose and mouth [127] . although their purpose is to protect patients from healthcare professionals (and healthcare team from patients) by minimizing exposure to saliva and respiratory secretions, they do not create a seal against the skin of the face and therefore are not indicated to protect people from airborne infectious diseases. masks are available in several shapes (modeled and unprinted), dimensions, filtration efficiency and attachment method (ribbons, elastic through the ear). masks are disposable and must be changed for each patient. instead, during the treatment of patients with respiratory infections, particulate respiratory masks must be worn. particulate respirators (with filtering percentage) in use in various countries include: [126] . ffp2 european respirators are comparable to n95, and they are indicated for prevention of infectious airborne diseases. however, ffp3 respirators offer the highest level of protection against infectious agents and are the only ffp class accepted by the health and safety executive (hse) as regards the protection in the healthcare environment in the united kingdom [126] . the powered air purifying respirator is also considered a standard part of ppe in certain situations, including aerosol generation procedures in high risk environments. in the event of a pandemic infection, any aerosol generation procedure on infected patients should only be carried out with an ffp3 respirator. non-urgent procedures should be postponed until the infection resolves. in the us, the national institute for occupational safety and health (niosh) defined the following particulate filter categories in 2011, in title 42 code of federal regulations, section 84 (table 3) . there are several models of ffp2 and ffp3 respirators, both with valves and without valves. however, this is not a filter but a valve that regulates the flow of air at the outlet and therefore makes it easier to exhale. therefore, these masks are designed to be able to filter very well the air that comes in the mouth, nose, and lungs of those who wear them. instead, these masks are not designed specifically to prevent the wearer from infecting someone else with their own breathing. in practice, if a mask has a valve, it can let out particles, even if it manages to block almost all the inlet ones. and therefore, a healthy person can use it effectively so as not to get infected. for a sick person or one who could be contagious, however, using it could infect others by letting germs pass from their breath outwards. it is important to say that there is no specific test that has been done to verify the possibility that the virus spreads from an infected person passing through a mask equipped with a valve [128] . surgical masks, on the other hand, are similar in both directions. they have been designed to prevent healthcare workers and surgeons in particular from infecting their own breath with patients, who may have open wounds on the operating table, but also work to protect the healthcare staff themselves against a potentially contagious person. their effectiveness, however, is much lower also because they do not prevent the breath from spreading and allow a lot of air to pass through and to the mouth and nose [128] . the choice of individual eye protection devices (such as goggles or face mask) varies according to the exposure circumstances, other ppe worn. and the need for personal vision [10] . in order to protect the eyes, eyeglasses and contact lenses are not considered suitable [129] . eye protection must be effective but at the same time comfortable and allow sufficient peripheral vision. there are different measures that improve the comfort of the glasses, for example anti-fog coating, different sizes, the possibility of wearing them on prescription glasses. although they provide adequate eye protection, glasses do not protect from splash or spray the other parts of the face. disposable or sterilizable face shields can be used in alternative to glasses. face shield protects the other areas of the face besides the eyes (glasses only protect the eyes). the face shields that extend from the chin to the forehead offer better protection of the face and eyes from spray and splashes [83] . the removal of a facemask, goggles, and mask can be safely performed after removing dirty gloves and after performing hand hygiene. gowns and coveralls are additional personal protective equipment in the health sector [83] . operator hygiene, including wearing appropriate clothing and ppe, has a dual purpose: on the one hand, to defend the operator himself in an environment where the infectious risk is high, and on the other hand to prevent the operator from becoming responsible transmission of infections. to increase the protective function of the uniform or to carry out those procedures in which high contamination is expected, additional disposable clothing can be worn [83] . these clothes can be ppe certified for biological risk and for this recognition must comply with the requirements of the technical standards, namely european standards are en 14126 and iso 16604 (dpi) and en 24920 (dm). the material constituent is mainly tnt (texture not texture), which is suitable for "disposable" use in this specific area. to offer greater protection of the part front of the body, the most exposed to risk, it is required that such lab coats have standard features within the heterogeneity of the models, for example: back closure, covered or heat-sealed seams, long sleeves with cuffs tight and high collar. obviously, for these devices, comfort and practicality are also required, so the operator must be able to move freely and perceive good perspiration [83] . different types of gowns and overalls are available with varying levels of protection. the level of protection depends on various factors including the type of tissue, the shape and size of microorganisms, the characteristics of the conveyor, and various external factors [130] . in high-risk environments, it is recommended to use waterproof and fluid-resistant gowns or overalls. during minor oral surgery, surgical gowns must be worn with tight cuffs that must be inserted under the gloves. fabric work uniforms must be washed daily on a hot 60 • c cycle. fabric uniforms are not considered ppe since the material they are made of is absorbent and therefore offer little protection against infectious pathogens. during all dental procedures, it is impossible to avoid contact of the hands with blood and saliva [10] . that is why all operators must wear protective gloves before performing any type of procedure on patients [10] . gloves must be changed with each patient and at every contact with contaminated surfaces to prevent cross-infection [10] . not only the dentist, but also other dental team members must wear gloves during dental procedures [10, 131] . gloves used in dental clinic can be distinguished basically in two categories: those for purely use clinical and those for instrumentation reordering procedures and of the operational area. when cleaning dental appliances and instruments, more durable gloves should be worn than normal non-sterile gloves to prevent injury [10] . regarding clinical gloves, a clear distinction must be made between them procedures that require invasive action on the patient, or however at clear biological risk, and the procedures that do not require them, or in any case present a negligible biological risk for the operator. the two types of gloves resulting from this distinction are found in the words "inspection gloves" and "surgical gloves" one commonly used nomenclature [83] . both disposable products, from a macroscopic point of view usually have some obvious differences: • surgical gloves in general always distinguish the right side from the left, they are long enough to be worn over the cuffs of the gowns and always packaged in sterile pairs, • the inspection glove is usually an ambidextrous device, shorter and thinner than the previous one and rarely sterile [132] . in general, clinical gloves are made of latex, nitrile or vinyl. latex and nitrile have proven to be more resistant than and therefore are generally preferred. gloves contain powder to make them easier to wear, but which can cause skin irritation [10] . powder-free gloves exist on the market and they should be used when such reactions occur [10] . some people may experience allergies and contact dermatitis due to latex [10] . latex-free gloves for allergy sufferers are also available [10] . also, the weather of use is an absolutely relevant parameter in terms of protection. the use of the glove, especially if in latex, involves development not perceived of microperforations which become particularly significant from a numerical point of view after 60 min and which induce an increase in biological risk [133] . the simultaneous use of two pairs of gloves considerably reduces the passage of blood through microperforations [134] . there are no significant reductions in manual skills and the sensitivity of the operator wearing the double glove [132] . it was confirmed that the formation of microperforations can be also induced by washing gloves with soap, chlorhexidine, or alcohol. moreover, particular attention should be paid also while waiting for the total drying of the alcoholic substances applied on the hands, which has also proven to be potentially harmful to the integrity of the device, before wearing gloves [132] . other personal protective equipment include the disposable cap (headgear) and shoe covers. a disposable cap device is recommended for clear hygienic reasons, such as containment operator contamination and prevention of dispersion of dandruff in the environment, and even more generic protective functions for the worker, such as: interlocking with subsequent tearing of hair and possibly scalp from a part of moving and/or rotating organs, the burning of the hair due to flames or incandescent bodies, and hair fouling due to various agents, including powders and drops of blood-salivary material [83] . dentist personal hygiene is an absolute necessity for infection prevention [23] . the image that the doctor presents of himself and his study is related to the trust that the patient will show towards the doctor and the treatment itself, in an era in which there is increasing information and awareness of the risk. specific notes of hygiene include: • hair, if a doctor hair can touch the patient or dental equipment, should be attached to the back of the head or a surgical cap should be worn [23] ; • facial hair should be covered with a mask or shield [23] ; • jewels should be removed from the hands, arms, or facial area during the patient treatment [23] ; • nails should be kept clean and short to prevent the perforation of the gloves and the accumulation of debris [23] ; • full forearm and hand washing are mandatory before and after treatment [23] . it is very important to maintain an excellent level of hand hygiene in protection techniques that affects all members of the dental team [10] . "hand hygiene" includes several procedures that remove or kill microorganism on the hands [83] : • during handwashing, water and soap should be used in order to generate lather that is distributed on all surface of the hands and after rinsed off; • hand antisepsis, to physically remove microorganisms by antimicrobial soap or to kill microorganisms with an alcohol-based hand rub; • surgical hand rub procedure that kills transient organisms and reduces resident flora for the duration of a surgical procedure with antimicrobial soap or an alcohol-based hand rub [135] . there are different types of soap: • plain soap, that have no antimicrobial properties and works physically removing dirt ad microorganism; • alcohol-based hand rub, used without water, kills microorganism but does not remove soil or organic material physically; antimicrobial soap kills microorganism and removes physically soil and organic material [135] . in 1975 and in 1985, the cdc published a guideline on how to wash the hands, stating that the hands should be washed with antimicrobial soaps before and after procedures performed on patients [10] . the use of gloves is not an alternative to hand washing [10] . hand washing is different if it is a routine procedure or a surgical procedure: in the first case, normal or antibacterial soaps are sufficient [89] . alcohol-containing agents are preferable [10] . cold water must be of choice when washing hands because the repeatedly use of hot water can cause dermatitis [10] . it is recommended to wash hands using liquid soap for a minimum duration of 60 s. it is very important to reduce the number of microorganisms before each surgical procedure; that is why applying antibacterial soaps and acts a detailed cleaning followed by liquids containing alcohol is recommended [10] . despite the fact that the antibacterial effects of alcohol containing cleansers arise quickly, such antiseptics including compounds of triclosan, quaternary ammonium, chlorhexidine, and octenidine must be included [10] . before surgical hand washing, rings, watches, and other accessories must be taken off and no nail polishes or other artificial must be present [11, 89] . the use of disposable paper towels is preferable for drying hands. after every procedure and after taking off the gloves, it is highly recommended to wash hands once again with regular soaps. if soap and water are not readily available, it can be used an alcohol-based hand sanitizer that contains at least 60% alcohol [10] . • must consider all sharp objects contaminated with the patient blood and saliva as potentially infectious; • do not hood the used needles in order to avoid an accidental injection [83] ; • put all used sharp objects in suitable puncture resistant bins [83] . it is necessary to clean all instruments with detergent and water before sterilization [10] . during washing, it is advisable to avoid splashes of water a wear gloves and face protection. the instruments that penetrate the tissues must be sterilized in an autoclave [83] . it is advisable to heat sterilize items that touch the mucosa or to at least disinfect them, for example, with the immersion in a 2% glutaraldehyde solution in a closed bid, naturally following the instructions of the producer [83] . anything that cannot be autoclaved must be disinfected. the handpieces should be able to drain the water for two minutes at the start of the day. not autoclavable handpieces can be disinfected using viricidal agent. after sterilization, all instruments must be kept safely in order to avoid recontamination for a maximum of 30 days, 60 days if closed in double bags [83] . sterilization completely kills all vital agents and spores too. the classic sterilization procedure expects the use autoclave, with cycles at 121 • c for 15-30 min, or at 134 • c for 3-4 min [23, 83] . it is necessary to thoroughly wash and dry all items before sterilizing them as dirt and water can interfere with sterilization [83] . steam sterilization cannot be used for all facilities and a possible alternative can be the use of chemical sterilization using ethylene oxide gas, formaldehyde gas, hydrogen peroxide gas, liquid peracetic acid, or ozone [83] . the disinfection processes do not destroy the bacterial load, rather reducing it to acceptable levels. commonly used disinfectants are described below (table 4 ). the action of cleaning and disinfection can be manual or automatized. for example, it is possible to use ultrasonic baths in order to clean complex, articulated, or notched stainless-steel instruments such as cutters. the washer-disinfectors provide a high temperature passage (generally 90 • c for one minute), which drastically reduces the microbial contamination of the items. the final rinse must be carried out with high quality water (table 5 ). it is necessary to have always a perfect protection of operative room with disinfected surfaces [10] . there are two ways to make a surface aseptic [23] : • clean and disinfect contaminated surfaces [23] and • prevent surfaces from being contaminated by using surface covers [23] . a combination of both can also be used [23] . the following chemicals are suitable for surface and equipment asepsis: • chlorine, e.g., sodium hypochlorite • phenolic compounds • water-based, water with ortho-phenylphenol, tertiary amylphenol, or o-benzyl-p-chlorophenol • alcohol-based ethyl or isopropyl alcohol with ortho-phenylphenol or tertiary amylphenol • iodophor-butoxy polypropoxy polyethoxy ethanol iodine complex [23] . in the literature there are still little information on 2019-ncov. similar genetic features between 2019-ncov and sars-cov indicate that covid-19 could be susceptible to disinfectants such as 0.1% sodium hypochlorite, 0.5% hydrogen peroxide, 62%-71% ethanol, and phenolic and quaternary ammonium compounds [4] . it is important to pay attention to the duration of use, dilution rate, and especially the expiration time following the preparation of the solution [4] . a recent paper pointed out that surface disinfection could be performed with 0.1% sodium hypochlorite or 62%-71% ethanol for one minute in order to eliminate sas-cov-2 [139] . after each treatment, work surfaces should be adequately cleaned and decontaminated with ethyl alcohol (70%). if blood or pus is visible on a surface, it is necessary to clean and disinfect that surface with sodium hypochlorite (0.5%). it is necessary to wear protective gloves and care taken to minimize direct skin, mucosal or eye contact with these disinfectants. in addition to disinfection with chemicals, a ultraviolet-c (uv-c) irradiation lamp can be used [140] . the uv light system for disinfection has several advantages, including: does not require room ventilation, does not leave residues after use and have a wide action spectrum in a very short time [140] . the uv-c lamp must be activated only when the room is empty, without staff and without patient. in the literature, there are no cases of damage to the materials present in the room; despite this, the acrylic material can be degraded if subjected to repeated exposure to uv-c light and for this reason it is recommended to cover it during disinfection with uv-c [141] . ultraviolet light has a wavelength between 10 and 400 nm, while ultraviolet-c (uv-c) light has a wavelength between 100 and 280 nm, and the greatest germicidal power is obtained with a wavelength of 265 nm [142] . the germicidal effect of uv-c light causes cell damage thus blocking cell replication [141] . in descending order of inactivation by uv-c light, there are bacteria, viruses, fungi, and spores [143] . uv-c rays can be generated by low pressure mercury lamps and pulsed xenon lamps which emit high intensity pulsed light with a higher germicidal action [141] . uv-c rays are equipped with high energy which decreases exponentially with the increase of distance from the light source: objects or surfaces closer to the uv-c source will have a greater exposure and therefore will have to be disinfected for less time than distant objects [142] . depending on the nature of the object affected by uv-c light, it can block the light rays or allow itself to be passed through allowing the irradiation of the objects placed behind it. for example, the organic material completely absorbs the uv-c light and blocks its diffusion. for this reason, the surfaces must be manually cleaned to remove the organic substances before decontamination with ultraviolet light [142] . the extent of inactivation of the microorganisms is directly proportional to the uv-c dose received and this, in turn, is the result of the intensity and duration of exposure [142] . therefore, according to the data in the literature, the use of uv-c rays for disinfection has proven effective in reducing the overall bacterial count and significantly more effective than just manual disinfection on surfaces [141] . in addition, to encourage the exchange of air, it is recommended to ventilate the rooms between one patient and another. if it is not possible to allow the exchange of natural air (at least 20-30 min), forced ventilation systems with high efficiency particulate air (hepa) filters must be used, paying attention to the periodic replacement of the filters. recommendations for environmental infection prevention and control in dental settings [136] : • establish a protocol for cleaning and disinfection of surfaces and environments of which health personnel must be informed; • cover with disposable films all the surfaces that are touched during the procedures (for example switches, it equipment) and change these protections between each patient; • surfaces that are not protected by a barrier should be cleaned and disinfected with a disinfectant after each patient; • use a medium level disinfectant (i.e., tuberculocidal indication) if a surface is visibly contaminated with blood; • for each disinfectant, follow the manufacturer's instructions (e.g., quantity, dilution, contact time, safe use, disposal) [136] (table 6 ). if proper maintenance is not carried out, microbial pathogens (e.g., pseudomonas or legionella spp.) can multiply in duwls. these organisms grow in the biofilm on the internal surfaces of the tubes, where they cannot be attacked with chemicals. to prevent the formation of this biofilm, the systems should be drained at the end of each day [144] . in dental unit water lines (duwl), water must flow and they must be washed regularly: it is recommended to rinse for two minutes at the beginning and end of each day and for 20-30 s between patients [144] . different agents for disinfection of duwl are available. all handpieces and ultrasonic meters must be equipped with backstop valves and must undergo periodic maintenance and inspection. the filters used in the duwl must be checked periodically or, if they are disposable, they must be changed daily. recommendations for dental unit water quality in dental settings: • use water compliant with environmental protection agency (epa) standards for drinking water (i.e., ≤ 500 cfu/ml of heterotrophic water bacteria), • follow the recommendations for water quality monitoring given by the manufacturer of the unit or waterline treatment product, • use sterile water or sterile saline for the irrigation during surgical procedures [136] . any waste containing human or animal tissue, blood or other body fluids, drugs, swabs, dressings or other infective material is defined as "clinical waste" and it must be separated from non-clinical waste [144] . used disposable syringes, needles, or other pointed instruments must be disposed of in a special rigid container, in order to avoid injury to operators and operators in charge of waste disposal. the waste must be kept in a dedicated area before it is collected, away from public access, and excessive accumulation of waste must be avoided [4, 144] . the whole dental team must be vaccinated against hepatitis b in order to increase personal protection [83] . individuals who have already been vaccinated should monitor their levels of immunity against hbv over time and make booster shots [145] . all dental health care professionals should also receive the following other vaccinations: flu, mumps (live-virus), measles (live-virus), rubella (live-virus), and varicella-zoster (live-virus) [10] . in addition, the rubella vaccine is strongly recommended especially for women who have pregnancy uncertainty [131] . the influenza vaccine is very useful for dental health professionals as they are at risk for respiratory droplets infections by working in close proximity to the patients [10] . when the covid-19 vaccine is ready, healthcare professionals should take it. as additional infection prevention and health care worker measures, rapid tests can be used in dental practices to diagnose covid-19 before each treatment. this is because, as mentioned above, a patient without symptoms is not necessarily a healthy patient. from all these data, it is evident that the dentist and his team need to use rigid and precise operating protocols in order to avoid infectious contagion [23] . several authors proposed some right procedures in the operative dentistry [2] [3] [4] 10, 23, 83, 139, [146] [147] [148] [149] . for this reason, we reassume them in a precise operative protocol organized for all the patients and characterized by some defined steps: prevention of infections must be a priority in any healthcare setting and therefore also in any dental clinic. to do this, staff training and information, adequate management of resources, and use of well-defined operating protocols is necessary. adequate management of the protection for operators (and therefore also for patients) begins with the roles of the secretariat. in order to better organize the workflow, the secretariat must provide a telephone triage. it would be advisable to phone each patient to make sure he is healthy on the day of the appointment. patients with acute symptoms of any infectious disease should be referred at the time of symptom resolution. the medical history of patients may not reveal asymptomatic infectious disease of which they are affected. this means the operator must adopt the same infection control rules for all patients, as if they were all infective. in addition, the secretariat must organize appointments in order to avoid crowding in the waiting room. it would be advisable for the patient to present himself alone, without companions (only minors, the elderly and patients with psycho-physical conditions can be accompanied). in some urgent and non-deferrable cases, it is necessary to treat the patient despite being in the acute phase of infection with any virus. examples of urgent treatments are: pulpitis, tooth fracture, and avulsion [2] . in these cases, the operator must implement the maximum individual protection measures. in the waiting room all material (e.g., magazines, newspapers, information posters) that can represent a source of contamination must be eliminated so that the room is easy to disinfect. patients are requested to go to the appointment without any superfluous objects. at the entrance of the dental structure, the patient must wear shoe covers, disinfect the hands with hydroalcoholic solution according to the following indications, affix any jacket on a special hanger and disinfect the hands again with hydroalcoholic solution. if there are several patients in the waiting room, they must be at least two meters away from each other. the correct hand disinfection procedure with hydroalcoholic solution is as follows: a) apply a squirt of sanitizer in the palm of hand, b) rub hands palm against each other, c) rub the back of each hands with the palm of the other hand, d) rub palms together with your finger interlaced, e) rub the back of fingers with the opposite palms, f) rotate thumbs in the other hand, g) do a circle on palm with finger clasped, h) once dry, hands are safe. the same procedure is performed for washing hands with soap and water. the operators must be adequately dressed in the correct ppe. healthcare professionals will need to remove any jewel before starting dressing procedures. all the necessary ppe must already be positioned clearly visible and intact, in a room that will be distinct from the one where the undressing phase will take place. in both areas, hydroalcoholic solution and/or items necessary for washing hands with soap and water should be available. in the dressing room there must be trays for the collection and subsequent disinfection of the non-disposable ppe and special containers for the collection of waste where to dispose of the disposable ppe. a dressing and undressing procedure is described below, imagining that the dentist has to operate under a high risk of infection. dressing and undressing procedures must be particularly considered. dressing procedure: a) eliminate jewels and personal items from the pockets of the uniform; b) long hair must be tied and inserted into a cap not mandatory for single use (no tufts of hair must come out of the cap); c) wear shoe covers; d) perform social hand washing or disinfection with antiseptic gel; e) wear the first pair of gloves of the right size; f) wear the water repellent gown by tying it on the back without double knots (first the upper part and then the lower part, the latter must be tied on the front) being careful not to leave parts of the uniform exposed; g) wear the mask (ffp2-ffp3) which must adhere well to both the nose and the mind; h) put on the disposable water-repellent cap and be tied under the chin, the excess ribbons must be inserted inside the gown; i) wear glasses/protective screen; j) wear a second pair of gloves for direct patient assistance. these gloves must cover the cuffs of the disposable gown. undressing procedure: a) remove the second pair of (dirty) gloves being careful not to contaminate the underlying gloves; b) gloves still worn with a hydroalcoholic solution are disinfected and a new pair of gloves is worn on them; c) the face shield is removed: if it is disposable it should be trashed, and if it is not disposable, it should be placed in a container with disinfectant; d) the second pair of gloves is removed without contaminating the underlying gloves; e) the gloves are rubbed with hydroalcoholic solution and a new pair of gloves is worn; f) disposable gown removal starting from the top, then the bottom, rolling it up to touch the inside, clean; g) throw disposable shirts and second pair of gloves; h) the gloves are rubbed with hydroalcoholic solution and a new pair of gloves is worn; i) remove the water-repellent cap; j) the gloves are rubbed with hydroalcoholic solution and a new pair of gloves is worn; k) remove mask taking it by the elastics with the head bent forward and down; l) both the first pair and the second pair of gloves are removed; m) hands are disinfected with hydroalcoholic solution. before entering the surgical room, the patient must be dressed in a disposable gown and headgear worn in order to avoid any contagion on clothing and hair. 7. before dental session patient should rinse and gargle with a specific mouthwash. chlorhexidine is commonly used for pre-procedural oral rinses in dental offices, but its capacity of 2019-ncov destruction has not yet been demonstrated [4] . instead, pre-procedural oral rinses with oxidizing such as 1% hydrogen peroxide or 0.2% povidone-iodine are recommended [4] . so, the pre-procedural use of mouthwash, especially in cases of inability to use a rubber dam, can significantly reduce the microbial load of oral cavity fluids [3] . in fact, even if oral rinses seem to "limit" the viral load, virus can spread through the complete respiratory tract and it is not scientifically possible to guarantee that this reduction is constant during the operative manoeuvre (e.g., cough, sneezing, runny nose). then the following pre-operative procedure is recommended to the patient: a) 1% hydrogen peroxide 15" gargle followed by 30" rinse, b) do not rinse with water at the end of the rinse and continue with chlorhexidine 0.20% 60" rinse with final gargle of 15" [146] . at the end of the procedure, the patient must be appropriately undressed, and have another oral rinse performed before washing hands and face thoroughly. 8. after every patient, carefully clean all surfaces, starting from the least contaminated to the most potentially infected, taking care not to overlook the handles of the doors and the various drawers, worktops and all the devices used during the treatment and which are not disposable or autoclavable. cover switches, mice, computer keyboards, and anything else that may be more difficult to clean with disposable film. the worktops must be free from anything that is not strictly necessary to perform the service. an accurate disinfection of the surfaces includes a preventive cleaning of the same in order to eliminate the soil which otherwise would not allow the disinfectant to inactivate the microorganisms [29] . in the same way, if you want to use disinfectant wipes, you must use one to cleanse and after another to disinfect. as regards spray disinfectants, the percentage of dilution and the time of application vary from product to product: you must follow the instructions provided by the company. moreover, alcohol-based disinfectants (75%), 0.5% hydrogen peroxide, 0.1% sodium hypochlorite are recommended to be left to act on the surfaces for 1 min. disinfect the circuits of the treatment center at each patient change. between patients, the tubing of high-volume aspirators and saliva ejectors should be regularly flushed with water and disinfectant such as 0.1% sodium hypochlorite. always air the rooms after each patient (at least 20-30 min) or use germicidal lamps. clean floors with bleach at least two times a day. 9. during every procedure minimize the use of an air/water syringe: dry the site with cotton rollers when possible; use suction at maximum power (it might be an idea to use autoclavable plastic suction cannulas that have a greater suction capacity than normal disposable pvc cannulas) or use two saliva ejectors; in the case of exposed carious dentine, try to remove it as manually as possible using excavators; be sure to first mount the rubber dam, disinfect the crown with pellets soaked in 75% alcohol and recommend with the second operator to position the aspirator as correctly as possible to avoid excessive spraying and/or splashing; do not use air-polishing; avoid intraoral x-rays as they stimulate salivation, coughing and/or vomiting; prefer exams like opt (orthopantomography) or cbct (cone beam computed tomography). in case of extractions, it is preferable to use resorbable sutures to seal the post-extraction site. in the case of patients who are definitely positive for any infectious agent or on which there are greater possibilities of positivity highlighted by the medical history, it is necessary to plan their treatment at the end of the day. do not touch patient card and pens with dirty gloves. it is good practice to cough or sneeze into the elbow. the operator must avoid touching his eyes, nose and mouth with dirty gloves or hands. 10. isolation with rubber dam [4] . isolating the oral cavity with the use of rubber dams greatly reduces (about 70%) the spread of respiratory droplets and aerosols containing saliva or blood coming from the patient and aimed to the operator area of action [4] . after positioning the dam, the operator must provide an efficient high-volume intraoral aspiration in order to prevent the spread of aerosol and spray as much as possible [148] . if rubber dams cannot be used for any reason, the operator should prefer to use manual tools such as hand scalers [4] . 11. anti-retraction handpiece [4] . during the covid-19 pandemic, operators should avoid using dental mechanical handpieces that do not have an anti-retraction function [4] . mechanical handpieces with the anti-retraction system have valves (anti-retraction) that are very important in order to prevent the spread and dispersion of droplets and aerosol [148, 149] . 12. all instruments which have been used for the treatment of a patient or which have only been touched by operators during a session and which cannot be sterilized according to standard protocols, must be disinfected (e.g., immersed in a container with phenol) [23] . this tools bagged in disinfection solution must remain in solution for about 10 min [23] . some materials, such as polysulphide, polyvinylsiloxane, impression compound, and zoe impressing materials, after being in the patient mouth, are rinsed with water and immersed in a 5.25% sodium hypochlorite solution for about 10 min [23] . the alginate or polyether impressions are also rinsed with water, sprayed with a 5.25% sodium hypochlorite solution and placed in a container for about 10 min [23] . wax, resin centric relation records, and zoe are rinsed with water and sprayed with a 5.25% sodium hypochlorite solution and placed in a plastic bag for about 10 min [23] . provisional restorations and complete dentures removed from the patient mouth are immersed in a 5.25% sodium hypochlorite solution for 10 min [23] . otherwise, removable partial prostheses with metal bases are treated with 2% glutaraldehyde solution and placed in a plastic bag for 10 min [23] . a novel and useful indication is that of classifying each common dental procedure according to the likelihood of a contagion by one or more infective agents (via saliva, blood, droplets or aerosol) for the team and for the patient (under the cure or the subsequent), nevertheless its type and intrinsic operative difficulty (table 7) . according to this paradigm, all dental procedures involving the use of the air-water syringe and/or rotating/ultrasound/piezo tools are able to produce high levels of aerosols and droplets and for this reason the dentist must consider them dangerous for himself, the dental team, and the subsequent patients. meanwhile, procedures, even if refined (e.g., soft tissues biopsy for oral cancer suspicion) but characterized by a low/absent production of aerosol and droplets, must be considered not particularly threatening. for all these considerations, the dental team must reconsider its operative protocols and modulate the ppe use according to level of risk of common dental procedures of generating droplets or aerosols. table 8 presents the use of different ppes for each common dental procedure in pre-covid vs post-covid era. it is definitively clear that the use of air-water syringe and/or rotating/ultrasound/piezo tools able to produce high levels of aerosols and droplets need the use of the safest ppe in order to reduce/eliminate viral or other infectious agent diffusion within the dental setting. table 8 . proposal of modulation of personal protective equipment (ppe) according to level of risk or common dental procedures both in pre-covid and post-covid era (bold style means the introduction of the new ppe due the transition from a risk category to a higher one). in the face of the covid-19 pandemic, new biosafety measures are necessary to reduce contagion. dentistry is a profession that works directly with the oral cavity and is therefore very exposed to this virus or other infectious agents. because of this, some measures need to be taken to minimize contagion. in fact, dentists can play an important role in stopping the transmission chain, assuming correct procedures in order to reduce the viral agent diffusion, or in promoting undesirable infectious disease diffusion, if operating in adherence to adequate safety protocols. dental-care professionals must be fully aware of 2019-ncov and other viral agent spreading modalities, how to identify patients with active infections and, most importantly, to prioritize self and patient protection. finally, the dental team must reconsider the overall infective risk level of every dental procedure and respect the new operative protocols that are or will be formulated by respective national official committees [150, 151] in order to reduce as much as possible the risk of the contagion for the health and safety of their community. author contributions: authors equally contributed to conceptualization, methodology, validation, investigation, writing-original draft preparation, writing-review and editing, supervision. all authors have read and agreed to the published version of the manuscript. funding: this research received no external funding. the authors declare no conflict of interest. covid-19 transmission in dental practice: brief review of preventive measures in italy covid-19): emerging and future challenges for dental and oral medicine transmission routes of 2019-ncov and controls in dental practice being a front-line dentist during the covid-19 pandemic: a literature review fear and practice modifications among dentists to combat novel coronavirus disease (covid-19) outbreak assessing knowledge, attitudes and practices of dental practitioners regarding the covid-19 pandemic: a multinational study dentists' awareness, perception, and attitude regarding covid-19 and infection control: cross-sectional study among jordanian dentists coronavirus disease (covid-19): characteristics in children and considerations for dentists providing their care editorial: dental practitioners' role in the assessment and containment of coronavirus disease (covid-19): evolving recommendations from the centers for disease control personnel protective measures for infection control in dental health care settings epithelial cells lining salivary gland ducts are early target cells of severe acute respiratory syndrome coronavirus infection in the upper respiratory tracts of rhesus macaques pathogenicity and transmissibility of 2019-ncov-a quick overview and comparison with other emerging viruses. microbes infect transmission of blood-borne pathogens in us dental health care settings: 2016 update aerosols and splatter in dentistry dentistry and coronavirus (covid-19)-moral decision-making persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents transmission of sars and mers coronaviruses and influenza virus in healthcare settings: the possible role of dry surface contamination guideline for isolation precautions: preventing transmission of infectious agents in health care settings risk of community-acquired pneumococcal bacteremia in patients with diabetes: a population-based case-control study the evolution of transmission mode hepatitis"-prevention and management in dental practice transmission of hiv and hepatitis c virus from a nursing home patient to a health care worker underreporting of blood and body fluid exposures among health care students and trainees in the acute care setting: a 2007 survey acquisition of nosocomial pathogens on hands after contact with environmental surfaces near hospitalized patients aerosol and surface distribution of severe acute respiratory syndrome coronavirus 2 in hospital wards review of surface disinfection protocols in dentistry: a 2019 update cleaning and disinfection of dental practice surfaces aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 airborne or droplet precautions for health workers treating covid-19? droplets and aerosols in the transmission of sars-cov-2 airborne transmission of sars-cov-2: the world should face the reality the size distribution of droplets in the exhaled breath of healthy human subjects infectivity of respiratory syncytial virus by various routes of inoculation characterization of infectious aerosols in health care facilities: an aid to effective engineering controls and preventive strategies how far droplets can move in indoor environments ? revisiting the wells evaporation?falling curve a field indoor air measurement of sars-cov-2 in the patient rooms of the largest hospital in iran use of airborne infection isolation in potential cases of pulmonary tuberculosis urban airborne particle exposure impairs human lung and blood mycobacterium tuberculosis immunity detection of airborne mycobacterium tuberculosis complex in high-risk areas of health care facilities in thailand modeling the airborne infection risk of tuberculosis for a research facility in emalahleni, south africa the continuing 2019-ncov epidemic threat of novel coronaviruses to global health-the latest 2019 novel coronavirus outbreak in wuhan induction of pro-inflammatory cytokines (il-1 and il-6) and lung inflammation by coronavirus-19 (covi-19 or sars-cov-2): anti-inflammatory strategies high il-6/ifn-gamma ratio could be associated with severe disease in covid-19 patients insights from immuno-oncology: the society for immunotherapy of cancer statement on access to il-6-targeting therapies for covid-19 antirheumatic agents in covid-19: is il-6 the right target? the conundrum of covid-19 treatment targets: the close correlation with rheumatology. response to: 'management of rheumatic diseases in the time of covid-19 pandemic: perspectives of rheumatology pracitioners from india' by gupta et al and 'antirheumatic agents in covid-19: is il-6 the right target the cytokine release syndrome (crs) of severe covid-19 and interleukin-6 receptor (il-6r) antagonist tocilizumab may be the key to reduce the mortality comparison of the dynamics and correlates of transmission of herpes simplex virus-1 (hsv-1) and varicella-zoster virus (vzv) in a sample of the israeli population extensive atypical hsv-2 ulceration of the finger. acta médica port textbook of oral and maxillofacial surgery oral shedding of hsv-1 and ebv and oral manifestations in paediatric chronic kidney disease patients and renal transplant recipients asymptomatic shedding of hsv-1 in patients undergoing oral surgical procedures and attending for noninvasive treatment infection control of herpes simplex virus infections in obstetrics and gynecology varicella zoster virus: chickenpox and shingles varicella-zoster virus, shingles and postherpetic neuralgia the natural history of shingles. events associated with reactivation of varicella-zoster virus airborne transmission of chickenpox airborne transmission of chickenpox airborne transmission of chickenpox in a hospital quantitative analysis of shedding of epstein-barr virus in saliva from patients with connective tissue diseases: a pilot study modeling the dynamics of virus shedding into the saliva of epstein-barr virus positive individuals evaluation of epstein-barr virus load in saliva before and after renal transplantation high levels of epstein-barr virus dna in saliva and peripheral blood from ugandan mother-child pairs detection of epstein-barr virus in saliva by real-time pcr infectious mononucleosis human herpesvirus 6 (hhv6) dna persistence and reactivation in healthy children three new human herpesviruses (hhv6, 7, and 8) hand-to-hand transmission of rhinovirus colds rhinovirus transmission rhinovirus neutralizing antibody in tears, parotid saliva, nasal secretions and serum blood lead concentrations and antibody levels to measles, mumps, and rubella among u.s. children protection of medical and paramedical university students in lebanon against measles, mumps, rubella and varicella: active measures are needed assessment of the potency and potential immunomodulatory effects of the measles mumps rubella and varicella vaccine in infants oral medicine in practice: viral infection salivary excretion of coxsackie b-1 virus in rabbits the transfusion safety study group transmission of human t?lymphotropic virus type i by blood components from a donor lacking anti?p24: a case report transfusion transmission of human t?lymphotropic virus type i (htlv?i) from an asymptomatic blood donor: conservation of ltr u3, env, and tax nucleotide sequences in a recipient with htlv?i?associated myelopathy transfusion-associated transmission of human t-lymphotropic virus types i and ii: experience of a regional blood center intrafamilial transmission and risk assessment of htlv-i among blood donors in southern taiwan guidelines for infection control in dental health-care settings-2003 risk and management of blood-borne infections in health care workers residual risk of hiv, hcv, and hbv transmission by blood transfusion between 2015 and 2017 at the regional blood transfusion evolution of the residual risk of hbv, hcv and hiv transmission through blood transfusion in the region of valencia, spain, during a 15-year period occupational blood exposures in health care workers: incidence, characteristics, and transmission of bloodborne pathogens in south korea hepatitis b transmission through blood and body fluids exposure of school personnel cover story guidelines for infection control in dental health care settings-2003 hepatitis c virus the comparison of human immunodeficiency virus type 1 transmission between couples through blood or sex in central china transmission of human immunodeficiency virus type 1 (hiv-1) by exposure to blood: defining the risk common oral opportunistic infections in human immunodeficiency virus infection/acquired immunodeficiency syndrome: changing epidemiology; diagnostic criteria and methods; management protocols correlation between oral lesions and opportunistic infections among human immunodeficiency virus-infected individuals in indian population oral human papillomavirus and human herpesvirus-8 infections among human immunodeficiency virus type 1-infected men and women in italy relationship between prevalent oral and cervical human papillomavirus infections in human immunodeficiency virus-positive and -negative women salivary iga antibodies to mumps virus during and after mumps differences in antigenic sites and other functional regions between genotype a and g mumps virus surface proteins re-emergence of tuberculosis and its variants: implications for dentistry risk of tuberculosis transmission in dentistry. results of a retrospective chart review tuberculosis infection control: a reasonable approach for dentistry dentistry and tuberculosis in the 1900s tuberculosis in the 1990s: current implications for dentistry tuberculosis: a growing concern for dentistry? contamination of a dental unit water line system by legionella pneumophila in the mashhad school of dentistry in 2009 legionella in dentistry equipment syphilis in relation to dentistry neisseria meningitidis: pathogenesis and immunity preventing secondary meningococcal disease in health care workers: recommendations of a working group of the phls meningococcus forum whole-genome sequencing to explore nosocomial transmission and virulence in neonatal methicillin-susceptible staphylococcus aureus bacteremia route of transmission of staphylococcus aureus necrotizing fasciitis following primary peritonitis caused by streptococcus pyogenes with covs mutation in a healthy woman: a case report periorbital necrotizing fasciitis induced by streptococcus pyogenes: a case report and clarification necrotizing fasciitis caused by streptococcus pneumoniae preventing group a streptococcus cross-infection on ear, nose and throat wards outbreak of invasive group a streptococcus infection: contaminated patient curtains and cross-infection on an ear, nose and throat ward from nose to lung: the regulation behind streptococcus pneumoniae virulence factors oral health over the life course. in revisiting economic vulnerability in old age prospective study of potential sources of streptococcus mutans transmission in nursery school children mother-to-child transmission of streptococcus mutans transmission of periodontal bacteria and models of infection porphyromonas gingivalis, periodontal and systemic implications: a systematic review infection control from the point of dentistry personal protective equipment and improving compliance among healthcare workers in high-risk settings world health organization. infection prevention and control of epidemic-and pandemic-prone acute respiratory diseases in health care; world health organization particle size-selective assessment of protection of european standard ffp respirators and surgical masks against particles-tested with human subjects flow analyses to validate sars-cov-2 protective masks considerations for selecting protective clothing used in healthcare for protection against microorganisms in blood and body fluids updated cdc infection control guidelines for dental health care settings: 1 year later le regole di gestione dello studio odontoiatrico: dispositivi di protezione individuale (dpi) incidence of microperforation for surgical gloves depends on duration of wear study of blood contact in simulated surgical needlestick injuries with single or double latex gloving summary of infection prevention practices in dental settings: basic expectations for safe care and human services infection control committee. guidelines on infection control practice in the clinic settings of department of health infection control committee of dh guidelines on infection control in dental clinics covid-19 surface persistence: a recent data summary and its importance for medical and dental settings comparison of uv c light and chemicals for disinfection of surfaces in hospital isolation units evaluation of an ultraviolet c (uvc) light-emitting device for disinfection of high touch surfaces in hospital critical areas ultraviolet-c decontamination of a hospital room: amount of uv light needed short-term exposure to uv-a, uv-b, and uv-c irradiation induces alteration in cytoskeleton and autophagy in human keratinocytes general medicine and surgery for dental practitioners: part infections and infection control infection control in the dental office projecting the transmission dynamics of sars-cov-2 through the postpandemic period the efficacy of rubber dam isolation in reducing atmospheric bacterial contamination severe acute respiratory syndrome and dentistry approaches to the management of patients in oral and maxillofacial surgery during covid-19 pandemic interim guidance for management of emergency and urgent dental care; ada: niagara falls plan estratégico de acción para el periodo posterior a la crisis creada por el covid-19 key: cord-253135-0tun7fjk authors: robin, charlotte; bettridge, judy; mcmaster, fiona title: zoonotic disease risk perceptions in the british veterinary profession date: 2017-01-01 journal: prev vet med doi: 10.1016/j.prevetmed.2016.11.015 sha: doc_id: 253135 cord_uid: 0tun7fjk in human and veterinary medicine, reducing the risk of occupationally-acquired infections relies on effective infection prevention and control practices (ipcs). in veterinary medicine, zoonoses present a risk to practitioners, yet little is known about how these risks are understood and how this translates into health protective behaviour. this study aimed to explore risk perceptions within the british veterinary profession and identify motivators and barriers to compliance with ipcs. a cross-sectional study was conducted using veterinary practices registered with the royal college of veterinary surgeons. here we demonstrate that compliance with ipcs is influenced by more than just knowledge and experience, and understanding of risk is complex and multifactorial. out of 252 respondents, the majority were not concerned about the risk of zoonoses (57.5%); however, a considerable proportion (34.9%) was. overall, 44.0% of respondents reported contracting a confirmed or suspected zoonoses, most frequently dermatophytosis (58.6%). in veterinary professionals who had previous experience of managing zoonotic cases, time or financial constraints and a concern for adverse animal reactions were not perceived as barriers to use of personal protective equipment (ppe). for those working in large animal practice, the most significant motivator for using ppe was concerns over liability. when assessing responses to a range of different “infection control attitudes”, veterinary nurses tended to have a more positive perspective, compared with veterinary surgeons. our results demonstrate that ipcs are not always adhered to, and factors influencing motivators and barriers to compliance are not simply based on knowledge and experience. educating veterinary professionals may help improve compliance to a certain extent, however increased knowledge does not necessarily equate to an increase in risk-mitigating behaviour. this highlights that the construction of risk is complex and circumstance-specific and to get a real grasp on compliance with ipcs, this construction needs to be explored in more depth. veterinary professionals can encounter a variety of occupational health risks. a high prevalence of injury has been reported, predominantly in relation to large animal work (beva, 2014; fritschi et al., 2006; lucas et al., 2009) , dog and cat bites and/or scratches and scalpel or needle stick injuries (nienhaus et al., 2005; phillips et al., 2000; soest and van fritschi, 2004) . in addition to the risk of injury, the profession is also at risk of other occupational hazards including exposure to chemicals, car accidents (phillips et al., 2000) and infec-tious diseases from zoonotic pathogens (constable and harrington, 1982; dowd et al., 2013; epp and waldner, 2012; gummow, 2003; jackson and villarroel, 2012; lipton et al., 2008; weese et al., 2002) . work days lost because of zoonotic infections are less frequent than days lost to injury (phillips et al., 2000) ; however, because of the potential seriousness of some zoonotic infections and increasing reports of occupationally-acquired antimicrobial resistant bacteria in veterinary professionals (cuny and witte, 2016; groves et al., 2016; hanselman et al., 2006; jordan et al., 2011; weese et al., 2006) , zoonotic risk in the veterinary profession deserves attention. there are no recent data on the risk of zoonotic infections in the british veterinary profession. one study published over 30 years ago estimated 64.1% of veterinary surgeons working for government agencies reported one or more zoonotic infections during their career (constable and harrington, 1982) . research from veterinary populations overseas indicates a substantial risk of http://dx.doi.org/10. 1016/j.prevetmed.2016.11 .015 0167-5877/© 2017 elsevier b.v. this is an open access article under the cc by license (http://creativecommons.org/licenses/by/4.0/). infection within the profession, with incidence of reported infections during their career ranging from 28% in the united states (lipton et al., 2008) , 45% in australia (dowd et al., 2013) , 47.2% in canada (jackson and villarroel, 2012) to 64% in south africa (gummow, 2003) . in both medical and veterinary professions, infection prevention and control (ipc) practices are fundamental to reduce the risk of healthcare-associated infections in patients, as well as occupationally-acquired infections in practitioners. in the united kingdom (uk), universal and standard precautions are recommended by the department of health. in human medicine, research has highlighted sub-optimal compliance with ipc practices. in one uk study, observed hand hygiene adherence in nurses was 20.4% and 60.1%, before and after contact with patients, respectively. in doctors in the same study, the compliance was much lower, at 8.1% and 51.4%, before and after patient contact (jenner et al., 2006) . non-adherence to guidelines is a global issue, with reported hand hygiene compliance rates of 58% in hospitals in finland (laurikainen et al., 2015) , 41.2% in an infectious diseases care unit in france (boudjema et al., 2016) and 40% in paediatric hospitals in new york (løyland et al., 2016) . in veterinary medicine in the uk, there are no enforceable national policies for ipc practices. for veterinary practices in the royal college of veterinary surgeons (rcvs) accreditation scheme, guidelines are available and specific standards have to be met to retain accreditation status. only 51% of practices are members of the accreditation scheme (rcvs, 2014) and although guidelines and recommendations are available for non-members, they tend to be practice-specific. additionally, the emphasis is on patient, rather than practitioner health. other countries have developed national standards for ipc in veterinary medicine, specifically related to occupationallyacquired zoonotic infections. these include the australian veterinary association guidelines for veterinary personal biosecurity and the compendium of veterinary standard precautions for zoonotic disease prevention in veterinary personnel, developed by the national association of state public health veterinarians in the united states (nasphv). even when national guidelines exist, not all practices have ipc programmes (lipton et al., 2008; murphy et al., 2010) . where effective procedures and resources are available, their effectiveness is dependent on uptake (dowd et al., 2013) . decision-making surrounding ipc practices will depend on a number of different factors. there are few data available focussing on awareness and perceptions of zoonotic diseases within the veterinary profession in the uk, however from studies that have been conducted overseas it appears that awareness is poor and compliance with ipc guidelines is low (dowd et al., 2013; lipton et al., 2008; nakamura et al., 2012; wright et al., 2008) . in a survey of american veterinary medicine associationregistered veterinary surgeons, under half (48.4%) of small animal vets washed or sanitised their hands between patients and this proportion was even lower in large and equine vets (18.2% for both). in addition, only a small proportion of large and equine vets washed their hands before eating, drinking or smoking at work (31.1% and 28.1%, respectively), compared with 55.2% in small animal vets. veterinary surgeons who worked in a practice that had no formal infection control policy had lower awareness, as did male veterinary surgeons (wright et al., 2008) . in a smaller survey of american veterinary professionals, although 77% of respondents agreed it was important for veterinary surgeons to inform clients about the risk of zoonotic disease transmission, only 43% reported they initiated these discussions with clients (lipton et al., 2008) . in a study of veterinary technicians and support staff, only 41.7% reported washing their hands regularly between patients (nakamura et al., 2012) . in a sample of australian veterinary surgeons, 43.4% wore no personal protective equipment (ppe) for handling clinically sick animals and the majority (67.4%) wore inadequate ppe for handling animal faeces and urine (dowd et al., 2013) . in the veterinary profession, the dichotomy between a professional status and increased risk of infection has been viewed as counterintuitive (baker and gray, 2009) , as it could be expected a comprehensive understanding of zoonotic disease risks would manifest in more risk-averse behaviour. in both medical and veterinary medicine, education has been identified as a key intervention to increase compliance (dowd et al., 2013; ward, 2011) ; however good knowledge does not necessarily lead to good practice (jackson et al., 2014) . compliance is influenced by many factors, including motivation, intention, social pressure and how individuals understand or 'construct' risk (jackson et al., 2014) . understanding of risk and why people engage in risk-mitigating behaviour (or not) is complex and perceived knowledge of the disease is only one factor that should be considered. a better understanding of how veterinary professionals in britain understand the risks surrounding zoonotic diseases will aid in the development of effective and sustainable ipc practices, reducing the risk of zoonotic infections within the profession. this paper examines how the veterinary profession in britain understand zoonotic risk and motivators and barriers for using ppe. a cross-sectional study was conducted october to december 2014; the sampling frame was all 3416 veterinary practices in great britain registered in the rcvs database. the rcvs database holds information on registered veterinary businesses, including private practice, referral hospitals, veterinary teaching hospitals and veterinary individuals. sample size calculations indicated that information from 348 veterinary practices was required for an expected prevalence of 50%, with a precision of 5%. assuming a 30% response rate, 1000 practices were selected from the rcvs database by systematically selecting every third practice. the principle veterinary surgeon and head nurse were identified at each practice using the rcvs register and sent a postal questionnaire. a total of 2000 questionnaires were posted to 1000 veterinary practices. for non-responders, reminder emails were sent out from four weeks after the initial posting and a second reminder, including an electronic copy of the questionnaire was sent out a further four weeks after the first reminder, to any remaining non-responders. the questionnaire was developed based on a similar study in australian veterinary professionals (dowd et al., 2013) and a larger, multi-country risk perception study on severe acute respiratory syndrome (de zwart et al., 2009) . the questionnaire was an a4 8page booklet (available in supplementary information), containing four sections including veterinary qualifications and experience, disease risk perceptions, infection control practices and management of zoonotic diseases. the questionnaire included both closed and open-ended questions and was piloted on a small convenience sample of veterinary surgeons, but not veterinary nurses, prior to being finalised. questionnaires were designed in automatic data capture software (cardiff teleform v 9.0), which allowed completed questionnaires to be scanned and verified and the data imported directly into a custom-designed spreadsheet (microsoft excel, redmond, wa, usa). the clinical scenarios respondents were asked to assess the risk from included contact with animal faeces/urine; contact with animal blood; contact with animal saliva or other bodily fluid; performing post mortem examinations, assisting conception and parturition for animals, contact with healthy animals; contact with clinically sick animals and accidental injury. * post mortem examination. descriptive statistics were performed using commercial software (ibm spss version 22, armonk, ny, usa). proportions were calculated for categorical data; median and interquartile ranges (iqr) for continuous data. a "risk perception score" was calculated as the mean value of the scores (high risk = 3; medium risk = 2; low risk = 1), based on the participant's opinion of the risk (high, medium or low) of contracting a zoonosis from eight different clinical scenarios detailed in fig. 2 . scores for ppe use in five clinical scenarios were calculated using pearson's correlation coefficient to compare reported use of gloves, masks and gowns/overalls to the recommendations in the nasphv guidelines. these guidelines were chosen because no uk equivalent that applies across all veterinary species could be found, but the nasphv standards are likely to be considered as reasonable levels of protection in the uk situation. the clinical scenarios included handling healthy animals (no specific protection advised: possible scores 0-3); handling excreta and managing dermatology cases (gloves and protective outerwear advised: possible scores −2 to 1); performing post mortems and performing dental procedures (gloves, coveralls and masks advised: possible scores −3 to 0). a score of 0 indicated compliance, <0 indicated less ppe than recommended was used and >0 more ppe than recommended was used. redundancy analysis (rda) was used to determine if demographic or other factors accounted for any observed clustering of the motivators or barriers to use of ppe, or for the reported ppe use in different scenarios. redundancy analysis is a form of multivariate analysis that combines principal component analysis with regression, to identify significant explanatory variables. this was performed using the r package "vegan" (oksanen et al., 2016) , based on the methods described by (borcard et al., 2011) . the adjusted r 2 value was used to test whether the inclusion of explanatory variables was a significantly better fit than the null model and a forward selection process was used to select the significant variables that explained the greatest proportion of the variance in the response data (borcard et al., 2011) . permutation tests were used to test how many rda axes explained a significant proportion of the variation. barriers and motivators to use of ppe were assessed by asking respondents to grade the influence of certain factors on their use of ppe (see fig. 4 for a full description of the barriers and motivators). the response options "not at all", "a little" and "extremely" were ranked as 0, 1 and 2, respectively. redundancy analyses, as described above, were used to determine if demographic or other factors accounted for any observed clustering of a) barriers or b) motivators to use of ppe. explanatory variables investigated were gender, age, length of time in practice, position (veterinary surgeon or nurse; owner or employee); type(s) of veterinary work undertaken (small, large/equine or exotics/wildlife); previous experience of treating a zoonotic case; level of concern over risk (for themselves or clients). additional explanatory variables investigated in the redundancy analysis for reported ppe use were the barrier and motivator scores and the attitude and belief scores (described below). participants were also asked about their level of agreement with certain statements describing their attitudes and beliefs around zoonotic disease risk and ppe use (see fig. 5 for a full description of the statements); the responses "disagree", "agree" and "strongly agree" were scored as −1, 1 and 2, respectively. principal component analysis was used to investigate clustering of these "attitude" statements. as only two axes contributed variation of interest (according to the kaiser-guttman criterion, which compares each axis to the mean of all eigenvalues), the attitude statements were grouped into two subsets; those that contributed principally to pca1 (seven statements) and those that contributed to pca2 (three statements). cronbach's alpha was calculated on these subsets of the attitude statements, using the "psy" package in r (falissard, 2011) , to test whether any of these variables may indicate an underlying latent construct. where correlation was judged to be acceptable or better (cronbach's alpha coefficient >0.7), the principal component scores were used as a proxy measure for this latent construct. potential explanatory variables, including the same demographic variables used for the redundancy analyses, and responses to motivators and barriers, were tested using linear regression modelling. multivariable regression models were fitted using the base and stats packages in r software (r core team, 2015). a manual stepwise selection of variables was performed based on knowledge of expected potential associations and confounders that made biological sense. variables were added one by one to the null model. two-way interactions were tested and variables or interactions were retained if likelihood ratio tests showed a significant improvement in model fit (p < 0.05). non-significant variables were removed, including variables that later became non-significant when additional variables were added. over the 12-week study period, a total of 252 useable questionnaires were returned from the invited individuals, giving an overall response rate of 12.6%. for a number of questions, there were some missing data; therefore the denominator for all results was 252 unless otherwise stated. a summary of demographic characteristics of the respondents is presented in table 1 . the majority of respondents had managed a zoonotic case within the 12 months prior to completing the questionnaire (93.1%; n = 230/247). the most commonly reported infections treated were campylobacter (n = 111), dermatophytosis (n = 99) and sarcoptes scabeii (n = 86). overall, 24.6% (n = 62/248) of respondents reported they had previously contracted at least one confirmed occupationallyacquired episode of zoonotic disease. when including suspected zoonotic diseases, this increased to 44.7% (n = 111/248). the most common zoonotic disease experienced by respondents who reported confirmed or suspected zoonotic infection was dermatophytosis (58.6%; n = 65/111). the relative frequency of reported zoonotic infections (confirmed and suspected) is reported in fig. 1 , showing the reported frequency in respondents who had qualified or practised outside of britain, compared with veterinary professionals with exclusively british experience. overall, the majority (57.5%; n = 145/251) of respondents were not concerned that they or their colleagues would contract an occupationally-acquired zoonotic disease, however a considerable proportion were (34.9%; n = 88/251). only a small proportion (7.1%; n = 18/251; 4.0-10.4) stated they had not thought about the risk of infection. in total, 84.6% (n = 209/247) of respondents agreed or strongly agreed they had a high level of knowledge regarding zoonotic diseases. based on the eight different clinical scenarios respondents were asked to assess, the highest risk situation for zoonotic disease transmission was considered to be accidental injury, such as a needle stick injury, bite or scratch. coming into contact with animal faeces/urine was also considered high risk for zoonotic disease transmission. these scenarios were classified as high risk by 18.3% (n = 46/245) and 17.1% (n = 43/246) of respondents, respectively. the aspect of the job considered to represent the lowest risk of exposure to zoonoses was contact with healthy animals, with 83.3% (n = 210/250) of respondents considering this to involve low risk of exposure to disease (fig. 2) . the amalgamated risk perception scores ranged from 1 (all scenarios considered low risk) to 3 (all scenarios considered high risk), with a median of 1.5 (iqr 1.25-1.75). the majority of respondents reported they were aware of their practice having standard operating procedures (sops) related to infection control practices (75.0%; n = 189/236). all workplaces provided ppe for members of staff, although 12.3% did not provide training on how to use it. the majority provided separate eating areas (92.9%; n = 234/247) and restricted access from staff and visitors to patients in isolation (92.5%; n = 225/233). when asked about what level of ppe was used in five different clinical settings, 68.3% (n = 168/246) reported they would not use any specific ppe for handling healthy animals, in line with the nasphv guidelines. when handling dermatology cases, 23% (n = 56/243) reported using no ppe. only 2.4% (n = 8/331) reported not using any ppe for handling urine or faeces; one respondent did not use any ppe for post mortem examination (n = 230; 0.4%), and 2% (n = 5/244) did not use any for performing dentistry work. correlation between the ppe scores for the different scenarios was low, the greatest correlation (r = 0.39) was between the scores for handling excreta and for handling dermatology cases. there was no evidence that respondents who wore more ppe than required in the guidelines (i.e. gloves and/or masks) for handling healthy animals would correctly select the appropriate level of ppe (i.e. gloves, masks and a protective coverall) for post mortem or dentistry. a redundancy analysis indicated that greater ppe use (a higher ppe score) was negatively correlated with a fatalistic attitude for the two higher risk scenarios. belief that sops acted as a motivating factor to use ppe and agreement that "i consciously consider using ppe in every case i deal with" were positively correlated with greater ppe use in dermatological cases, handling healthy animals and excreta (fig. 3) . all respondents indicated that perceived risk would have some effect on their motivation to use ppe, either a little (n = 63/248; 25.4%) or extremely (n = 186/248; 74.6%). respondents were also strongly motivated by previous experience with similar cases (n = 135/248; 54.5%) and a high profile or recent disease outbreak (n = 132/245; 53.9%). few respondents indicated any of the suggested barriers to ppe would have a strong influence as a deterrent to using ppe; safety concerns was most frequently cited, with 7.1% (n = 18) respondents stating this would be an extreme deterrent to using ppe. when combining both positive responses (extreme and a little influence), time constraints and safety concerns were the most frequently cited barriers, with 56.0% (n = 139/248) and 56.9% (n = 141/248) of respondents indicated these barriers would affect their decision not to use ppe, respectively. potential barriers that most respondents considered had no influence on their decision to use ppe were negative client perceptions and ppe availability, with 78.2% (n = 194/248) and 76.9% (n = 190/247) of respondents stating this, respectively. demographic variables that had significant associations with responses regarding motivators and barriers towards the use of ppe are illustrated in fig. 4 . the explanatory variables in the model were statistically significant, however they only explained a small amount of the variation in the respondents' perceptions of barriers (adjusted r-square 3.2%) and motivators (adjusted r-square 3.4%). respondents with previous experience of treating a case of zoonotic disease were less likely to regard time or financial constraints, or concern for adverse animal reactions as a deterrent to using ppe (fig. 4a) . veterinary surgeons were more likely than nurses to be deterred from using ppe because of concerns about negative client perceptions (fig. 4a) ; although positive client perceptions were marginally more likely to act as encouragement in both vets and nurses who reported themselves concerned about zoonotic risk in relation to clients (fig. 4b) . those working in large animal practice were more likely to be motivated to use ppe by concerns over liability and nurses tended to be more motivated than veterinary surgeons by sops and concern over the perceived risk to themselves. respondents were asked to state their level of agreement with 10 "attitude" statements (see fig. 5 for a description of the statements) reflecting different aspects of zoonotic disease risk control in the workplace. all respondents agreed that using ppe and practising good equipment hygiene was an effective way of reducing the risk of zoonotic disease transmission. the majority thought they had a high level of knowledge regarding zoonoses (n = 209/247; 84.6%) and that they were expected to demonstrate rigorous infection control practices (n = 229/247; 92.7%). however, 45 respondents (18.2%) stated they just hoped for the best when trying to avoid contracting a zoonotic disease and 37 (14.9%) were concerned their colleagues would think they were unnecessarily cautious if they used ppe in their workplace. responses to seven of these "attitude" statements tended to cluster together along the first pca axis (fig. 5 , statements a to g). cronbach's alpha coefficient for these statements was 0.76, suggesting an acceptable level of internal consistency and a potential underlying latent construct (interpreted here as a "positive attitude" towards ipcs) for these responses. statements h to k, whilst all contributing greater weight to pca axis 2, had an alpha coefficient of below 0.5 and were therefore evaluated individually. respondents' scores from the first principal component axis (fig. 5) were used as a proxy to represent this potential underlying "positive attitude" towards zoonotic disease risk reduction and a multivariable linear regression model was used to investigate potential explanatory factors. the only demographic variable that significantly altered model fit was profession, with veterinary surgeons tending to score lower than nurses in this "positive attitude". some of the factors identified as motivators and barriers also had a statistically significant association with the outcome. those who agreed that sops, positive client perceptions and risk to themselves motivated them to use ppe scored more highly; whereas those who regarded time constraints as a barrier to ppe use tended to have lower positive attitude scores (table 2) . there were 18.2% (n = 45/247) of respondents who agreed or strongly agreed with the statement, "i just hope for the best when it comes to trying to avoid contracting a zoonotic disease". a multivariable model suggested that respondents who had spent less time in practice tended to agree more with this "fatalistic" attitude, as did those who held the opinion that negative client perceptions deterred them from using ppe. furthermore, individuals with higher risk perception scores (i.e. who believed they tended to have a medium to high risk of exposure to zoonoses from clinical work) were more likely to agree that they "just hope for the best" (table 2) . a regression model was also constructed for the statement, "if i use ppe, others in my workplace think that i am being unnecessarily cautious". explanatory variables included an interaction between gender and profession; nurses, particularly male nurses, were more likely to agree, whereas there was no significant gender difference in veterinary surgeons. the aim of this research was to explore zoonotic disease risk perceptions within a cross-section of the veterinary profession in britain, and to identify barriers and motivators towards infection control practices and the use of ppe to minimise the risk of disease transmission. the large proportion of respondents (44.0%) who had contracted either a confirmed or suspected occupationallyacquired zoonotic infection highlights the level of occupational risk encountered by veterinary surgeons and veterinary nurses. a substantial proportion of respondents stated they were concerned about the risk of zoonoses (35%), and the majority thought the highest risk of transmission was through accidental injury, despite few reported zoonoses in the study being transmitted this way. this dissonance may be reflecting other occupational risks encountered by veterinary professionals, of which zoonotic diseases only represent a small proportion. data from studies conducted overseas suggests veterinary medicine is a high risk profession. in one survey of australian veterinary professionals, 71% reported at least one physical injury over a 10 year period (phillips et al., 2000) . in addition to practice-acquired injuries, such as dog and cat bites, scalpel blade cuts and lifting of heavy dogs, the risk of car accidents was also noted (phillips et al., 2000) . further research in the german veterinary profession highlighted workplace accidents as the most prevalent occupational hazard (87.7%), followed by commuting accidents (8.2%). occupationally-acquired zoonoses only represented 4.1% of the total hazards in the study (nienhaus et al., 2005) . practitioners are clearly working in a risky environment, particularly large animal vets, where farm environments are known to be inherently dangerous. a total of 7 fatal injuries and 292 major injuries were reported in british farmers or farmworkers in -2014 (hse, 2014 , and a recent survey by the british equine veterinary association revealed that on average, equine vets sustain seven to eight work-related injuries during a 30 year period (beva, 2014), highlighting just how hazardous these environments can be. few data are available on occupational injuries in the british veterinary profession; however, when working in what could be interpreted as a high-risk environment, a constant exposure to risk for those living or working in these types of environment may lead to habituation to, or normalisation of risk (clouser et al., 2015) . individuals in this study who tended to grade common clinical scenarios as posing a moderate to high risk of zoonosis exposure were also more likely to "just hope for the best", perhaps suggesting they have normalised these situations and do not perceive them as requiring additional precautions. within the veterinary environment, it is also possible that risks are rationalised; when faced with a very tangible risk of accident or injury, the more imperceptible risk of zoonotic infection becomes less important. this rationalisation of risk is also noted in the healthcare profession, where healthcare workers are more careful when handling sharps, compared with demonstrating compliance with ipc practices for infectious diseases (nicol et al., 2009) . the invisibility of the disease also plays a role here; the pathogens are not visible therefore the perception of the risk they pose is more abstract. in addition, there is often a time lapse between exposure to the pathogen and onset of clinical signs, making an association between suboptimal ipc behaviour and outcome difficult (cioffi and cioffi, 2015) . in the uk, personal risk receives little attention in the veterinary profession's media, especially when compared with issues such as mental health, with reports of high levels of psychological distress and suicide in the profession (bartram et al., 2010) and inclusion of issues around stress and mental wellbeing in surveys (vet futures, 2015) and veterinary curricula. this makes zoonotic disease risk less visible and may subject it to an availability heuristic, where the likelihood of an event is judged based on how easily an instance comes to mind (tversky and kahneman, 1974) . the absence of diseases such as rabies from the uk may also mean that veterinary professionals underestimate the risk of zoonoses because they consider the impacts to be relatively minor, short-term and treatable. this affect heuristic may be especially pronounced when decisions are made under time pressure (finucane et al., 2000) , perhaps reflected in this study's finding that those who viewed time constraints as a barrier to their use of ppe had less positive attitudes towards it. the disconnect between risk perception and health protective behaviour in the present study could be explained by perceived vulnerability. a risk might be acknowledged, yet if an individual does not feel vulnerable to this risk, there is no motivation or intention to change their behaviour. this perceived vulnerability is one of the factors considered in the protection motivation theory, where concern about a potential threat influences perception of the risk i.e. the more concerned an individual is about a disease, the higher risk they perceive it poses. if an individual feels vulnerable, this acts as a motivator for behaviour change (schemann et al., 2013 ). this behavioural model has been applied to horse owners following the equine influenza outbreak in australia where different levels of perceived vulnerability were identified in a cross section of the equine sector (schemann et al., 2013 (schemann et al., , 2011 . perceived vulnerability may be influencing health protective behaviour in the present study. it is possible that veterinary professionals, because they feel knowledgeable about zoonotic diseases, feel less vulnerable to the risks they pose. this lack of perceived vulnerability may account for the substantial proportion of respondents who stated they would not use ppe when handling clinically sick animals; perhaps because they are confident in their ability to identify those cases with potentially zoonotic or infectious aetiologies. identification of risk to self as a motivating factor was associated with a more "positive attitude" towards ppe use, but being a nurse was independently correlated with both of these variables. possibly because nurses often have less influence in decisions over diagnostics or handling of cases, they may feel more vulnerable. the protection motivation theory is only one of numerous health behaviour models that have been applied to both medical and veterinary research. these models are useful for explaining behaviour change in relation to infection control or biosecurity however they have had limited success in practice (pittet, 2004) . the main criticism of these models is that they make an assumption that behaviour is rational, controllable and therefore modifiable (cioffi and cioffi, 2015) . in reality, behaviour is affected by many external influences such as culture and society. society and culture are fluid, constantly changing concepts and consequently it makes incorporating them into behavioural models problematic. so while these models of behaviour are useful in explaining behaviour change to a certain extent, to gain a full understanding of what drives or inhibits behaviour change, social psychology and qualitative research is essential for making real impacts on practice. in the current study, individuals motivated by sops were found to have more positive attitudes towards ppe and also to report better compliance with ppe guidelines for medium-risk scenarios, such as dermatology cases and handling excreta. the "positive attitude" construct, related to self-efficacy, knowledge and confidence in equipment and practices, also clustered with a feeling that there is an expectation to demonstrate good practice. this could be a reflection of the influence of the practice culture on behaviour. in human healthcare, organisational factors, have been identified as one of the main drivers behind poor compliance with ipc practices (cumbler et al., 2013; de bono et al., 2014) . as compliance with infection control intersects individual behaviour and the cultural norms of the practice, the culture of veterinary practice will also be influencing behaviour surrounding infection control. it appears from the present study that when veterinary practices promote a culture of positive health behaviour and have high expectations of employees, this acts as a motivator for compliance with ipc practices. this highlights that behaviour change should also be implemented at an organisational level, rather than just focussing on individual behaviour. veterinary surgeons were more concerned than nurses that using ppe would be perceived negatively by clients. this attitude could be reflecting the importance of the vet-client relationship in veterinary practice. this is particularly relevant in farm animal practice, where vet-farmer relationships are often cultivated over extended time periods and each individual agricultural client represents a significant proportion of practices' income. respondents working in large animal practice were more likely to be motivated to use ppe by liability concerns, again potentially a reflection of the pressure felt by veterinary professionals from their clients. this is an interesting dichotomy, as the use of ppe not only protects the practitioner, but also the animal from zoonotic disease transmission. educating farm clients as to what infection control practices they should expect during clinical work on the farm may help mitigate concerns about negative client perceptions. choices around ppe use appear to be specific both to individuals and contexts, demonstrated by the low correlation between ppe scores in different clinical scenarios. this finding that protocols are often adapted to a specific situation has been observed previously in veterinary professionals (enticott, 2012) . the models that people construct to inform their behavioural decision making are highly individual and influenced by their biology and environment, but also their past experiences (kinderman, 2014) . in the present study, previous experiences of treating zoonotic cases were correlated with lower concern about potential barriers to ppe use. this may suggest that practical experience of dealing with zoonoses is more influential than the theoretical knowledge in negating negative attitudes to ppe use. a limitation of this study, as with any questionnaire based study, is that self-reported behaviours may not necessarily reflect actual practice. this discrepancy between reporting behaviours and actually performing them has been observed previously, particularly in relation to infection control practices and hand hygiene. one ukbased study highlighted no association between self-reported and observed hand-hygiene practices in a sample of healthcare professionals (jenner et al., 2006) , reflecting how self-reported behaviour should be interpreted with caution in any context. observation is considered the gold standard method of assessing behavioural practices, however is still subject to bias in the form of observer bias (racicot et al., 2012) and video recording has been used recently to monitor hand hygiene practices (boudjema et al., 2016) . these methods could also be effectively applied in a veterinary context and qualitative research methods, such as ethnography, would also provide valuable insights into the culture and practices of infection control and health protective behaviours in veterinary practice. the veterinary practices invited to take part in this study were randomly selected, using systematic random sampling, from the rcvs database. this system of using the rcvs database to sample the veterinary profession has been used previously for other research studies and is an established method of sampling this target population (nielsen et al., 2014) . the selection of practices was random, however the selection of participants at each practice may have been subject to selection bias. to facilitate a greater response rate, where data were available, individual respondents at each practice were selected from the rcvs register. to ensure this was consistent, the principal veterinary surgeon and head nurse were selected for each practice. using individual names may have increased the likelihood of the participant responding, however this may have introduced some selection bias as the selected participants are likely to be a more experienced professional. our results suggested that some workplace factors, such as sops and expectations of colleagues, influenced respondents' perceptions and attitudes to ppe use. these might be expected to cluster within practice; the response from a veterinary surgeon and nurse from the same practice might not be completely independent. however, it was not feasible to introduce practice as a random effect, as not enough practices returned two responses (22.2% returned responses from a veterinary nurse and veterinary surgeon from the same practice). as with any questionnaire-based research, this study will be subject to an element of responder bias, and the relatively low response rate of this study may accentuate this bias. this is particularly evident with male nurses, who are few in number, making them difficult to target using random selection methods. according to the latest rcvs annual report, male nurses represented just 2.1% of the total veterinary nurse population in the uk (rcvs, 2014), in the present study, 6% (95% ci 1.7-10.4) of respondents were male nurses. the rcvs database used to sample the veterinary population for this study does not contain information on specialism or type of practice, therefore it is not possible to assess whether this sample is representative of the wider veterinary profession. however, the demographic data on respondents are similar to data from the rcvs annual report; the mean age in our study was 42 years, compared with 41 years in the annual report. in addition, the gender split was similar; in our study, 61.1% (95% ci 55.1-67.1) of respondents were female and the rcvs reported 57.1% were female (rcvs, 2014) . despite similarities between the respondents and the veterinary population in the uk, the low response rate means the results from this sample may not necessarily be generalisable to the wider veterinary population, however this study is the first to provide these baseline data on attitudes and beliefs regarding zoonoses in the british veterinary population, which can be built on with future studies. the majority of respondents worked in small animal practice, which partly reflects the distribution of british practice types, but as the questionnaire was posted to the practice, this may have made it easier for small animal practitioners to respond as the majority of their time is spent within the practice premises. this means the study may be more representative of small animal veterinary professionals, rather than large and equine practice. to negate this in future studies, the use of stratified sampling would be a useful sampling method to ensure representative samples from each sector of the veterinary profession. this study aimed to investigate risk perceptions of zoonotic disease transmission in the veterinary profession in britain. the high infection rate within the profession suggests transmission of zoonotic infections from patient to clinician should be of concern. this study identified a few concepts that were reported to influence the use of ppe including a fatalistic attitude, the social environment and an individual's position within the practice. improving education provided to veterinary professionals may help improve compliance with sops and infection control practices to a certain extent, however this study has highlighted that increased knowledge does not necessarily equate to exhibiting riskmitigating behaviour. this suggests construction of risk is complex, circumstance-specific and can be influenced by a number of different internal and external factors. a qualitative study, using mixed qualitative methods including in-depth interviews and focus group discussions, to explore the construction of risk in the veterinary profession, is currently being developed to understand these concepts in more depth. survey reveals high risk of injury to equine vets a review of published reports regarding zoonotic pathogen infection in veterinarians interventions with potential to improve the mental health and wellbeing of uk veterinary surgeons numerical ecology with r journal of nursing & care hand hygiene analyzed by video recording challenging suboptimal infection control keeping workers safe: does provision of personal protective equipment match supervisor risk perceptions? risks of zoonoses in a veterinary service culture change in infection control mrsa in equine hospitals and its significance for infections in humans organizational culture and its implications for infection prevention and control in healthcare institutions zoonotic disease risk perceptions and infection control practices of australian veterinarians: call for change in work culture the local universality of veterinary expertise and the geography of animal disease occupational health hazards in veterinary medicine: zoonoses and other biological hazards psy: various procedures used in psychometry the affect heuristic in judgments of risks and benefits injury in australian veterinarians molecular epidemiology of methicillin-resistant staphylococcus aureus isolated from australian veterinarians a survey of zoonotic diseases contracted by south african veterinarians health and safety in agriculture in great britain methicillin-resistant staphylococcus aureus colonization in veterinary personnel a survey of the risk of zoonoses for veterinarians infection prevention as a show: a qualitative study of nurses' infection prevention behaviours discrepancy between self-reported and observed hand hygiene behaviour in healthcare professionals carriage of methicillin-resistant staphylococcus aureus by veterinarians in australia new laws of psychology: why nature and nurture alone can't explain human behaviour hand-hygiene practices and observed barriers in pediatric long-term care facilities in the new york metropolitan area adherence to surgical hand rubbing directives in a a survey of veterinarian involvement in zoonotic disease prevention practices significant injuries in australian veterinarians and use of safety precautions evaluation of specific infection control practices used by companion animal veterinarians in community veterinary practices in southern ontario hand hygiene practices of veterinary support staff in small animal private practice the power of vivid experience in hand hygiene compliance survey of the uk veterinary profession: common species and conditions nominated by veterinarians in practice work-related accidents and occupational diseases in veterinarians and their staff disease and injury among veterinarians the lowbury lecture: behaviour in infection control rcvs facts evaluation of the relationship between personality traits, experience, education and biosecurity compliance on poultry farms in québec. can horse owners' biosecurity practices following the first equine influenza outbreak in australia perceptions of vulnerability to a future outbreak: a study of horse managers affected by the first australian equine influenza outbreak occupational health risks in veterinary nursing: an exploratory study judgment under uncertainty: heuristics and biases report of the survey of the bva voice of the profession panel the role of education in the prevention and control of infection: a review of the literature occupational health and safety in small animal veterinary practice: part i -nonparasitic zoonotic diseases suspected transmission of methicillin-resistant staphylococcus aureus between domestic pets and humans in veterinary clinics and in the household infection control practices and zoonotic disease risks among veterinarians in the united states perceived threat, risk perception, and efficacy beliefs related to sars and other (emerging) infectious diseases: results of an international survey the authors gratefully acknowledge all participating veterinary nurses and veterinary surgeons, and dr j.l. ireland for her guidance and advice. this work was supported by the national institute for health research health protection research unit (nihr hpru) in emerging and zoonotic infections at university of liverpool in partnership with public health england (phe), in collaboration with liverpool school of tropical medicine. charlotte robin is based at the university of liverpool. the views expressed are those of the author(s) and not necessarily those of the nhs, the nihr, the department of health or public health england. no competing interests were declared. approval for this study was agreed by anglia ruskin university faculty of health, social care and education research ethics' panel. key: cord-316327-0hpthrjo authors: brar, branden; bayoumy, mohamed; salama, andrew; henry, andrew; chigurupati, radhika title: a survey assessing the early effects of covid-19 pandemic on oral & maxillofacial surgery training programs date: 2020-08-18 journal: oral surg oral med oral pathol oral radiol doi: 10.1016/j.oooo.2020.08.012 sha: doc_id: 316327 cord_uid: 0hpthrjo the coronavirus disease 2019 (covid-19) pandemic has specific implications for oral and maxillofacial surgeons due to an increased risk of exposure to the virus during surgical procedures of the aero-digestive tract. the objective of this survey was to evaluate how the covid-19 pandemic affected oral and maxillofacial surgery (omfs) training programs during the early phase of the pandemic. methods: a cross-sectional survey was sent to the program directors of 95 out of the 101 accredited omfs training programs between april 3(rd) and may 6(th), 2020. the 35question survey designed using qualtrics software, to elicit information about the impact of covid-19 on omfs residency programs and the specific modifications made to clinical care, ppe and resident training/wellness to meet the response to the covid-19 pandemic. results: the survey response rate from omfs program directors was 35% (33/95) with most responses from states with high incidence of covid19. all omfs programs (100%) implemented guidelines to suspend elective and non-urgent surgical procedures and limited ambulatory clinic visits by third week of march, with an average date of march 16(th), 2020 (date range march 8(th) -23(rd)). programs used telemedicine (40%) and modified in-person visit (51%) protocols for dental and maxillofacial emergency triage to minimize exposure risk of hcp to sars cov2. ppe shortage was experienced by 51% of the programs. almost two-thirds (63%) of the respondents recommended the use of a filtered respirator (i.e., n95 respirator) with full face shield as their preferred ppe, while 21% recommended powered air purifying respirators (paprs) during omfs procedures. only (73%) of the programs had resources for resident wellness and stress reduction. virtual didactic training sessions conducted on digital platforms, most commonly “zoom” formed a major part of education for all programs. conclusion: all programs promptly responded to the pandemic by making appropriate changes to suspend elective surgery and, to limit patient care to emergent and urgent services. omfs training programs should give more consideration to provide residents with adequate stress reduction resources to maintain their wellbeing and training to minimize exposure risk during an evolving global epidemic. dental and maxillofacial emergency triage to minimize exposure risk of hcp to sars cov2. ppe shortage was experienced by 51% of the programs. almost two-thirds (63%) of the respondents recommended the use of a filtered respirator (i.e., n95 respirator) with full face shield as their preferred ppe, while 21% recommended powered air purifying respirators (paprs) during omfs procedures. only (73%) of the programs had resources for resident wellness and stress reduction. virtual didactic training sessions conducted on digital platforms, most commonly "zoom" formed a major part of education for all programs. conclusion: all programs promptly responded to the pandemic by making appropriate changes to suspend elective surgery and, to limit patient care to emergent and urgent services. omfs training programs should give more consideration to provide residents with adequate stress reduction resources to maintain their wellbeing and training to minimize exposure risk during an evolving global epidemic. our lives in every aspect including medical and surgical training programs and, disrupted the economy of our societies across the world. the first cases of atypical pneumonia due to the novel coronavirus were detected in wuhan city, china and, reported to the world health organization (who) in december 2019. [1, 2] subsequently, on january 8 th 2020, the chinese center for disease control and prevention announced identification of sars-cov2 an enveloped, positive-sense, single-stranded rna virus as the causative pathogen of covid-19. [3] since then it has spread rapidly within weeks to every part the world. the rapid spread of this virus to every continent was facilitated by ever-increasing international air travel, the integration of global supply chains, and in part, due to the greater transmissibility of the sars-cov2 virus. [4, 5] on january 30, 2020, the world health organization (who) declared the covid-19 outbreak a public health emergency of international concern and, shortly thereafter on march 11, 2020 classified it as a pandemic at which point there were 130,000 confirmed cases in 118 countries. [6] health care personnel (hcp), particularly dentists, oral and maxillofacial surgeons, otolaryngologists and head & neck surgeons, craniofacial surgeons and others who operate in the aero-digestive tract are at high risk for exposure to this virus. the primary mode of transmission of sars-cov-2 is via respiratory droplets (>5um) and through airborne transmission of droplet nuclei (<5um). manipulation of the upper respiratory or oral mucosa or surgical procedures in aero-digestive tract can generate aerosol containing virus particles, increasing the risk to personnel operating in these anatomic areas. [7] [8] during the initial phase of the outbreak, data from wuhan showed that healthcare personnel accounted for 29% of the patients, emphasizing the importance of appropriate ppe to reduce the risk of nosocomial transmission. [2] [7] around the same time in january 2020, communication from stanford university revealed anecdotal evidence of nosocomial spread of covid-19 among surgeons and other health care personnel involved in trans-sphenoidal pituitary surgery. [9] [10] also, previous reports from hong kong during the first sars outbreak in 2002-2003 revealed a high risk to health care personnel (hcp) who accounted for 35% of the cases. [11] in the united states (us), the evolution of this outbreak started with the first reported case on january 19 th 2020 in washington state. [12] less than 2 months after the detection of this index case a national health emergency was declared in the us on march 13 th 2020. to date there are more than 5.5 million confirmed cases and 350,000 fatalities worldwide, with more than 1.6 million of these cases and over 100,000 deaths in the united states (us). [13] in the absence of a vaccine and, limited effective anti-viral therapies, the management of the covid-19 pandemic has centered on supportive care for those with severe symptoms, and the use of physical means such as quarantine and "social distancing" for mitigation of spread. [14] in the first 2 weeks of march 2020, through personal communication and the news, we became aware of the changes that were already implemented in washington state and other metropolitan areas like san francisco. on march 13 th the american college of surgeons (acs) issued a statement based on the preceding events in italy and china, recommending to reschedule elective surgeries and to shift inpatient procedures to outpatient settings, when feasible. subsequently, on march 18 th 2020, the centers for medicare and medicaid services (cms) issued a directive to halt all elective, and non-essential, nonemergent surgeries and preventive services. [15] this was done to reduce demands on hospitals and their resources including personnel, ppe, ventilators, beds, icus and to lower potential exposure of healthcare personnel. cms also increased access to medicare telehealth services for its beneficiaries under the coronavirus preparedness and response supplemental appropriations act. this rapid turn of events led to some urgent modifications to clinical care including surgery, by us health care providers in all specialties, to accommodate the critical shortages of hospital resources as the pandemic was evolving. at this early stage (march 6th-18th, 2020) there was sparse information as to what other omfs training programs in teaching hospitals were experiencing and, how they handled emergent procedures, and, what measures they instated to maintain the safety and wellness of the residents and faculty. this evoked the need to survey omfs training programs and to start a discussion regarding some of the changes in emergency triage, urgent surgical procedures, and use of ppe to protect health care personnel. by the fourth week of march, most of the professional societies including the american association of oral and maxillofacial surgeons (aaoms), the british association of oral and maxillofacial surgeons (baoms)-british association of oral surgeons (baos) had issued guidance statements to minimize exposure risk to hcp. they suggested methods to avoid in-person encounters by using telemedicine triage, keeping emergency visits brief, having faculty or senior residents make definitive decisions for treatment to mitigate exposure risk. further updates were provided, for high-risk procedures in aerodigestive tract such as, nasal endoscopy, and tracheostomy. [16] the aim of this survey was to assess the impact of covid -19 on oral and maxillofacial surgery (omfs) training programs in the different regions of usa during the early phase of this pandemic between march 6 th to may 6 th 2020. as the pandemic was rapidly growing in the us, we wanted to know what changes were implemented by other omfs training programs in the country to maintain the safety of their providers and patients, while accommodating for the surge of new infected patients. we specifically asked questions with respect to management of dental and maxillofacial emergencies, recommendations for ppe during clinical care, staffing changes, and resources used for resident didactic surgical training and wellness. a questionnaire titled "national survey assessing the impact of covid-19 pandemic on oral and maxillofacial surgery training programs" was sent out via electronic mail on april 3 rd 2020 to the program directors of the 95 out of 101 accredited omfs training programs throughout the united states. we had access to public email addresses of only 95 out of 101 accredited omfs programs at the time the survey was distributed. the questionnaire was developed using qualtrics software, which is a valuable online survey tool that allows one to build and distribute surveys, and analyze responses. the survey questions were reviewed by omfs faculty and boston university" institutional review board (irb) officer and a waiver was granted, as none of the questions requested identifiable information about the respondents. this allowed us to expedite the survey distribution during the early phase of this pandemic. the survey was first sent to the 95 omfs program directors on april 3 rd 2020 and subsequently a weekly follow-up reminder was sent to those who did not respond and to those who did not complete the survey over a 4-week period until the closing date of may 6 th 2020. shortage and type of ppe used during clinical encounters and surgical procedures; 4) resident didactic training and wellness: resources used to maintain resident wellbeing. (table i ) descriptive statistics were automatically computed by boston university" qualtrics  software. we analyzed the data by region to compare the differences in west, midwest, south, northeast, and other territories. we compared the differences among the programs who suspended routine clinical activities earlier than march 16 th 2020 to those who did so on or after that date. emergency services: all participating programs implemented a modified dental and maxillofacial emergency triage protocol. these emergency services were primarily rendered in the hospital setting in the emergency department (37.8%) or omfs ambulatory clinic (28.4%). emergency services were provided less often (16.2%) in the dental school setting. remote consultation for emergency care was also provided through telemedicine (17.6%) by a limited number of programs. during the covid-19 pandemic, the majority of programs (76%) reported an average reduction of 63% in emergency department encounters. a few programs (6%) reported a 15% average increase in the number of emergency encounters and the remaining reported no change during the pandemic. when asked about the frequency of the emergency department encounters 82% of the programs reported less than 10 encounters per day, with the majority reporting having less than 5 encounters. only 15% reported greater than 10 emergency department encounters daily. the type of emergency encounters are shown in figure 6 . treatment: emergent surgical procedures in the operating room were rendered by 93.9% of programs, whereas 6.1% provided no operating room services during this time. the emergent surgical procedures that were performed in the operating room during the pandemic are shown in figure 7 . the emergency procedures conducted in the ambulatory (hospital or dental school) setting included clinical evaluation for dental emergencies, extractions, splinting dento-alveolar fractures, incision and drainage of dental abscesses and closed reduction of mandibular fractures. almost all programs (97%) reported following guidelines established by their hospital with the exception of 3% who followed state health department guidelines. of the 97% who followed hospital guidelines, (28.1%) used these guidelines alone, whereas 65% reported using them in combination with other guidelines including those from center for diseases control (cdc), dental school (21.9%), and state dental society (3.1%). there were no major differences in the level of ppe recommended regardless of the clinical setting operating room vs. ambulatory clinic or ed for oral surgical procedures. there was a slight preference for using a powered air purifying respirator (papr) in the operating room. practitioners had a number of guidelines on appropriate ppe use while performing procedures. health care personnel to respond promptly with caution and valor, risking their lives; but the impact of this pandemic is unique for several reasons. unlike the earlier outbreaks, which were largely regional epidemics/events, but in the same pattern, covid-19 spread rapidly across the globe; disrupting the social, economic and emotional wellbeing of most societies. health care personnel (hcp) were requested to make rapid changes within hours/days to adapt and work with the challenges of physical and social distancing, additional uncomfortable ppe, shortage of hospital resources, and to function under stressful conditions with limited assistance and many unknown facts about the virus. as the pandemic evolved the governing authorities had to rapidly modify plans from an "emergency preparedness" mode to the possibility of resorting to a "crisis standards of care" and make ethical decisions to accommodate the surge. [17] specific to oral and maxillofacial surgeons and other specialists working in the aero-digestive tract, is the concern regarding increased exposure risk due to aerosol generating procedures in the oral cavity, nose, and/or oropharynx. [7, 10, 16] we had 35% survey response rate with representation from 33/95 omfs programs surveyed in all regions. the majority of our survey respondents were located in states with higher incidence of covid-19 with (9/33) early survey responses from new york state. this is likely due to the rapidly changing situation in their region as well as the awareness of the omfs program directors who were encountering many questions or dilemmas as we did, during this early phase of the pandemic. the vast majority (79%) of the survey responses were received from hospital based-university affiliated programs. we our survey showed that 7 /33 programs (21%) reported having trainees or faculty members infected by sars-cov2. this is inevitable given the nature of our professional responsibilities and the type of procedures we perform, especially given the shortage of ppe during the pandemic. lancaster et al reported on how the surgery department at an academic medical center optimized human resources. they identified key skills in each team member and ensured there were multiple team members with similar skill sets in order to accommodate for absences in case they were infected. they also limited faculty to single hospital sites and reduced the number of providers on-site each day, with contingency plans for section or department leadership. [29] similarly other surgical departments rapidly redesigned and shifted workforce based on need. [30] a number of omfs trainees and faculty were redeployed to other services during the surge/ height of the pandemic, based on need. more residents were redeployed in comparison to faculty. fourteen out of the 33 programs reported reallocation of residents to other services including covid-19 wards and 5 /33 programs reported redeployment of faculty. this may be a reflection of those trainees who were on their general surgery or medicine or anesthesia rotations. ten of these 14 programs were dual degree programs . personal communication with program directors revealed one omfs trainee fatality during the early phase of this pandemic. in their manual on how to protect health care personnel during global epidemics, the who has proposed recommendations to educate hcp to reduce exposure risk, to reduce anxiety and fear, and to promote health of wellbeing of responders. they also emphasized the importance of direct, face-face communication with hcp in a fair environment without blame. [26] clinical operations: all programs directors responded that only urgent and emergent procedures were performed during the pandemic. about 9% of the participants continued to provide new patient consultations. it was not clear whether these were urgent and whether they were performed using telemedicine. about 63 % of the programs reported utilizing some form of telemedicine for patient care mainly postoperative follow up visits. active participation in clinical care through telemedicine can complement residents" clinical training and facilitate emergency triage by decreasing exposure risk. on march 17 th 2020 several temporary regulatory waivers and new rules were ordained to allow flexibility in the healthcare system to respond to the covid-19 pandemic. this temporary relaxation in regulations helped many patients to seek care in non-traditional ways through telehealth, allowing hospitals to deal with any patient surges. [31] when in-person encounters were necessary, institutions and professional organizations have recommended that the most experienced or skilled team member assess the patient to make definitive treatment decisions, in order to limit exposure of multiple individuals. as a result, surgical faculty in many institutions, as well as in the boston area performed surgical procedures either independently or with another faculty member or senior resident when assistance was necessary. operating during these conditions can be difficult, stressful, and more prone to errors. it is important to make time to plan, delegate and make difficult decisions. [32] many treatment decisions during the pandemic had to be modified even for emergent and urgent situations. decisions to surgically intervene or choose a non-surgical alternative, to perform treatment immediately or delay treatment, admit or not to admit were some of the dilemmas faced by clinicians during the height of the pandemic while preparing for the surge. it is important to consider the risks and benefits from a societal standpoint as well as the individual patient"s perspective, when making these ethical decisions. reduction in volume of operating room procedures was difficult to estimate as our questionnaire did not specifically ask programs to quantify this. based on the authors" institutional experience, we expected there would be an 80-85% reduction in operating room volume after cms directive on march 18 th 2020 to suspend elective and non-essential surgery. [15] most omfs programs indicated about 62% reduction in emergency department patient encounters. despite the significant reduction, deep neck infections and maxillofacial injuries continued and comprised the majority of omfs emergency room encounters. the number of maxillofacial injuries due to assaults was higher than motor vehicular crashes (mvc) and falls. one can expect this due to increase in violence, given the food and shelter insecurity and frustration from social distancing. the reduced road traffic may have also contributed to increased trauma from assault compared to mvc's during the pandemic. increase in domestic violence, altercations among incarcerated and homeless individuals was reported during the pandemic. [33] situations such as this pandemic require strong leadership providing direction to all, and cohesive teams that can work well and respond to take actions immediately. the the access to and use of ppe has been a major concern during this pandemic. we felt the choice of ppe may be influenced by the availability in their institutions. therefore, we questioned participants on what they would recommend rather than what ppe they used during the pandemic. a little over half of the participating programs (52%) reported ppe shortages. of those experiencing a shortage, n95 respirators were the most commonly reported (94.1%), which led to the subsequent plan to recycle n-95 masks. there was an overwhelming consistency in the ppe recommendations for all oral and maxillofacial surgery procedures given the high-risk for exposure to sars-cov2. most of the surgeons (62%) recommended n-95 respirator with full-face shield in conjunction with fluid resistant gown, gloves. powered air purifying respirators (paprs) were recommended by a few (21%) for operating room procedures. all programs reported having hospital guidelines in place for the appropriate use of ppe. there is evidence that paprs provide greater protection due to higher microbial filtration efficiency than n-95 masks, however, these devices can be cumbersome and preclude use of head light and ability to communicate well with others during the operation. surgeons in other sister specialties consider paprs as essential for optimal safety while performing aerosol generating procedures. otolaryngologists have recommended a higher level of ppe during aerosol generating procedures as a precautionary measure. they also feel that further clarification is necessary to determine the type of ppe to reduce the risk of exposure. resident training: all training programs responded that their residents had access to virtual didactic training sessions and self-study resources. it is important to have some structure to the didactic training and continue their core activities using virtual classroom technology. residents were resourceful and several education webinars. programs such as covid collaborative lecture series (three hours per week) hosted by the university of michigan and, partner institutions has become popular. such initiatives may be the beginning of a national curriculum. other surgical specialties such as otolaryngology and urology have reported using similar collaborative lecture series. they also used surgical simulations models for training residents. [36] the most common digital platform used was "zoom". some others used "microsoft teams", which has better security features and collaborative options. the cost, real-time collaborative features and, the number of participants allowed can vary in each of these video conferencing applications [37] our survey did not address the question about resident research activities, but personal communication with a number of programs revealed that many residents and faculty were productive in research and scholarly activities. steadiness, compassion and resilience are important qualities to nurture during these demanding times. among the surveyed omfs programs, 73% (24/33) reported that their residents had access to wellness programs, such as mindfulness and meditation seminars, yoga, and other exercise activities. some programs reported access to tele-psychiatry services, if necessary, to relieve anxiety and stress. some other specialties reported the benefits of virtual departmental social hours. in order to facilitate connecting with colleagues and faculty, they made time for social hours within their weekly schedules. practical issues affecting hcp include childcare, housing, and meals. our survey revealed that many residents used food delivery, transportation and housing services. similar surveys have been conducted by most surgical specialties including otolaryngology, urology, orthopedic surgery and general surgery. [30, [36] [37] [38] they reported more stringent schedules to manage the staffing shortages and, structured didactic training including virtual surgical simulation programs, seminars and access to video libraries as well as, time for virtual social hours with colleagues and faculty. a qualitative study conducted by he et al. surveyed general surgery residents in 2 major hospitals in the boston area regarding their concerns about the covid-19 outbreak. [26] most residents responded that their main concern was health of their older family members and the possibility of transmitting infection to their family members. they did not worry as much about increased work load or even getting infected by the sars-cov-2 virus. [26] their study also emphasized the recommendations of the world health organization (who) that hcp should be educated well about exposure risk through direct face-to-face communication in a blame free environment during these global epidemics. the paper titled "a survey assessing the early effects of covid-19 pandemic on oral & maxillofacial surgery training programs is a current topic of interest for all dental specialty training programs during this pandemic. this study highlights the importance of adequate wellness resources for trainees and the need for structured training for proper use of personal protective equipment and infection control tables: table i figure 11 : guidelines used to help implement changes in resident didactic activities during the covid-19 pandemic. coda = commission on dental accreditation; acgme = accreditation council on graduate medical education; ada = american dental association. figure 13 : video conferencing platforms used by residency programs to conduct didactic activities during the covid-19 pandemic. wellness initiatives offered to omfs residents, faculty and staff during the covid-19 pandemic. a novel coronavirus from patients with pneumonia in china a pneumonia outbreak associated with a new coronavirus of probable bat origin detection of 2019 novel coronavirus (2019-ncov) by real-time rt-pcr the novel coronavirus originating in wuhan, china: challenges for global health governance early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia china coronavirus: who declares international emergency as death toll exceeds 200 aerosol-generating otolaryngology procedures and the need for enhanced ppe during the covid-19 pandemic: a literature review aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review letter: precautions for endoscopic transnasal skull base surgery during the covid-19 pandemic covid-19 and the otolaryngologist -preliminary evidence-based review comparative epidemiology of human infections with middle east respiratory syndrome and severe acute respiratory syndrome coronaviruses among healthcare personnel first case of 2019 novel coronavirus in the united states who coronavirus disease (covid-19) dashboard covid 19 isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus (2019-ncov) outbreak cms, cms recommendations on adult elective surgeries, non-essential medical, surgical, and dental procedures during covid-19 response updated covid-19 advice from baoms and ent uk for our surgical teams crisis standards of care: a toolkit for indicators and triggers covid-19: protecting health-care workers high risk of covid-19 infection for head and neck surgeons approaches to the management of patients in oral and maxillofacial surgery during covid-19 pandemic surgical considerations for tracheostomy during the covid-19 pandemic: lessons learned from the severe acute respiratory syndrome outbreak covid-19 pandemic: effects and evidence-based recommendations for otolaryngology and head and neck surgery practice covid-19: what has been learned and to be learned about the novel coronavirus disease sars-cov-2: virus dynamics and host response quantitative detection and viral load analysis of sars-cov-2 in infected patients addressing general surgery residents' concerns in the early phase of the covid-19 pandemic early dynamics of transmission and control of covid-19: a mathematical modelling study characterization of spike glycoprotein of sars-cov-2 on virus entry and its immune cross-reactivity with sars-cov rapid response of an academic surgical department to the covid-19 pandemic: implications for patients, surgeons, and the community redesigning a department of surgery during the covid-19 pandemic operating during the covid-19 pandemic: how to reduce medical error family violence and covid-19: increased vulnerability and reduced options for support covid-19 coronavirus: recommended personal protective equipment for the orthopaedic and trauma surgeon perioperative considerations in urgent surgical care of suspected and confirmed covid-19 orthopaedic patients: operating room protocols and recommendations in the current covid-19 pandemic adapting urology residency training in the covid-19 era orthopaedic education during the covid-19 pandemic otolaryngology resident practices and perceptions in the initial phase of the u.s. covid-19 pandemic key: cord-318660-47dqa1dd authors: jain, mehr; kim, sonya t; xu, chenchen; li, heidi; rose, greg title: efficacy and use of cloth masks: a scoping review date: 2020-09-13 journal: cureus doi: 10.7759/cureus.10423 sha: doc_id: 318660 cord_uid: 47dqa1dd during the coronavirus disease 2019 (covid-19) pandemic, there has been a global shortage of personal protective equipment (ppe). in this setting, cloth masks may play an important role in limiting disease transmission; however, current literature on the use of cloth masks remains inconclusive. this review aims to integrate current studies and guidelines to determine the efficacy and use of cloth masks in healthcare settings and/or the community. evidence-based suggestions on the most effective use of cloth masks during a pandemic are presented. embase, medline, and google scholar were searched on march 31, 2020, and updated on april 6, 2020. studies reporting on the efficacy, usability, and accessibility of cloth masks were included. additionally, a search of guidelines and recommendations on cloth mask usage was conducted through published material by international and national public health agencies. nine articles were included in this review after full-text screening. the clinical efficacy of a face mask is determined by the filtration efficacy of the material, fit of the mask, and compliance to wearing the mask. household fabrics such as cotton t-shirts and towels have some filtration efficacy and therefore potential for droplet retention and protection against virus-containing particles. however, the percentage of penetration in cloth masks is higher than surgical masks or n95 respirators. cloth masks have limited inward protection in healthcare settings where viral exposure is high but may be beneficial for outward protection in low-risk settings and use by the general public where no other alternatives to medical masks are available. disposable surgical face masks (also termed procedure masks) and respirators are essential components of personal protective equipment (ppe) for preventing the transmission of infectious diseases. both the canadian and international guidelines highlight the importance of proper usage of ppe among frontline healthcare workers (hcws) during the current coronavirus disease 2019 (covid-19) pandemic [1] [2] [3] [4] . the shortage of ppe observed worldwide as a result of this pandemic places both hcws and patients at risk [5, 6] . although guidelines from the world health organization (who) and centre for disease control and prevention (cdc) suggest various strategies to optimize the supply of ppe in healthcare settings [4, 7] , there are limited data on alternatives to surgical masks. in these situations, 3d-printed respirators or community-sourced homemade cloth masks may be potential sources to meet demand in healthcare and community settings. cloth masks are defined as masks made of cloth or any other fabric that has been previously used to make masks, such as cotton, gauze, silk, or muslin [8] . surgical masks are certified/rated medical ppe that are fluid-resistant and are effective to protect the wearer from large particles of respiratory secretions known as droplets. comparatively, respirators, which are also certified medical ppe and have a variety of ratings (of which n95 is the most commonly used in north america), are useful for user protection against small respiratory particles known as aerosols or droplet nuclei [9] . in both cases, the primary reason these ppe are used in healthcare is the protection of the wearer or inward protection. however, there is an additional role of both surgical masks and respirators to retain respiratory particles in order to avoid spread to others, also known as outward protection. prior to the covid-19 pandemic, the usage of cloth masks in healthcare and the community is commonly observed in many asian countries, including china and vietnam [10, 11] . during the severe acute respiratory syndrome (sars) outbreak in 2002, there were reports of the usage of cotton cloth masks among hcws in china [12] . in the current covid-19 pandemic, chinese recommendations on face mask use in community settings suggest that cloth masks could be used in a very low-risk population to prevent the spread of disease [13] . in the western world, the use of cloth masks is rarely witnessed in healthcare settings due to the availability of surgical masks and respirators. in times of a global pandemic with limited resources, cloth masks may be useful in protecting hcws and retaining fluids and droplets in infected patients. however, there is a lack of comprehensive literature that summarizes the latest findings on the extended use and reusability of cloth masks [9] along with limited guidance on its use during the covid-19 pandemic. this review aims to integrate current studies and guidelines to determine the efficacy of cloth masks as both inward and outward protective equipment and whether they can be used in healthcare settings and/or the community in light of the ppe shortage. furthermore, evidence-based suggestions are made on the most effective use of cloth masks during the times of pandemic. the search strategy was conducted on march 31, 2020, using an open date search strategy. the search terms used were "masks", "respiratory protective device", "facemask" to capture articles studying face masks. the terms "cotton", "cloth", "homemade", "home made", "diy", "do it yourself", "t-shirt", "muslin", "gauze", "cheese cloth", "towel", "fabric", "tight woven" and "tight weave" were used to find articles related to cloth masks. the search strategy was employed on embase, medline, and google scholar. the search strategy was updated on april 6, 2020. the titles and abstracts obtained from search strategies were screened by three reviewers (c.x., s.k., m.j.). discrepancies were resolved by discussion between the three reviewers. the same reviewers also completed the full-text review. the reference list of studies selected for the review was screened by one reviewer to gather additional articles. the study population comprised hcws and healthy volunteers. two studies, one observational and one rct, were conducted on hcw participants [10, 14] . another three studies were conducted on healthy volunteers [18, 20, 21] . of the nine studies, four used cotton cloth masks [10, 14, 17, 18] , one used polyester masks [19] , and four [15, 16, 20, 21] compared different types of materials commonly found in a home as possible materials for homemade masks. the characteristics and results of each study are summarized in table 1 three studies measured inward protection of cloth masks in human subjects [10, 14, 21] . out of three studies, one rct showed that the cloth mask group had the highest rate of influenza-like illness compared to the medical mask group and control group and cautioned that cloth masks should not be recommended for hcws in high-risk settings [14] . however, the results from this study are difficult to interpret as the control group was "standard practice", comprising individuals using both medical and cloth masks. one other study showed that homemade masks made of tea cloth provided protection during short-and long-term activities compared to no mask [21] . ma et al. showed that while n95 respirators blocked 99.98% avian influenza virus, cloth homemade masks and surgical masks were comparable (95.15% and 97.14%, respectively). these homemade masks used in the experiment were made from polyester and kitchen towels [19] . three articles showed that cloth masks resulted in higher rates of infection or particle exposure as compared to surgical masks [10, 14, 21] . three studies specifically measured outward protection either with human subjects [18, 20] or by simulating expiration with an artificial head [21] . in human subjects, both surgical and cloth masks were effective in controlling the number of microorganisms released into the environment when coughing, though surgical masks were more effective, especially with smaller particles [20] . in an older study, quesnel showed that a cotton mask, which was not homemade, provided equivalent outward protection as two other surgical masks [18] . in an experimental setup with an artificial head, cloth masks provided marginal outward protection [21] . a few studies compared the filtration efficacy of various household materials [16, 20] . one such study assessed pressure drop across different household materials to assess comfort of material when used in the masks along with filtration efficiency against microbial aerosols. davies et al. used both bacillus atrophaeus (0.95-1.25 um) and bacteriophage ms2 (23 nm) to generate microbial aerosols for the simulation of particle challenge. they found pillowcases and 100% cotton t-shirts to be most suitable to construct more efficacious cloth masks compared to tea towels, vacuum cleaner bags, silk, and so on [20] . another laboratory study evaluated the penetration of monodispersed nacl aerosol particles through cloth masks made of various materials (sweatshirts, t-shirts, towels, or scarves). the penetration of these masks was 35-68% at 20 nm in diameter and 73-82% at 100-400 nm [16] . assuming that sars-cov2 particles are of a similar size as sars-cov particles from the 2002-2004 outbreak (80-140 nm), these nanoparticles are in the relevant size range [22] . studies that compared filtration efficacy of cloth masks to surgical masks or n95 respirators found that particle penetration was consistently higher in cloth masks [14, 15] . another study showed no significant difference in the efficacy of surgical masks compared to wellconstructed reusable four-ply cotton muslin masks when testing micro-and nanoparticles together [18] . higher compliance with cloth masks is seen in low-to middle-income countries and during pandemics due to the overall lack of ppe [10, 15, 20] . during the h1n1 pandemic, the majority of doctors and nurses used cloth masks (self-reported: 59.8%) over medical masks across eight hospitals in beijing, china [10] . another study reported that hcws showed equal compliance when wearing cloth as compared to medical masks (57%), where compliance was defined as wearing the mask more than 70% of the time [14] . the main adverse events that decreased compliance were general discomfort and difficulty breathing, though adverse events were reported in both medical and cloth mask groups (40.4% and 42.6%, respectively) [14] . in kathmandu, nepal, 31% of the general population surveyed were found to wear cloth masks on the streets to protect themselves against pollution [15] . the fit of a mask is an important variable in determining its efficacy. it is considered an area of weakness for cloth masks. davies et al. used the wilcoxon sign rank test to assess the fit of surgical and cotton cloth masks. the participants underwent a variety of head and body movements while wearing the masks, and fit testing was also performed at rest. they determined the fit of surgical masks to be significantly superior (p < 0.001) than cotton cloth masks in all activities and at rest [20] . some studies reported reusability and resulting contamination of cloth face masks; however, only one study quantified this. this study showed a negative linear trend between washing and drying cycles and filtration efficacy (r 2 = 0.99). after the fourth wash and dry cycle, the efficacy of the mask had decreased by 20%. microscopic imaging of these masks after wash and dry cycles showed an increase in pore size, change in pore shape, and decrease in the number of microfibers in each pore after these cycles [15] . there are no current guidelines or standardized protocols on the use or creation of cloth masks. the who presented interim guidelines in march 2020 in the context of the covid-19 pandemic stating that they do not recommend the use of cloth masks in healthcare settings, in the community, or at home [23] . another set of recommendations from who published on april 6, 2020, also stated that cloth masks are not appropriate for hcws. if cloth masks are used locally, the who highly encourages local authorities to assess the masks [24] . the cdc suggests that hcws use homemade masks if certified face masks are not available. however, they state that these masks are not considered ppe. the cdc also recommends that homemade masks should be used with a face shield covering the entire face [25] . furthermore, on april 3, 2020, the cdc released recommendations asking the general population to wear cloth masks in areas where socially distancing is not possible [26] . they also released tutorials on how to create these masks [27] . to our knowledge, this is the first review to descriptively synthesize and evaluate the best available evidence on the efficacy of cloth masks, providing relevant and useful information that can guide public health guidelines during the current covid-19 pandemic. to date, there are little data to make definite recommendations as only one rct [14] and a few observational studies [10, 20, 21] have been conducted on this topic. when assessing the overall clinical efficacy of cloth masks compared to surgical masks, two factors must be considered: inward and outward protection. the general consensus of the included studies is that cloth masks confer some degree of inward and outward protection, but are less effective than surgical masks and n95 respirators [10, 14, 20, 21] . the clinical efficacy of a face mask is determined by the filtration efficacy of the material, fit of the mask, and compliance to wearing the mask [21] . filtration efficacy of a material is the ability to function in both inward and outward protective gear. in general, household fabrics such as cotton t-shirts and towels [16, 20] have some filtration efficacy and were shown to have some protection against virus-containing particles. however, the percentage of penetration in cloth masks was higher than surgical masks or n95 respirators. one study, however, suggested that a reusable cloth mask can have the same filtration efficacy as a surgical mask (98.8%) [18] . surgical and cloth masks provide less outward protection partly due to the weaker seal around these masks. when pressurized droplets or aerosolized particles are released from the user (e.g., during a cough or sneeze), these particles have a higher likelihood of escaping from the sides than the front of the mask due to the mask's fit. cloth masks are inferior to surgical masks or n95 respirators when assessing the fit of the mask [20] . there is greater opportunity for air leakage around the sides of a cloth mask than the other two mask types, which decreases its ability to contain particles released by the user. however, dato et al. showed a reasonable fit of their homemade mask in a letter to the editor of emerging infectious disease. they presented a protocol for homemade 100% cotton masks that yielded a fit factor up to 67 (n95 respirators must have a fit factor of at least 100). their homemade mask provided significant protection in an aerosol challenge. the recommended use of these masks was in situations where n95 respirators were unavailable [27] . compliance of cloth masks does not differ from that of medical masks, indicating that homemade masks or masks of varying household fabrics are not any less comfortable. the main side effects were difficulty breathing and general discomfort, which were not unique to cloth masks [14] . in fact, in low-to middle-income countries, compliance may be higher due to a lack of availability of surgical masks. a study was conducted on focus groups of doctors and nurses in vietnam to assess their compliance and opinions of face masks. the groups reported both cloth and medical masks to be comfortable to breathe through. surgical masks were found to be associated with words such as "safe" and "effective", whereas cloth masks were associated with "dirty" [28] . given the variety of options available for different types of cloth masks, all that have shown comparable efficiency [15] while also allowing users to exert their preference and pick a material more comfortable to them. of the various sources searched, guidelines on the use and efficacy of cloth masks were limited to the who and cdc's commentary on cloth masks not qualifying as ppe and the cdc's suggestion of the general population using homemade masks [23, 25, 26] . the who and earlier cdc [23, 24] guidelines focused on the usage of cloth masks as ppe to protect the user from the environment (inward protection) and did not address the use of cloth masks to contain droplets and secretions produced by infected individuals (outward protection). cloth masks showed some evidence of outward protection [20] and filtration against microbial aerosols and nanoparticles [15] [16] [17] 19, 20] , albeit in varying degrees, depending on the material. as a result, the potential for outward protection of cloth masks in healthcare settings should be better assessed and addressed in international guidelines. there have been other guidelines posted on the websites of the who, cdc, and canadian government, which suggest that cloth masks can aid in covering the mouth and nose when coughing [23, 25, 29] . wearing a mask as prophylactic protection against a cough serves as better source control compared to finding mouth coverings spontaneously as needed. it should be noted that cdc recommended disposing of materials sneezed into [26] . cloth masks can be cleaned to address this point in the guidelines. the government of canada also recommended the use of cloth masks by the public in situations where social distancing is not possible and stated that homemade cloth masks are not a replacement for surgical masks [30] . moreover, british columbia centre for disease control (bccdc) guidelines state that contaminated cloth can be cleaned with other pieces of clothing in a laundry machine. hot water (60-90â°c) with soap should be used to clean the laundry machine [26] . many low-and middle-income use cloth masks in healthcare settings due to a lack of financial resources to support the wide use of surgical masks. recommendations regarding cloth mask use in vietnam, pakistan, and china include wearing them during low-risk activity (e.g., slashes of fluid or blood, bacterial infection) in the situation of the influenza season and a pandemic [31] . therefore, cloth masks that are regulated may provide some protection against viruses and bacteria. another benefit of using cloth masks in healthcare or community settings is that the production of these masks can be outsourced to freelancers or volunteers in the community if a stringent and tested protocol is developed. for example, in the covid-19 pandemic, the lack of face masks and other ppe has been a global concern. michael garron hospital in toronto, canada, asked volunteers to create cloth masks at home for use in healthcare due to lack of face masks. the project has provided volunteers with a protocol to follow when making the mask, but whether this protocol has been studied is unknown [32] . there is a tested protocol available through davies et al.'s research study. this group designed and studied a protocol for cotton cloth masks; however, this protocol was not widely implemented as an effort to standardize or certify commercially available cloth masks [20] . moreover, the cdc has also released a tutorial on creating homemade cloth masks; however, the web article does not state if this protocol or recommended materials to make the mask have been tested [33] . there are several strengths to this review. this review provides a unique detailed analysis of the various characteristics that contribute to droplet retention and mask efficacy, including the filtration efficacy of the material, fit of the mask, and compliance of the user. the strength of this review lies in its systematic search of multiple databases and search strategies developed and conducted in conjunction with a research librarian. moreover, international and national guidelines were collected to present the real-world implementation of existing research on cloth masks. there are also several limitations to consider. firstly, the scope of the recommendations presented in this review was limited by the lack of data available on cloth masks. only one rct has been conducted to date and few observational studies exist. included studies did not present a quantitative analysis of the filtration efficacy and penetration of materials commonly used in cloth masks or report on the number of layers of cloth material required for maximized benefit and comfort. this highlights important research questions that future high-quality studies should explore to increase our understanding of the efficacy and use of cloth masks. secondly, the heterogeneity of the included studies notably precluded a meta-analysis. future studies should focus on defining comparable outcomes. another limitation includes the fact that our search criteria limited our review to focus only on published studies. by not including grey literature, the review potentially misses out on other perspectives and information about the usage of cloth masks. future studies should investigate the effectiveness of masks in reducing travel velocities and distances of droplets and aerosols during expiration and coughing, which may reduce the transmission of covid-19. secondly, studies should also investigate the ability of cloth masks to reduce virus transmission by preventing the user from touching their face or droplets from landing on naso-oral surfaces. lastly, to support the cdc recommendation of only using homemade masks in a healthcare setting if a face shield is worn [25] , studies should investigate the efficacy of cloth masks used with 3d-printed face shields. both are easily producible in situations of ppe shortage such as the covid-19 pandemic, and if proven to provide adequate protection for hcw, they can be easily be produced in bulk by the general public. results from these studies may be used to guide recommendations on the use of cloth masks for the general public when social distancing measures are in place. to better understand the role that cloth masks play in pandemics and infectious control generally, further rcts must be conducted. however, a study by macintyre et al. highlights the ethical challenge in designing a rct for mask use, as hcws in the control group cannot be asked to wear a mask when working in high-risk situations [14] . as this rct did not address outward protection, future studies should look at whether cloth masks worn by infected patients can protect the transmission of infection among hcws by retaining droplets and fluids. future studies should make evident whether they are studying inward or outward protection as this discrepancy was unclear in some studies. cloth masks are shown to have limited inward protection in healthcare settings where viral exposure is high but may be beneficial for outward protection in low-risk settings and use by the general public where no other alternatives to medical masks are available. during unprecedented times, such as the covid-19 pandemic, when some organizations like the cdc are suggesting the general population to use cloth masks in public settings, further studies on cloth masks are imperative. the current data are not enough to guide clinical decision-making. given that cloth masks are used when the supply of surgical masks is low, it is important to assess the true efficacy of cloth masks compared to not wearing any masks. in compliance with the icmje uniform disclosure form, all authors declare the following: payment/services info: all authors have declared that no financial support was received from any organization for the submitted work. financial relationships: all authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. other relationships: all authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work. care of the adult critically ill covid-19 patient covid-19 guidance: independent health facilities using personal protective equipment (ppe) rational use of personal protective equipment ( ppe) for coronavirus disease ( covid-19) : interim covid-19: doctors still at "considerable risk" from lack of ppe, bma warns challenges to the system of reserve medical supplies for public health emergencies: reflections on the outbreak of the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) epidemic in china optimizing supply of ppe and other equipment during shortages use of cloth masks in the practice of infection controlevidence and policy gaps understanding the difference mask-wearing and respiratory infection in healthcare workers in beijing, china health care worker practices around face mask use in hospitals in hanoi, vietnam evaluation of control measures implemented in the severe acute respiratory syndrome outbreak in beijing rational use of face masks in the covid-19 pandemic covid-19, shortages of masks and the use of cloth masks as a last resort optical microscopic study of surface morphology and filtering efficiency of face masks simple respiratory protection-evaluation of the filtration performance of cloth masks and common fabric materials against 20-1000 nm size particles a study on the microbial filtration efficiency of surgical face masks--with special reference to the non-woven fabric mask the efficiency of surgical masks of varying design and composition potential utilities of mask-wearing and instant hand hygiene for fighting sars-cov-2 testing the efficacy of homemade masks: would they protect in an influenza pandemic? professional and home-made face masks reduce exposure to respiratory infections among the general population a novel coronavirus associated with severe acute respiratory syndrome advice on the use of masks in the context of covid-19 strategies for optimizing the supply of facemasks accessed simple respiratory mask: simple respiratory mask maclntyre cr 2015: current practices and barriers to the use of facemasks and respirators among hospital-based health care workers in vietnam communication resources accessed examining the policies and guidelines around the use of masks and respirators by healthcare workers in china, pakistan and vietnam we need 1000 masks every week! use of masks to help slow the spread of covid-19 key: cord-286977-330p60oh authors: barcala-furelos, roberto; szpilman, david; abelairas-gómez, cristian; calvete, alejandra alonso; graña, maría domínguez; martínez-isasi, santiago; palacios-aguilar, josé; rodríguez-núñez, antonio title: plastic blanket drowning kit: a protection barrier to immediate resuscitation at the beach in the covid-19 era. a pilot study. date: 2020-09-16 journal: am j emerg med doi: 10.1016/j.ajem.2020.08.101 sha: doc_id: 286977 cord_uid: 330p60oh objective: introducing a new, simple and inexpensive portable equipment for lifeguards, consisting of a pre-assembled full-size plastic blanket with a mask and hepa filter, which could offer significant time-saving advantages to reduce covid-19 risk transmission in the first few minutes of cpr after water rescue, avoiding the negative impact of delayed ventilation. method: a pilot study was carried out to determine the feasibility of the pre-assembled kit of face-mask and hepa filter adapted on a pre-set plastic-blanket. the first step consisted of washing hands, putting on safety glasses and gloves as the first personal protection equipment (ppe) and then covering the victim with an assembled plastic blanket. the second step consisted of 10 min of cardiopulmonary resuscitation (cpr) with ppe and plastic blanket, following the technical recommendations for ventilation during covid-19. results: ten rescuers took part in the pilot study. the average time to wear ppe and place the pre-assembly kit on the victim was 82 s [ic 58–105]. after 10 min the quality of the resuscitation (qcpr) was 91% [87–94]. quality chest compressions (cc) were 22% better than ventilations (v). most of the rescuers (60%) thought that placing the plastic blanket on the victim on the beach was somewhat simple or very simple. conclusions: resuscitation techniques in covid-19 era at the beach have added complexities for the correct use of ppe. plastic blanket plus basic ventilations equipment resource could be a new alternative to be considered for lifeguards to keep ventilation on use while reducing risk transmission. with the emergence of covid-19 [1] disease, there has been a drastic change in the way emergency teams deal with out-of-hospital cardiac arrest and other emergencies. new recommendations for basic life support (bls) from the european resuscitation council during the covid-19 era (erc-covid), [2] propose the use of protective personal equipment (ppe), which significantly delays the starting of chest compressions (cc) and ventilations (v) or do not recommend ventilation at all. drowning is a critical time-dependent circumstance in which cardiac arrest is of an asphyxia origin, so ventilations are essential to revert systemic hypoxia [3] and achieve return of spontaneous circulation. ensuring consistent, correct use of ppe is challenging. it requires training and additional time for donning. [4] when cardiac arrest happens in aquatic environments and lifeguards have to put on and doffing ppe: certain maneuvers are initiated just after the rescue, in which instance both the victim and the lifeguards are wet; and environmental conditions such as hypothermia or hyperthermia difficult its use. additionally, considering that drowning kills 320,000 people worldwide every year, most of whom are in low to medium income countries (lmics), [5] it seems unrealistic to assume that ppe will be available in most of settings. we developed a simple, cost-effective and portable barrier kit to be used in case of drowning cpr. the primary aim of the study was to test the feasibility of this cpr kit designed for the covid pandemic. the ppe kit consists of a pre-assembled full-size transparent plastic blanket with an adaptation to a ventilation face mask with a high efficiency particulate air (hepa) filter.  standard face mask for medical use ambu® mark iv adult size (ballerup,  hepa filter able to adapted to the face mask.  adult size bag with oxygen reservoir. (fig. 1) to optimize the time to deployment, the stored lifeguard backpack kit should be ready to use. it is quite easy to prepare a small opening in the drape. this opening will allow the patient and bvm on the inside of the drape to be connected to the hepa filter, oxygen bag, and rescuer on the outside of the drape. we placed this opening 50 cm from the superior border of the drape. the fixation is be secured by placing a waterproof tape around the connection. the full kit must be placed on the unconscious drowning victim without signs of life in 5 simple steps lasting just one minute, allowing immediate full cpr. -simple‖ and only two participants (20%) considered this process as -difficult‖ or -very difficult‖ (fig.4) . the aim of this report was to show a simple and low cost method, which can help lifeguards at the beach in various ways: as an extra protection attached to ppe, as initial protection when they are wet and cannot wear quickly or correctly ppe (gloves, glasses and plastic coat), in case they decide to provide cpr with a bag-valve mask with hepa filter, or also in lmics that do not have ppe (gloves, glasses and plastic coat), in case they decide to provide cpr with a bag-valve mask with hepa filter. in the covid-19 pandemic the risk of transmission during medical attendance is high. this occurs in techniques or procedures that generate aerosols, such as intubation [7] or any invasive or non-invasive ventilation technique, including the use of bag-valve mask. [8, 9] chan et al showed, how the use of bag-valve mask even with hepa filter, does not prevent 100% air leakage, and how this air leak could reach the rescuer performing cc. [8] . for this reason the use of plastic drapes/patient covering, begins to be explored, to add extra protection during airway interventions[7,10], protecting the laryngoscopist during airway interventions [11] , or covering the patient during prehospital cardiopulmonary resuscitation. [12] these studies and our previous experience in lifesaving have inspired the authors to bring it to an environment with a higher more uncertainty and less control, like a beach. an inadequate lifeguard evaluationvictim is not in cardio-pulmonary arrestmay pose a theoretical limitation if victim is fully covered by interfering with the victim spontaneous breathing. this implies an extra lifeguard training to detect signs of life on the victim and be able to quickly remove the plastic cover. in other circumstances, rescuers may need to remove the blanket: usufoam is generated in drownings of all severity [3] , so the face mask may have to be removed for cleaning up and this may pose a difficulty while using the plastic blanket; foam and water may be need to be aspirated; automatic external defibrillation (aed) may be need as part of bls or the patient may need to be ecg monitored at some point. in addition, some authors have warned of possible risks, such as the permanence of aerosols under the plastic, with the risk of dispersion upon removal [9] . matava et al has suggested the careful removal of the drape plastic to avoid the dispersion of j o u r n a l p r e -p r o o f aerosols. [7] an alternative to aerosol control could include a suction circuit under the drape, [13] but this is not possible in an emergency on the beach. we suggest, in case of use, remove it in an upwind direction, using the plastic as a shield between the patient and the lifeguards. the sea breeze would likely disperse the aerosols in the opposite direction of the lifeguard situation. transport and easy use: the plastic blanket with the hepa filter and mask can be folded and carried in an airtight bag, inside the lifeguard's backpack (rescue bag) along with other rescue material including ppe for cpr. the bag-valve mask should now be a permanent tool for the lifeguard, just like the fins, rescue tube or rescue buoy. suitable for environmental conditions: wind, extreme heat, wet and/or hypothermia after rescue it is a handicap for a correct use/wear ppe, but not for use a blanket plastic. quality cpr maneuvers are possible (at least in this pilot study). both v and cc exceeded an average of 70%, an arbitrary value attributed to quality cpr. [14] an important fact is its low cost. plastic blanket is cheap (less than € 1), which can give access to rescuers without resources or without training in ppe use who want to have extra protection. the need to use ppe during resuscitation of the drowning patient during the covid pandemic has added difficulty to the resuscitation techniques on the beach. plastic blanket could be an alternative to consider for lifeguards when the environment, training or resources require infection transmission protection. the method described here is not intended to replace materials specifically designed for virus transmission prevention. the results of this proposal must be interpreted with the limitations of an experimental model without tests in real patients. we encourage research groups with more resources and emergency medical/lifeguards teams with real experiences using blanket-plastic to report their outcomes. none of the authors has a conflict of interest. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. none of j o u r n a l p r e -p r o o f naming the coronavirus disease (covid-2019) and the virus that causes it european resuscitation council covid-19 guidelines executive summary cognitive load and performance of health care professionals in donning and doffing ppe before and after a simulation-based educational intervention and its implications during the covid-19 pandemic for biosafety world health organization. violence and injury prevention-drowning. world health organization european resuscitation council guidelines for resuscitation 2015: section 4. cardiac arrest in special circumstances mask ventilation and dispersion of exhaled air possible sars coronavirus transmission during cardiopulmonary resuscitation tracheostomy during covid-19 pandemic-novel approach barrier system for airway management of covid-19 patients use of drape/patient covering during potentially aerosolizing procedures clear plastic drapes for aerosol-generating medical procedures in covid-19 patients: questions still remain abc of resuscitation journal pre-proof the authors manufactures medical devices. all authors work for government institutions (hospitals and universities) or non-profit organizations. plastic blanket drowning kit: a protection barrier to immediate resuscitation at the beach in the covid-19 era. a pilot study. key: cord-273748-xy4f5kon authors: armijo, priscila r.; markin, nicholas w.; nguyen, scott; ho, dao h.; horseman, timothy s.; lisco, steven j.; schiller, alicia m. title: 3d printing of face shields to meet the immediate need for ppe in an anesthesiology department during the covid-19 pandemic date: 2020-08-04 journal: am j infect control doi: 10.1016/j.ajic.2020.07.037 sha: doc_id: 273748 cord_uid: xy4f5kon anesthesia providers are at risk for contracting covid-19 due close patient contact. proper personal protective equipment (ppe) use is critical to providing a safe environment and to minimize the risk of contagion. during the covid-19 pandemic, a series of supply chain issues, constant changes in ppe use policy, and higher demand for ppe led to shortages in ppe, specifically n95 masks and face shields. implementation of decontamination protocols successfully allowed n95 mask reuse but, required masks to be unsoiled. face shields not only act as a barrier against the soiling of n95 face masks, they also serve as more effective eye protection from respiratory droplets over standard eye shields. the university of nebraska medical center produced face shields using a combination of 3d printing and assembly with commonly available products. approximately 112 face shields were constructed and made available for use in 72 hours. importantly, we created and implemented a simple but effective decontamination protocol, which allowed reuse of the face shields. these methods were successfully implemented for in-house production of face shields used at tripler army medical center (tripler amc, hawaii). the effectiveness of the decontamination protocol was evaluated using the average log(10) reduction in colony counts for escherichia coli atcc 8937 and staphylococcus aureus atcc 25923 from the american type culture collection (atcc, manassas, va). in this manuscript, we present our detailed protocol and supplies needed for printing 3d face shields to enable the rapid production of this product by individuals with little to no 3d printing experience, in times of urgent need. (sars-cov-2) was first isolated in human airway epithelial cells from a cluster of patients with pneumonia of unknown etiology in december 2019 from wuhan, china [2] . the novel virus has since spread to every continent, except for antarctica, infecting greater than 1.5 million people and causing greater than 170,000 deaths as of today. it is estimated that millions of americans will get infected by the sars-cov-2 virus that causes coronavirus disease 2019 and that 40% of the healthcare workforce will be infected and removed from the workforce due to exposure to the virus primarily through respiratory droplets emitted by patients [3, 4] . anesthesia providers are at increased risk for exposure because of their primary role in airway instrumentation for symptomatic and asymptotic covid-19 patients during diagnostic, therapeutic, and surgical procedures. 5 surgical masks, the standard personal protective equipment (ppe) before the covid-19 outbreak for anesthesia providers, do not offer satisfactory protection from covid-19 during close patient interaction, partly due to the risk for aerosol generation at the time of intubation. current literature indicate that surgical masks provide insufficient protection against inhalation of viral particles that exist in both respiratory droplets and aerosolized sub-micron particles generated by infected patients [6] . to overcome this challenge, stringent policies and appropriate use of ppe, such as face shields, safety glasses, and n95 masks, are indicated for providers performing aerosol-generating procedures [7] . n95 filtering face piece respirators (ffr) and powered air-purifying respirators (papr) are a more sophisticated ppe that provides full face and body coverage, respectively, enhancing the level of protection against aerosolized particles. however, there are several challenges associated with the continuous use of ppe, especially for papr and ffr, including the limited supply chain due to the high demand, communication barriers between provider and patient, and discomfort after long-hours of wear [8] [9] [10] . therefore, extending the use of n95 masks, as recommended by the cdc, is an appropriate and suitable alternative in a resource-constrained environment, in which the use of papr and ffr is not practical [11] . with the fast development of the covid-19 pandemic and the incredibly high transmission rates of sars-cov-2, shortage of ppe has become one of the greatest and most concerning challenges among healthcare professionals. high cost, limited availability, low storage stocks to meet surge capacity, and limited capabilities for reuse of ppe all contribute to unavailability. additionally, changing recommendations of appropriate ppe use rapidly evolved in response to the pandemic, producing previously unused supply chain requests [5, [8] [9] [10] . the cdc recommends the implementation of procedures that extend the use of n95 masks 11 to combat the shortage of ppe. this sentiment is echoed by a joint position statement supported by the american society of anesthesiologists (asa), anesthesia patient safety foundation (apsf), american academy of anesthesiologist assistants (aaaa) and american association of nurse anesthetists (aana). 5 one strategy to mitigate the soiling of n95 masks and extend their use is the addition of a face shield that is capable of withstanding decontamination. the physical barrier provided by the face shield provides an added layer of protection of the n95 mask and the face of the provider from respiratory droplets. it prevents the n95 from becoming soiled, allowing for prolonged use. in response to the covid-19 pandemic, the university of nebraska medical center (unmc), department of anesthesiology, mandated that anesthesia providers use face shields during patient care to extend the life of n95 masks and adequately protect providers from infection with sars-cov-2. this mandate required the immediate procurement of 112 face shields for approximately 60 clinical providers working at any one time. our goal was to meet the immediate demand for an increased level of provider protection by providing face shields to reduce viral transmission to the provider. the face shields also prevent the soiling of n95 masks, allowing for reuse with a previously developed ultra-violet radiation sterilization protocol recently approved by cdc/niosh [12] . due to the high demand and low supply of commercially produced face shields, unmc turned to in-house 3d printed face shields using publicly available resources. using this strategy, unmc was able to quickly and efficiently produce 112 face shields in approximately 72 hours using four relatively inexpensive and readily available 3d printers. the face shields were deployed for use by our clinical anesthesia providers the very next day, along with a sterilization protocol that allowed for the reuse of the face shields. the methods developed by unmc as described in this paper was also successfully replicated by the 15th maintenance squadron (15th wing airmen joint base pearl harbor-hickam) and the combat logistics battalion 3 marines (marine corps base hawaii) to rapidly produce and supply face shields to healthcare providers (nurses, medics, physicians, intensivists) at tripler army medical center (tripler amc, hi). they were able to produce approximately 100 face shields in 72 hours with follow-up plans to equip greater than 1000 military and military associated healthcare providers and first responders on the island of oahu. all the information we used to make the face shields was readily available from various sources in the public domain. however, we had to overcome several significant, time-wasting challenges to produce a final, working product. first, we were limited in materials acquisition, to only using locally available materials and previously acquired equipment. secondly, we needed to understand and produce a product that had the appropriate dimensions not to impede our providers in clinical care. finally, we had a significant learning curve to overcome a significant learning curve to produce face shields without prior 3d printing experience. consequentially, we are providing a complete step-by-step instructional guide to producing 3d printed face shields rapidly. our protocol is specific to producing a face shield that is sized appropriately to not interfere with commonly performed procedures, such as endotracheal intubation, and are reusable after decontamination. however, the methods we provide can be used to produce and decontaminate face shields for general use at all treatment facilities. additive manufacturing, or what is commonly referred to as 3d printing, is a fabrication process in which layers of material are added successively to form the desired object. methods of additive manufacturing fall under several different categories, such as filament deposition manufacturing (fdm), also known as fused filament fabrication (fff), stereolithography (sla), digital light processing (dlp), selective laser sintering (sls), or multi-jet fusion (mjf). the key similarity among the methods is the process by which layer-by-layer an object is built through the addition of material. while the same object may be created using any of the methods mentioned above, each has its strengths and limitations [13] . for all 3d printing platforms, the electronic file of the object to be printed (commonly a stereolithography or .stl file) can either be created by the user or downloaded from the shared sources on the internet. in order to print an object, the electronic file must first be loaded into the printer software, and potentially altered to be compatible with the specifications of the printer. a major consideration is the printing platform to use. printers used for fdm and dlp are commonly used desktop-sized printers. of these, fdm is the most frequently used 3d printing platform for non-industrial applications because it is relatively affordable in both the printer and the required thermoplastic filament. fdm printing platforms offer both low-cost filament use and often a more substantial build plate compared to a dlp platform, enabling fdm printers to produce larger or more objects in one run. thus, this was our platform of choice. a significant disadvantage of fdm is that it results in individual layers of a thermoplastic material that, while fused, may not be air-or watertight. dlp printing utilizes a digital projector screen to flash images of the object on to photosensitive resin in order to cure the resin layer by layer. this process results in objects with the potential for higher-layer resolution and are solid pieces that are air and watertight. the authors recognize that all fdm prints generated for the headband of the face shield are not watertight, allowing water and air to pass through them to some degree. this would make uv sterilization or a simple wipe down with anti-bacterial/viral wipes inappropriate and ineffective. given this information, we developed a decontamination protocol that utilized a dilute bleach solution that would allow penetration into any of the pores that are generated in the 3d printing process and permit the reuse of the face shields. the solid headband and chin piece of the face shield we created were 3d printed via fmd, while all other materials, including the transparent face guard, were purchased commercially, and then used to construct the face shield ( table 1 ). the fdm fabrication process, even with a clear pet filament, does not allow for the type of uniformity and consistency that would permit the creation of a truly clear shield that allows good visual acuity for the wearer. fdm filament types include polylactic acid (pla), acrylonitrile butadiene styrene (abs), polyethylene terephthalate (pet). pla requires lower printing temperatures (200-210ºc) and has less warping than abs or pet but is more brittle. abs has higher printing temperatures (230-255ºc) and more durability, but is more prone to warping and can generate toxic gas fumes during printing. pet has a moderate printing temperature (220-235ºc) with durability similar to abs with the ease of use similar to pla. however, it absorbs water and requires additional care when storing the filament. nylon is very durable and is a high-temperature (240-260ºc) filament. while other thermoplastic filaments are available, the need for high-speed and low-cost prompted the use of pla in the current protocol. we chose pla as our printing material due to the fact that the material was readily available, we were very familiar with its use, and the material was low-cost. moreover, pla has excellent printing properties, allowing a fdm printer to print at very high speeds for the make and model (150mm/sec on a prusa mk3 and/or mk3s printer). after careful consideration, we chose to use a prusa i3 mk3s model printer for our 3d face shield printing needs. this model of printer is relatively low-cost (approximately $600), handles pla filament well, and has sufficient printing surface area. additionally, many files are available in the public domain that are designed for use with this printer, thus lowering the barrier for production for individuals who may have little or no 3d printing experience. the specifications for the computer used for designing, modeling, processing, and printing of the .stl file depends on the 3d printing software used. for the face shields printed at unmc, we used a standard dell desktop (xps) computer running slic3r software ( table 1 ). the processed .stl file was then saved to an sd card, and the sd card inserted into the prusa 3d printer for printing. a wide array of software options is available, ranging from relatively simple such as google sketchup (free software) to highly complex such as autodesk autocad. mid-range software includes blender, autodesk maya, and solidworks. as complexity increases, the computer requirements also increase. for example, google sketchup requires a 2.1+ghz cpu and 4gb ram, while autodesk autocad requires, at minimum, an intel pentium 4 processor with 8gb ram. due to the need to transfer files from computer to 3d printer, downloading and installation of software, downloading of .stl files, there may be limitations/challenges to producing face shields at government and military installations, treatment facilities, or hospitals with secure networks that do not allow for easy transfer of files from computer to printer by an external drive. additionally, at these locations, there may be restrictions on acquiring or installing 3d printing software onto network computers. the successful production of a 3d printed face shield will require the following steps: a) creating or obtaining the electronic file for the 3d printed parts; b) printing the face shield parts ( figure 1 ); and c) assembling the face shields with the additional required supplies. first, one must either make or find the file of the idealized model of the desired object. the .slt files used in this paper are located on the prusa face shield website (https://www.prusaprinters.org/prints/25857-prusa-face-shield), under files. this file is optimized for use in the prusa printer and thus would require minimal, if any, modifications by the user to print a quality product. once the .stl file was obtained, it was loaded onto a computer capable of running the slicer software. the slicer software takes the 3d virtual model and determines the process required for the printer to produce the object layer by layer. the slicer printer software can assist in setting the appropriate speed, layer height, and generation of tool paths (the path that the printer extruder follows while printing) for the 3d printer being used. unlike traditional ink printers, where most settings are universal and ink pages would be printed the same regardless of the printer used, 3d printers will require unique modifications based on the model and brand of printer used. the headband print file was adjusted using slicer software to control speed, layer height, support material and the use of other supporting materials. using the prusa rc3 quattro file, a .gcode file was produced that would result in an optimized print speed. using and 0.2mm layer height, 2 outer layers and 3 layers for top and bottom layers along with 0% infill, a stack of 4 head and lower pieces could be printed in 7.5 hours. this print file also utilized a raft to provide optimum adhesion to the build plate give the small amount of contact area this design has with the build plate. no support material is used as the chamfered undersides of the headband allow the printer to successively print layers vertically without issue. prepare all components of the face shield for assembly. figure 1 contains the terminology of the face shield components, whereas figure 2 depicts a pictorial description for the initial face shield assembly. 1. remove the printed headbands and chins (item 7) from the printing deck of the 3d printer. separate into individual components. 2. using the face guard template from the prusa website, item 7 (www.prusa3d.com), mark the location of the needed holes in the clear pvc binding cover (item 3) that will be used for the face guard, using a permanent marker. 3. using a standard hole punch (item 5), punch the holes marked in the face guard. our choice to utilize a high speed and low cost fdm printer with pla, had a known result of leaving small pores present in the final 3d printed product, making the use of uv light sterilization not possible. to circumvent this challenge, we created a liquid sterilization protocol that would allow reuse of our face shields. in brief, the face shields were dissembled, placed briefly in a dilute bleach solution, and allowed to be air dry. when dry, the clear face guard was wiped to remove any spots, and the face shield reassembled for use. our detailed decontamination protocol is included in appendix a. the surface of each face shield part was cleaned by wiping surfaces with caviwipes (metrex, orange, ca) followed by 70% ethanol prior to spiking. following drying, spots to be inoculated were marked with permanent marker. subsequently, 10 µl of bacterial concentration was applied to each marked spot. as a positive control, organism suspensions were inoculated to each face shield part, allowed to dry, and swabbed without decontamination. pbs was inoculated to each part as a negative control. the droplets were left to air dry for 1 hour. each face shield part was disinfected according to appendix a. after adequate drying, a cottontipped swab (puritan medical products company, guilford, me) was used to sample each marked spot. swabs were moistened in sterile pbs and the area was swabbed using a firm sweeping and rotating motion. organisms were enumerated using the spread-plate technique on ba plates. the plates were incubated at 37°c for 20-24 hours. experiments were repeated five times per face shield part (head band, head piece, face shield) and organism (e.coli, s. aureus) for a total of 30 experiments not including positive and negative controls. decontamination effectiveness was evaluated using the average log10 reduction in colony counts. to assess the effectiveness of the appendix a decontamination protocol, we inoculated bacterial suspensions of e. coli atcc 8937 and s. aureus atcc 25923 directly onto each part of the face shield unit. all positive organism and pbs controls were as expected. the decontamination protocol effectiveness against e. coli was greater than s. aureus. two-spiked e. coli spots exhibited growth, one colony each, whereas five-spiked s. aureus spots had characteristic growth. e. coli was observed on the face guard piece, s. aureus was detected from the chin piece and face guard. no organisms were recovered from the head bands. overall, the decontamination protocol was highly effective against both e. coli and s. aureus, achieving a ≥ 4 log10 (99.99%) reduction in colony counts for every replicate. the masks we created are comparable and sometimes superior, to standard commercially available face shields, in terms of the protection area and coverage (figure 3) . a known limitation of our face shield design is the gap between the clear shield and the forehead of the wearer. this space is usually occupied by a foam barrier present in several commercially available face shield models. while this foam provides comfort, it limits the ability to extend the use of the product. in order to reduce the possibility of provider contamination from droplets entering this top opening, a bouffant surgical cap can be pulled forward and attached to the four pins of the headband holding the face guard in place. another option to mitigate this concern is to print a cover piece for the headband, which is currently under development [14] . however, for our purposes of rapidly producing enhanced ppe in the form of face shields, this design met the needs of our department. given the emergent circumstances and perceived time constraints, institutional infection control was notified, provided input, and was responsible for determining the sites for donning, doffing, and disinfection protocol. while the goal of the authors is to provide a detailed protocol and methodology that met the urgent needs of the unmc department of anesthesiology, modifications may be desired, or even necessary, depending on the availability of resources. to that end, we have included popular modifications and additional product resources. if a prusa brand printer is unavailable, or undesirable for other reasons, printer options with similar functionality are available. we recommend the creality cr-10s pro v2 (https://www.creality3dofficial.com/) or the creality ender 5 series that was used to produce face shields in-house for tamc personnel. for this protocol, we recommend using pla due to its characteristics and compatibility with this project. other types of filaments could be used; however, they would require significant modifications of this protocol and additional steps. a 10" piece of foam is optional and can be attached to the headband. for the purchase, foam window seal can be found at any departmental store. make sure you have a 1/2 wide by 1/4 thick. to ensure that the foam holds in place, glue the foam into the headband. however, we do not recommend its use since it cannot be sterilized, nor detached from the headband. hence, if using the foam, the face shield will have to be disposed after a single use, and we therefore elected to not utilize a layer of foam inside the headband. there are several materials that can be used for the head strap. we tried three materials: rubber bands, elastic strips with buttonholes, and tourniquets. rubber bands have the advantage of being readily available, low-cost, ability to be sterilized in liquid and disposable. however, they were very difficult to adjust and tended to slip, making the security of the face shield a concern. however, they are easy to acquire and could be used if the urgency of the situation merited it. the elastic strip with buttonholes was also low-cost and somewhat easy to acquire, requiring a trip to a fabric or craft store. the buttonholes made adjustment and security of the face shield sufficient. however, the fabric-type and porosity of the material would not allow for reliable sterilization and reuse of the face shields. the material of choice for our design was a tourniquet used clinically for the placement of ivs or phlebotomy. this material was readily available, lowcost, able to be sterilized and did not get stuck in hair as easily as rubber bands we settled on an 8.5x11" clear 10mil polyvinyl chloride (pvc) binding cover as it was readily available and only created a small amount of distortion to the wearer's vision. the width permitted the holes to be punched to fit the rc3 headband. the edges were trimmed to prevent the lower corners from contacting the wearer's chest if they flexed their neck. the binding covers are offered in fixed width, to be used with standard-sized paper. nonetheless, if there is a need for adjusting the dimensions and size of the clear shield, one can replace the binding cover with laminating foil or plexiglas. however, there are limitations to using such materials, such as the need for additional equipment, such as a die cutter for the plexiglas or a laminating machine for the laminating foil. however, pvc poses no other benefits over these materials if this equipment and expertise in use are already available. due to the cleaning solution, the clear face guard became slightly blurred with time. additional clear face guards were available for providers who wanted to replace it. however, the number of times needed for the clear face guard to lose its transparency varied. we performed the swab method to recover organisms from the face shield surfaces, this method is commonly used in transfer studies [15, 16] , although other methods exist such as direct elution which may be more efficient in organism recovery from porous surfaces [17, 18] . the swab method was selected because it is simple and less labor-intensive than the direct elution method. it is acknowledged that swabs may retain some portion of organisms during plating. the rapid manufacturing capacity of commercially available desktop fdm printers paired with open source designed and readily available materials allowed for the creation of sufficient face shields to provide protection until other, more durable shields could be procured. at the time of this writing, these face shields have been in use in the unmc anesthesiology department for 97 days, and at tamc for 93 days. unmc is currently awaiting a locally-sourced injection molding type face shield that has a cover over the opening in the top. 3d printing can allow for not only rapid prototyping and iterative changes but can allow the user to manufacturer and augment key components of ppe when providers and first responders are faced with supply shortages. center for disease control and prevention. coronavirus disease 2019 (covid-19) a novel coronavirus from patients with pneumonia in china supporting the health care workforce during the covid-19 global epidemic covid-19: protecting healthcare workers covid-19 faq's commentary: masks-for-all for covid-19 not based on sound data interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings f2019-ncov%2finfection-control%2fcontrol-recommendations.html behavioral considerations and impact on personal protective equipment (ppe) use: early lessons from the coronavirus (covid-19) outbreak covid-19: doctors still at "considerable risk" from lack of ppe, bma warns headaches associated with personal protective equipment -a cross-sectional study among frontline healthcare workers during covid-19 the efficacy of medical masks and respirators against respiratory infection in healthcare workers. influenza other respir viruses additive manufacturing (3d printing): a review of materials, methods, applications and challenges comparative surface-to-hand and fingertip-to-mouth transfer efficiency of gram-positive bacteria, gram-negative bacteria, and phage transfer efficiency of bacteria and viruses from porous and nonporous fomites to fingers under different relative humidity conditions transfer of bacteria from fabrics to hands and other fabrics: development and application of a quantitative method using staphylococcus aureus as a model assessment of surgical instrument bioburden after steam sterilization: a pilot study clear face protector portion of shield 10 key: cord-301402-andxwyi3 authors: ding, benjamin tze keong; soh, tamara; tan, bryan yijia; oh, jacob yoong-leong; mohd fadhil, muhammad farhan bin; rasappan, kumaran; lee, keng thiam title: operating in a pandemic: lessons and strategies from an orthopaedic unit at the epicenter of covid-19 in singapore date: 2020-05-06 journal: j bone joint surg am doi: 10.2106/jbjs.20.00568 sha: doc_id: 301402 cord_uid: andxwyi3 ➤. with severe limitations in manpower, facilities, and equipment, and the concern for nosocomial transmission, operating in a pandemic is fraught with danger from multiple fronts. ➤. strategies to mitigate nosocomial spread include prioritization of existing patients, triaging and treatment of new patient encounters, infection control protocols, perioperative considerations, manpower management, and novel strategies for interdisciplinary interaction and education. ➤. the decision to proceed with or postpone surgery should be based on the urgency of the surgical procedure and the physiological health of the patient. ➤. when performing an operation on a patient who has suspected or confirmed infection with novel coronavirus disease 2019 (covid-19), personal protection equipment should include hair covers, face shields or goggles, n95 respirator masks, a blood-borne pathogen-resistant surgical gown, shoe covers, and double-gloving with single-use gloves. ➤. loose-fitting, powered air-purifying respirators should be considered for prolonged surgeries. ➤. an astutely formulated and comprehensive business continuity plan is an orthopaedic unit’s best strategy for maintaining critical standards, discipline, and morale in severe and prolonged outbreaks. the year 2020, and perhaps the future of health care, is likely to be defined by the novel coronavirus disease 2019 . the world health organization declared covid-19 to be a pandemic on march 11, 2020 , and as of april 12, 2020, reported a total of 1,696,588 confirmed cases and 105,952 deaths in all 197 countries 1, 2 . singapore was among the first countries to be affected by covid-19 when a tourist from wuhan, china, was confirmed to be infected on january 23, 2020 3, 4 . as one of the worst afflicted countries during the 2003 severe acute respiratory distress syndrome (sars) outbreak 5 , singapore developed and adopted a disease outbreak response system condition (dorscon) plan with clear leadership and oversight from a multi-ministry task force 6 . health-care measures included limiting unnecessary cross-institutional movement of manpower, engaging private sector doctors, and aggressive contact tracing of infected individuals. the national centre for infectious diseases (ncid) in singapore, which was built for this purpose, became the epicenter of the national health-care response in combating at the onset of the disease, orthopaedic surgeons at all levels were immediately deployed to the ncid frontline in 10-day rotations after a crash course in personal protective equipment (ppe) handling. the remaining surgeons maintained key orthopaedic services and consultations for infected patients with concomitant orthopaedic conditions before being rotated to the front line. with multiple considerations regarding prioritization of existing patients, initial contact with new patients, infection control strategies, perioperative considerations, manpower management, and novel communication technologies, the aim of this article was to outline the successful strategies that our department employed for the outbreak. patients with conditions requiring elective surgeries form a large proportion of the caseload for a busy orthopaedic practice in a tertiary referral center. with a substantial reduction in resources and manpower, the risk of nosocomial covid-19 infections, and the increased dangers of performing surgery on elderly individuals with multiple comorbidities 7, 8 , case selection needs to be even more stringent. considerations for proceeding with surgery should be dependent on the current and projected covid-19 cases in the region, ppe supply, staffing and bed availability (especially intensive care unit [icu] beds), ventilator availability, age and health of the patient, urgency of the procedure, and covid-19 clearance prior to performing surgery. elective surgeries requiring potential intensive care and prolonged hospitalization for recovery, such as joint arthroplasties and spinal surgery, were delayed. the decisions were made in consultation with the patients, surgeon, anesthetist, operating-room (or) staff, and hospital management. a tiered approach 9 (table i) to guide decision-making may be considered according to the urgency of surgery, fitness of the patient, and potential for ambulatory surgery. one of the important but easily overlooked duties during the initial phases of the outbreak was informing patients about the postponement of their surgeries. while some patients called in to postpone on their own accord, most patients were still looking forward to their surgeries on the scheduled dates. previous studies have shown that patients tend to react negatively to postponements in the form of anxiety and disap-pointment 10 . multiple factors contribute to such negative perceptions, mainly if the patients thought that they were given inadequate information, were excluded from the decisionmaking process, felt that their medical well-being was threatened, were not rescheduled for surgery, and were informed by someone other than a doctor 11 . in our department, the senior surgeon spoke to the patient and/or family members directly to convey the information, answer questions, allay concerns, and reschedule to a date that was acceptable to both parties. patients were advised to continue medications, such as blood thinners and antihypertensive drugs, and a suitable preanesthetic screening date was arranged if repeat investigations were required. prescriptions were refilled for patient collection or home delivery while office procedures, such as joint blocks and nerve root injections, were offered to relieve unbearable pain. as a standard precaution, all patients were screened at a triage station, prior to being seen at outpatient clinics or the emergency department, to determine their travel and contact history and to assess for fever, cough, sore throat, anosmia, or coryzal symptoms. when in doubt, consultation was performed in full ppe and chest radiographs were ordered. radiologists prioritized the reading of chest radiographs from the emergency department, which were reported within an hour. while patients with suspected or confirmed covid-19 infection require urgent negative-pressure rooms with an anteroom, patients with other communicable diseases such as pulmonary tuberculosis also require isolation in a single room or placement in a dedicated isolation ward, with appropriate precautions being instituted on the basis of the known mode of spread (table ii) . social distancing social distancing has been identified as one of the best strategies to mitigate covid-19 transmission 12 . social gatherings during and after office hours were strongly discouraged, and pantry areas were reconfigured to ensure at least 2 m (6 ft) of physical distancing between personnel. health-care personnel were advised to eat alone or stagger mealtimes, minimize interaction when unmasked, and maintain effective hand hygiene when handling food. the underlying principles for ppe components are that they must protect the health-care provider from inhalation of and contact with droplets that may be generated during procedures. the components used to accomplish this level of protection when dealing with patients with suspected or confirmed covid-19 infection include gloves, gowns, eye protection, hair covers, shoe covers, and an n95 particulate respirator 13 (u.s. national institute for occupational safety and healthcertified n95, european union standard filtering face piece [ffp]2, or equivalent) that is fitted to the individual. health-care workers were given adequate training on when and how to use ppe as well as what ppe to use, and any ppe component that became heavily soiled during aerosol-generating medical procedures was replaced immediately. special attention was paid to avoiding contact with one's hair or face while placing or removing the ppe, and used ppe was discarded into touch-free bins. surgical masks are loose-fitting devices that provide a physical barrier without restricting airborne contaminants and are used in our institution for health-care worker interaction with all patients unless they were suspected of or confirmed as having covid-19 infection. an n95 respirator is a disposable, protective device that provides efficient filtration of airborne particles by forming a seal around the respiratory orifices. the n95 designation implies that the respirator blocks at least 95% of very small (<0.3 mm) test particles. there is considerable discrepancy among the recommendations for the use of face masks in community settings 14 . while the effect of n95 respirators on preventing covid-19 infection requires further investigation, only n95 respirators are able to filter particles from 0.01 to 0.1 mm in diameter 15 . as viral sizes fall within this 1, 2020 range, well-fitted n95 respirators were used by all health-care workers in our institution when dealing with suspected or confirmed covid-19 cases. eye protection is another strategy to prevent ocular transmission of covid-19 in health-care workers as the virus has been found in the tears of patients with ocular signs and symptoms 16 . the goggles provide maximal peripheral vision while adequately covering the frontal, lateral, and top surfaces. surgical gowns are classified under the association for the advancement of medical instrumentation (aami) grading (table iii) according to the liquid barrier performance 17,18 . for activities involving low or minimal bodily fluid exposure risk, such as intravenous cannulation, level-1 or 2 gowns, which resist penetration of water by spray impact and increasing hydrostatic pressure, may be used to provide barrier protection. level-3 or 4 gowns, which resist synthetic blood and bloodborne pathogen penetration under continuous liquid contact, were utilized when performing surgical procedures, or when there was a medium to high risk of contamination, such as intubation and setting of central lines. shoe and hair covers theoretically reduce the risk of disease transmission by decreasing the exposed lower-body surface area and keeping hair away from the procedural field. coveralls are a form of barrier protection that provide 360°of continuous protection by covering the whole body, limbs, and typically the head and feet. in our institution, single-use gowns with shower caps appear sufficiently protective against covid-19 transmission. disposable patient-examination gloves are appropriate for examining and caring for patients with suspected or confirmed covid-19 infection. in our institution, patients requiring general or contact precautions are handled with single gloves. when managing patients with covid-19, double gloves are utilized to preserve ppe, and not to reduce the risk of viral transmission, such that only the outer gloves need to be changed when soiled or when managing multiple patients 19 . hand washing mechanically removes microorganisms, and laboratory data have demonstrated that alcohol-based hand sanitizers with ‡70% isopropanol or ‡60% ethanol inactivate viruses that are genetically similar to covid-19. while the quantitative effect of hand hygiene in reducing direct and indirect spread of coronaviruses between humans is indeterminate, both hand washing and alcohol-based hand sanitizers can reduce the number of viable pathogens that transiently contaminate an individual's hands 20, 21 . disposable gloves and disinfectant wipes were utilized and discarded after cleaning equipment such as stethoscopes. products with environmental protection agency approval for use against emerging viral pathogen claims are expected to be effective against covid-19 22 . disinfection with 62% to 71% ethanol, 0.5% hydrogen peroxide, or 0.1% sodium hypochlorite appears to be effective for surfaces on which the virus may persist. hydrogen peroxide vaporization has been deployed in addition to terminal cleaning to enhance disinfection of patient rooms and ors in our hospital. this method utilizes the vapor form of the antimicrobial chemical to decontaminate a sealed area. for intricate machines such as arthroscopic devices, ultraviolet cleaning machines were used to decontaminate the equipment safely instead. a papr is a type of respirator that protects its user by filtering out airborne contaminants using a battery-powered blower. tight-fitting paprs require fit testing, while loose-fitting paprs do not. the components of a papr (fig. 1) include a face piece, hood or helmet, breathing tube, canister or cartridge with filter, and a battery-powered blower. when paprs were considered for use during the pandemic, the efficacy, availability, familiarity with, and affordability of the device were considered in detail. the advantages of using a papr included its reusability and increased familiarity with repeated usage. loose-fitting paprs also did not require fit testing and provided additional comfort for the health-care worker. the disadvantages of using a papr included its high cost, regular maintenance, considerable difficulties in hearing, reduced visual fields, and short battery life. positive-pressure exhaust suits utilize a surgical helmet with a head-mounted fan to circulate air filtered through the hood material itself. this is in contrast to paprs, which utilize a high-efficiency particulate air (hepa) filter and blow filtered air over the wearer's face at high flow rates 23 . positive-pressure exhaust suits, while protective against splash injuries and blood-borne pathogens, are unable to filter particles of the coronavirus size range, and we do not recommend the utilization of positive-pressure exhaust suits alone to protect against covid-19. while all medical staff should ideally be protected in full ppe when attending to all patients during a global pandemic, indiscriminate use of ppe may expedite its global shortage. to mitigate the potential of such a scenario, medical staff should demonstrate an understanding of when to use ppe and what ppe is necessary. our institution's ppe protocols are outlined in table iv and are based on the singapore ministry of health guidelines and institutional practices 24 . we adhered strictly to our institution's ppe protocols and are encouraged to report that there were no cases of nosocomial transmission of covid-19 among health-care workers and patients after 60 days of managing the pandemic, while simultaneously conserving precious ppe supplies. loose-fitting paprs were used in our surgical division for prolonged (>4-hour-long) surgery in patients with covid-19 infection. this was due to the increased risk of transmission from prolonged exposure, considerable discomfort at pressure areas, potential loosening of n95 masks 25 , and increased deadspace concentrations of carbon dioxide, which may compromise work performance 26 . for short surgeries in patients with covid-19 infection, we utilized hair covers, goggles, n95 masks, aami level-4 gowns, shoe covers, and double gloving with sterile single-use gloves. surgeons remained outside ors during intubation until the airway was secured and connected to a closed-circuit ventilator because of the aerosolization of viral particles. infection requiring surgery surgeons will inevitably need to operate on patients with suspected or confirmed covid-19 infection. such a decision should be made in tandem with the patient, family members, intensivists, anesthetists, and or staff as recovery from covid-19 may require 2 weeks for milder forms and 3 to components of a loose-fitting powered air-purifying respirator. e67(5) 6 weeks for severe or critical disease 27 . surgical timing should be determined on the basis of whether the surgeries are urgent or life or limb-saving, and whether the patient's condition is stable or unstable. patients in stable condition requiring nonurgent surgery, such as a patient with a closed radial and ulnar fracture and a concomitant covid-19 infection without oxygen requirements, should be isolated for treatment first. the fracture can be immobilized in a splint, and surgery should be delayed until the patient is deemed to be not infected by the infectious disease (id) specialist. patients in unstable condition who require nonurgent surgery, such as a patient with patellar tendon rupture and concomitant covid-19 pneumonia requiring oxygen supplementation, should be isolated in a negative-pressure icu for optimization. surgery should be delayed until the patient is deemed to be not infected by an id specialist. patients in unstable condition who require urgent surgery, such as a patient with necrotizing fasciitis and concomitant covid-19 pneumonia, should have the surgery performed in a surgical suite that is negatively pressurized relative to the corridor and adjacent spaces. after surgical stabilization, the patient should be monitored in a negativepressure icu. transfer of patients with suspected or confirmed covid-19 infection to the or required careful planning and predesignated corridors to mitigate the risk of transmission. the patients were fitted with a surgical mask during transport to and from the operating room. staff involved in the care and transport of the patient wore ppe, and the number of staff members involved was minimized with minimal exchange of staff. patients were intubated, were extubated, and recovered in negative-pressure ors, with a minimum of 15 air changes through a hepa filter per hour. they were transported directly back to negative-pressure rooms without contaminating the postanesthesia care unit. after surgery, regular chest and ambulatory physiotherapy minimized pulmonary complications and relieved symptoms of dyspnea, anxiety, and depression. for patients who remained critically ill, pulmonary rehabilitation was not initiated until their condition stabilized 28 . pulmonary rehabilitation guidance can be conducted through educational videos and remote consultation, if facilities are available, as patients are monitored and continuously reassessed. even after patients have been discharged, internet-based telerehabilitation allows real-time interaction with a physical therapist during which remote guidance of self-applied exercises can be administered in the comfort of the patient's own home. previous studies have shown that telerehabilitation with only common household equipment was comparable with conventional rehabilitation 29 and should be incorporated into practice for prolonged pandemics. during the sars outbreak in 2003, 40% of the 238 reported cases were in health-care workers 30 , a grim reminder that nosocomial infections can spread rapidly and cripple a health-care system. during the current pandemic, many initiatives were instituted to address the key risk factors. at an organizational level, there were dedicated isolation wards and triage areas, training and monitoring of hospital staff in infection-control procedures, strict enforcement of droplet precautions for covid-19 patients, and minimization of staff exposure to high-risk aerosol-generating procedures. alternative sites of accommodation were arranged to house potential health-care workers evicted from their residences and for those staying with vulnerable elderly individuals, infants, and pregnant partners. at an individual level, all staff undertook mandatory twice-daily temperature surveillance and self-reporting of respiratory symptoms through a centralized online system. occupational health clinics and covid-19 screening centers were established for health-care workers to seek medical attention. to avoid unnecessary depletion of precious ppe supplies, no ppe or surgical masks were required for staff in administrative offices or where there was no direct patient contact except when in congregate settings (involving >10 personnel). secondary transmission of covid-19 among health-care workers has been well documented 31, 32 . one of the key strategies to prevent this transmission was through manpower segregation. manpower segregation strategies can be divided into temporal or spatial segregation. for departments with sizeable manpower and resources, temporal segregation by rotating shifts is a good option to prevent burnout and ensure service continuity in prolonged outbreaks. for departments with more modest manpower and resources, spatial segregation may be a better option. our department was divided into individual teams with a recognized chain of command and members of key subspecialty capabilities, seniorities, and experiences (table v) . inpatient, outpatient, and or duties were segregated and run by each individual team. these approaches allowed for preservation of business continuity and maintenance of core orthopaedic capabilities throughout the outbreak. multidisciplinary meetings and medical education have traditionally been conducted via face-to-face interactions. with the risk of transmission among personnel, such meetings were discontinued at the initial phases of the pandemic with the exception of small group discussions (involving <10 participants) on an as-needed basis. such meetings have since been substituted with teleconferencing using web-based software such as skype, meet by google meet, and amazon chime. our institution decided on zoom cloud meetings, as the program incorporated the following features. the software allowed meetings to be initiated by any user, provided video and audio-conferencing features, allowed external guest participation with web links, included recording features, facilitated screen-sharing with presenter modes, and was available on smartphones. the video web conferencing software also provided technological assistance and fit into the budget. education and continuing medical education e-learning, in the field of surgical education, refers to the use of internet-based resources such as case studies and video recordings of surgical procedures to enhance teaching 33 . after an initial suspension of teaching activities, the curriculum was shifted online for residents across multiple affiliated hospitals. clinical case scenario-based discussions and a structured oral examination using slides can be a way for most programs to transition their educational activities online in the initial phases as only digitalized content is required. as they are physicians first, the orthopaedic surgeon and the department are obligated to serve the needs of the many during an outbreak, and they can do so only if there are established plans for maintaining business continuity. performing surgery in a pandemic is fraught with danger and considerable restrictions from multiple fronts. surgery can be performed safely only if the surgeon has an overarching view of the potential problems and strategies to mitigate them. in a prolonged outbreak, sustainability is essential for maintaining standards, discipline, and morale among health-care workers. by presenting the strategies utilized by a national institution e67 (7) t h e j o u r n a l o f b o n e & joint surgery d j b j s . o r g volume 102-a d number 13 d july 1, 2020 that prevailed at the epicenter of the pandemic, we hope that others may be able to incorporate them into their practices to respond, recover, and prevent the pandemic from escalating further. clinical features of patients infected with 2019 novel coronavirus in wuhan world health organization preparing for a covid-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore novel coronavirus outbreak research team. epidemiologic features and clinical course of patients infected with sars-cov-2 in singapore interrupting transmission of covid-19: lessons from containment efforts in singapore what do the different dorscon levels mean clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study non-emergent, elective medical services, and treatment recommendations patient reactions to cancelled or postponed heart operations postponed or cancelled heart operations from the patient's perspective world health organization. social distancing, quarantine, and isolation: keep your distance to slow the spread association between 2019-ncov transmission and n95 respirator use rational use of face masks in the covid-19 pandemic surgical helmets and sars infection association for the advancement of medical instrumentation and american national standards institute. liquid barrier performance and classification of protective apparel and drapes intended for use in health care facilities effect of single-versus doublegloving on virus transfer to health care workers' skin and clothing during removal of personal protective equipment apic guideline for handwashing and hand antisepsis in health care settings centers for disease control and prevention. cleaning and disinfection for households: interim recommendations for u.s. households with suspected or confirmed coronavirus disease 2019 (covid-19) physiological impact of the n95 filtering facepiece respirator on healthcare workers. respir care chinese association of rehabilitation medicine; respiratory rehabilitation committee of chinese association of rehabilitation medicine; cardiopulmonary rehabilitation group of chinese society of physical medicine and rehabilitation internet-based outpatient telerehabilitation for patients following total knee arthroplasty: a randomized controlled trial 9 occupational health aspects of emerging infections -sars outbreak affecting healthcare workers characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention who strategic and technical advisory group for infectious hazards. covid-19: towards controlling of a pandemic e-learning in orthopedic surgery training: a systematic review key: cord-309751-7elnvjk3 authors: abdelnasser, mohammad kamal; morsy, mohamed; osman, ahmed e.; abdelkawi, ayman f.; ibrahim, mahmoud fouad; eisa, amr; fadle, amr a.; hatem, amr; anter abdelhameed, mohammed; hassan, ahmed abdelazim a.; shawky abdelgawaad, ahmed title: covid-19. an update for orthopedic surgeons date: 2020-07-01 journal: sicot-j doi: 10.1051/sicotj/2020022 sha: doc_id: 309751 cord_uid: 7elnvjk3 the covid-19 pandemic has affected our world in a short period of time, and the orthopedic surgery practice was not an exclusion. elective care was deferred in most health care facilities and emergency care was continued with strict precautions. with rapid progression of the pandemic, the response of the medical community is also rapidly changing in all aspects of delivering care. this led to a large number of publications with reports, guidelines, measures, ways to react to the crisis, and post-pandemic predictions and speculations. in this review we aimed at summarizing all the relevant information to the orthopedic surgery community. to do this, a comprehensive search was performed with all related terms on two scientific search engines, pubmed and scopus, and the results were filtered by the preferred reporting items for systematic reviews and meta-analyses (prisma) method. the result was 72 articles that were further reduced to 33 articles after full text reading. the resultant information was organized under 5 main headings; the impact of pandemic on the orthopedic practice, covid-19 and the trauma patient, elective and emergency surgeries during the pandemic, peri-operative management of the patient with covid-19, miscellaneous effects of the pandemic such as those on training programs and the evolution of telemedicine. this review represents the most up to date information published in the literature that is a must-know to every orthopedic surgeon. covid-19 or sars-cov-2 was first identified as a potential infectious threat in china in december 2019, [1] [2] [3] and declared as a pandemic by the world health organization on march 11, 2020 [4] . with the massive burden on health systems around the world, covid-19 has heavily impacted all aspects of the medical practice including specialities that are not directly related to its clinical effects such as orthopedic surgery. elective surgical procedures have been postponed in order to reduce the burden on health systems and allow for more availability of hospital beds for the more needy. management of emergent and urgent surgical cases has also been affected [5] . a continuous need is present to address the daily new information and to employ them in our orthopedic practices. moreover, with more countries reaching their peak and plateau phase, healthcare facilities are getting ready to reopen and resume medical care. this will require a solid understanding of the precautions required for this resumption during such a critical phase, which may extend for a few months ahead, not to mention some speculations of a second wave of covid-19 infection in the near future. we aimed at delivering a comprehensive review summarizing the most recent information and guidelines relevant to the orthopedic community available in the literature to help us plan for the current phase and those yet to come. to provide the most relevant and up to date information for the orthopedic community, a systematic approach was used to gather information. a literature search was conducted on may 22nd on medline and scopus with the terms "covid-19", "covid 19", "covid", "corona virus" or "corona", together with "orthopedic", "orthopaedic", "orthopedics", "orthopaedics", "surgery", and "surgical" including all possible combinations. the preferred reporting items for systematic reviews and meta-analyses (prisma) method and flowchart were used to filter the results of the search (figure 1 ) [6] . the search retrieved a total of 1546 articles, which were reduced to 1170 after omitting duplicates. screening by title and abstract further reduced the number to 262 after exclusion of non-english language articles and those addressing details not relevant to the orthopedic specialty. the full texts of these articles were read, and 209 articles were further excluded that lacked relevant information. relevant information was digested and organized under 5 main headings; the impact of covid-19 pandemic on the orthopedic practice, covid-19 and the trauma patient, elective and emergency surgeries during the pandemic, perioperative management of the patient with covid-19, miscellaneous effects of the pandemic such as those on training programs and the evolution of telemedicine. lack of sufficient evidence and the highly contagious nature of covid-19 led to drastic measures implemented by many countries varying from social distancing to total lockdown, which had tremendous global economic and social effects [7, 8] . the covid-19 pandemic represents an unprecedented challenge to healthcare systems mainly due to the exponential expansion of the patient population in need of hospitalization surpassing available resources [9] [10] [11] [12] [13] [14] . with the risks posed by shortage of personal protective equipment (ppe) [13] [14] [15] non-traditional solutions were developed such as 3d printed face shields, reusable gowns, and protocols for the re-use of ppe [18] . moreover, the sudden overload of healthcare systems mandated institution of new hospitals as well as changing the bed capacity to increase respiratory care beds; this was coupled with initial reduction and later cancelation of all elective procedures in order to save the available resources and limit spread of the virus [19] [20] [21] [22] [23] [24] [25] [26] [27] . in the midst of this crisis, the orthopedic surgeon was surely affected: from de-specialization and serving on the frontline, to upgrades from fellow to faculty and reassignment of residents to clinical care rotations [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] . managing covid-19 patients with surgical emergencies and trauma with the risk of self-infection have led to a higher degree of anxiety and depression [32] . with the mandatory decrease in face-toface encounters, online communication systems have flourished to provide meetings for faculty, quick and wide spread of knowledge, and outreach to patients through telehealth systems [18] [19] [20] [21] . so far, very few studies reported the association between covid-19 and trauma patients [33] [34] [35] . given the fact that patients with fractures especially of the lower extremity and those with limited ambulatory capacity are more susceptible to respiratory infection [36] , the association between covid-19 and trauma patients is not unlikely. mi et al. reported on 10 trauma patients with covid-19, seven of them (70%) had a nosocomial infection after admission to the hospital because of their fracture [34] . although sars-cov-2 was positive in only 6 patients, the characteristic ct ground-glass opacities were evident in all patients. clinical symptoms were not different from those present in patients without factures. lymphopenia was more common in patients with fractures. moreover, d-dimer and the median neutrophilic count were higher than the upper normal limits of the corresponding indicators. these might be special laboratory indicators of fractures in patients with covid-19. four patients (40%) died and three others (30%) developed severe pneumonia. the authors concluded that the association between covid-19 pneumonia and fractures can lead to severe adverse outcomes and increased mortality [34] . catellani et al. reported on 16 patients of proximal femoral fractures positive for covid-19 [35] . all patients presented with fever and oxygen desaturation on ambient air; 14 of them required respiratory support. improved respiratory parameters were evident in 12 out of 13 patients who underwent early fracture stabilization. the authors concluded that early fixation may contribute to the overall patient stability, improvement in physiological ventilation, seated mobilization, and general patient comfort in bed [35] . nevertheless, the association between covid-19 characteristic ct picture and trauma patients has also been reported in absence of symptoms related to covid-19 pneumonia [33] . the necessity to choose which operations to proceed with and which can wait is a challenging and sometimes difficult decision during the pandemic crisis. in the light of the available literature, this review will try to address the most relevant questions to our practice. a. what is the definition of an elective procedure? in the time of the pandemic, it is important to identify elective procedures or in other terms, the ones that could be delayed. although this may sound simple, the pandemic itself has made such a sharp distinction impossible, creating a large gray zone. this question is particularly relevant to the orthopedic practice as 47% of the expenditure is from elective surgeries [37] . with no consensus reached in the orthopedic community, some authors recommended that this should be individualized to each facility according to its resources and to each patient according to the condition [37] [38] [39] . the ohio hospital association (oha) defined elective surgeries as those not meeting the following criteria "threat to the patient's life if surgery or procedure is not performed, threat of permanent dysfunction of an extremity or an organ system, risk of metastasis or progression of staging, or risk of rapidly worsening to severe symptoms" [37, 38] . patients with stable diseases (low or moderate risk of clinical deterioration) can be postponed, while patients with unstable disease (risk of short-term clinical deterioration) should be considered for surgery with precautions [40] . the covid-19 status of the patient whether positive, negative, or not tested is another important factor that affects the time of surgical intervention [40] . reducing surgeries saves resources including hospital beds, ppes, as well as protecting the surgical staff [5] . this can also diminish the risk of perioperative complications and mortality, [40, 41] reduce unnecessary patient traffic and decrease the introduction and spread of disease among patients and health care providers [5] . c. what should be offered to patients as an alternative to surgical intervention? delays of operative intervention in elective cases although temporary, might extend for months as a best estimate. patients should be offered sound alternatives to assist them bear the anticipated waiting times, this could be in the form of optimized medical treatment, individualized non-surgical options through multidisciplinary approaches, supportive online counseling, psychological support, and in pediatric patients engaging families and stressing on safety measures [40] [41] [42] . many articles have tried to categorize various conditions according to urgency, [37, 38] as well as guidelines put forth by international societies [45] [46] [47] . awad et al. stratified orthopedic conditions into five categories according to urgency, a through e, a being the most urgent [45] . open fractures, acute neurovascular derangements as well as acute infections were rendered as emergent (a) to be operated within 24 h. closed fractures were grouped under b or c. deformities, arthroplasty and trigger finger were grouped under e [45] . table 1 gives relevant examples to these recommended categories. farrell et al. suggested some management plans for the pediatric orthopedic patient [42] . in the pediatric trauma patient, modifications to standard care were mostly to the follow-up instructions and methods. table 2 demonstrates two examples. as for elective orthopedic patient, the authors advocated either postponing the surgery or doing a minimally invasive procedure if feasible. table 3 gives examples to these situations. donnally et al. published on triaging patients with spine pathologies according to the rothman institute guidelines during the covid-19 era [48] . patients were classified into three levels according to the urgency of surgical intervention and the facility in which the patient should be operated upon. awad et al. recommended regional organization by assigning designated hospitals with orthopedic staff to treat only suspected or confirmed covid-19 patients and other hospitals in the same regions to treat exclusively non-infected patients [45] . this may not be feasible in some regions or districts and in such a case, the same hospital should be divided into areas or wards according to the risk of exposure to the virus, with a stratified increase in ppe according to the increase in the level of probable exposure (figure 2 ) [45] . on the personnel level, all should apply the general selfprotection rules like, safe distancing, face masks, goggles for eye protection, hand disinfection, regular decontamination of all patient/staff contact points, and avoidance of touching one's eyes, nose, and face [49, 50] . another notable recommendation is to establish a three-team approach where one team is working in the hospital involved in direct patient care, while the other teams are away from the hospital through 14 days as a "quarantine" between episodes of direct patient care [51] . this requires adequate number of medical staff which has not always been the case in the covid-19 pandemic. on the patient level, in hospitals still running outpatient clinics, patients should be screened for symptoms like (fever, cough, sore throat), if the patient shows positive symptoms consider delaying the outpatient management till test results are available. if a patient's operation could not be delayed for testing, then the patient should be re-triaged into the emergency category and presumed covid positive. all of this should be done with proper precautions such as wearing face masks, distancing, and well-aerated waiting areas [52, 53] . as for patients in the emergency department (ed) and crowded triage areas, same protective precautions apply, and if the patient is oriented, he/she is asked for the suspect criteria for covid-19 infection. suspected or confirmed covid-19 patients should be isolated in a separate room and should keep at least 6 feet distance from other patients or non-treating staff. covid-19 polymerase chain reaction (pcr) testing should be done for all patients that will be admitted or will undergo surgery. surgeons should not approach the triage area without the minimum standard ppe recommended. ppe should be exchanged if they are damaged or soiled or before leaving the ed. only required equipment and assessment tools should be brought into the triage room to minimize the number of items that need to be disinfected after the exposure [45] [46] [47] [48] [49] [50] [51] [52] [53] [54] . this should be incorporated into hospital plans and rules to face the pandemic, [55] and can be subdivided into measures involving the operating room, personnel, anesthesia, the procedure, and postoperative precautions. separate operating rooms (or) should be designated for covid-19 positive patients, isolated from other operating rooms . the operating room is preferred to have a separate ventilation system with negative pressure [5, [58] [59] [60] , which if not available, it is recommended to add high-efficiency particulate air (hepa) filters to positive pressure rooms [51] [52] [53] [54] . moreover, air conditioning should be turned off [59] [60] [61] [62] . only the materials necessary for the case should be brought into the or [5] . all equipment and screens should be covered with plastic sheets to facilitate decontamination [45] . consider attenuation of residual environmental contamination through cleaning with surface disinfectants and ultraviolet light (uv-c) [63] . all traffic in and out of the or should be minimized . all doors should be closed once the patient is transferred in and during the whole operation [5] . the path of the patient to and from the or should be kept clear and better to be separate from other operating rooms [5] . patients should cover their face with a surgical mask [5] . the patient should recover in the operating room and transferred directly to the isolation ward . the number of personnel inside the or should be kept to the minimum. services personnel should not enter the room compression fracture (without neurologic deficits) defer surgery or reconsider risks versus benefits of continued conservative management. consider course of steroid therapy (injection or oral). odontoid fractures in elderly will be managed conservatively, with option of treating symptomatic nonunion surgically in future. until enough time has elapsed for air changers to reduce the risk of contamination [45] [46] [47] [48] [49] [50] [51] [52] [53] [54] [55] [56] [57] [58] [59] [60] [61] . sales representatives, residents, and fellows should be discarded from or unless essential . the fewest number of personnel possible is the main goal, with the highest skilled surgeon performing the procedure to avoid prolongation of the surgery [51, 54, 59, 64] . all personnel in the operating room should wear the ppe which include association of advancement of medical instrumentation (aami) level iii surgical gowns, surgical hood (for head and neck covering), double gloves, facemasks and either n95, filtering face piece 2 (ffp2) respirators with a face shield/googles or powered air-purifying respirator (parp), fluid-resistant shoes or booties [5, [49] [50] [51] [52] [53] [54] [55] [56] [57] . donning and doffing of ppe should be done in an anteroom if available, with hand hygiene prior and after donning/doffing ppe [5] . avoid self-contamination during ppe doffing. disinfect the first pair of gloves with an alcohol solution, before removing the surgical mask with the shield and the hair cap . consider placing a simple surgical mask on top of the n-95 to prevent gross contamination. each time n95 respirator is taken off, it must be double-checked for not being soiled or damaged before reuse [5, [45] [46] [47] [48] [49] [50] [51] [52] [53] [54] [55] [56] [57] . full face shield is preferred to protective eye goggles [5, [52] [53] [54] [55] [56] [57] . dedicated anesthesia machines should be exclusively designated for covid-19 positive cases [62] . the most experienced anesthesiologist should intubate the patient in the shortest possible time with minimal airway manipulation, avoiding face mask ventilation and open-air way suction as possible [5, [45] [46] [47] [48] [49] [50] [51] [52] [53] [54] [55] [56] [57] [58] [59] [60] . keep the minimum number of personnel inside the anesthesia room which should be separate from the operating room, which should not be entered for 15-20 min after intubation [5, [51] [52] [53] [54] [55] [56] [57] . use deep anesthesia and neuromuscular blockage. preoxygenation should be performed via well-fitting face mask to avoid hypoxia in critically ill covid-19 patients with respiratory failure [60] [61] [62] [63] [64] [65] . it is preferred to avoid general anesthesia and use of regional/spinal anesthesia is recommended whenever possible [60] . consider the use of minimally invasive approaches to decrease operating staff exposure and shorten case duration [5, [51] [52] [53] [54] [55] [56] [57] [58] [59] [60] [61] [62] [63] [64] [65] [66] . use disposable medical supplies/instruments whenever possible, and absorbable sutures for wound closure to avoid a postoperative unnecessary visit [45] [46] [47] [48] [49] [50] [51] . the use of electrocautery should be reduced to minimize the surgical smoke and should be used in conjunction with a smoke evacuator [5, 58, 59, 67] . care should be taken when using sharp objects to avoid sharp injury or damage of ppe [61] . the use of power tools like bone saws, reamers, and drills should be reduced to the minimum and the power settings should be as low as possible, as they release aerosols, increasing the risk of virus spread. suction devices to remove smoke and aerosols should be used during their use [68] . all body fluids as blood, secretions, urine, or pathological specimens should be collected in double sealed bags for inspection or destruction [5, [45] [46] [47] [48] [49] [50] [51] [52] [53] [54] [55] [56] [57] [58] [59] [60] [61] . all contaminated instruments and devices should be disinfected separately followed by proper labeling [5, [45] [46] [47] [48] [49] [50] [51] [52] [53] [54] [55] [56] [57] [58] [59] [60] [61] . the transfer to isolation wards should be through dedicated corridors and elevators which should be carefully sterilized after transport [55, -62] . during the transfer, transport personnel should wear ppe which should not be the same as worn during the procedure and patients should be wearing n-95/ffp2 masks and covered with disposable operating sheets [5, [58] [59] [60] [61] [62] . surgeons must be aware of common postoperative complications from covid-19 infections. in the presence of fever and one of the symptoms of a respiratory infection (dry cough, etc.), laboratory tests for covid-19 diagnosis must be ordered. suspected cases should be reported immediately together with transfer of the patient to an isolation ward [69] . patients should receive adequate nutrition, fluid hydration, and electrolyte balance to promote immune recovery and rapid rehabilitation [61] . frequent monitoring of temperature, laboratory complete blood count (cbc), c-reactive protein, and ferritin level should be done [70] . severe covid-19 infection might cause a "cytokine storm syndrome", which is characterized by a fulminant and fatal hyper-cytokinemia with multiorgan failure. an increased level of ferritin occurs in approximately 50% of patients. all patients with severe covid-19 should be screened for hyper-inflammation markers [71] . safe and effective patient care during the pandemic and telemedicine in order to resume safe patient care, telemedicine has been widely used during this pandemic [72] [73] [74] [75] . telemedicine allows health care providers to deliver clinical services to patients through the use of the widely available telecommunication technologies. it can be used for patient triage, postoperative follow-up and monitoring patients with chronic diseases. postoperative rehabilitation can be also resumed remotely via online educational programs or videoconferences. moreover, rehabilitation can be tele-monitored through special technologies such as wireless sensors for range of motion such as the knee following knee arthroplasty. nonetheless, telemedicine has its limitations. patients with sutures to remove, cast to change or need comprehensive clinical examination will still have to pay an in person visit to the health care facility. also, there are obstacles for wide implementation of such services such as infrastructure cost, provider and patient education, data protection, ethical consideration, legalization, and payment regulation [64] . in order to facilitate the use of telemedicine, the office for civil rights at the u.s. department of health and human services on march 17, 2020 allowed physicians to utilize commercially available platforms, such as, skype, whatsapp, zoom, and facetime without imposing penalties for noncompliance. in all cases, documentation within the patient medical record is mandatory [76] . the covid-19 crisis called for alternative methods to resume resident and fellow education [77] [78] [79] , an example is the flipped virtual classroom method, in which the learners are asked to review the lecture online, with a subsequent virtual meeting focused on active learning and case-based discussions. other methods include online practice questions, academic webinars, and telehealth clinics with resident involvement. many applications such as webex, google classroom, microsoft teams, and zoom offer platforms for remote online conferences. the main drawback to this approach is that it cannot involve actual clinical or surgical skills teaching. others include difficulties some senior staff may have with utilizing modern technology, slow internet speed in some regions, and difficulties with viewing some pictures especially radiology [80] . to overcome these obstacles high-definition 3d operative videos and surgical simulations are being employed. various simulation modalities are available including surgical skills laboratories, cadaveric dissections and procedural training, and computer-based virtual reality training [81] [82] [83] [84] . the 2020 annual meeting of american academy of orthopedic surgeons (aaos) is now being made available through the aaos website. this includes instructional course lectures, and ask expert sessions, in addition to the traditional research paper and poster presentations. the american association of hip and knee surgeons (aahks) has developed the focal initiative: fellows online covid-19 aahks learning, a series of online lectures by invited faculty to continue fellow education during this time [81] . follow-up of the online training has to be followed up by the person responsible for resident and fellow training through recording attendance and completion of online sessions and modules, and completing online assessments and quizzes [81] . making use of the crisis and planning for the post-pandemic era global cooperation and exchange of experiences are still to be improved. the pandemic is still in various stages in different countries. countries with increasing numbers of cases and mortalities are learning from those recovering from the crisis. the future requires better planning and re-allocation of resources to be prepared for such events. to make use of the available technologies in telemedicine is of utmost importance. remote triaging and examination techniques, feedback through mobile applications, and virtual interdisciplinary meetings should be encouraged. urgent legislative reforms to adapt to these changes are mandatory. e-learning, virtual conferences, webinars, and simulation training initiatives must be supported by the international scientific societies. curricula should be revised to adapt to these needs. non-technical skills should constitute integral part of learning programs. plans should be prepared to manage the accumulated long waiting lists of elective surgeries [85] [86] [87] [88] [89] . prioritization should be rational without inferring excessive burden on the recovering health system after the crisis. all in all, the authors believe that the medical practice, including orthopedic surgery will differ after the pandemic is over. implementation of new technologies, restructuring our health systems with incorporation of telemedicine as well as reorganizing of our traditional training programs will be crucial for a more effective and optimal delivery of care. first case of 2019 novel coronavirus in the united states early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia understanding of covid-19 based on current evidence new options for vascularized bone reconstruction in the upper extremity managing covid-19 in surgical systems preferred reporting items for systematic reviews and meta-analyses: the prisma statement the surgeons and the covid-19 pandemic practice management during the covid-19 pandemic staiger do (2020) older clinicians and the surge in novel coronavirus disease 2019 (covid-19) a bioethical perspective for navigating moral dilemmas amidst the covid-19 pandemic ventilator stockpiling and availability in the us impact of the covid-19 pandemic on surgical services: early experiences at a nominated covid-19 centre critical supply shortagesthe need for ventilators and personal protective equipment during the covid-19 pandemic the toughest triageallocating ventilators in a pandemic prevention cfdca (2020) strategies for optimizing the supply of n95 respirators roles and responsibilities of the orthopaedic community and the society during covid-19 pandemic covid-19 pandemic and personal protective equipment shortage: protective efficacy comparing masks and scientific methods for respirator reuse rapid response of an academic surgical department to the covid-19 pandemic: implications for patients, surgeons, and the community crispr-mediated epigenome editing annotation: the covid-19 pandemic and clinical orthopaedic and trauma surgery covid-19: initial experience of an international group of hand surgeons covid-19 and spinal surgery response of a european surgical department to the covid-19 crisis disruption of joint arthroplasty services in europe during the covid-19 pandemic: an online survey within the european hip society (ehs) and the european knee associates (eka) disruption of arthroplasty practice in an orthopedic center in northern italy during the coronavirus disease 2019 pandemic resource reallocation during the covid-19 pandemic in a suburban hospital system: implications for outpatient hip and knee arthroplasty surgical response to covid-19 pandemic: a singapore perspective effects of covid-19 pandemic in the field of orthopaedics maximizing the calm before the storm: tiered surgical response plan for novel coronavirus (covid-19) what's important: redeployment of the orthopaedic surgeon during the covid-19 pandemic: perspectives from the trenches psychological status of surgical staff during the covid-19 outbreak incidentally diagnosed covid-19 infection in trauma patients; a clinical experience characteristics and early prognosis of covid-19 infection in fracture patients treatment of proximal femoral fragility fractures in patients with covid-19 during the sars-cov-2 outbreak in northern italy risk of long-term infection-related death in clinical osteoporotic vertebral fractures: a hospitalbased analysis how to risk-stratify elective surgery during the covid-19 pandemic? a review of state guidelines for elective orthopaedic procedures during the covid-19 outbreak elective surgeries during the covid-19 outbreak we asked the experts: covid-19 outbreak: is there still a place for scheduled surgery? "reflection from pathophysiological data clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid-19 infection recommendations for the care of pediatric orthopedic patients during the covid pandemic guidelines for ambulatory surgery centers for the care of surgically necessary/time-sensitive orthopaedic cases during the covid-19 pandemic orthopaedic surgical selection and inpatient paradigms during the coronavirus covid-19 pandemic perioperative considerations in urgent surgical care of suspected and confirmed covid-19 orthopedic patients: operating rooms protocols and recommendations in the current covid-19 pandemic surgical management of patients with covid-19 infection. recommendations of the spanish association of surgeons covid-19 contagion and contamination through hands of trauma patients: what risks and what precautions? triaging spine surgery in the covid-19 era working through the covid-19 outbreak: rapid review and recommendations for msk and allied heath personnel covid-19 & the general surgical department -measures to reduce spread of sars-cov-2 among surgeons the orthopaedic trauma service and covid-19 -practice considerations to optimize outcomes and limit exposure precautions for operating room team members during the covid-19 pandemic rules on isolation rooms for suspected covid-19 cases in gp surgeries to be relaxed novel coronavirus covid-19: current evidence and evolving strategies covid-19 outbreak and surgical practice: unexpected fatality in perioperative period preparing to perform trauma and orthopaedic surgery on patients with covid-19 systematic review of recommended operating room practice during the covid-19 pandemic ventilation performance in operating theatres against airborne infection: review of research activities and practical guidance what we do when a covid-19 patient needs an operation: operating room preparation and guidance practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-ncov) patients interventional radiology and covid-19: evidence-based measures to limit transmission perioperative management of patients infected with the novel coronavirus: recommendation from the joint task force of the chinese society of anesthesiology and the chinese association of anesthesiologists perioperative covid-19 defense: an evidence-based approach for optimization of infection control and operating room management novel coronavirus and orthopaedic surgery: early experiences from singapore infection control measures for operative procedures in severe acute respiratory syndrome-related patients current evidence for minimally invasive surgery during the covid-19 pandemic and risk mitigation strategies: a narrative review minimally invasive surgery and the novel coronavirus outbreak: lessons learned in china and italy characterization of aerosols produced during surgical procedures in hospitals global guidance for surgical care during the covid-19 pandemic pulmonary involvement in patients with hemophagocytic lymphohistiocytosis covid-19: consider cytokine storm syndromes and immunosuppression telehealth utilization in response to the novel coronavirus (covid-19) pandemic in orthopaedic surgery telemedicine in the era of covid-19: the virtual orthopaedic examination internet of medical things (iomt) for orthopaedic in covid-19 pandemic: roles, challenges, and applications digital orthopaedics: a glimpse into the future in the midst of a pandemic what's important: weathering the covid-19 crisis: time for leadership, vigilance, and unity spine fellowship training reorganizing during a pandemic: perspectives from a tertiary orthopedic specialty center in the epicenter of outbreak covid 19 and training in the uk -correspondence orthopedic surgery training during the covid-19 pandemic: dusting off my stethoscope using technology to maintain the education of residents during the covid-19 pandemic orthopaedic education during the covid-19 pandemic virtual surgical training during covid-19: operating room simulation platforms accessible from home virtual interviews for surgical training program applicants during covid-19: lessons learned and recommendations we asked the experts: virtual learning in surgical education during the covid-19 pandemic-shaping the future of surgical education and training reinstating elective orthopaedic surgery in the age of covid-19 resuming elective orthopaedic surgery during the covid-19 pandemic: guidelines developed by the international consensus group (icm) economic recovery after the covid-19 pandemic: resuming elective orthopedic surgery and total joint arthroplasty covid-19 -esska guidelines and recommendations for resuming elective surgery returning to orthopaedic business as usual after covid-19: strategies and options abdelgawaad as (2020) covid-19. an update for orthopedic surgeons the authors declare that they have no conflict of interest related to the submitted article.there is no funding source. this article does not contain any studies with human participants or animals performed by any of the authors. key: cord-267791-v10eh408 authors: chughtai, abrar ahmad; khan, wasiq title: use of personal protective equipment to protect against respiratory infections in pakistan: a systematic review date: 2019-02-07 journal: j infect public health doi: 10.1016/j.jiph.2019.01.064 sha: doc_id: 267791 cord_uid: v10eh408 like other low-income countries, limited data are available on the use of personal protective equipment (ppe) in pakistan. we conducted a systematic review of studies on ppe use for respiratory infections in healthcare settings in pakistan. medline, embase and goggle scholar were searched for clinical, epidemiological and laboratory-based studies in english, and 13 studies were included; all were observational/cross-sectional studies. the studies examined ppe use in hospital (n = 7), dental (n = 4) or laboratory (n = 2) settings. policies and practices on ppe use were inconsistent. face masks and gloves were the most commonly used ppe to protect from respiratory and other infections. ppe was not available in many facilities and its use was limited to high-risk situations. compliance with ppe use was low among healthcare workers, and reuse of ppe was reported. clear policies on the use of ppe and available ppe are needed to avoid inappropriate practices that could result in the spread of infection. large, multimethod studies are recommended on ppe use to inform national infection-control guidelines. healthcare workers are at the frontline when treating infectious disease cases and at high risk of acquiring influenza and other respiratory infections [1] [2] [3] . several outbreaks of new infectious diseases have occurred in recent decades, such as the outbreak of severe acute respiratory syndrome coronavirus (sars-cov) in 2002-2003 [4] , influenza pandemic (h1n1) in 2009 [5] , middle east respiratory syndrome coronavirus (mers-cov) in 2012 [6] and ebola virus diseases in 2014-2016 [7] . many healthcare workers were infected and died during these outbreaks because of a lack of infection control [4, 8, 9, 10] various infection control strategies are used to protect healthcare workers from respiratory and other infections in healthcare settings [11, 12] . these strategies can be broadly classified as administrative control measures, environmental control measures and the use of personal protective equipment (ppe). administrative control measures include developing policies and procedures, implementing triage protocols and providing health education and trainings. environmental control measures includes ensuring proper ventilation, establishing airborne infection isolation and negative pressure rooms, developing systems for cleaning and waste disposal. [13, 14] . ppe is commonly used in healthcare settings as standard or transmission based precaution to protect healthcare workers from infections and to prevent further spread to patients around them [14, 15] . ppe is generally ranked lowest in the infection control hierarchy due to less effectiveness compared to other control measures and high expenditure in the long run. therefore, most infection control guidelines recommend using ppe together with other administrative and environmental control measures. however, ppe is important during the early stage of an outbreak or a pandemic when drugs, a vaccine and other control measures are not available, or access is limited. commonly used ppe to protect from respiratory infectionsare; face masks, respirators, gloves, and goggles or face shields [16] . face masks (or medical masks) and respirators are the most commonly used ppe to protect from influenza and other respiratory infection in healthcare settings. however, these two products are not the same. face masks are not designed for respiratory protection and are used to avoid respiratory droplet and spray of body fluids on the face. they are also used by sick patients to prevent spread of pathogens to others (referred to as "source control"), or by surgeons in the operating theatre to maintain a sterile operating field. face masks are not fit to the face and have varying filtration capacities [17] . respirators ratory protection and are used to protect from respiratory aerosols [18] . a properly fitted respirator provides better protection again respiratory infections than a face mask. gloves are used to protect hands from blood and body fluids, including respiratory secretions. goggles and face shields are used to prevent transfer of respiratory pathogens into the eyes from contaminated hands and other sources. gowns, coveralls, surgical hoods and shoe covers can also be used where procedures on infectious patients generate aerosols or when a new respiratory virus has emerged [18] . there is an ongoing debate about the selection and use of various types of ppe in healthcare settings. this is mainly because of a lack of high quality studies on the use of ppe. most studies are observational and on the use of masks and/or respirators [18] . to date, only five randomized clinical trials have been conducted on use of ppe in hospital settings and all were on face masks/respirators [18] . moreover, most studies on ppe use were conducted in high/middle income countries and currently there are limited data from lowincome countries where the burden of infectious diseases is high. it is therefore important to examine the use of ppe in low resource countries to inform infection control policies. pakistan has a population of about 200 million. as a low-income country, its gross domestic product is low, as is its expenditure on health [19] . the country has one of highest rates of infant and maternal mortality in the south asia region. infectious diseases are still among the main causes of death, particularly in young children. health and surveillance systems are generally weak and limited data are available on infection prevention and control strategies. the aim of this study was to examine the use of ppe for respiratory infections in healthcare settings in pakistan. a systematic review was conducted using the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines. we searched for studies on the electronic databases medline and embase using selected key words. a combination of keywords were used including: 'face mask' or 'mask' or 'medical mask' or 'surgical mask' or 'cloth mask' or 'respirator' or 'gloves' or 'gowns' or 'coverall' or 'surgical cap/hood' or 'shoe/boot covers' or 'goggles' or 'face shield' or 'eye protection' and ' respiratory infection' or 'respiratory tract infection' or 'respiratory diseases', 'outbreaks' or 'infectious disease' or 'influenza' or 'pandemic influenza' or 'flu' or 'tuberculosis' or 'pneumonia' and 'pakistan' or 'punjab' or 'sindh' or 'balochistan' or 'khyber pakhtunkhwa'. we used an open date strategy up to december 2017. we anticipated that studies published in local journals might not be indexed on the medline or embase, therefore, an additional search was made on google scholar using the same keywords. we set a limit of 20 results per page on google scholar and first three pages were reviewed for each keyword search. after the initial search; we reviewed titles and abstracts and selected studies for full text review (fig. 1) . clinical, epidemiological and laboratory-based studies conducted in any part of pakistan and published in english were included in the review. the focus of this systematic review was on the use of ppe for prevention of respiratory infections. therefore, we only included those studies which examined the use of facemask and/or respirator in healthcare settings, with or without other ppe. we only included those studies where ppe was discussed for respiratory infections. studies where ppe was examined for general infection control were also included, given respiratory protective equipment (face masks and/or respirators) was mentioned. we excluded studies on the use of ppe only for bloodborne infections. conference abstracts and poster presentations were also excluded. a total of 137 studies were found in the initial search. after reviewing titles and abstracts, 46 studies were selected for full text review. finally, 13 articles were included in this review (table 1 ) [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] . we only found observational/cross-sectional studies on the use of ppe for infectious diseases in healthcare settings in pakistan. in all studies data were collected through questionnaires or interviews. no clinical trials or laboratory-based studies on the use of ppe in such settings were found. seven studies examined the use of ppe in hospital [20] [21] [22] [23] 25] and among those, two examined the ppe perceptions among medical students [24] or pharmacy students [32] . two studies were conducted in the laboratory settings [26, 27] while, four in dental settings [28] [29] [30] [31] two studies focused on the use of ppe for influenza [24, 32] , two were for tuberculosis [20, 25] and nine studies were on multiple respiratory diseases, including influenza [21, 22] or general infections [23, [26] [27] [28] [29] [30] [31] . only two studies examined the use of ppe alone [21, 22] , while other studies examined other infection control practices as well [20, [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] . guidelines and standard operating procedures on ppe do not exist in most of the hospitals [23] or laboratories [26, 27] in pakistan. two studies examined the guidelines and current practices on the use of face masks/respirators for influenza, tuberculosis and sars in pakistan [21, 22] . recommendations on the use of masks were reported to be inconsistent and different types of product were recommended and used in various healthcare settings [21, 22] . face masks were the most commonly used ppe to protect from respiratory infections in most hospitals in pakistan. medical masks were generally used to protect from influenza, tuberculosis and other respiratory infections, while the use of respirators was limited to high-risk situations [21, 22] . in a cross-sectional survey among final-year pharmacy students in seven universities of karachi, about 60% of 443 participants highlighted the need to cover the nose or mouth to protect from influenza and about 57% highlighted the use of face masks, gloves and other ppe [32] . laboratory coat and gloves were the most commonly used ppe in the laboratories in pakistan while face masks and eye covers were rarely used [26, 27] . a survey of dentists working in various settings (dental colleges, hospitals and private clinics) showed that face masks and gloves were also commonly used ppe [29] . the use of ppe was also reported to be low among health workers. according to a hospital-based survey, face masks are not provided to patients with tuberculosis and respirators are not provided to the healthcare workers [23] . another survey showed that 25% of participants used ppe for patients with suspected tuberculosis and 56% used ppe for patients with confirmed tuberculosis [25] . a study in a ward for patients with multidrug-resistant tuberculosis reported that 65% of the healthcare workers used n95 respirators and 58% were provided with a mask [20] . a study on 253 biosafety level (bsl) 2 laboratory workers showed that ppe was not used by about half of the staff (46.2%) [27] . a countrywide survey showed that almost one third (31.9%) of bsl-2 laboratory workers did not routinely use ppe [26] . both gloves and laboratory coats were used by only 26.7% of the personnel, while a laboratory coat or gloves alone were used by 30.4% and 8.1%, respectively. less than 1% of all the respondents across pakistan reported using eye covers [26] . in a survey of medical students during pandemic (h1n1) 2009, 75% said that they would use a face mask to protect from infection. students with less risk perception were more hesitant to use face masks [24] . the use of face masks was common in dental practice and according to various surveys, 68-100% of dentists wear masks during dental procedures [28] [29] [30] [31] . across all the studies in dental settings, more than 90% also used gloves. among the ppe, face masks were considered the most bothersome to use by wearers. reuse of ppe was also reported in many studies, mainly because of unavailability of ppe and lack of training. gowns are shared among the healthcare workers in hospital many times [23] . two surveys in dental clinics showed that more than half of the dentist reuse masks during routine work [28, 29] . the availability of ppe was generally low in all healthcare settings [21, 22, 28] and varied according to the type [23] ; gloves and masks were available while gowns and n95 respirators were not available in several wards [23] . a shortage of ppe was also reported during sars and pandemic (h1n1) 2009 [21, 22] . a lack of training was a common issue reported and most healthcare workers were not trained in the use of ppe. most of the studies (11/13) discussed other infection control practices as well, in addition to the use of ppe. other non-standard infection control practices included reuse of syringes, improper waste disposal, a lack of hand hygiene practices, non-isolation of infectious cases and low influenza vaccination among healthcare workers. we reviewed the use of ppe in various healthcare settings in pakistan. a lack of guidelines and standard operating procedures, inconsistent policies and practices, low compliance, and non-availability and reuse of ppe were the main issues highlighted in this study. evidence is lacking on the use of ppe in hospitals and other healthcare settings in pakistan and most studies are of low quality. clinical studies should be conducted to examine the effectiveness of ppe and improve the compliance. reuse of ppe may increase the risk of self-contamination to the wearer and this practice should be discontinued. there is a need to improve the availability of ppe and healthcare workers should be trained. ppe is generally considered lowest in the infection control hierarchy and is generally recommended in combination with other control measures. other infection control practices in such settings should also be examined. different types of ppe are used by healthcare workers in pakistan, which reflects a lack of standard policies and guidelines. the different policies and practices may be because of the different recommendations by the world health organization (who) and the united states (us) centers for disease control and prevention (cdc) [33, 34] . debate continues about the selection and use ppe for different infections, for example, face masks versus respirators, gowns versus coveralls, face shields versus goggles [7, 18, 34, 35] . selection of ppe mainly depends on mode of transmission, however, several individual and organizational factors also contribute the selection and use of ppe, such as risk perception, presence of adverse events, pre-existing medical illness, availability and cost [7] . respiratory infections are generally transmitted through contact, droplet and/or airborne routes. gloves should be used to protect from infections transmitted through contact (e.g. respiratory syncytial virus and adenovirus), face masks should be used for droplet infections (e.g. influenza and coronavirus) and a respirator should be used to protect form airborne infection (e.g. tuberculosis and measles). however, infection transmission is rarely by only one route and most infections are transmitted by more than one route [36] . for example, influenza and sars primarily transmit through droplet and contact routes, but airborne transmission has also been reported [37, 38] . similarly, ebola primarily transmits through direct contact with blood and body fluids [39] , but animal studies have shown that airborne transmission is also possible [7] . the risk of transmission further increases during aerosol-generating and other high-risk procedures [40, 41] . moreover, uncertainty exists about how pathogens transmit during outbreaks and pandemics [14, 34, 42, 43] . therefore, superior ppe should be used where the mode of transmission is uncertain, the case-fatality rate is high and pharmaceutical interventions are not available [7] . infection control guidelines in pakistan need to be updated urgently to reflect these recommendations. given that mers cov is circulating in the eastern mediterranean region (emr), policies and practices on the use of ppe in other countries of the region should also be examined. our study also reported low availability of ppe in hospital, dental and laboratory settings in pakistan. the availability of ppe is a challenge, not only in low-resource counties, but also in highincome countries, particularly during outbreaks and pandemics when the use of ppe greatly increases [46, 47] . this may result in non-standard practices such as reuse and extended use of ppe. shortages of ppe were even reported in many high-income countries during the 2009 influenza h1n1 pandemic and staff had to use various alternatives [46] [47] [48] . the availability of ppe is important to ensure proper use and compliance. low use of ppe among laboratory workers in pakistan may be due to non-availability and a lack of resources. for example, ppe use was relatively higher in laboratory workers in punjab, which is an affluent province, than other provinces [26] . moreover ppe use was reported more in the private sector in pakistan than the public sector which has fewer resources [27] . proper use of ppe depends on several factors such as availability, knowledge, training, risk perception and comfort [7, 44, 45] . this study showed the compliance with the use of ppe was generally low among healthcare workers and was mainly due to unavailability of ppe, discomfort and a lack of training. while the use ppe depends on many factors, a greater perception of risk was positively associated with compliance [24] . continuous use of face masks and respirators may have psychological and physiological effects on the wearer and result in more adverse events [49] [50] [51] . compliance with the use of face masks has been shown to be based on the nature of the disease, infectiousness of patients and the performance of high-risk procedures [52] . previous studies have tested the precede (predisposing, reinforcing and enabling) framework to examine healthcare workers' compliance with universal precautions [53] . the results showed that reinforcing factors, such as availability of ppe and less job hindrance, and enabling factors, such as safety climate and regular feedback, were significant predictors of compliance with ppe [53] . in addition, the health belief model [54] was also used to examine the compliance and use of face mask during the sars outbreak [55, 56] . perceived susceptibility (vulnerability to acquiring sars and close contact with case), perceived benefits (that face masks can prevent infection) and cues to action (someone asked them to use face masks) were significant predictors of protective behaviour and use of face masks [55] . our study showed that most healthcare workers were not trained on the use of ppe in pakistan. the risk of infection can be reduced with proper training and availability of policies and standard operating procedures [57] . however, regular monitoring is also required to make sure that healthcare workers are using ppe according to the protocols. a study in the us reported many deviations from the protocols even though all healthcare workers were trained [15] . this may result in self-contamination to the wearers and the spread of infection to others [58] . training programmes should be arranged for newly recruited staff and then annual refresher courses should be provided. our study had some limitations. the initial search was made on medline and embase but very few studies were retrieved because many papers are not indexed on these databases. therefore, we also searched google scholar but we only reviewed the first 3 pages after each search so some studies could have been missed. however, we checked the references lists of the relevant studies and could not find any other studies. our search was up to 2017 and studies in 2018 were not included. we only considered ppe in this study and did not examine other infection control practices. the use of ppe is generally recommended with other administrative and environmental control measures. the selection and use of ppe vary according to the type of healthcare worker and working environment. face masks and gloves were the most commonly used ppe to protect from respiratory and other infections. overall, compliance with the use of ppe was low, and non-availability and reuse of ppe were reported. most studies were observational and large-scale prospective studies are needed to collect more evidence about the use of ppe in healthcare settings in pakistan. no funding sources. aac tested the filtration of mask samples by 3 min in another study; 3m products were not used in this study. wk declares none. as this was a systematic review of published data, ethics approval was not required. aac devised the structure and topic areas for this review and made the initial search. wk and aac reviewed titles and abstracts and selected studies for full text review. aac prepared the first draft of manuscript and both authors contributed equally to the final manuscript. influenza and rhinovirus infections among health-care workers nosocomial transmission of measles among healthcare workers tuberculosis among health care workers emergencies preparedness, response. summary of probable sars cases with onset of illness from 1 world health organization. emergencies preparedness, response. pandemic (h1n1) 2009 -update 112 comparative epidemiology of middle east respiratory syndrome coronavirus (mers-cov) in saudi arabia and south korea respiratory protection for healthcare workers treating ebola virus disease (evd): are face masks sufficient to meet occupational health and safety obligations? epidemiology of h1n1 (2009) influenza among healthcare workers in a tertiary care center in saudi arabia: a 6-month surveillance study h1n1 influenza infection in korean healthcare personnel uncertainty, risk analysis and change for ebola personal protective equipment guidelines interim guidance on infection control measuresfor 2009 h1n1 influenza in healthcare settings, including protection of healthcare personnel infection prevention and control guidance for care of patients in health-care settings, with focus on ebola. interim guidance guideline for isolation precautions: preventing transmission of infectious agents in health care settings infection prevention and control of epidemic-and pandemic-prone acute respiratory infections in health care. who guidelines. geneva: world health organization assessment of healthcare worker protocol deviations and self-contamination during personal protective equipment donning and doffing guidance on personal protective equipment (ppe) to be used by healthcare workers during management of patients with confirmed ebola or persons under investigation (puis) for ebola who are clinically unstable or have bleeding, vomiting, or diarrhea in u.s. hospitals, including procedures for donning and doffing ppe protecting healthcare staff from severe acute respiratory syndrome: filtration capacity of multiple surgical masks face masks for the prevention of infection in healthcare and community settings infection control in hospitals managing drug-resistant tuberculosis in pakistan: how are we doing? infection control survey in the hospitals to examine the role of masks and respirators for the prevention of respiratory infections in hcws practices around the use of masks and respirators among hospital health care workers in 3 diverse populations infection control at a government hospital in pakistan medical students' knowledge, perceptions, and behavioral intentions towards the h1n1 influenza, swine flu, in pakistan: a brief report assessment of the protective measures taken in preventing nosocomial transmission of pulmonary tuberculosis among health-care workers biosafety perspective of clinical laboratory workers: a profile of pakistan practices and awareness regarding biosafety measures among laboratory technicians working in clinical laboratories in karachi cross infection control infection control practices across karachi: do dentists follow the recommendations? infection control practices among dental practitioners of lahore, pakistan knowledge attitude and practice of infection control measures among dental practitioners in public setup of karachi, pakistan: cross-sectional survey perspectives about pandemic influenza and its prophylactic measures among final year pharmacy students in karachi examining the policies and guidelines around the use of masks and respirators by healthcare workers in china, pakistan and vietnam availability, consistency and evidencebase of policies and guidelines on the use of mask and respirator to protect hospital health care workers: a global analysis a highly precautionary doffing sequence for health care workers after caring for wet ebola patients to further reduce occupational acquisition of ebola aerosol transmission of infectious disease aerosol transmission of influenza a virus: a review of new studies environmental transmission of sars at amoy gardens persistence of ebola virus in various body fluids during convalescence: evidence and implications for disease transmission and control health workers need optimal respiratory protection for ebola transmission of ebola viruses: what we know and what we do not know preventing transmission of pandemic influenza and other viral respiratory diseases: personal protective equipment for healthcare personnel interim recommendations for facemask and respirator use to reduce 2009 influenza a (h1n1) virus transmission the use of face masks to prevent respiratory infection: a literature review in the context of the health belief model compliance with the use of medical and cloth masks among healthcare workers in vietnam infection preventionists' experience during the first months of the 2009 novel h1n1 influenza a pandemic initial response of health care institutions to emergence of h1n1 influenza: experiences, obstacles, and perceived future needs insufficient preparedness of primary care practices for pandemic influenza and the effect of a preparedness plan in japan: a prefecture-wide cross-sectional study a cluster randomized clinical trial comparing fit-tested and non-fit-tested n95 respirators to medical masks to prevent respiratory virus infection in health care workers physiologic and other effects and compliance with long-term respirator use among medical intensive care unit nurses discomfort and exertion associated with prolonged wear of respiratory protection in a health care setting the cookie monster muffler: perceptions and behaviours of hospital healthcare workers around the use of masks and respirators in the hospital setting behavioral-diagnostic analysis of compliance with universal precautions among nurses social learning theory and the health belief model factors influencing the wearing of face masks to prevent the severe acute respiratory syndrome among adult chinese in hong kong practice of habitual and volitional health behaviors to prevent severe acute respiratory syndrome among chinese adolescents in hong kong personal protective equipment for the ebola virus disease: a comparison of 2 training programs risk of self-contamination during doffing of personal protective equipment key: cord-287653-69nfi379 authors: lacy, j. matthew; brooks, erin g.; akers, joshua; armstrong, danielle; decker, lauren; gonzalez, adam; humphrey, william; mayer, romana; miller, matthew; perez, catherine; arango, jose antonio ruiz; sathyavagiswaran, lakshmanan; stroh, wendy; utley, suzanne title: covid-19: postmortem diagnostic and biosafety considerations date: 2020-04-24 journal: am j forensic med pathol doi: 10.1097/paf.0000000000000567 sha: doc_id: 287653 cord_uid: 69nfi379 as a result of the 2019 novel human coronavirus (covid-19) global spread, medical examiner/coroner offices will inevitably encounter increased numbers of covid-19-infected decedents at autopsy. while in some cases a history of fever and/or respiratory distress (e.g. cough or shortness of breath) may suggest the diagnosis, epidemiologic studies indicate that the majority of individuals infected with covid-19 develop mild to no symptoms. those dying with—but not of—covid-19 may still be infectious, however. while multiple guidelines have been issued regarding autopsy protocol in cases of suspected covid-19 deaths, there is some variability in the recommendations. additionally, limited recommendations to date have been issued regarding scene investigative protocol, and there are a paucity of publications characterizing covid-19 postmortem gross and histologic findings. a case of sudden unexpected death due to covid-19 is presented as a means of illustrating common autopsy findings, as well as diagnostic and biosafety considerations. we also review and summarize the current covid-19 literature in an effort to provide practical evidence-based biosafety guidance for me/c offices encountering covid-19 at autopsy. respectively. 1 based on currently available global data, covid-19 is thought to cause mild, limited, or no symptoms in at least 80% of those infected. [2] [3] [4] a substantial portion of covidinfected individuals are suspected to be asymptomatic carriers; estimates derived from select populations of quarantined individuals who underwent widespread testing (e.g. cruise ship passengers and japanese citizens evacuated from china) range from 18-33%. [5] [6] of those known to be covid-19 positive, approximately 20-30% will develop more severe disease necessitating hospitalization. such disease may progress to acute respiratory distress syndrome (ards), sepsis, multiorgan failure, and death. [7] [8] [9] risk factors for severe disease have been reported to include advanced age, hypertension, and diabetes-although recent data suggests hospitalization may be more common among younger covid-19 patients than previously suspected. [7] [8] case fatality ratios range widely from 0.2-7.7% depending on the population age, prevalence of comorbidities, testing criteria and availability, health care capacity, and how cases are defined. 10-13 a variety of electronic databases provide ongoing daily monitoring of covid-19 cases tabulated by country. 14-16 inevitably there will be an increased number of suspected or confirmed covid-19 deaths encountered at autopsy. while multiple guidelines have been issued regarding autopsy protocol in cases of suspected or confirmed covid-19 deaths, there is some variability in the recommendations. [17] [18] [19] [20] [21] additionally, limited recommendations to date have been a c c e p t e d 5 issued regarding scene investigative protocol. we present a case of sudden unexpected death due to covid-19 as a means of illustrating suggestive autopsy findings, diagnostic considerations, and recommended scene and morgue biosafety practices in novel coronavirus deaths. history a 58-year-old woman reported a week of fevers and respiratory difficulty. her medical history was significant for insulin-dependent type 2 diabetes mellitus (hemoglobin a1c range: 7 -11%), obesity, hyperlipidemia, mild intermittent asthma, and chronic lower extremity swelling with ulceration. she was instructed to stay home and self-quarantine by her retail store employer. she was found dead in her bedroom after last being known alive the night before. emergency medical services responded to the scene and attempted resuscitation before pronouncing death and notifying the medical examiner's office. two medicolegal death investigators performed a scene investigation. family members were interviewed outside the residence, eliciting the information that several of the decedent's coworkers and an adult member of her household had also developed respiratory illness symptoms. at least 6 feet (i.e. 2 meters) of separation was maintained between investigators and family members during interview. prior to entering the residence, investigators donned personal protective equipment (ppe) sufficient for contact and droplet precautions including gloves, fluidresistant gown, a barrier face mask and goggles. 17-18, 20 a camera was employed to document the scene photographically; otherwise, minimal equipment was brought into the residence. following a c c e p t e d documentation, the body was examined and placed in a plastic shroud and then sealed in a body bag and loaded into the transport vehicle. after the body was secured, investigators doffed their ppe and performed hand hygiene with an alcohol-based gel. the body was then transported to the morgue and logged in without opening the outer body bag. the transport vehicle was disinfected with a dilute bleach solution. an autopsy was performed in a separate negative pressure isolation suite adjacent to the main morgue room but on its own heating, ventilation and air-conditioning (hvac) circuit with 16 air changes per hour. only two operators (i.e. a pathologist and a technician) were permitted in the isolation suite during the case. a second technician acted as a circulator and monitored the case via an observation window; communication was facilitated via inexpensive low-power walkie-talkies. a small isolation cooler attached to the isolation room acted as an airlock to facilitate transfer of materials into and out of the isolation suite during the prosection (fig. 1 ). in accordance with guidelines, ppe utilized by autopsy prosectors included scrubs, dedicated autopsy footwear with shoe covers, a long-sleeve water resistant gown or tyvek suit, a long-sleeved splash apron, double gloves and cut gloves, hair covers, and a powered air-purifying respirator (papr) with full-face shield (fig. 2 ). 17-21 grossly soiled ppe was frequently wiped down with disinfectant wipes or dilute bleach solution during the procedure. doffing of ppe at the end of the procedure occurred in the isolation cooler airlock and was monitored by an inspector. the autopsy was performed with minor modifications to standard procedures. in order to minimize potential organism aerosolization, the sink-mounted vacuum aspirator, sink drain tissue grinder, and station hose were not used. all fluid collections were ladled from body cavities. although the head was opened with a powered oscillating saw, the upper half of the body, head of the table, and floor surrounding these areas was misted with disinfectant immediately upon cessation of powered sawing and before brain removal. only one prosector remained in the room during the sawing; for at least 10 minutes afterwards (i.e. 2 full air changes) no additional personnel entered the room. cleaning of the body and autopsy table was accomplished with towels that were subsequently discarded. limited body and specimen photography was accomplished either in situ or on a small photography board near the body. following autopsy, the body was closed in the standard fashion and cleaned with damp towels and disinfectant. a clean body table with a clean body bag and plastic shroud spread out on it had been placed in the isolation cooler airlock by the second technician. this was moved into the isolation suite and the body was transferred onto the clean shroud, wrapped tightly and sealed with tape, then zipped into the clean body bag. this procedure allowed the outer surfaces of the shroud and body bag to remain essentially clean. once sealed, the outer bag was labeled and signed by the pathologist and technician, each verifying the identity of the decedent. the outer surface of the body bag was then sprayed with disinfectant and the body table was removed to the isolation cooler where residual liquid disinfectant was removed and the bag labeled as infectious. release procedures were modified to prevent opening the body bag or shroud for visual identification confirmation by funeral home staff while the body was still in the facility. the dual signatures of the pathologist and technician acted as the confirmation that the body bag contained the correct decedent, and release to the funeral home was performed without opening the outer bag. the infectious nature of the case was disclosed to the funeral home personnel at the time of release. notably, none of the personnel involved in this index case (i.e. pathologist, technicians, scene investigators) suffered any symptoms consistent with covid infection in the two weeks following their involvement in the case nor since. external examination revealed an obese (bmi: 38 kg/m 2 ) middle-aged adult woman with fully developed rigor mortis and blanching livor mortis. changes of lower extremity venous stasis and scarring consistent with the history of lower leg ulcers were present. on internal examination there were no pleural effusions or other abnormal fluid collections. thick mucus was noted in the airways, however. the lungs were moderately heavy and edematous (right: 818 g, left: 705 g) and had a relatively firm texture throughout. areas of hemorrhage were evident in the right upper and middle lobes, and to a lesser extent in the left lower lobe (fig. 3 .) hilar and mediastinal lymph nodes appeared enlarged. the heart weighed 438 g and exhibited moderate coronary atherosclerosis in each of the main coronary distributions, but there were no occlusions or critical stenoses. the myocardium was free of obvious infarcts and had the expected firm texture and red-brown color. the left ventricle was 1.2-1.4 cm thick. the cardiac valves were normal. there was moderate infrarenal a c c e p t e d aortic atherosclerosis. the kidneys were finely granular and had focal cortical scars (right 170 g, left 183 g). the spleen had a normal appearing capsule and parenchyma (148 g). the liver (1990 g) was grossly unremarkable. the brain (1221 g) exhibited hydrocephalus ex vacuo; the frontal horns measured 2.8 cm in greatest dimension at the level of the temporal poles. tissue sections were placed in 10% neutral-buffered formalin and allowed to fix for 72 hours prior to histologic sampling. hematoxylin and eosin (h&e) staining was performed by an outside laboratory. histologic examination of the lungs revealed diffuse proteinaceous edema and dense amphophilic concretions along alveolar septae consistent with hyaline membranes. the lung architecture was preserved and the septae were of normal thickness, but mild mononuclear infiltrates were present throughout. there was prominent desquamating pneumocyte hyperplasia with focal multinucleated cells and bizarre forms. acute alveolar hemorrhage and collections of reactive foamy alveolar macrophages were focally present as were collections of alveolar fibrin based on the above autopsy and investigative findings, and in accordance with us national vital statistics certification guidelines, the cause of death was determined to be acute respiratory distress syndrome due to viral pneumonia due to covid-19. 22 other significant contributory factors included type 2 diabetes mellitus, hypertension, and obesity. the state department of health was notified. currently every state in the u.s. has reported covid-19 cases, resulting in a total of over 7600 deaths to date. 23 inevitably me/c offices will encounter increased numbers of sars-cov-2 infected decedents at autopsy as a result of covid-19 spread. while in some cases a history of fever and/or respiratory distress (e.g. cough or shortness of breath) may suggest the diagnosis, epidemiologic studies indicate that the majority of individuals infected with covid-19 develop mild to no symptoms. 2 even those dying with-but not of-covid-19 may still be infectious. transmission of sars-cov-2 from presymptomatic/asymptomatic individuals has been documented, although the frequency remains to be established. 24-27 me/c must use their judgment to determine whether postmortem covid-19 testing and/or autopsy should be pursued. in addition to suggestive antemortem signs/symptoms, epidemiologic factors may also help guide decisions such as history of contact with a known covid-19 positive case, or being a part of a cluster of respiratory illness cases in a closed setting (e.g., a nursing care facility). 17 the presented autopsy case and literature review are intended to help familiarize me/c offices with covid-19 disease features, diagnostic strategies, and key biosafety principles. it is suspected that sars-cov-2-similar to sars-cov and mers-cov-began as a zoonotic coronavirus that subsequently spread to humans. 1 community and healthcare-associated person-to-person transmission were documented early in the pandemic, and direct or close contact with infectious persons is believed to be the major mode of transmission. [28] [29] transmission occurs through exposure to infectious droplets originating from the respiratory tract; infectious droplets may be released from an infected individual via sneezing, coughing, talking or undergoing an a c c e p t e d aerosolizing procedure such as intubation or autopsy. [30] [31] reportedly droplets do not typically spread beyond 6 feet (2 meters) nor linger in air, although some evidence has suggested a longer range of spread may be possible. [31] [32] less commonly infection may arise as a result of indirect transmission through fomites, especially if the eyes, face, or mouth are contacted after touching an infected surface. 31, 33 sars-cov-2 has also been detected in blood and anal swabs; increasing evidence suggests that fecal-oral transmission may be another potential route of spread. [34] [35] [36] scene investigation as in the current presented case, investigators are advised to mitigate risk of potential sars-cov-2 exposure at death scenes by standing at a distance > 6 feet when conducting interviews and requesting interviewees to remain outside the residence while investigators enter. as the cdc has recently issued recommendations for the public to wear cloth facial coverings when at risk of social-based transmission, scene investigators may consider encouraging interviewees to don cloth facial masks. 37 scene investigators should don contact and droplet precaution ppe when entering residences. decontamination of all potentially contaminated equipment, careful body bagging procedures, and investigator hand hygiene are also encouraged. anecdotally, this has been the scene investigative policy of the snohomish county medical examiner's office which despite being the country with the second highest number of positive/confirmed covid cases in the state of washington has had no scene investigators test positive for sars-cov-2 to date. in order to more efficiently triage cases, me/c offices may elect to have scene investigators procure nasopharyngeal viral testing swabs at the scene. scene investigative recommendations are summarized in table 1 . each office is advised to carefully assess its own infrastructure, supplies, and staffing to determine whether suspected or confirmed covid-19 deaths can be safely prosected on-site. current cdc and who recommendations are that suspected/confirmed covid-19 autopsies be prosected in an airborne infection isolation rooms at negative pressure relative to surrounding areas, and ideally with at least 12 air changes per hour (though 6 will suffice in older structures.) with hepa filter is also indicated. [17] [18] [19] [20] [21] given national ppe supply limitations, me/c offices are encouraged to restrict autopsy attendance to key personnel only (i.e. prosector and technician). 38 in order to preserve eyewear, preferential use of powered air purifying respirators or goggles which can be reused following appropriate disinfection should be considered. 39 in general, paprs are preferable to n95 respirator masks as they provide even higher protection to prosectors and-with appropriate disinfection of reusable elements after use-can be repeatedly employed thus assisting with ppe conservation efforts. 40 papr filters should be replaced in accordance with manufacturer recommendations. some studies have suggested the possibility of decontaminating and reusing a c c e p t e d n95 masks via ultraviolet germicidal irradiation (uvgi), hydrogen peroxide vapor sterilization, and simply allowing respirators to hang to dry for 3 days. 38, [41] [42] [43] [44] [45] proposals for respirator mask construction have also been offered. 38 further details regarding ppe conservation strategies are beyond the bounds of the current review but are available through the cdc. 39 aerosol generation at autopsy may occur through inadvertent splashing of fluids, puncturing of fluid pockets under pressure, and use of vacuum-assisted suction devices and sinkmounted tissue grinders. [38] [39] [40] [41] [42] however, the most likely aerosol generating autopsy procedure is use of powered oscillating bone saws, particularly during brain removal. [46] [47] [48] [49] [50] high densities of aerosolized particles are generated in the region of the saw placing the user at risk. while n95 respirator masks physically filter 95% of particles at least 1m in size from the inspired air, cdc and osha guidelines nonetheless suggest avoiding use of an oscillating bone saw at autopsy in cases of suspected/confirmed covid-19. if a saw is employed, it is recommended that a vacuum shroud be attached to assist in capturing aerosols. 17-18 other oscillating saw aerosol reduction techniques to consider include moistening the saw blade before cutting, using autopsy tables with built-in ventilation, tenting plastic around the decedent's neck and head to entrap aerosols, and wearing a hepa-filtered papr rather than n95 mask. [46] [47] [48] [49] as in the current presented case, other general splash and aerosol reduction techniques (e.g. eschewing use of vacuum assisted aspirator, sink tissue grinder, or hose) are also advised. autopsy protocol recommendations are summarized in table 2 . while much literature has been published regarding covid-19 signs/symptoms and clinical course, there is currently a paucity of data regarding expected postmortem gross and histologic findings. the case presented herein adds to those few previously published studies. lungs are often heavy and histologically reveal edema with focal/diffuse hyaline membrane formation, pneumocyte hyperplasia, patchy mononuclear inflammatory infiltrates, some multinucleated cells, and a lack of definitive intranuclear or intracytoplasmic viral inclusions. [51] [52] overall, pulmonary pathologic features generally appear consistent with early/organizing diffuse alveolar damage, and resemble those seen in sars autopsies .51-53 while myocarditis has been reported in association with covid-19, it appears to be a less common complication. [54] [55] most typically (as in the presented case) minimal mononuclear myocardial inflammatory involvement is found. rarely, covid-19 associated encephalitis has been reported. 56 in one experimental study, viable sars-cov-2 was detected up to 72 hours after being placed onto plastic and stainless steel surfaces; it also remained viable in an experimentally created aerosol for at least 3 hours, although infectious titers per liter of air decreased over time. 57 a recent review and analysis of literature found that generally human coronaviruses can remain infectious for up to 9 days on inanimate surfaces, depending on surface type and temperature; at temperatures > 30° c (i.e. 86° f) viral persistence shortened. 58 given that sars-cov-2 may remain viable on a variety of inanimate surfaces for a matter of days, careful morgue decontamination procedures are key. surface disinfection with diluted household bleach solutions (i.e. of 0.1% sodium hypochlorite), 0.5% hydrogen peroxide solutions, or alcohol solutions (i.e. with at least 70% a c c e p t e d ethanol) have been shown to inactivate human coronaviruses within 1 minute. [58] [59] for hospitalgrade disinfectants, staff should verify their suitability for use against sars-cov-2 and ensure disinfectants remain on surfaces in accordance with us environmental protection agency recommendations. [60] [61] while conclusive data regarding how long infectious human remains may harbor infectious sars-cov-2 is lacking, autopsies in cases of sars found that sars-cov could be recovered from lung tissue and grown in cell culture up to seven days after death. [62] [63] considering that there is reportedly 75-80% similarity between the viral genomes of sars-cov-2 (causative agent of covid-19) and sars-cov (causative agent of sars), these results suggest that protective precautions are called for even in cases of delayed suspected covid-19 death investigations or autopsies. 1, 64 while limited data exists regarding formalin inactivation of sars-cov-2 infected tissue, formalin fixation at room temperature has been shown to inactivate most of sars-cov (i.e. close to assay detection limits) within a day. [64] [65] diagnosis in cases of suspected covid-19 in which full autopsies are performed, submission of sars-cov-2 swabs from both upper and bilateral lower respiratory tracts is recommended by the cdc. 17 if nasopharyngeal as well as bilateral tracheobronchial/lung swabs are procured it is recommended they be submitted in separate vials each containing 2-3 ml of viral transport medium. 17 me/c offices, however, must be cognizant of their current state health department testing capacity and proceed accordingly. 17,19 a rational strategy for minimizing the number of swab submissions per autopsy is to submit swabs only from the lower respiratory tract. additionally, sampling both lungs with a single swab may increase recovery of viral rna. concurrent testing for other causes of respiratory illness such as influenza is also strongly 17, 19 in order to preserve limited viral testing kit supply, me/c offices are encouraged to communicate with their testing laboratories to verify whether covid-19 as well as other respiratory viral pathogen testing can be performed on a single swab. prosectors should submit a separate samples for bacterial/fungal organisms as indicated. in cases of suspected covid-19 in which autopsy is not performed, nasopharyngeal swab testing for covid-19 as well as other respiratory pathogens is recommended. 17 only synthetic fiber swabs with plastic shafts should be submitted for sars-cov-2 reverse-transcriptase polymerase chain reaction (rt-pcr) testing, as others may inactivate virus or otherwise inhibit the testing. in the event that swabs were not procured at autopsy, fixed autopsy tissue specimens may also be submitted to cdc in suspected covid-19 deaths for immunohistochemical, molecular, or other assay characterization. 17 recent diagnostic advancements include the food and drug administration (fda) emergency use authorization (eua) enabling us laboratories already certified for high complexity testing to develop and validate their own sars-cov-2 testing; this markedly augmented diagnostic capability as previously all testing was performed mainly by us public health laboratories. 66 additionally, there has been eua approval of rapid covid-19 pcr diagnostic tests that some manufacturers report can deliver results in less than an hour. 67 recently, a serologic enzyme-linked immunosorbent assay (elisa) testing to assess for covid-19 antibodies has received fda approval and more are in development; these are expected to prove of utility in more accurately calculating disease transmission and mortality rates. 67-69 previous surveys have indicated that morgues are heterogeneous in their preparedness to handle highly infectious disease cases. 70-71 facility environmental controls, availability of personal protective equipment (ppe), and staffing are all factors that me/c must carefully assess in determining whether suspected/confirmed covid-19 deaths will be autopsied. 17, 19 the majority of known covid-19 deaths technically should not fall under me/c office jurisdiction as they are natural deaths predominantly occurring in hospitalized patients. 72 while autopsy is unlikely to be necessary in such cases-and is, in fact, discouraged by osha-me/c may nonetheless be called upon to facilitate death certification ensuring accurate public health disease tracking, or in cases of medicolegal significance (homicides, accidents or suicides) where a decedent expires in the hospital and is covid-19 positive due to community spread. 18, 72 in deaths occurring outside of the hospital setting me/c offices are tasked with determining whether deaths are attributable to covid-19 or not, and performing autopsies as needed. 72 me/c offices may elect to triage cases by taking viral np swabs in suspected covid-19 deaths and reserve autopsy for those decedents with negative testing results or else cases in which sars-cov-2 infection is thought to be incidental rather than the cause of death. performing a nasopharyngeal (np) swab for sars-cov-2 requires neither a negative pressure room nor n95 respirator; basic contact and droplet precaution ppe are sufficient. 17 in cases in which autopsy is merited, the above described precautions should be followed to prevent morgue staff-acquired covid-19 infection. some offices have elected to perform limited autopsies (e.g. precluding brain/spinal cord removal) in cases of suspected/known covid-19 positivity to reduce morgue staff aerosol exposure. others have incorporated antemortem or postmortem ct radiology as a a c c e p t e d means of helping triage decedents meriting testing and/or autopsy. 19,21 establishing collaborative relations with larger me/c offices capable of safely autopsying suspected highly infectious disease cases should be encouraged. globally, mobile biosafety autopsy facilities/laboratories with sophisticated infrastructure have been deployed during disease epidemics such as sars and ebola virus; advantages include the ability to mobilize rapidly to areas of need with minimal footprint. [73] [74] [75] such mobile facilities may be advisable in the us as well. neither cdc nor who guidelines require double-bagging of known covid-19 positive decedents; however, me/c offices should ensure that any body fluids leaking from orifices are contained. 17,20 utilizing cotton packing of orifices, a plastic shroud, or a second body bag are all potential methods of preventing fluid leakage. following appropriate decontamination of the body bag, a method of clearly designating the infectious nature of contents to funeral home personnel should be employed (e.g. body bag notification sticker); me/c offices may want to consider modifying body release procedures to preclude contamination risks of opening body bag in morgue for funeral personnel identification. 76 cases  employ social distancing practices during scene interviews outside the residence  require interviewees to remain outside when entering residence  doff contact and droplet precaution ppe during scene investigations  if covid-19 testing is warranted, consider obtaining np swab at scene to expedite process  minimize exposure of excess personnel or equipment to scene  decontaminate exposed equipment and vehicles  perform hand hygiene after any unprotected contact with a potentially infectious surface and after doffing ppe  ensure bodies are fully enclosed in secure bag during transport to reduce change of leakage  do not expose the body until it is in an isolation suite a c c e p t e d table 2 table 2  prosect cases in negative pressure isolation suite with at least 6-12 air changes per hour  doff contact and droplet precaution ppe, as well as n95 respirator or papr  limit personnel in the isolation suite to the minimum necessary to perform the examination  employ splash and aerosol reduction techniques during prosection; oscillating saws are discouraged but if used should have vacuum shroud attachment  use caution when handling sharps; allow only one person to prosect at a given time  ensure a technician is outside isolation room to monitor procedure and provide support as needed  procure synthetic nasopharyngeal (+/-lung) respiratory swabs in sterile tubes of 2-3 ml of viral transport media for sars-cov-2 testing as needed  carefully decontaminate morgue surfaces and outer body bag following autopsy  ensure body is fully enclosed in a secure bag, tag as infectious and ensure funeral home is informed  consider modifying release procedures to prevent bag being opened in morgue for identification  perform hand hygiene after doffing ppe a c c e p t e d genomic characterization and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. the lancet characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention report of the who-china joint mission on coronavirus disease 2019 (covid-19) substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov2) estimation of the asymptomatic ratio of novel coronavirus infections (covid-19) estimating the asymptomatic proportion of coronavirus disease 2019 (covid-19) cases on board the diamond princess cruise ship clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study. the lancet. 22. national vital statistics system (nvss) covid-19: cases in u.s transmission of 2019-ncov infection from an asymptomatic contact in germany clinical characteristics of 24 asymptomatic infections with covid-19 screened among close contacts in nanjing presymptomatic transmission of sars-cov-2 -singapore evidence of sars-cov-2 infection in returning travelers from wuhan, china a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster first known person-to-person transmission of severe acute respiratory syndrome coronavirus sars-cov-2 viral load in upper respiratory specimens of infected patients how coronavirus spreads turbulent gas clouds and respiratory pathogen emissions: potential implications for reducing transmission of covid-19 early release -indirect virus transmission in cluster of covid-19 cases detection of sars-cov-2 in different types of clinical specimens molecular and serological investigation of 2019-ncov infected patients: implication of multiple shedding routes. emerg microbes infect air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) from a symptomatic patient covid-19: gastrointestinal manifestations and potential fecal-oral transmission recommendation regarding the use of cloth face coverings, especially in areas of significant community-based transmission sourcing personal protective equipment during the covid-19 pandemic the national personal protective technology laboratory (npptl): respirator fact sheet effects of ultraviolet germicidal irradiation (uvgi) on n95 respirator filtration performance and structural integrity ultraviolet germicidal irradiation of influenzacontaminated n95 filtering facepiece respirators n95 filtering facepiece respirator ultraviolet germicidal irradiation (uvgi) process for decontamination and reuse decontamination and reuse of n95 respirators with hydrogen peroxide vapor to address worldwide personal protective equipment shortages during the sars-cov-2 (covid-19) pandemic. available at: decontamination and reuse of n95 respirators with hydrogen peroxide vapor to address worldwide personal protective equipment shortages during the sars-cov-2 (covid-19) pandemic [pdf information and faqs on performance, protection, and sterilization of masks against covid-19 biosafety considerations for autopsy aerosol production during autopsies: the risk of sawing in bone minimizing aerosol bone dust during autopsies aerosol generation during bone-sawing procedures in veterinary autopsies autopsy biosafety: recommendations for prevention of pulmonary pathology of early-phase 2019 novel coronavirus (covid-19) pneumonia in two patients with lung cancer pathological findings of covid-19 associated with acute clinical predictors of mortality due to covid-19 based on an analysis of data of 150 patients from wuhan, china. intensive care med cardiac involvement in a patient with coronavirus disease 2019 (covid-19) beijing hospital confirms nervous system infections by novel coronavirus aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents detailed disinfection guidance: interim recommendations for us households with suspected/confirmed coronavirus disease 2019 covid-19)-fighting products list n: disinfectants for use against sars-cov-2 quantitative temporal-spatial distribution of severe acute respiratory syndrome-associated coronavirus (sars-cov) in post-mortem tissues pulmonary pathological features in coronavirus associated severe acute respiratory syndrome (sars) coronavirus disinfection in histopathology inactivation of the coronavirus that induces severe acute respiratory syndrome, sars-cov coronavirus (covid-19) update: fda issues new policy to help expedite availability of diagnostics here's how coronavirus tests work-and who offers them. scientific american cellex sars-cov-2 igg/igm rapid test -letter of authorization medical examiner/coroner capability to handle highly infectious decedents a 2009 cross-sectional survey of procedures for post-mortem management of highly infectious disease patients in 48 isolation facilities in 16 countries: data from euronhid national association of medical examiners (name) mobile biosafety level-4 autopsy facility-an innovative solution sierra leone during the 2014 ebola virus epidemic mobile high-containment biological laboratories deployment: opportunities and challenges in expeditionary deployments to outbreak response medical examiner's covid-19 release procedure & handling guidelines covid-19): frequently asked questions key: cord-287707-ng0ha3vv authors: pal, arghya; gupta, prashant; parmar, arpit; sharma, pawan title: ‘masking’ of the mental state: unintended consequences of personal protective equipment (ppe) on psychiatric clinical practice date: 2020-06-04 journal: psychiatry res doi: 10.1016/j.psychres.2020.113178 sha: doc_id: 287707 cord_uid: ng0ha3vv nan 'masking' of the mental state: unintended consequences of personal protective equipment (ppe) on psychiatric clinical practice "when your face says it all, your mouth waits its turn"this quotation by anthony t. hincks applies as much to psychiatry as to life. the mental state examination (mse) derives significantly from simple observation of someone"s facial expressions and body language, in addition to clinical questions. but, the current covid-19 pandemic has necessitated certain changes in the way mse is conducted, e.g., face masks, alcohol hand-rubs, social distancing, etc., and these changes may be here to stay ("when and how to use masks," n.d.). in this paper, we have highlighted some of the major issues which are likely to arise during mse and psychiatric interviews with the pandemic-related precautions in place, and the need to find alternative strategies to deal with these problems. the use of masks hampers the observation of facial expressions which is very important for any mse. the fact that whether someone is smiling, frowning,has flat expressions, or is looking around out of suspicion or confusion, gives significant clues into their mental state (martin, 1990 ). this may be even more difficult in settings where the use of other protective gears like face-shield and goggles is necessary (mistry et al., 2009) . similar to problems in observing expressions, we are likely to miss orofacial movement disorders such as tics or tardive dyskinesias, subtle mumbling which may occur as a part of hallucinatory behaviour in psychosis andsubstance use-related signse.g. tobacco (oral mucosal changes), opioids (pupillary constriction/dilation, lacrimation)or cannabis (conjunctival injection). also, due to the smell of alcohol hand-rubs, psychiatrists may miss on subtle smell cues such as body odour arising out of poor self-hygiene and smell of substances like alcohol and cannabis which might suggest intoxication. furthermore, making eye contact and establishing a rapport is challenging given the distraction of the ppe and the "non-humanly" feeling it gives. e.g., ppe might accentuate the suspiciousness in patients who have paranoia, the new smells and appearances may be extremely difficult to cope with for patients with autism spectrum disorders, patients having depression might require a gentle human touch and support during an interview which becomes near impossible with ppe and social distancing, it might be very challenging to provide reorientation to patients having delirium, or memory cues to those having dementia when they cannot see the faces of those around them, etc. speaking through masks can muffle the speech, which hurdles the coherence and volume of speech. in disorders like severe depression and negative symptom schizophrenia, where the patient might be barely audible in usual circumstances, masks might make conversations near impossible (priebe et al., 2011) . also, because of the difficult conversation, the therapist and patient might have to frequently ask each other to repeat what they are saying, thus making the conversations more tedious and time consuming. as mentioned above, there can be hurdles in observing expressions in presence of ppe. this makes it extremely difficult to estimate the objective affect, range of emotion and presence of reactivity to stimuli, which are important markers for some mental health conditions. eliciting thought and perceptual abnormalities often requires detailed phenomenological explorations. the difficulties in understanding speech, as mentioned above, make this task very challenging., e.g., muffled speech makes it difficult to pick formal thought disorders and ineffective conversations make it difficult to understand the phenomenological content of delusions and hallucinations. apart from the difficulties in conducting mse, ppe may also pose a barrier to observe some clinical signs which are as important to psychiatry as for other medical disciplines, e.g., injuries, pallor, icterus, cyanosis, etc. inability to pick up signs of potentially life-threatening conditions such as pupillary constriction in opioid overdose, tremors in lithium toxicity and dehydration in catatonia, can prove to be disastrous. in such scenarios, psychiatrists might find themselves in ethical dilemmas where they might be tempted to remove their own ppes or ask the patients to remove theirs, for unimpeded mses and clinical interviews, potentially putting their own or the patients" health and life at risk. there seems to be no easy answer to this (mehta et al., 2020) . potential strategies to bypass some of these problems may include the creation of a transparent physical barrier between the psychiatrist and the patient or teleconsultations, but they may have their own shortcomings.ultimately, it boils down to the quintessential comparison of risk vs benefit of such practices. it would be highly beneficial for psychiatrists and patients alike if the national or international psychiatric bodies can prepare guidelines while weighing all the pros and cons, to conduct interviews and mses during the current pandemic. international psychiatry fellow, barnet, enfield and haringey mental health (nhs) trust, london, uk 3. national consultant (harm reduction) clinical methods: the history, physical, and laboratory examinations. butterworths the "mind" behind the "mask": assessing mental states and creating therapeutic alliance amidst covid-19 veiled communication: is uncovering necessary for psychiatric assessment? good communication in psychiatry -a conceptual review when and how to use masks none key: cord-294591-793ywpcd authors: hu, xiaoyun; zhang, zhidan; li, na; liu, dexin; zhang, li; he, wei; zhang, wei; li, yuexia; zhu, cheng; zhu, guijun; zhang, lipeng; xu, fang; wang, shouhong; cao, xiangyuan; zhao, huiying; li, qian; zhang, xijing; lin, jiandong; zhao, shuangping; li, chen; du, bin title: self-reported use of personal protective equipment among chinese critical care clinicians during 2009 h1n1 influenza pandemic date: 2012-09-05 journal: plos one doi: 10.1371/journal.pone.0044723 sha: doc_id: 294591 cord_uid: 793ywpcd background: critically ill patients with 2009 h1n1 influenza are often treated in intensive care units (icus), representing significant risk of nosocomial transmission to critical care clinicians and other patients. despite a large body of literature and guidelines recommending infection control practices, numerous barriers have been identified in icus, leading to poor compliance to the use of personal protective equipment (ppe). the use of ppe among critical care clinicians has not been extensively evaluated, especially during the pandemic influenza. this study examined the knowledge, attitudes, and self-reported behaviors, and barriers to compliance with the use of ppe among icu healthcare workers (hcws) during the pandemic influenza. methodology/principal findings: a survey instrument consisting of 36 questions was developed and mailed to all hcws in 21 icus in 17 provinces in china. a total of 733 physicians, nurses, and other professionals were surveyed, and 650 (88.7%) were included in the analysis. fifty-six percent of respondents reported having received training program of pandemic influenza before they cared for h1n1 patients, while 77% reported to have adequate knowledge of self and patient protection. only 18% of respondents were able to correctly identify all components of ppe, and 55% reported high compliance (>80%) with ppe use during patient care. in multivariate analysis, vaccination for 2009 h1n1 influenza, positive attitudes towards ppe use, organizational factors such as availability of ppe in icu, and patient information of influenza precautions, as well as reprimand for noncompliance by the supervisors were associated with high compliance, whereas negative attitudes towards ppe use and violation of ppe use were independent predictors of low compliance. conclusion/significance: knowledge and self-reported compliance to recommended ppe use among chinese critical care clinicians is suboptimal. the perceived barriers should be addressed in order to close the significant gap between perception and knowledge or behavior. on april 29, 2009 , the world health organization (who) announced the outbreak of a novel influenza a (h1n1) 2009 virus to be a public health emergency of international concern [1] , which ultimately led to the declaration of the first phase 6 global influenza pandemic on june 11, 2009 [2] . as of september 6, 2009 , the who had reported more than 277,607 laboratoryconfirmed cases, with at least 3,205 deaths [3] . studies estimated that up to 2.7 million patients would be hospitalized, and about 25% of these patients might experience rapid deterioration, leading to intensive care unit (icu) admission within 1 day after hospitalization, equivalent to an increase in the volume of mechanical ventilation of 23% to 45% over the current use [4, 5] . all these data suggested an excessive workload during the initial period of the pandemic, as perceived by 80% of frontline healthcare workers (hcws) [6] . a simulation study by swaminathan and the colleagues reported that, for a patient with suspected avian or pandemic influenza who was not clinically unwell or hypoxic, the mean number of close contacts was 12.3 (range 6-17; 85% hcws), and mean exposures were 19.3 (range [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] during the first 6 hours in the emergency departments [7] . in comparison, critical care clinicians are likely to encounter even more repeated close contacts, and are at significantly high risk of acquiring such an infectious disease during patient care. evidence does exist suggesting nosocomial transmission within hospital settings. apart from earlier findings that more than 20% of patients who acquired severe acute respiratory syndrome (sars) were hcws [8] , possible healthcare-related 2009 h1n1 influenza transmission was identified in 9 out of 63 exposed hcws [9] . protection of hcws from acquisition of infectious diseases can be achieved by compliance to established infection control guidelines [10] [11] [12] [13] , including rigorous infection control practices, prescriptive instructions for the use of personal protective equipment (ppe), and postexposure antiviral prophylaxis [7] . however, reported compliance to ppe use might be extremely low. in response to a survey conducted by the center for disease control and prevention following the pandemic influenza, among 11 hcws with probable or possible patient-to-hcw transmission, only 3 reported always using either a surgical mask or an n95 respirator [14] . a variety of barriers have been identified to hinder compliance to infection prevention and control guidelines, including knowledge, attitude, belief and behavioral factors [15] . daugherty and colleagues explored the behavior, knowledge, and attitudes of critical care clinicians about recommended precautions for prevention of healthcare-associated influenza infections in an anticipated influenza pandemic [16] . with the same methodology using a modified questionnaire, we previously reported that 82.3% of the icu hcws expressed willingness to work in a pandemic, with professions, knowledge training prior to patient care, and the confidence to know how to protect themselves and the patients independently associated with more likelihood to care for h1n1 patients [17] . however, little is known about their behavior and factors influencing compliance during a real influenza pandemic. as the second part of the above survey, we wish to evaluate the self-reported compliance to the use of ppe during the current influenza pandemic among critical care clinicians in chinese icus, as well as independent predictors of the compliance. this study was approved by the institutional review board (irb) of peking union medical college hospital. all participants were informed about the study. however, the irb waived the need for written informed consent from the participants because the identities of all respondents would be completely anonymous during data collection and analysis, and there would be minimal risk as perceived by the irb for being involved in this study. the design of this study was described in details elsewhere [17] . in brief, this study was conducted in 21 adult icus in 17 provinces in china. all participating icus admitted patients with 2009 h1n1 influenza during the pandemic. a 36-item survey questionnaire was designed based on the study of daugherty and coworkers [16] , to assess the knowledge, attitudes, and behaviors of icu hcws related to the 2009 h1n1 influenza pandemic, which was available as supporting information; see questionnaire s1. on december 25, 2009 , the questionnaire with an instruction was sent by e-mail to the contact persons of individual participating icus, who encouraged as many hcws as possible to participate the study. all questionnaires were collected and sent back by e-mail before january 15, 2010. any hcws not responding after the deadline were regarded as non-respondents. data on the demographic characteristics of respondents, including age, sex, marital status, living status, status of influenza vaccination, and profession, were recorded. the professional status of the respondents was categorized as physicians, and nurses, and others (including respiratory therapists, student nurses, and nurse assistants). for the purpose of this study, we only included physicians and nurses in the final analysis. the respondents were asked to report their experience of caring for h1n1 patients, as well as relevant training. they were also required to report the level of knowledge and the level of confidence in their ability to protect themselves and their patients from exposure to influenza at work. a 5-point likert scale (complete agree, agree, neither agree nor disagree, disagree, and complete disagree) was used to elicit preferred answers. we defined recommended ppe as use of hand hygiene, gloves, gown, mask (including surgical mask and n95 respirator), and goggles [13] . in the final analysis, answers with a higher level of protection than recommended (e.g. use of goggles when no aerosolgenerating procedures were anticipated) were deemed as correct because they represented adequate protection [16] . as a response to the 2009 h1n1 influenza pandemic, all hospitals were required by local healthcare authorities to provide training programs to all hospital staffs during seminars. these training programs were mainly 2 to 3-hour lectures, developed based on the guidelines issued by ministry of health, often involving diagnosis, treatment, and infection control of 2009 h1n1 influenza. there was no posttest to evaluate the extent of information attainment by the attendees. all likert-scale responses were dichotomized into complete agree/agree versus neither agree nor disagree/disagree/disagree/ complete disagree, and expression in proportions. continuous variables were compared with student's t-test or mann-whitney u test. categorical variables were compared with chi-square test or fisher's exact test when appropriate. self-reported compliance to ppe use of .80% was considered as high compliance [16] . correlations were measured using kendall rank correlation coefficient. for determination of independent predictors for high compliance to ppe use during patient care, odds ratio (or) was estimated on the basis of both univariate analysis and multivariate logistic regression analysis. variables including clinicians characteristics, knowledge, attitudes, and behaviors were added into the model using stepwise conditional forward entry, if p,0.1 in univariate analysis. an or of less than 1 was associated with low compliance to ppe use, while an or of greater than 1 was associated with high compliance to ppe use during patient care. in the 21 icus surveyed, 733 eligible participants were identified, and 695 returned completed surveys, for an overall response rate of 94.8%. forty-five respondents were excluded (including 25 other professionals, and 20 with missing data), therefore 650 respondents (including 229 physicians and 421 nurses) were included in the final analysis (table 1) . compared with physicians, more nurses were single, and living with parents or living alone. more than half respondents received vaccination for 2009 h1n1 influenza. five hundred and eighty-six respondents (90.2%) reported that they had received the pandemic training program, although only 364 (56.0%) claimed to complete the pandemic training program before they cared for h1n1 patients. in comparison, about three-fourths of respondents reported to wear goggles and gown during aerosol-generating procedures, and to wear n95 respirator in droplet precaution or close contact, respectively. however, 435 respondents (66.9%) reported to wear goggles and gown during entire treatment and/or nursing care, indicating overprotection. significant correlation was found between self-reported adequate knowledge of pandemic influenza and correct identification of ppe and knowledge of goggles (kendall tau-b 0.184 and 0.131, p,0.001 and p = 0.001, respectively), but not knowledge of hand hygiene or mask (kendall tau-b 20.007 and 20.029, p = 0.851 and 0.467, respectively). about 80% of respondents believed that they knew self-and patient protection during the pandemic (table 2 ). in particular, 87.5% of respondents believed that use of appropriate ppe would confer adequate protection for hcws, while only 68.5% stated that this protection was adequate for vulnerable patients. half of respondents reported that ppe use was inconvenient, while 21.2% believed that ppe use would interfere with patient care, with no difference observed between physicians and nurses. no significant correlation was found between self-reported adequate knowledge of both self-protection and patient protection and correct knowledge of hand hygiene, goggles, or masks. however, selfreported adequate knowledge was significantly correlated with the perception of further improvement of ppe compliance (kendall tau-b 0.143, p,0.001). with regards to organization factors, 63.2% of respondents reported that appropriate ppe was readily available in their icus (table 2 ). more physicians than nurses knew when influenza precautions were initiated in their patients (p = 0.015). by contrast, significantly more nurses than physicians (92.1% vs. 86.4%, p = 0.020) reported being reprimanded by the supervisor for noncompliance. as to behaviors of ppe use, about 21% of respondents reported that their colleagues often forgot to use ppe during patient care, while a similar proportion reported themselves to forget to change ppe between patients. among all respondents, 361 (55.5%) reported high compliance (.80%) to ppe use, with significant inter-institutional variation ranging from 0% (0/5) to 88.1% (37/42 (table 3 ). to our knowledge, this study represents the first effort to examine self-reported knowledge, attitude, behavior and influencing factors of ppe use during the pandemic influenza in chinese icus. among 650 respondents, although up to 77% reported to have adequate knowledge of self-and patient protection, fewer than 20% could correctly identify all components of ppe or exhibited correct knowledge of ppe use during patient care. this suggested significant gaps in the perception and actual knowledge with regards to infection control practices, in particular ppe use, among our critical care clinicians [17] . moreover, about 55% of respondents reported high compliance to the recommended ppe use. vaccination status, positive attitudes towards ppe use, cultural factor (perceived reprimand for noncompliance), and organizational factors (availability of ppe in icu, notice of influenza precautions) were identified as independent predictors of high compliance, while negative attitudes towards ppe use and violation of recommended ppe use were associated with low compliance. ppe referred to a variety of barriers and respirators used alone or in combination to protect mucous membranes, airways, skin, and clothing from contact with infectious agents [12] . the critical importance of compliance to ppe use was not only recognized in a variety of practice guidelines of infection control [9] [10] [11] [12] [13] , but also demonstrated during the outbreak of sars in 2003 [8, 18] . unfortunately, compliance by professionals was often suboptimal [19, 20] , due to knowledge, attitudes, and behavior among professionals, as well as to organizational and other factors [15, 21] . in this survey of chinese critical care clinicians, only 55% of respondents reported high compliance (.80%) to recommended ppe use, consistent with other relevant studies [16, 19] . however, significant gaps between perception and practice were a common finding in icu [22] , indicating overestimation of clinical practice judged by self-reported behavior, especially for infection control measures, such as hand hygiene [23] and ppe use [16, 19] . similar to the study of daugherty and coworkers [16] , we found a similar proportion (74%) of respondents claiming their confidence to improve compliance to ppe use, again suggesting perception of inadequate ppe use among most respondents. our results indicated that a number of factors, including attitudes, behavior, and organization, might significantly influence clinical practice. although behavior could be changed without knowledge or attitude being affected, behavior change (i.e. selfreported high compliance to ppe use) based on improving knowledge and attitude (e.g. ppe use could confer adequate protection for hcws) was probably more sustainable than indirect manipulation of behavior alone [15] . in the meanwhile, it was also self-intuitive that a negative attitude (e.g. perception that ppe use might interfere with patient care) often predicted low compliance. likewise, daugherty and coworkers found that the belief that ppe use was inconvenient was predictive of poorer adherence [16] . the perception that ppe use interfered with patient care was supported by previous studies. despite the fact that critical care clinicians were probably highly compliant with ppe use, patients in contact isolation might suffer from adverse effect of inadequate patient care, including less time spent in patient rooms not explained by severity of illness [24, 25] , less time examining patients [26] , more incomplete records of vital signs and progress notes, and increasingly likelihood of preventable adverse events. moreover, almost half hcws reported difficulty in communicating with patients through enhanced infection precautions during the sars outbreak [27] . organizational factors were commonly acknowledged as barriers that impede and hamper professionals' compliance to ppe. compliance to ppe use was closely related to the professionals' perception about the risks they were exposed to and their susceptibility to these risks. our study showed that, if critical care clinicians were aware of the patients on isolation precautions, they were twice likely to report high compliance to ppe use. similarly, in a survey of physicians working in canadian pediatric emergency departments, almost 90% considered identifying patients with complaints requiring ppe use prior to the physician entering the room as an important factor promoting ppe use [19] . in a study performed during the first wave of 2009 h1n1 influenza, banach and coworkers observed more unprotected exposures in patients who did not present with influenzalike illness [28] . this finding was not unexpected because such patients would not have been identified by the screening protocol, which might result in delays in consideration of influenza as a potential diagnosis when these patients were subsequently evaluated by clinicians, as well as delays in implementation of recommended infection control measures. studies have consistently demonstrated significant association of the availability of ppe in icu and self-reported compliance, as in our study, indicating unavailability as the major reason for noncompliance [16, 19, 21] . however, among the 256 critical care clinicians surveyed by daugherty and coworkers, self-reported high compliance was only 62%, despite the fact that 72% reported that recommended ppe was readily available near patients' rooms [16] . this evidenced the complexity of compliance to ppe, which might go beyond availability, confirming the interference of individual factors, perceptions, and relations in the work environment in decision making towards protection. professional's behavior was an important factor that determined the commitment to, and the style and proficiency of, an organization's health and safety management [29] . a study in 1986 examined the role of organizational factors in 13 hospitals in the united states, and found that severity-adjusted mortality were related more to the interaction and coordination of each hospital's icu staff than the icu administrative structure, amount of specialized treatment used, or the hospital's teaching status [30] . similar to other studies [16] , our study found close association between self-reported compliance and safety culture (i.e. hcw behavior, and perceived reprimand for noncompliance by the supervisors), underscoring the importance of icu safety culture in promoting behavior change, or even patient outcome [29] . perceived barriers of compliance to ppe use as described above should be addressed during development of practice guidelines, in order to prevent transmission of infectious diseases within hospital setting. despite the lack of data validating such concept with regards to 2009 h1n1 influenza in icu, studies did suggest that implementation of protocoled care and/or educational program, by addressing knowledge, attitude, and behavioral barriers, might significantly reduce catheter-related bloodstream infection [31] , and improve mortality in patients with severe sepsis [32] . the major limitation of our study was that it might be subject to social desirability bias (individuals may wish to present themselves or their organization in a favorable way) due to its reliance on self-reporting [33] . in addition, cause-effect relationship could not be determined due to the inherent ''chicken or egg'' caveat of the observational study. nevertheless, these data provided clue of the barriers that existed with regard to the implementation of infection control guidelines in icus and provided useful suggestions for the implementation. only 55% of chinese critical care clinicians reported high compliance to ppe use during pandemic influenza, putting hcws and their patients at risk. both attitudes towards ppe use and perceived organizational norms have been recognized as predictors of compliance, which should be addressed while developing educational program and/or practice guidelines, in order to prevent nosocomial transmission of influenza. questionnaire s1 survey questionnaire. (doc) swine influenza. statement by who director-general, dr margaret chan world now at the start of 2009 influenza pandemic. statement to the press by who director-general dr margaret chan h1n1 flu: international situation update swine origin influenza a (h1n1) virus and icu capacity in the us. are we prepared? hospitalized patients with 2009 h1n1 influenza in the united states impact of the 2009 influenza a(h1n1) pandemic on public health workers in the netherlands personal protective equipment and antiviral drug use during hospitalization for suspected avian or pandemic influenza sars plague: duty to care or medical heroism transmission of 2009 pandemic influenza a (h1n1) virus among healthcare personnel -southern california guideline for infection control in health care personnel healthcare infection control practices advisory committee guideline for hand hygiene in health-care settings. recommendations of the healthcare infection control practices advisory committee and the hicpac/shea/apic/idsa hand hygiene task force guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings pandemic influenza: guidance for infection control in critical care. dh novel influenza a (h1n1) virus infections among health-care personnel -united states why don't physicians follow clinical practice guidelines? a framework for improvement the use of personal protective equipment for control of influenza among critical care clinicians: a survey study knowledge and attitudes of healthcare workers in chinese intensive care units regarding 2009 h1n1 influenza pandemic effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory distress syndrome (sars) use of personal protective equipment in pediatric emergency departments a method for evaluating health care worker's personal protective equipment technique barriers to implementing infection prevention and control guidelines during crises: experience of health care professionals practice and perception -a national survey of therapy habits in sepsis understanding adherence to hand hygiene recommendations: the theory of planned behavior adverse effects of contact isolation contact isolation in surgical patients: a barrier to care? do physicians examine patients in contact isolation less frequently? a brief report the immediate psychological and occupational impact of the 2003 sars outbreak in a teaching hospital factors associated with unprotected exposure to 2009 h1n1 influenza a among healthcare workers during the first wave of the pandemic intensive care unit safety culture and outcomes: a us multicenter study an evaluation of outcome from intensive care in major medical centers an intervention to decrease catheter-related bloodstream infections in the icu improvement in process of care and outcome after a multicenter severe sepsis educational program in spain implementing quality indicators in intensive care units: exploring barriers to and facilitators of behavior change key: cord-283900-4pa93xqi authors: khan, m. ali; sivalingam, arunan; haller, julia a. title: perceptions of occupational risk and changes in clinical practice of u.s. vitreoretinal surgery fellows during the covid-19 pandemic date: 2020-05-22 journal: ophthalmology. retina doi: 10.1016/j.oret.2020.05.011 sha: doc_id: 283900 cord_uid: 4pa93xqi abstract purpose to assess perceptions of occupational risk and changes to clinical practice of ophthalmology trainees in the united states during the covid-19 pandemic. design an anonymous, non-validated, cross-sectional survey was conducted online. data was collected from april 7-16, 2020. participants 2019-2020 second year u.s. vitreoretinal surgery fellows in two-year vitreoretinal surgery training programs were invited to participate. intervention online survey. main outcome measures survey questions assessed policies guiding covid-19 response, known or suspected exposure to sars-cov-2, changes in clinical duties and volume, and methods to reduce occupational risk including availability of personal protective equipment. results completed responses were obtained from 62 of 87 eligible recipients (71.2% response rate). training settings included academic (58.1%), hybrid academic/private practice (35.5%), and private practice only settings (6.5%). overall, 19.4% of respondents reported an exposure to a covid-19 positive patient, 14.5% reported self-quarantining due to possible exposure, and 11.3% reported being tested for covid-19. in regards to ppe, n95 masks were available in the emergency room (n=40, 64.5%), office (n=35, 56.5%), and operating room settings (n=35, 56.5%). perceived comfort level with ppe recommendations was significantly associated with availability of an n95 respirator mask in the clinic (p<0.001), emergency room (p<0.001) or operating room (p=0.002) settings. additional risk mitigation methods outside of ppe were: reduction in patient volume (n=62, 100%), limiting patient companions (n=59, 95.2%), use of a screening process (n=59, 95.2%), use of a slit lamp face shield (n=57, 91.9%), temperature screening of all persons entering clinical space (n=34, 54.84%), and placement of face mask on patients (n=33, 53.2%). overall, 16.1% reported additional clinical duties within the scope of ophthalmology, and 3.2% reported being re-deployed to non-ophthalmology services. 98.4% of respondents expected a reduction in surgical case volume. no respondents reported loss of employment or reduction in pay or benefits due to covid-19. conclusion and relevance: suspected or confirmed clinical exposure to covid-19 positive patients occurred in approximately one-fifth of trainee respondents. perceived comfort level with ppe standards was significantly associated with n95 respirator mask availability. as surgical training programs grapple with the covid-19 pandemic, analysis of trainees’ concerns may inform development of mitigation strategies. patients (n=33, 53.2%). overall, 16 .1% reported additional clinical duties within the scope of 52 ophthalmology, and 3.2% reported being re-deployed to non-ophthalmology services. 98.4% of 53 respondents expected a reduction in surgical case volume. no respondents reported loss of 54 employment or reduction in pay or benefits due to . in all, 87 eligible fellows from 62 training programs were identified and received the 105 survey via email. survey questions assessed training program environment, policies guiding 106 covid-19 response, changes in fellow duties and clinical volume, and methods to reduce 107 occupational risk including availability of ppe. the survey was open from april 7 to april, 16, 108 2020. eligible recipients received an invitation email followed by 2 reminder emails. 109 participation was voluntary and no compensation was offered. data was exported to microsoft excel and descriptive characteristics were obtained. with 111 a population size of 87, a sample size of 61 would be required to achieve a 95% confidence 112 interval at a 7% margin of error. a fisher's exact test was used to determine, when applicable, 113 associations between two categorical variables, with a p value of <0.05 deemed statistically 114 significant. 115 completed responses were obtained from 62 of 87 eligible recipients (71.2% response 118 rate) from april 7-16, 2020 ( figure 1 ). two fellows chose to opt-out of the survey, and the 119 remaining 23 eligible fellows were non-responders. 120 58.1% (n=36) reported training at an academic center, 35.5% (n=22) in a hybrid 121 academic/private practice setting, and 6.5% (n=4) in a private practice setting. overall, 50% 122 reported that re-deployment is possible in coming weeks. ten respondents (16.1%) reported reassignment to duties within the scope of ophthalmology, including staffing of a non-retina 140 related urgent care clinic, staffing of general ophthalmology clinics, participation in tele-141 medicine visits, and being granted full attending privileges in the field of retina. 142 respondents who trained in a metro area considered high risk for covid-19 were not 143 more likely to be re-deployed (p=0.23) than those who did not. respondents who trained in a 144 metro area considered high risk for covid-19 were more likely to be assigned additional duties 145 within the scope of ophthalmology compared to those who did not, but this difference was not 146 statistically significant (p=0.08). 147 availability and use of ppe: 148 58 respondents (95.1%) reported they are required to wear, at minimum, a surgical mask 149 for all patient contact. in regards to n95 respirator masks, 35 (56.5%) respondents reported their 150 availability in the office setting, 40 (64.5%) in the emergency room setting, and 35 (56.5%) in 151 the operating room setting. 47 respondents (75.8%) reported their institution has a policy of 152 sterilizing n95 respirator masks for reuse. of surveyed ppe items -including n95 respirator 153 masks, surgical masks, eye protection, gloves, and gowns -the least available ppe item in the 154 emergency room or operating room setting was an n95 respirator mask (n=35, 56.5% available). 155 in the clinic setting, the least available ppe item was a gown (n=15, 24.2% available). 156 57 respondents (91.9%) stated that they believed current ppe recommendations at their 157 training institution were influenced by current or anticipated ppe shortages. 56.5% (n=35) of 158 respondents expressed being comfortable with the ppe recommendations at their institution 159 (n=28, 45.2% somewhat comfortable and n= 7, 11.3% extremely comfortable). 16 significantly associated with availability of n95 masks in the clinic (p<0.001), emergency room 164 (p<0.001), and operating room setting (p=0.002). 165 a total of 7 respondents (11.3%) reported they had no access to an n95 respirator mask. 166 of these 7, two trained at an academic institution, two trained in a private practice setting, and 167 three trained at a hybrid academic/private practice program. 168 reported occupational risk is depicted in figure 2 . 19.4% of respondents (n=12) reported 170 a clinical exposure to a covid-19 positive patient, 14.5% (n=9) reported self-quarantining due 171 to possible exposure, and 11.3% (n=7) reported being tested for covid-19. fellows who train in 172 metro areas considered high risk for covid-19 were not more likely to be exposed to (p=0.11), 173 tested for (p>0.99), or self-quarantined (p>0.99) due to covid-19. fellows who train in 174 academic institutions were not more likely to be exposed to (p=0.11), tested for (p=0.39), or self-175 quarantined (p=0.46) due to covid-19 than who did not. 176 risk mitigation strategies utilized at fellow respondent work places are depicted in figure 177 3. risk mitigation strategies included: reduction in patient volume/scheduling (n=62, 100%), expected volume reduction by 30%, 18 (29.0%) expected volume reduction by 20%, and 7 (11.3%) expected a volume reduction by 10% or less. one respondent (1.6%) expected an 208 increase in total surgical case volume. 209 a majority of respondents (n=35, 56.5%) reported concern about the effect of covid-19 210 on their surgical training. 14.5% of respondents (n= 9) were extremely concerned and 41.9% 211 (n=26) were somewhat concerned. 24.2% (n=15) reported having no concerns regarding the 212 effect of covid-19. 213 no respondents reported reduction in pay or benefits, or being unemployed or furloughed 214 due to covid-19. a total of 59 respondents (95.2%) stated they had accepted a position of 215 employment to start after completion of fellowship training. of these, 3.4% (n=2) reported their 216 employment contract was revoked (n=1) or start date delayed (n=1) due to covid-19. 217 health care professionals are at increased risk during the covid-19 pandemic. 16 access to n95 respirator masks, in particular, has been a flashpoint for risk perception. 243 many institutions are following current cdc guidelines that do not call for routine use of n95 244 respirator masks for lower risk interactions, instead reserving them to protect workers in higher 245 risk settings. in this study, the lone factor significantly associated with perceived comfort level 246 with ppe recommendations during the study period was the availability of an n95 respirator 247 mask, and further found that 91.9% of respondents stating they believe their institutional ppe 248 recommendations were influenced by ppe shortages. 11.3% reported they had no access to an 249 practice. two respondents (3.2%) reported being re-deployed to non-ophthalmology services 280 with an additional 19 (30.6%) reporting that this may be imminently possible. moreover, 16.1% 281 of respondents reported that they have been tasked with additional duties within the scope of 282 ophthalmology, including being granted higher level clinical privileges. the acgme, in 283 addition, has conveyed that furloughs of trainees are "unacceptable." 22 no respondents reported 284 reduction in pay or benefits, or being unemployed or furloughed due to covid-19. the clinical education of trainees in the face of reduced clinical care volume, particularly 286 as the need to limit care to emergent or urgent indications continues, is deserving of special 287 attention and effort. all but one respondent (n=61, 98.4%) in this study expected a reduction in 288 surgical case volume due to covid-19, with 45.2% (n=28) expecting a reduction by 50% or this study has several limitations. while the survey achieved a 71.2% response rate, non-297 response bias may be present. to limit this effect and improve response rates we utilized email 298 addresses that were recently listed as the primary contact address on fellowship application files 299 and no 'bounce-back' emails were generated from the survey software. grouping of question 300 topics was utilized to avoid order bias. allowing anonymity and avoiding organizational (e.g. 301 asrs, aupo) sponsorship were utilized to reduce any response bias. all results are self-302 reported, so validity of exposure perceptions, institutional policies, and other variables cannot be 303 ascertained. this survey assessed perceptions of occupational risk, and true risk cannot be 304 inferred by these responses. risk tolerance and comfort levels regarding institutional policies 305 may differ from physician to physician and thus influence the perceptions described herein. 306 discussion of data regarding differential reduction of sars-cov-2 or other coronavirus 307 transmission with surgical or n95 respirator masks is outside the scope of this study assessing ophthalmology trainee perceptions of occupational risk. although ppe availability was assessed, 309 more specific technical questions regarding precise ppe details (such as results of fit testing, size 310 of eye protection, use of a surgical versus standard n95 respirator masks, ppe manufacturer, 311 etc.) were not asked. vitreoretinal surgery fellows were selected for survey as their specialty 312 often requires urgent and emergent care, and their experience, exposure rates, and perceptions 313 may not be applicable to vitreoretinal surgery attendings or residents or fellows of different 314 subspecialties. conversely, since vitreoretinal fellows may be more clinically active during 315 covid-19, they may be less likely to be re-deployed to non-ophthalmology settings that could 316 influence their overall exposure risk. lastly, as the covid-19 pandemic continues to press on, 317 respondent sentiments should be taken in context of the study period evaluated as risk 318 perceptions and national, local, and institutional policies will continue to evolve, particularly as 319 guidance to re-open surgical facilities for elective and semi-elective surgery in may, 2020 are 320 in conclusion, covid-19 has, in a period of months, resulted in unprecedented stresses 322 on the us healthcare system and healthcare workers, including trainees. this study reports 323 occupational risk perceptions, currently utilized risk mitigation strategies, and surgical volume 324 training concerns for second year us vitreoretinal surgery fellows mid-pandemic escalation. 325 elucidating the concerns of ophthalmic surgical trainees, both physical and psychological, can 326 guide mitigation strategies aimed not only to alleviate concerns and enhance work force health, 327 but also optimize this key period of training, despite its challenges. 328 329 approximately one-fifth of u.s. vitreoretinal surgery fellows had suspected or confirmed clinical exposure to covid-19 positive patients. risk mitigation and support strategies were varied and were guided by a combination of institutional and national recommendations. a survey was sent to current, 2019-2020 senior u.s. vitreoretinal surgery fellows to assess perceptions of occupational risk during covid-19 and was open from april 7-16, 2020. a total of 62 of 87 eligible fellows responded (71.3% response rate). distribution of survey responses over the course of survey duration is presented above. respondents were asked if they had known clinical exposure to a covid-19 positive patient, if they self-quarantined due to possible exposure, and if they had been tested for covid-19 (serologic or viral polymerase chain reaction methods). results of these indicators of occupational risk are depicted above. a survey was sent to current, 2019-2020 senior u.s. vitreoretinal surgery fellows to assess perceptions of occupational risk during covid-19. respondents were asked what strategies are being utilized to reduce their occupational risk. common risk mitigation strategies not related to use of personal protective equipment are summarized above. complex immune 333 dysregulation in covid-19 patients with severe respiratory 334 failure. cell host microbe guillain-barré syndrome associated with 337 sars-cov-2 st-segment elevation in patients with covid-339 19 -a case series assessing viral shedding and infectivity of tears in coronavirus disease 342 2019 (covid-19) patients covid-19: a novel coronavirus and a novel challenge for 345 critical care neurologic features in severe sars-cov-2 infection. 348 manifestations and prognosis of gastrointestinal and liver 350 involvement in patients with covid-19: a systematic review and meta-analysis multiorgan and renal tropism of 353 sars-cov-2 perspectives on coronavirus disease 2019 control 355 measures for ophthalmology clinics based on a what impact has covid-19 had on 362 outpatient visits? to the point (blog), commonwealth fund list of urgent and emergent ophthalmic procedures updates and resources: retina emergent/urgent procedures. the american 368 society of retina specialists covid-19 united states cases by county death from covid-19 of 23 health care workers in china. 373 symptom screening at illness onset of 375 health care personnel with sars-cov-2 infection in king county characteristics of health care personnel with covid-19 -united states respiratory virus shedding in exhaled breath and 381 efficacy of face masks surgery in a time of uncertainty: a need for universal respiratory 383 precautions in the operating room acgme reaffirms its four ongoing requirement priorities during covid-19 pandemic details/articleid/10188/acgme-reaffirms-its-four-ongoing-requirement-priorities-388 during-covid-19-pandemic statement on furloughs resulting from the covid-19 pandemic emergency details/articleid/10194/acgme-statement-on-furloughs-resulting-from-the-covid-19-392 pandemic-emergency surgical retina and vitreous case volumes. association of university professors of 394 ophthalmology fellowship compliance committee key: cord-295514-vhymj0rw authors: lim, peter a; ng, yee sien; tay, boon keng title: impact of a viral respiratory epidemic on the practice of medicine and rehabilitation: severe acute respiratory syndrome date: 2004-08-01 journal: arch phys med rehabil doi: 10.1016/j.apmr.2004.01.022 sha: doc_id: 295514 cord_uid: vhymj0rw lim pa, ng ys, tay bk. impact of a viral respiratory epidemic on the practice of medicine and rehabilitation: severe acute respiratory syndrome. arch phys med rehabil 2004;85:1365–70. severe acute respiratory syndrome (sars) is a new respiratory viral epidemic that originated in china but has affected many parts of the world, with devastating impact on economies and the practice of medicine and rehabilitation. a novel coronavirus has been implicated, with transmission through respiratory droplets. rehabilitation was significantly affected by sars, because strict infection control measures run counter to principles such as multidisciplinary interactions, patients encouraging and learning from each other, and close physical contact during therapy. immunocompromised patients who may silently carry sars are common in rehabilitation and include those with renal failure, diabetes, and cancer. routine procedures such as management of feces and respiratory secretions (eg, airway suctioning, tracheotomy care) have been classified as high risk. personal protection equipment presented not only a physical but also a psychologic barrier to therapeutic human contact. visitor restriction to decrease chances of disease transmission are particularly difficult for long-staying rehabilitation patients. at the height of the epidemic, curtailment of patient movement stopped all transfers for rehabilitation, and physiatrists had to function as general internists. our experiences strongly suggest that rehabilitation institutions should have emergency preparedness plans because such epidemics may recur, whether as a result of nature or of bioterrorism. o n march 1, 2003, a previously healthy patient in her early twenties was admitted to tan tock seng hospital (ttsh), a public teaching hospital in singapore, with progressively severe pneumonia nonresponsive to routine antibiotic therapy. this was the start of a new viral respiratory epidemic for the island-nation of 4 million; the infection rapidly spread from this index case, who was in a multibed ward without barrier infection control measures. those infected at ttsh included 9 of approximately 30 family members and friends who visited this patient, 1 of the 12 patients in adjacent beds, 1 of the 8 physicians, and 9 of the 30 nurses who attended to her. 1 based on nasopharyngeal and serum samples of patients, the infective agent implicated was a novel coronavirus. [2] [3] [4] the name severe acute respiratory syndrome (sars), adopted for this infection, was an appropriate recognition of its nature and virulence. sars started as an atypical pneumonia in the guangdong province of china in november 2002, affecting 792 people and causing 31 deaths. 2, 3 it was carried into hong kong and transmitted to 3 vacationing singaporeans (including the index case), apparently while they were waiting for a hotel elevator along with a sars-infected person. the epidemic spread to many countries across the globe, with the hardest hit areas being the cities of beijing, hong kong, 5 taipei, singapore, and toronto. the last probable case of sars in singapore was hospital-isolated on may 11. as of june 20, 2003, the tally in singapore was a total of 206 probable cases, with 170 recovered and discharged home, 32 dead, and 3 still hospitalized. on july 5, 2003 , the world health organization issued a declaration that sars had been contained worldwide. although the sars outbreak had a relatively high mortality rate and sars can lead to residual lung damage in serious cases, the epidemic arguably had a devastating impact well beyond the absolute numbers affected by the disease. fear of the unknown with a new disease entity and the potential for uncontrollable spread resulted in much apprehension and the implementation of far-reaching measures. in singapore, the economic toll has been significant and estimates suggest that sars may have taken 2% from the gross domestic product growth in 2003. this resulted not only from direct costs to control the epidemic, but also from losses in productivity, decreased demand for sales and services, and a massive blow to the important airline and tourist industries. tourism to singapore decreased drastically and international conferences were postponed. many multinational business corporations instituted policies against travel to affected countries like singapore. travel from singapore to other sars-affected countries was similarly curtailed. in simple terms, nobody wanted to put themselves at risk of contracting the sars virus. in health care, the costs to combat sars have been in the hundreds of millions-us$110 million was spent on direct operating expenditures, such as medical supplies, protective gear for health care workers and patients, free sars screening and ambulance services, administering and enforcing home quarantine orders, setting up fever clinics, contact tracing, and a sars hotline center. us$60 million was spent on infrastructure expenditures, including construction of isolation rooms and renovation of wards and medical facilities. 6 the fears and concerns generated by the disease also had a considerable impact on hospitals. 7 a striking feature of sars was the significantly increased risk to health care workers, with a large proportion of those infected in singapore (90/206 [44%]) from among these ranks. the fear of the "super-spreader" (a person who directly infected ն10 other persons 8 with minimal contact), lying undiscovered in the wards, asymptomatic or minimally symptomatic, was of considerable concern and caused much stress. the singapore general hospital (sgh), from which this account of events arose, is a 1400-bed public tertiary teaching hospital. with the national dental, eye, heart and cancer centres on the same campus, it offers services in most areas of medical expertise. the department of rehabilitation medicine in sgh provides comprehensive inpatient and outpatient services, and had between 20 and 28 inpatients at the time of the epidemic. this article recounts chronologically the effect of sars on medical and rehabilitation services. it reviews the preventive and control measures taken, and it describes the solutions and adaptations taken to overcome some of the problems faced by rehabilitation medicine. once the highly infectious and virulent nature of sars became apparent, a process was rapidly implemented for identifying suspected patients. this process centered on the clinical findings of fever, cough, respiratory difficulties, and radiographic changes, including consolidation or findings of adult respiratory distress syndrome. it was also important to determine any history of close contact with someone infected by sars or travel to sars-affected regions (appendix 1). at the time, the nature of the virus was still unconfirmed, and no diagnostic tests were yet available. the ministry of health (moh) singapore, which had authority over 8748 of the 11,820 hospital beds in the country, 9 placed ttsh and its communicable disease centre under quarantine. ttsh was designated for assessment and isolation of suspected sars cases, either by direct admission or by transfer from any other health care facility. 8 non-sarssuspected cases were diverted to the other public sector hospitals, resulting in a shift of acute health care workloads to the other hospitals. for rehabilitation medicine, this meant having to cope with a noticeable increase of patients needing rehabilitation from events such as strokes and traumatic injuries. hospital staff who became sick or had a fever, defined as a tympanic temperature higher than 37.5°c confirmed by oral retesting, had to report to the employee clinic or to the emergency department for screening. this in turn necessitated redeployment of staff from other departments to these 2 areas, to help cope with the dramatically increased workload, because they had become busy frontline areas for staff and patients, respectively. ironically, a significant number of healthy staff with higher body temperatures were ordered to take sick leave until it was determined that these people had higher baseline temperatures and waivers were issued. all nonemergency leave and vacation time were suspended. an appeal was put out by the moh for private practitioners to help out by filling locum clinic roles and nonspecialized areas, such as employee clinics and clinical audits. all staff received retraining in infection control practices, as appropriate. this included proper hand-washing techniques and donning and doffing of personal protection equipment (ppe), which included head cover, goggles, n-95 masks, gowns or plastic aprons, gloves, and shoe covers. n-95 masks, certified by the national institute for occupational safety and health, with a 95% or greater filter efficiency against oil-free particulate aerosols of 0.3 in size, became mandatory for health care workers with direct patient contact. although potentially preventing sars transmission, these masks required increased breathing effort, and the staff found itself fatigued more quickly or even dizzy after using these masks. this was particularly difficult for our therapy and nursing staff because of their physical work duties, although doctors and others were also affected. work efficiency dropped considerably with the need for donning and doffing fresh ppe with each patient. the discomfort and stress of ppe was particularly difficult for pregnant or claustrophobic staff, and it was made worse by having to wear gowns in a tropical climate. knowing that one could still get infected while using protective measures was not helpful. 10 equipment such as stethoscopes, sphygmomanometers, therapy plinths or platforms, examination tables, and trolleys had to be wiped down after each use with an antiseptic solution (eg, alcohol, sodium hypochlorite, phenolic acid). fastidious and frequent hand washing affected staff with eczema and allergies to the antiseptic soaps or hand rubs that were compulsory after each and every patient contact no matter how trivial. in rehabilitation medicine, a heightened vigilance and a tighter screening process was adopted before transfer of patients to the rehabilitation ward, especially those with fever or a history of pneumonia. specifically explored during rehabilitation consultations were the issues of patient fever, travel or contact history, and respiratory symptoms or issues. rehabilitation medicine was increasingly affected by everstricter infection control measures regarding close contacts and interactions between health care workers. multidisciplinary team meetings were canceled; instead, telephone updates or intranet e-mails were strongly encouraged. nevertheless, oneon-one meetings between masked team rehabilitation members still occurred, to pass on progress reports and to discuss important issues. the use of telephone or e-mail was encouraged for specialist consultations unless a personal examination or bedside consultation was felt to be necessary, in which case ppe was expected before entering the patient's room. the hospital was already partially converted to electronic medical records; hence, it was possible to pull out laboratory tests, radiologic reports, and medical summaries from any hospital computer terminal using individualized physician passwords. rehabilitation consultations often ended with a recommendation for transfer to a smaller community hospital with therapy services, because sars had left these institutions relatively unaffected. alternatively, those well enough to go home were sent for outpatient therapies at one of the various facilities for day rehabilitation across the city, and home-based therapy was also available although limited because of personnel constraints. the first death from sars in singapore was reported on march 25, 2003. moh's official strategy focused on 3 areas of control: (1) eliminate nosocomial transmission through sub-stantially enhanced infection-control practices; (2) prevent additional importation of infection through health screening and travel advisories at the airport and seaports; and (3) stop community transmission through education, contact tracing, and quarantine measures. 8 sgh implemented a modular system, with physical barriers (eg, gypsum boards, closed fire doors) quickly installed between sectors, in an attempt to contain and limit any subsequent outbreaks. rehabilitation medicine was organized into such a module. doctors were not permitted to move out of modules or between outpatients and inpatients. no patient transfers were permitted between modules, except to the isolation or intensive care units. departments were encouraged to separate into teams to enable a backup in case 1 team became exposed and prophylactic quarantine necessary. where possible, only 1 doctor was to examine the patient to avoid excessive contact. visitors to the hospital were restricted and eventually banned altogether, except for immediate family of dangerously ill patients. temperatures and contact history were taken at checkpoints set up at entry points to the patient wards and the visitor restrictions enforced here. group therapy and patients using therapy gyms in relatively close quarters were prohibited to avoid spread of the virus. therapies thus became exclusively one-on-one and were provided at the bedside. rehabilitation equipment, such as parallel bars, step platforms, therapy balls, and assistive walking devices, were distributed to modules depending on estimated therapy load because the therapy gyms were closed. rehabilitation medicine was directly affected when the entire neurology ward, including patients and health care staff, were transferred out to ttsh for isolation and observation because of suspicious clusters of fevers that involved both patients and staff. several patients from this neurology ward, who had previously been transferred to us for rehabilitation, were also transferred out. as secondary contacts, the rehabilitation team, including doctors, nurses, and therapists, were placed on a prophylactic 10-day home quarantine. fortunately, our policy of grouping transferred patients into 1 physical area according to previous wards meant the chance of their contaminating other rehabilitation patients was minimal. management of the remaining rehabilitation patients was taken over by physicians from the adjacent ward for the quarantine period, with continued input from the 1 physiatrist unaffected by the quarantine order-he was running the outpatient clinic at the time of the outbreak and hence had not been exposed to the virus. ultimately, it was determined that none of the staff nor patients had the sars virus. nevertheless, it demonstrated how entire units, including rehabilitation medicine, could abruptly be closed down by any possibility of sars. the need to avoid unnecessary contact and interactions, as well as to generally isolate our patients from one another, struck the rehabilitation unit with full force. rehabilitation patients were not allowed to move around or interact with each other. surgical masks, which some patients found uncomfortable or intolerable, had to be worn by those with a fever or cough. the rehabilitation staff had to don full ppe, including n-95 mask, head cover, face shield, gown, and gloves, before contact with each patient, introducing not only a physical but also a psychologic barrier. conceivably, close patient contact (eg, during transfers) could transmit infection by way of fomites. the amount of physical, occupational, or speech therapy that each patient received was significantly reduced, because of staff fatigue from the masks and heat from the gowns. staff had to refrain from the usual acts of comforting patients, such as holding hands and appropriate touching, unless it was through the ppe. scrubs and t-shirts were provided to all staff working in patient areas or having patient contact. shower facilities were opened for baths and staff changed into street clothes before heading home at the end of the shift. because the virus is typically found in the respiratory secretions (and, to a lesser extent, in feces), certain tasks were now deemed to need a higher level of precaution and protection. to prevent spread of the sars virus among staff, a positive air purifying respirator (papr) was worn on top of the ppe during procedures such as suctioning of respiratory secretions. the papr is a battery-operated device that continuously blew filtered air out through the hood worn, thus preventing the virus from being inhaled. however, the additional protection had a price in terms of heat retention and weight, both of which resulted in profuse sweating, especially in non-air conditioned patient care areas. it also restricted movements and required adequate operator hydration and rest periods. sufficient numbers were necessary because of the many procedures for which it would be needed, and effort and time was required for cleaning after each use. 11 staff lounges and cafeterias were closed, to avoid interactions between health care workers, and free packed meals were provided for all on duty. foreign guest workers, especially nursing staff and aides who shared apartments but worked in different hospitals in singapore, were provided with optional housing, such as hostels and rented apartments. teaching programs and meetings were suspended, again to avoid unnecessary interactions. bedside teaching with patients was stopped. face-to-face and group meetings were avoided where possible, and a system (lotus sametime) for virtual meetings and conferencing via the hospital intranet was instituted for heads of clinical departments, to ease communication. after the incident involving the transfer of neurology patients (see risks of rehabilitation transfers), no other patients were transferred into the rehabilitation unit. instead, rehabilitation medicine, along with other specialty departments such as neurology, renal medicine, and gastroenterology, provided general internal medicine care for any patient admitted to their respective wards. our department took care of patients with diagnoses ranging from congestive heart failure to renal failure, and from fresh strokes to psychiatric disorders including drug overdose. it became a matter of chance whether a patient would be transferred from the emergency department to the rehabilitation ward. it was understood, however, that during triage in the emergency department, staff would try to direct patients to an appropriate departmental ward-for example, strokes to the neurology or rehabilitation medicine module. patients admitted with fevers were sent to the isolation wards and were managed by respiratory medicine and infectious-diseases physicians, with the help of medical personnel seconded from other departments, including ours. all elective procedures and surgeries were canceled, and only urgent or emergency surgeries were performed. training for rehabilitation medicine physicians in singapore is a 3-year program after a residency-equivalent training and certification examination in internal medicine. in addition, rehabilitation medicine trainees are part of the internal medicine call schedule for the hospital. this turned out to be an important reason for the relatively easy time our doctors had coping with their new roles as internists. similarly, therapists with special interests or those who worked predominantly with certain patients (eg, stroke, amputees, sports medicine) now found themselves practicing outside their usual area of expertise. despite experience or training with populations such as those with spinal cord injury, therapists might find themselves working with amputee patients or performing chest physiotherapy (pt). the number of patients presenting for outpatient evaluations and follow-ups dropped dramatically, because the public avoided hospitals whenever possible. recognizing this, medical record reviews of scheduled outpatients who did not show up for appointments were performed to determine the urgency of follow-up. telephone contact was made as necessary, especially where follow-up was important to assess for any problem. where indicated, medication refills were dispensed and sent by courier to patients' homes. new appointments were rescheduled before the end of the medication prescription period, by which time the sars epidemic we hoped would have abated. the pt department set up a service known as e-physio via the hospital's internet web site (http://www.sgh.com.sg), whereby patients with access to the internet could book appointments for assessment and therapy sessions through webcams from their own homes. lock-downs of modules occurred sporadically, whenever a fever cluster or sars-suspicious patient was discovered. patients and staff affected were monitored for at least a 10-day period, longer than the sars incubation period of 6 days previously described, to allow for an increased margin of safety. 5 this meant, however, that patients in the same physical vicinity, who might have otherwise been discharged home, ended up with an enforced prolongation of hospital stay while being monitored for development of fever and other signs and symptoms. active contact-tracing efforts by the moh and at each hospital was in full force, with every suspected or infected patient mapped for movements and recent human contacts, and home quarantined for the disease incubation period imposed. patients with immune system disorders and pathologies were deemed to be immunocompromised, and this included people with diabetes mellitus, malignancies, and chronic renal failure. the possibility of these patients contracting sars and not presenting with the typical fever and respiratory symptoms was a very real concern. this was borne out by a cluster of sars infections at sgh that originated from a single patient with renal failure. 8 patients eligible for discharge who were immunocompromised in some manner were instructed to stay at home for 10 days and to monitor their temperatures. needless to say, this included many of our patients with diabetes, which is such a common risk factor for stroke and amputation. discharging these patients to a step-down facility, such as a community hospital or an extended-care facility, became a problem, because these facilities stopped accepting such cases as a precaution against inadvertently importing sars. as discussed earlier, certain ward procedures relatively common for rehabilitation patients were among those classified as high risk. these included nasopharyngeal aspiration, bronchoscopy, endotracheal intubation, airway suctioning, and even noninvasive ventilation procedures. 12 caution was also needed with chest pt and postural drainage, because there was potential for coughing and producing respiratory secretions, as well as with the occasional cardiopulmonary resuscitation. during such procedures, full ppe and papr were mandatory, which meant that several sets of this equipment had to be ready and available at all times. because of the risk of aerosolized virus particles or droplet spread of the virus, nebulizers for respiratory medications, such as albuterol (salbutamol), were used only when absolutely necessary, and only under controlled situations, generally in a closed single room and with the health care worker in papr. wherever possible, spacer devices, to which the medications' pocket inhalers could be connected, were substituted. care was also taken when using nasal intermittent positive pressure ventilation devices for respiratory rehabilitation patients. fecal transmission was theoretically possible; hence, even patient hygiene and laundering bedding after fecal incontinence were classified as a high-risk procedure. 12 handling of diapers, disposal of excreta, and manual digital evacuation were done with full ppe worn and due care and diligence. patients. with regulations that initially limited visitors and subsequently prohibited visitors except to patients on the dangerously ill list, boredom and lack of emotional support became a major factor for our longer-staying patients. only private-rate paying patients had individual bedside telephones; hence, hospital-wide loaner cellular phones (with airtime donated by local telecommunication companies) were made available on request to any other patient who wished to talk with family. connections were made for video conferencing whereby the family, either at the sgh visitors' center or at 1 of several designated community centers, booked slots to use real-time video cameras to talk to their loved ones on the ward. personal laptop computers were permitted and encouraged for those with their own e-mail accounts. rather than aiming for optimal functioning, the rehabilitation goal became one of quickly getting patients as adequately functional as possible, to where their families could manage caregiving at home despite an earlier discharge than pre-sars days. staff. beyond the underlying fear of infection and the physical stress of working with protective equipment and regulations, security staff in particular came under risk of verbal abuse and physical threats from aggravated members of the public. this mainly originated from frustration with the regulations restricting visitors, but it was occasionally triggered by someone who refused to be screened for contact or travel history or to undergo a temperature check. incidents occurred where armed police were needed to enforce security. incidents also arose in which health care workers were shunned and even discriminated against, probably because of the fear of catching sars. nursing staff in particular, who still routinely wore uniforms in singapore, were easily identified. nurses reported that taxicabs did not stop when hailed. they also noticed having ample seating on public transportation, because no one wanted to sit next to them. on a more subtle level, children of health care workers noted that their friends' parents canceled play dates and social events for vague reasons. this issue was quickly picked up by the media, and a successful campaign ensued that helped health care workers be treated as brave professionals, rather than as potentially infectious persons. as the number of new sars cases dropped and affected patients were discharged home, cautious attempts at service recovery and a return to normality began. this was dampened in part by news of a resurgence of sars in toronto, canada, when an infected elderly patient with hip fracture transferred to a rehabilitation facility, thus creating another cluster of infections. the principle of the day for singapore hospitals thus became one of vigilance and caution, to avoid a similar occurrence. fever monitoring in both patients and staff several times daily continued as a routine, and infection control audit teams roamed the hospitals to detect and discourage breaches of control measures. a computerized system was set up for cluster monitoring in the wards, whereby any cluster of 3 or more patients in the vicinity with fever greater than 38°c triggered an alert. the coronavirus genome was sequenced and a polymerase chain reaction (pcr) test became available. it was a valuable tool for testing stools and respiratory secretions, although the test's accuracy was still believed to be relatively low. other tests available included blood tests for sars antibody seroconversion (appendix 1). a vaccine for sars was still not available and not expected for several years. regulations for readmission and transfer of patients between hospitals, generally still to be avoided, were instituted and included absence of clinical findings, negative chest radiographs, stool pcr test, or serum sars antibody. step-down facilities, such as community hospitals and nursing homes, cautiously began accepting patients again, after placing similar preconditions (eg, absence of fever, negative sars pcr or antibody tests). this shifted some of the burden of unnecessary prolonged stays, because disabled patients who were still unable to return home but were otherwise suitable for a step-down facility could now be moved appropriately. the impact that sars had on health care, and rehabilitation medicine in particular, would have been the same as that for any uncontrolled infectious disease, whether arising from nature (eg, a zoonotic infection), or from bioterrorism, a growing concern in these times. infection control measures effectively compromised the fundamental principles of rehabilitation, including interdisciplinary interactions, patients mingling and learning from each other, use of touch to encourage and comfort patients, and close physical contact during therapy. there were significant financial considerations that stemmed from limited group therapies and reversion to a strictly oneon-one therapy approach. similarly, routine use of infection control measures, including the costs of ppe, time taken to don and doff, and greatly reduced work efficiency among health care workers need to be factored in. the question of expertise arose when physiatrists had to manage medical complications themselves instead of being able to call in consultants or transfer patients to an appropriate specialist. the accuracy of a telephone consultation that relies on the reported history and examination findings of the doctor calling the consult may be questioned. there is a high probability of fatigue and stress after a prolonged period under semimilitary rules and regulations, and attentiveness and vigilance to precautions may slip. health care workers may need to prepare for extended periods in full ppe. rehabilitation departments may need to split into self-contained teams, each with physiatrist, nurses, and therapists, to avoid cross-infection. preparations need to be made to ensure continuity of care for outpatients unable to come for clinic reviews by systematic chart review. potential offsite facilities should be identified as satellites for caregiver teaching and possibly as outpatient clinics for follow-up and therapies in the event of an outbreak. an adequate supply of ppe, including masks, gown, and gloves, needs to be stockpiled and available while awaiting sources to ramp up emergency supplies. rethinking may be necessary about having large common and open therapy areas for patients from several wards. alternatively, smaller areas located near patient wards could be identified for rapid conversion, if necessary, into "mini"-therapy areas by moving in basic therapy equipment. technologic and telecommunication aids, such as the computer, video, and television, can be used to teach rehabilitation. the emotional well-being of patients, especially the ability to communicate easily with loved ones, can also be aided by technology. a system of segregating rehabilitation patients transferred to the hospital should be developed to avoid cross-infection in the early stages or in the event of a controlled outbreak. admission criteria, such as patient temperature, contact and travel history, chest radiographs, and laboratory or serologic evidence of being noninfected, can be predetermined. many of these recommendations will not be so critical if a vaccine is developed soon. physiatrists may also need to keep current with internal medicine skills. this will allow them to continue to care for patients in a crisis where at least for the interim the practice of rehabilitation medicine is limited. therapists may want to engage in crosstraining or intermittently work with patients outside their usual realm, in order to remain comfortable with nonfamiliar therapy activities. sars is a new respiratory epidemic with a devastating impact on the practice of medicine, and, in particular, rehabilitation medicine. besides changes to patient care, the measures taken to control sars have implications for personal freedom and privacy; they may also involve medicolegal issues. the psychobehavioral and medicolegal questions raised will need to be explored and dissected, and it is suggested that committees be set up to examine potential issues and to formalize protocols. new legislation possibly akin to good samaritan laws may have to be proposed, to allow all physicians to function as best as possible under emergency circumstances. we have been able to proceed with service recovery and to return to normal levels of service as the sars epidemic has abated. nevertheless, our experience leads us to conclude that leaders in rehabilitation medicine should anticipate such an infectious epidemic occurring in their institutions. an emergency preparedness plan should be put in place at the facility level, and possibly at the state and national levels, ready for implementation if the need arises so that it does not have to be created as events unfold. severe acute respiratory syndrome (sars) in singapore: clinical features of index patient and initial contacts coronavirus as a possible cause of severe acute respiratory syndrome a novel coronavirus associated with severe acute respiratory syndrome identification of a novel coronavirus in patients with severe acute respiratory syndrome a major outbreak of severe acute respiratory syndrome in hong kong sars battle cost govt $300m-and more. straits times the immediate psychological and occupational impact of the 2003 sars outbreak in a teaching hospital severe acute respiratory syndrome-singapore singapore ministry of health. statistics health facts singapore cluster of severe acute respiratory syndrome cases among protected health-care workers-toronto, canada development of a standard treatment protocol for severe acute respiratory syndrome sars: experience at prince of wales hospital, hong kong world health organization. case definitions for surveillance of severe acute respiratory syndrome (sars) (revised 1 use of laboratory methods for sars diagnosis positive sars diagnostic test a) confirmed positive pcr for sars virus at least 2 different clinical specimens (eg, nasopharyngeal and stool), or same clinical specimen collected on 2 or more days during illness (eg, 2 or more nasopharyngeal aspirates), or two different assays or repeat pcr using original clinical sample on each occasion b) seroconversion by elisa or ifa negative antibody test on acute serum followed by positive antibody test on convalescent serum, or four-fold or greater rise in antibody titer between acute and convalescent phase sera tested in parallel c) virus isolation isolation in cell culture of sars cov from any specimen, plus pcr confirmation using validated method note. adapted by permission of the world health organization. 13, 14 abbreviations: cov, coronavirus; elisa, enzyme-linked immunosorbent assay; ifa, immunofluorescent assay. key: cord-295305-dfulr6nu authors: mcisaac, sarah; wax, randy s.; long, brit; hicks, christopher; vaillancourt, christian; ohle, robert; atkinson, paul title: just the facts: protected code blue – cardiopulmonary resuscitation in the emergency department during the coronavirus disease 2019 pandemic date: 2020-04-24 journal: cjem doi: 10.1017/cem.2020.379 sha: doc_id: 295305 cord_uid: dfulr6nu emergency medical services (ems) is called for a 65-year-old man with a 1-week history of cough, fever, and mild shortness of breath now reporting chest pain. vitals on scene were hr 110, bp 135/90, spo2 88% on room air. ems arrives at the emergency department (ed). as the patient is moved to a negative pressure room, he becomes unresponsive with no palpable pulse. what next steps should be discussed in order to protect the team and achieve the best possible patient outcome? answer: a pcb is an emergency response to a life-threatening illness in a patient with a suspected or confirmed novel respiratory or communicable illness. the pcb concept was developed during the severe acute respiratory syndrome coronavirus (sars-cov) crisis in 2003, when many healthcare providers were exposed to sars-cov, resulting in several deaths. the pcb shifts the mentality away from patient outcome and puts healthcare provider safety front and centre. 1 the decision to initiate a pcb is based on suspected or confirmed presence of a novel respiratory illness. if a reliable history of this cannot be obtained, pcb should be initiated. in the setting of significant community burden of disease, the decision to treat all cardiac arrests as protected should be considered. answer: cpr refers to the combination of chest compressions, defibrillation, and airway management. the world health organization and the american heart association list cpr as an aerosolizing medical procedure. 2 ), but chest compressions were performed in conjunction with intubation; thus, it is unclear whether the increased risk of infection is attributable to performing chest compressions, airway management, or a combination of the two. 4 defibrillation alone was not associated with increased risk of healthcare provider infection. 4 3. what personal protective equipment (ppe) is recommended during a pcb? answer: general recommendations from leading resuscitation experts include a fluid-resistant gown, long-sleeved gloves, full face shield with eye protection, and fit-tested n95 respirators. hair covers or hoods should also be worn. defibrillation is not considered to be an aerosolizing procedure; therefore, contact droplet precautions are sufficient. however, given the potential association of chest compressions with aerosolization, enhanced airborne precautions should be worn by all team members prior to commencing any other resuscitative efforts. the resuscitation should take place in a negative pressure room if one is available. powered air purifying respirators are not readily available and have not been shown to reduce viral transmission. 5 ed and ems providers should have ppe, including airborne precautions (i.e., n95), readily available at all times given the risk of coronavirus disease 2019 (covid-19) infection in the undifferentiated cardiac arrest. in making ppe recommendations, we acknowledge the relative lack of high-quality available data from which current public health policy is derived evaluating the likelihood of aerosol production from chest compressions. it is therefore acceptable for a staff member to don droplet contact or full enhanced airborne ppe, including an n95 respirator. answer: the guiding principle for a pcb is to minimize the number of people in the room. a team leader plus three additional members represent a reasonable trade-off between team size and coordination of multiple tasks. minimizing the number of individuals in the room reduces the risk of exposure. the exact number of people will vary by institution culture and availability of personnel. a code team leader (physician or nurse) plus two cpr-trained support staff of any designation (to cycle and perform chest compressions) would be sufficient for the initial stages of the pcb; however, four team members would allow regular cycles between individuals performing chest compression and a dedicated airway leader (physician). when resources permit, a designated safety and logistics officer who remains outside of the room can observe strict adherence to team safety and donning and doffing of ppe. an additional member outside of the room in enhanced airborne precautions ppe may allow for a quick relief of chest compression duties. answer: early intubation should be prioritized to reduce aerosolization. chest compressions should not be delayed for intubation but must be paused during intubation to facilitate first-pass success and reduce risk of viral droplet/aerosol spread. if the patient is making any respiratory effort, rapid sequence intubation medications should be provided prior to attempting intubation. in order to protect the pcb team, intubation should be prioritized to establish closed circuit ventilation. a fluid resident face mask should be placed on the patient's mask to shield the team from any droplets. a high flow nonrebreather o2 mask with a hepa filter can be considered to enable passive oxygenation; however, care should be taken to turn off the o2 flow prior to intubation. bag-valve-mask ventilation is problematic in a pcb, as it is an aerosolizing procedure, and it can be difficult to maintain an adequate seal during a cardiac arrest. intubation should be performed by the most experienced operator optimized for first-pass success. video laryngoscopy is suggested as the preferred modality, as it allows the operator to increase distance from the patient's head. chest compressions should be held while intubation is performed until the endotracheal tube placement is confirmed and closed circuit is established. insertion of a supraglottic airway with an attached filter is preferred to bag valve mask ventilation as a rescue manoeuvre in the event of a difficult intubation. outside of the room, the pcb team dons enhanced airborne ppe under supervision of a safety officer. inside of the room, a fluid resistant mask is applied to the patient, and the patient is quickly transferred to the ed stretcher. a nurse in droplet contact precautions attaches the patient to a defibrillator. the patient is in ventricular fibrillation and defibrillation is provided. the pcb team enters, after the nurse in contact droplet leaves chest compressions are commenced, until the team is ready to intubate. the physician states loudly "ready to intubate," and the nonessential team steps away from the patient while chest compressions are held. the airway is secured quickly with a video laryngoscope; no ventilation is performed until the airway is secured and the endotracheal cuff is inflated. after a further 2 minutes, return of spontaneous circulation is achieved. the patient is stabilized in the ed and transferred according to local infection prevention and control protocols. the team doffs safely under supervision of a safety officer and debriefs. using simulation for training and to change protocol during the outbreak of severe acute respiratory syndrome interim guidance for healthcare providers during covid-19 outbreak advice-on-the-use-of-masks-in-the-community-during-home-care-and-in-healthcare-settings-in-the-context-ofthe-novel-coronavirus-(2019-ncov)-outbreak aerosol-generating procedures and risk of transmission of acute respiratory infections: a systematic review. ottawa (on): canadian agency for drugs and technologies in health practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-ncov) patients • early defibrillation can be provided by staff wearing only contact/droplet precautions prior to entry of the pcb team. • all pcb team members should be in appropriate enhanced airborne precautions before entering the room and commencing higher risk resuscitation interventions. • no bag-valve-mask ventilations are to be performed prior to tube delivery and cuff inflation.• early intubation should be performed by the most experienced provider and chest compressions paused to facilitate first-pass success. • a safety officer is recommended to ensure strict adherence to safe donning and doffing. key: cord-308409-0n2ysgsa authors: pawlak, katarzyna m.; kral, jan; khan, rishad; amin, sunil; bilal, mohammad; lui, rashid n.; sandhu, dalbir s.; hashim, almoutaz; bollipo, steven; charabaty, aline; de-madaria, enrique; rodríguez-parra, andrés felipe; sánchez-luna, sergio a.; żorniak, michał; walsh, catharine m.; grover, samir c.; siau, keith title: impact of covid-19 on endoscopy trainees: an international survey date: 2020-06-11 journal: gastrointest endosc doi: 10.1016/j.gie.2020.06.010 sha: doc_id: 308409 cord_uid: 0n2ysgsa nan the coronavirus disease 2019 (covid-19) pandemic has had a profound impact on the provision of gi endoscopy services worldwide, with the radical curtailment of elective procedures to restrict disease transmission. 1 consequently, multiple gastroenterology and endoscopy societies have published rigorous recommendations on triaging endoscopy procedures, appropriate use of personal protective equipment (ppe) and postprocedure decontamination for gi endoscopy during the pandemic. [2] [3] [4] [5] surveys from italy and north america have reported over 75% reductions in procedure numbers in many centers. 6, 7 as institutions attempt to limit periendoscopic exposure to covid-19 and conserve ppe, this will inevitably impact trainee engagement in hands-on endoscopy procedures. the covid-19 pandemic creates challenges for endoscopy trainees for several reasons. for trainees who are in direct contact with patients, providing clinical care during a pandemic can evoke fear and anxiety regarding personal safety and viral transmission. 8, 9 trainees also face social isolation due to restricted contact with their families and friends. 10 these concerns can be further exacerbated by inconsistency in scheduling, both due to trainees being quarantined and redeployment to other services. 11 finally, trainees may be concerned about delays in competency acquisition and future job security. novice endoscopists must become proficient in a range of diagnostic and therapeutic modalities during a training period, often of finite duration. as it remains unclear when endoscopy units will fully resume regular activities, endoscopists-in-training may be concerned about attaining and maintaining competence in procedural skills. additionally, trainee exposure to inpatient and ambulatory gi patients may be significantly reduced if institutions are limiting contact between consulting services and inpatients and cancelling non-essential office visits. shortages of ppe could worsen these issues because trainees may be the first to be excluded when there is inadequate ppe. despite these issues, there are no published data on the impact of the covid-19 on endoscopy training and trainee well-being. therefore, in this international survey, we aimed to assess the impact of the covid-19 pandemic on endoscopy trainees, including procedure numbers, barriers to training, and the physical and emotional well-being of trainees. we also aimed to explore variation in this impact internationally. a 37-item survey (appendix 1) was developed through consensus by an international group of representatives from 10 countries with expertise in endoscopy training and education. the survey was conducted using the surveymonkey platform (svmk inc, san mateo, calif, usa) and was structured into the following domains: 1) demographics, including age, gender, country of training and specialization; 2) monthly endoscopy volumes before and during covid-19; 3) training and availability of personal protective equipment (ppe); 4) impact on physical, mental and emotional well-being. the primary outcome studied was the percentage reduction in the monthly volume of hands-on endoscopy procedures performed by trainees as a result of covid-19. this was studied using 2 methods: (1) as a comparison over two 30-day periods before and during the covid-19 pandemic, and (2) as a categorical variable according to trainee indication of an overall reduction in procedure volume. endoscopy procedures studied comprised esophagogastroduodenoscopy (egd), colonoscopy, eus, ercp, and upper gastrointestinal bleed hemostasis (included within the egd numbers), for supervised, unsupervised and total numbers. secondary outcomes comprised: 1) barriers to hands-on training and the impact on residual training opportunities; 2) changes to institutional case volume 3) trainee concerns regarding competency development and prolongation of training; 4) anxiety, assessed using the generalized anxiety disorder-7 (gad-7) scale, 12 and rates of burnout, measured using the single item burnout scale. 13 for each outcome, analyses were compared across continents to denote international variation in survey responses. at the beginning of april 2020, the endotrain survey was distributed to trainees both directly and indirectly via program directors, trainee representatives, and to representatives within national and international societies (supplementary table 1 ). the survey was open for three weeks from april 11 to may 2, 2020. all continuous variables were subjected to normality assessment (shapiro-wilk) and presented as medians with interquartile ranges (iqrs) or means and standard error (se) as appropriate. for each procedure, trainees who did not indicate any procedures in a given modality over the 2 comparison periods were excluded from analyses to identify active trainees for each procedure category. pairwise comparisons of procedural numbers were performed at trainee-level between pre-covid-19 and covid-19 periods using wilcoxon signed-rank tests. nonparametric data across procedure types and continents were compared using kruskal-wallis, followed by dunn's test for pairwise comparisons. continuous variables were compared across continents using one-way analysis of variance (anova). categorical data were compared using the pearson chi-square test. binary logistic regression analysis was performed for univariable and multivariable analysis of factors associated with anxiety in endoscopy trainees. the gad-7 outcomes were stratified into 2 groups by composite score: <5 and ≥5 (indicating at least mild anxiety). a forward stepwise approach to factor selection was used and outcomes presented as odds ratios (or) and 95% confidence intervals (95% ci). statistical analyses were performed using spss v26 (arkmont, ny, usa: ibm corp) and prism v8 (san diego, calif, usa: graphpad corp), with p<0.05 considered statistically significant. in total, 1199 respondents participated in the international training survey. after excluding incomplete responses (n=429, 35.8%), 770 trainees from 63 countries within six continents (supplementary table 2 and supplementary fig. 1) were included for analysis. trainee characteristics and the differences across continents are presented in table 1 overall, 770 trainees (93.8%) reported a reduction in their monthly endoscopy case volume attributable to covid-19. by procedure type, the differences in estimated monthly volumes before and during covid-19 are presented in figure 1 , with significant (p<0.0001) decrements over the two 30-day periods. across all modalities (figure 2) , the median percentage reduction in procedural volume was 99% (iqr 85%-100%). this did not vary significantly by trainee specialty (p=0.658), or whether procedures were performed under supervision or independently (p=0.614), but varied by procedure type (p<0.001). on subgroup analysis, percentage reductions were greater for colonoscopy (median 100%, iqr 88%-100%) compared with ercp (median 100%, iqr 60%-100%; p=0.003) and upper gastrointestinal bleeding (ugib) procedures (median 100%, iqr 50%-100%; p<0.001). this outcome also varied across continents (p<0.001), with significantly greater percentage reductions observed in europe (median 100%, iqr 91%-100%) and north america (median 99%, iqr 88%-100%) compared to asia (median 87%, iqr 75%-97%) and south america (median 91%, iqr 70%-100%). of the 770 (93.8%) trainees who reported a reduction in endoscopy procedural volumes during the covid-19 study period, the reasons cited included: changes to institutional policy to exclude trainees from procedures (79.9%); lack of cases (58.3%); shortage of available ppe (28.8%); redeployment to another clinical area (24.0%); and personal reasons (10.2%). access to endoscopy training remained accessible on an ad hoc basis to 60.5% (n=466) of trainees, with rates varying internationally ( table 2) . of these, 36.1% (n=168) could perform endoscopy on patients at low risk or negative for covid-19, and 7.9% (n=37) on unsupervised procedures only. 46.7% (n=359) reported access to ad hoc emergency cases and 15.4% (n=119) to intensive care unit (icu) cases. only 6.2% (n=29) reported no restrictions on their endoscopy privileges. reductions in institutional endoscopy case volume due to covid-19 were reported by 98.2% of trainees, with 73.5% of trainees reporting a decrease of ≥50% and 3.6% reporting the cancellation of all endoscopy activity. regarding ppe, 73.7% (n=520) received training on the use of ppe for covid-19 patients. 50.5% (n=356) received training specific to managing covid-19 in their endoscopy unit. this was mainly delivered through face-to-face teaching (34.0%, n=121), virtual teaching (22.4%, n=80), or written communication (43.5%, n=155). the level of ppe used within the endoscopy unit was felt to be adequate in 67.6% (n=476), but this varied internationally (p<0.001) ( table 2) . 47.0% (n=331) believed that a lack of ppe was contributory to reductions in institutional endoscopy case volume. endoscopy-specific practice guidelines on ppe use were available for 89.2% (628) of respondents. ppe policy within the endoscopy unit was predominantly directed by national guidelines (47.4%), individual unit/hospital policy (33.0%), or international guidelines (19.6%). trainees were asked to rate their level of concern regarding the impact of covid-19 on the outcome of their endoscopy training (table 3; figure 4 ). concerns with competency development were raised by 90.1% (n=629) of trainees across continents (p=0.844). concerns regarding the need to prolong specialty training to reach the required competency were raised by 71.9% (n=502) of respondents. this concern varied internationally (p<0.001), with the lowest proportion of concerned trainees in north america (49.5%). in total, 68.9% (n=472) of trainees believed that existing national/international guidelines should be modified to better support endoscopy training during the covid-19 pandemic. concerns of acquiring covid-19 were expressed by 79.3% of trainees (figure 4) . in total, 23.9% (n=168) reported taking time off work for covid-19 related reasons; 76.8% (n=129) took time off for themselves and the remaining 23.4% (n=39) for a household member. of trainees affected, 14 .7% (n=19) tested positive, 52.7% (n=68) negative, 30.2% (n=39) were not tested, and 2.3% (n=3) preferred not to answer. anxiety and burnout were assessed in 695 trainees ( table 3 ). the following anxiety levels were reported according to gad-7 criteria: no anxiety (47.6%, n=331), mild (33.2%, n=231), moderate (14.2%, n=99) and severe anxiety (7.8%, n=54). on multivariable analysis ( table 4) to our knowledge, this is the first study to comprehensively evaluate the impact of covid-19 on endoscopy trainees. survey responses from 770 trainees across 63 countries indicate that covid-19 has had a profound adverse effect on endoscopy volume worldwide, with reductions in training opportunities for the majority of trainees (93.8%), and a drastic median reduction in case volume of 99% (iqr, 85%-100%). this has raised concerns among trainees in regard to competency development (90%) and the potential need to prolong training to achieve endoscopic competence (72%). these concerns were among the cited factors leading to covid-19 associated anxiety (52.4%) and burnout (18.8%) among trainees. these results highlight the urgent call to action for institutions, training programs, gi societies, and accreditation councils to address the 2 overarching issues identified: (1) reductions in endoscopic training opportunities and (2) the emotional welfare of trainees. the emphasis on minimum endoscopy procedure numbers as a competence safeguard is ubiquitous across international training settings. 14 these serve to indicate readiness for certification, credentialing, and program completion. although training in all procedures was disrupted by covid-19, the decrement was most pronounced for colonoscopy and less so for emergency procedures (ercp and gi bleeding). this is important as colonoscopy is regarded as a core endoscopic skill. over 50% of trainees estimated a reduction in institutional endoscopy volumes of 75% or more, in line with international recommendations to curb elective procedures. however, the exclusion of trainees was another major barrier, with ppe shortages and redeployment being contributory. the significant impact of covid-19 has raised doubts among trainees over whether endoscopic competence in various procedures is realistically achievable within the duration of their training, with a substantial proportion expressing concerns that training will need to be prolonged. addressing these issues could potentially have disruptive implications at many levels: restructuring of training curricula and schedules, redistribution of endoscopy cases between junior and senior trainees, delays in entering the workforce, financial strain and negative effects on trainees' mental well-being. indeed, relatively little has been published on the physical and mental well-being of endoscopy trainees, even before covid-19. from our survey, covid19 affected trainees beyond reductions in endoscopy training opportunities: 79.3% had concerns of acquiring covid-19 and a significant proportion of trainees had to take time off work for covid-19 related reasons. inadequate ppe was raised as a concern by a third of respondents and was independently associated with increased anxiety. overall, 52.4% of trainees met criteria for at least mild generalized anxiety, with 22.0% reaching a threshold score of ≥10, which has 89% sensitivity and 82% specificity for clinically significant anxiety. 12, 15 predictors of anxiety included female gender (consistent with population-based studies), 16 concerns regarding prolongation of training, inadequate ppe, and a lack of emotional and mental health support. anxiety levels positively correlated with burnout which was identified in 18.8% of trainees. burnout is a consequence of unmitigated chronic stress which requires urgent intervention as it can lead to emotional exhaustion, depersonalization, negativity and impaired professional performance, 17 including suboptimal medical care and medical error. 18, 19 the association between the availability of emotional support and lower anxiety levels suggests that training programs should strongly consider implementing support strategies to proactively address anxiety and burnout in trainees and promote their wellbeing. formalized interventions to improve trainee well-being, such as group stress management and resiliency training (smart) may also play a positive role in improving job satisfaction and well-being. 16, 21, 22 there is additional need for attending gastroenterologists to proactively engage with trainees to discuss their learning gaps and career development and devise individualized curricula. internationally, there was significant heterogeneity in survey responses for both primary and secondary outcomes (tables 1-3) . these may be partially explained by locoregional differences in severity and the phase of the covid-19 pandemic during the survey period. nearly 50% of respondents were from the united states, united kingdom, and spain, which were in the acceleration to plateau phase in the 30 days leading up to the survey. 23 this is likely to account for the reductions in exposure to endoscopy training, institutional caseloads, uptake of ppe and time off work from covid-19. it is possible that, as covid-19 caseloads subside, training opportunities will slowly resume, although trainee exposure is still likely to be impacted due to prolonged turnaround times for decontamination and our study has several limitations. surveys are vulnerable to bias and misinterpretation inherently. data validation was performed by excluding respondents who provided incomplete responses of primary outcome data, did not indicate a training modality, and where endoscopy numbers performed each month in a given modality exceeded 100. it was also not possible to estimate the response rate as the survey was disseminated through multiple national and international societies and organizations. not all countries and specialties were represented which might affect the generalizability of findings. next, our data provide a snapshot of training in time and was not matched to regional differences in pandemic activity. our completion rate was limited at 65%, with a further dropout rate of 11% for completing all survey questions. contributory factors include the length of the survey, complexity of individual questions, and dissemination only in english, which may have affected comprehension. additional data, such as unit-level information and lifetime procedure counts were not collected. finally, baseline data for anxiety and burnout could not be retrospectively captured in a valid manner and therefore, the high rates of anxiety cannot be directly attributed to covid-19 alone. the effects of covid-19 are projected to persist until at least 2022. 24 as such, an urgent review of endoscopy training is warranted to adapt accordingly and provide direction. in our survey, 68.9% of respondents indicated that guidelines should be modified to support training. training programs should openly recognize that minimum procedural numbers may not be achievable in some countries and adopt mitigation strategies. first, emphasis should shift toward maximizing gains from evidence-based, hands-off training interventions. for beginners, simulation-based training can be used to develop technical skills, 25, 26 nontechnical skills, 27 and accelerate time to achievement of competence. 28 although simulation training requires performance feedback to be optimally effective, 29 selfassessment with benchmark videos and computerized feedback are viable alternatives. 30, 31 for all trainees, cognitive competencies can be developed through distance education using educational resources, webinars, and open access social media education, such as structured conversations on twitter. 32 all 3 major american gi societies have high-quality, expert-led, endoscopy training videos; notably the american society for gastrointestinal endoscopy (asge) with its catalogue of education materials in gi leap, its online learning platform. 32, 33 second, determination of competence should rely less on attaining minimum numbers and more on the use of objective and validated methods of competency assessment. this is best achieved through the use of objective performance tools with strong validity evidence, such as ace (assessment of competency in endoscopy), 34 dops (direct observation of procedural skills), [35] [36] [37] and giecat (gastrointestinal endoscopy competency assessment tool), 38 which can allow trainers to target feedback provision in a formative manner, and to benchmark global competence for summative sign-off. 35 despite these measures, it may be necessary for some trainees to extend their endoscopy training. 39 additionally, it will be important for institutions and private practices to ensure that new faculty are closely mentored to promote continued skills development. with meaningful application of evidence-based training paradigms, the gi community can mitigate the ongoing impact of covid-19 on trainees and ensure that they achieve the cognitive, technical, and integrative competencies needed for independent endoscopic practice. the recent literature on the impact of covid-19 on trainees stems from individual experiences and expert opinion. 10, 33 our trainee-centered survey has now quantified the impact of covid-19 on procedural volumes and on the well-being of endoscopy trainees, and shown how this varies internationally across different continents. as countries engage in collaborative endeavors to tackle the global impact of covid-19, it is hoped that our findings will help to inform future strategies to mitigate the impact of the pandemic on endoscopy training. in this article, we aimed to assess the impact of covid-19 on procedural volumes and the emotional well-being of endoscopy trainees worldwide. our study showed that the covid-19 pandemic has led to drastic reductions in endoscopic volumes and restrictions on endoscopy training, with detrimental effects on trainee well-being, including high rates of anxiety and burnout among trainees worldwide. therefore, existing curricular requirements and delivery of endoscopy training should be urgently reviewed and adapted to support the educational and emotional needs of trainees during the covid-19 pandemic. covid-19) outbreak: what the department of endoscopy should know overview of guidance for endoscopy during the coronavirus disease 2019 pandemic practice of endoscopy during covid-19 pandemic: position statements of the asian pacific society for digestive endoscopy (apsde-covid statements) aga institute rapid recommendations for gastrointestinal procedures during the covid-19 pandemic esge and esgena position statement on gastrointestinal endoscopy and the covid-19 pandemic endoscopy units and the covid-19 outbreak: a multi-center experience from italy changes in gastroenterology and endoscopy practices in response to the covid-19 pandemic: results from a north american survey the impact of severe acute respiratory syndrome on medical house staff: a qualitative study covid-19 and the digestive system covid-19 pandemic through the lens of a gastroenterology fellow: looking for the silver lining adapting a gi fellowship to a pandemic: novel approaches to accommodating a novel virus a brief measure for assessing generalized anxiety disorder: the gad-7 using a single item to measure burnout in primary care staff: a psychometric evaluation training in endoscopy psychometric properties of the generalized anxiety disorder scale-7 (gad-7) in outpatients with anxiety and mood disorders generalized anxiety disorder prevalence of burnout among physicians: a systematic review physician burnout: contributors, consequences and solutions medical student and resident burnout: a review of causes, effects, and prevention supporting the health care workforce during the covid-19 global epidemic smart-r: a prospective cohort study of a resilience curriculum for residents by residents intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial johns hopkins coronavirus resource center projecting the transmission dynamics of sars-cov-2 through the postpandemic period impact of a simulation training curriculum on technical and nontechnical skills in colonoscopy: a randomized trial progressive learning in endoscopy simulation training improves clinical performance: a blinded randomized trial a non-technical skills curriculum incorporating simulationbased training improves performance in colonoscopy among novice endoscopists: a randomized controlled trial impact of a simulation-based induction programme in gastroscopy on trainee outcomes and learning curves the impact of constructive feedback on training in gastrointestinal endoscopy using high-fidelity virtual-reality simulation: a randomised controlled trial influence of video-based feedback on self-assessment accuracy of endoscopic skills: a randomized controlled trial computerized feedback during colonoscopy training leads to improved performance: a randomized trial society for gastrointestinal endoscopy: guidance for trainees during the covid-19 pandemic how to maximize trainee education during the covid-19 pandemic: perspectives from around the world asge's assessment of competency in endoscopy evaluation tools for colonoscopy and egd colonoscopy direct observation of procedural skills assessment tool for evaluating competency development during training ercp assessment tool: evidence of validity and competency development during training direct observation of procedural skills (dops) assessment in diagnostic gastroscopy: nationwide evidence of validity and competency development during training in-training gastrointestinal endoscopy competency assessment tools: types of tools, validation and impact variation in exposure to endoscopic haemostasis for acute upper gastrointestinal bleeding during uk gastroenterology training key: cord-272726-ljjirt4g authors: brethauer, stacy a.; poulose, benjamin k.; needleman, bradley j.; sims, carrie; arnold, mark; washburn, kenneth; tsung, allan; mokadam, nahush; sarac, timur; merritt, robert; pawlik, timothy m. title: redesigning a department of surgery during the covid-19 pandemic date: 2020-04-28 journal: j gastrointest surg doi: 10.1007/s11605-020-04608-4 sha: doc_id: 272726 cord_uid: ljjirt4g background: covid-19 has created an urgent need for reorganization and surge planning among departments of surgery across the usa. methods: review of the covid-19 planning process and work products in preparation for a patient surge. organizational and process changes, workflow redesign, and communication plans are presented. results: the planning process included widespread collaboration among leadership from many disciplines. the department of surgery played a leading role in establishing clinical protocols, guidelines, and policies in preparation for a surge of covid-19 patients. a multidisciplinary approach with input from clinical and nonclinical stakeholders is critical to successful crisis planning. a clear communication plan should be implemented early and input from trainees, staff, and faculty should be solicited. conclusion: major departmental and health system reorganization is required to adapt academic surgical practices to a widespread crisis. surgical leadership, innovation, and flexibility are critical to successful planning and implementation. the covid-19 pandemic has created unprecedented challenges for surgery departments throughout the country. swift planning and strong leadership have been required to prepare for this crisis. the challenges are especially dire as no situation in recent memory has had such an impact on healthcare in the usa. we describe our department of surgery preparation for an anticipated covid-19 surge. the strategies highlighted here address the challenges we faced in operational and clinical restructuring, communication plans, the educational and training mission, and resource management. the first cluster of novel coronavirus cases was identified in wuhan, china, in december 2019, and the virus was subsequently named by the world health organization (who) as covid-19 in february of 2020 ( figure 1 ). 1 after the first reports from china, the virus quickly spread globally, and the first case in the usa was reported in january 2020 in washington state. 2 at the time of this writing, there are over 350,000 cases and over 10,000 deaths related to covid-19 in the usa. a national emergency was declared in the usa on march 13, 1 day after the who declared the coronavirus a pandemic. this rapidly changing situation resulted in dramatic changes in the way health systems needed to function. normal hospital operations were significantly reduced by postponing all non-essential procedures. statewide "stay-at-home" orders required radical changes triaging personnel to be present at hospital facilities and those who may work remotely from home. simultaneously, enormous efforts were made to stockpile personal protective equipment (ppe) and to establish policies regarding its use. within the department of surgery, these challenges required leadership to form new workgroups and reporting structures, establish clear communication strategies, redefine clinical activities for the faculty, and modify the workloads of trainees. as the pandemic continues, it will be imperative that initial plans and strategies presented here be continuously evaluated and modified to address the fluidity of the situation. making evidence-based decisions as a crisis develops and evolves is difficult. information changes daily, data can be unreliable, and new assumptions are required as the scenario progresses. nevertheless, it is important to understand where the most reliable sources of data exist, both within and outside the health system. within the health system, the faculty and staff should expect regular updates on the crisis and new policies that affect their practices. internal data will come from a variety of sources including the c-suite and university leadership, health system analysts, and a variety of workgroups established specifically for the hospital incident command. the workgroups that were established to prepare for the covid-19 crisis at our institution are shown in table 1 . appropriate surgical representation is needed within these workgroups. personnel chosen for these roles should play an active part in task management, communication, and innovation. appealing to the genuine call for service to the hospital community is critical as these roles cannot be seen as the stereotypical passive "committee member" role. data sources outside the health system included the centers for disease control, the ohio department of health, the ohio hospital association, and information from our affiliate hospitals and network of clinics. 3 ohio was one of the first states to implement social distancing and stay-at-home policies, and this information was provided by the governor's office with regular updates to the medical center. these policies resulted in immediate and major changes in workforce planning, staffing, hospital operations, and clinical schedules. predicting the number of patients during the expected covid-19 surge is difficult and has been based on both internal and external data. the ohio department of health provided updates based on modeling from a variety of sources and data regarding the virus activity throughout the state. analysts focused on predictive models for our state and county to estimate what our health system would encounter ( figure 2 ). these data were used to model the number of beds, ventilators, personnel, and ppe that will be required for a surge of that magnitude. the decision to suspend all elective and non-essential procedures was a major disruptor to the medical center and the faculty practices. anticipation of such a policy prompted the departmental leadership to define the type of cases that would continue early in the course of the crisis. once the policy was implemented, each division had already decided on a finite list of procedures or indications to perform operations based on the more general guidelines provided by the medical center, state, and professional societies. the perioperative leadership for each hospital pavilion was responsible for reviewing the operative case lists 2 days prior and escalating any questionably non-essential cases to the attending surgeon and then to the surgeon-in-chief if needed. in general, the policy was implemented in a way that respected the faculty's clinical decision regarding the consequences of postponement. the surgical leadership across the health system established patient categories to prioritize procedures based on the urgency ( table 2) . as the pandemic progresses, there are many factors that will impact the ability to perform surgery. day-to-day, datadriven risk-benefit analyses must influence care delivery and case triage. avoidance of blanket policies in lieu of careful and frequent analysis of the multiple factors is needed. these factors include operating room capacity, bed availability, equipment, supplies and ppe availability, ventilator availability, staffing, blood availability, and assessment of the national, regional, and local conditions and trends that may affect the magnitude of the surge. two weeks after the initial policy was implemented, guidance was given to tighten the window for essential cases from 3 to 1 month based on modeling for the surge and limited resources. we also established different threat levels to the health system to guide our surgical case scheduling (table 3) . each clinical division developed a coverage schedule that minimized the number of faculty coming to work every day. each division in the department of surgery was given the latitude to create their own coverage policy. for services with no elective cases, a single attending typically rounded on the service each day. for services still performing some essential operations (e.g., advanced cancer, emergent cardiac, trauma, or acute care surgery), every effort was made to minimize the number of faculty coming to work with coverage provided by those who were coming in for operative cases or on call. delivery of outpatient care was dramatically altered as well. as social distancing policies were implemented, in-person clinic appointments were limited to only those patients whose visit was deemed essential by the attending surgeon. clinic staffing was evaluated and reduced to the minimum number of providers needed to see scheduled or urgent add-on patients. telemedicine was implemented across the system, and consults and follow-up visits were transitioned as individually appropriate. two following modalities of telemedicine were utilized: telephone based visits or video visits. an unintended, but positive, consequence of this rapid shift and adoption of patient deemed to be in a non-life threatening status, whose surgery could safely be deferred for a short period of time (< 3 months). surgeons will determine that these patients are not put at undue risk. if their priority changes, they will be moved to category a. patients can be categorized in the following sub-groups b1: case can be deferred no more than 1 month b2: case can be deferred 2-3 months case category c: patient whose evaluation or treatment can safely be delayed for an extended period (> 3 months). these patients are for the most part non-essential cases that can reasonably wait until the pandemic is over mva, motor vehicle accident; gsw, gunshot wound telemedicine forced the institution to quickly develop protocols and assistance with telemedicine operations, billing, workflow, compliance, information technology, and equipment. the shift was so rapid due to necessity that regulatory and compliance guidance was often lacking or very difficult to find. within the department of surgery, a needs assessment was completed to formulate an acute care surgery surge capacity plan, recognizing that those currently serving in this capacity may be needed for their intensivist skillset. a call for volunteers to cover the icu, trauma, or acute care surgery services was sent to faculty members outside the division covering trauma and acute care surgery and the surgical intensive care units. specifically, surgeons were asked about their comfort level and privileging to manage critically ill patients and take emergency general surgery or trauma call. when the surveys were returned, surgeons were placed into different tiers to be called upon when needed during the surge. tier 1 represented those who were comfortable with these skills and were currently credentialed to perform them. tier 2 represented a pool of surgeons who were reasonably comfortable with ventilator management and icu care but were not currently credentialed to do so, and tier 3 represented the pool of surgeon who were not comfortable with these skills and were not credentialed to perform them. only those individuals with current atls certification were placed in the trauma call pool. training was then initiated by the trauma and critical care staff to provide refresher training to those who would potentially be redeployed to the icu. these training sessions were conducted via videoconference and included presentations on ventilator management, critical care for the non-intensivist, pharmacotherapy, and modules from the society of critical care medicine's "icu care for the non-icu physician". 4 it was important to communicate to the faculty, to alleviate anxiety and provide the safest care, that if they are to be deployed to the intensive care unit that there would always be an intensivist available to provide oversight and assistance throughout their assignment. prior to the surge, the faculty were asked to refocus their time on nonclinical activities related to career development and scholarly pursuits (table 4) . importantly, the department established a covid-19 wellness team that organized virtual social and entertainment activities with the staff and residents during this trying and stressful time. clear, accurate, and frequent two-way communication is necessary in times of crisis. a situation like covid-19 presents many communication challenges including a dynamic situation, simultaneous development of multiple policies, uncertainty about the scale of the future surge, and conflicting information on the same topic. the department chair is in the best position to relay messages from multiple sources above and below them in the chain of command. the cadence and meeting composition will differ depending on the size and scope of each department, but we established weekly or bi-weekly calls with our division chiefs, department executive committee, and the perioperative cabinet (table 5) . additionally, the chair held open virtual "chair hours" once a week for people to ask questions are express concerns. an "all hands" call was held every other week for all of the clinical (faculty, trainees, mid-level providers) and administrative personnel that provided key updates and allowed for a town hall type of interaction. the presenters at these informational meetings included members of various work groups, supply chain, epidemiology, infectious disease, and senior leadership for the system. of note, it has been critical that leadership informs attendees at every meeting that the data presented on that day represented our current knowledge and may change tomorrow. setting this expectation with the faculty alleviates some of the angst and frustration of conflicting or changing messages. finally, the residency program director and chairman held a weekly "happy hour" with all of the residents to get their feedback and address their needs. to protect the health of the trainees and preserve the workforce, our residency schedule was changed to a holiday schedule in which only half of the residents cover the services for blocks of several days. fellows were incorporated into the faculty rounding and call coverage whenever credentialing allowed. plans were developed for deployment of trainees to areas of critical need during the surge. education conferences continued virtually including morbidity and mortality conference and grand rounds. specific guidance for how residents should interact with covid-19 patients was provided as follows: residents shall: a. defer evaluation and consultation of covid-19 positive patients to a faculty member. i. be physically present outside the isolation area and be prepared to assist if the faculty member requires immediate assistance (e.g., level 2 or 3 trauma activation). b. perform evaluation and consultation of covid-19 positive patients simultaneously with a faculty member when care of the patient will not be able to be performed alone by the faculty member (e.g., level 1 trauma activation) c. perform evaluation and consultation of patients without suspicion of covid-19. d. participate in the operative care of covid-19 positive patients on whom their team is operating. cases will proceed with expediency and care, focused primarily on the care of the patient and the safety of the team rather than teaching. with normal work activities and assignments being altered during the osu and dos response to the covid-19 pandemic, we believe that there will be opportunities for faculty to further their professional and personal development. we share this list for all faculty, recognizing that each faculty member has different professional, family and personal realities during this time consider taking advantage of some of the following personal, academic, educational, research, and scholarly opportunities for yourself and the department of surgery we ask that you commit to at least one of these activities in the personal row, and customize, based on your at-hospital work schedule, and plan to undertake activities in rows 2-5 in the weeks ahead 1. personal a. make time for family/friends (virtually if necessary) b. remember to exercise-move in a way that makes you happy! c. work on good nutrition choices d. consider or develop your mindfulness practices: headspace is now offering free subscription to all health care professionals (https://www.headspace.com/health-covid-19)-a great time to explore and try. calm is another meditation and mindfulness resource that has developed free resources for this time. https://www.calm.com/blogtake-a-deep-breath e. expand your knowledge/skills-pick up a book you have always wanted to read; catch up on your journal reading; consider ways to enhance your work as a master clinician f. give yourself 15 min a day (at least) to do something that brings you joy g. reach out to your colleagues-both here and remotely-and find out how they are doing; whether there is anything you can do to help them. sometimes that is as listening to them! 2. professional/academic a. update your osu find-a-doctor profile information (your 'front office'-https://onesource.osumc. edu/sites/audience/physicians/pages/findadoctor.aspx) b. review you cv and refine its formatting and completeness. also, consider updating your nih biosketch c. review the department of surgery p&t document relevant to your track and career stage; the center for fame will be hosting an upcoming virtual session on p&t (https://oaa.osu. edu/sites/default/files/updloads/governance-documents/college-of-medicine/surgery/suergery apt 2017-10-28.pdf). the com apt toolbox can be found here https://medicine.osu.edu/faculty/promotion-and-tenure/apt-toolbox. please contact suzanne knott with questions d. methods to document talks and posters presented at conferences that have been moved to online only, been postponed or that are being held but the faculty member cannot attend (apastyle.apa.org/blog/canceled-conferences) e. complete required training in buckeye learn (https//:buckeyelearn.osu.edu) f. complete osu fd4me (very relevant online faculty development modules) free to all osu faculty-https://fd4me.osu.edu/ g. complete on-line cme (sesap, selected readings in general surgery), or clinical congress webcasts; many journals also have cme available including all members of the jama network) a. complete manuscripts in progress; consider drafting an abstract on your work that can be submitted for future meeting; write a review article (if not in the works, consider collaborating with colleague(s) and submit a proposal to a favorite editor) b. work on new research or scholarly projectsconsider virtual 'brainstorming' meetings with colleagues, collaborators, mentees c. a. be assigned to patient care duties as determined by the program director of general surgery, in consultation with the chair and dio, which may include the medical care of covid-19 positive patients who are ill but do not specifically require a surgical intervention. b. continue to practice under the direction of the faculty and seek assistance and guidance as needed. one of the issues that has created the most stress among the faculty and trainees leading up to the surge was the availability of ppe. policies were established early to help preserve ppe, particularly n95 masks, and to avoid overuse or waste when use was not warranted. aerosolizing and high-risk procedures were identified and included oral-maxillofacial surgery, thoracic, surgery, and head/neck and dental interventions with the intent to disrupt or break the mucosal membrane in the oral cavity, airway, and/or pulmonary tract, and cause prolonged exposure to aerosolization and/or droplets. it was recommended that n95 masks only be used for these aerosolizing procedures. at the point of care, the default was for clinicians to proceed with an abundance of caution. continuous messaging and reinforcement are needed to avoid excessive use of ppe early in the "curve." part of preparations for the surge was to include updates from the medical director of supply chain (sb) to provide real time data regarding our ppe inventory, especially n95 masks. part of that messaging included the projections for ppe use through the surge that emphasized the need for conservation prior to the surge. while it is still fairly unique for a health system to have a medical director for their supply chain, it proved to be an important part of the messaging plan to clinicians and helped alleviate faculty stress regarding the ppe planning. for systems without a supply chain medical director, we strongly encourage some engagement from a supply chain representative to directly answer questions and address faculty around ppe issues. once non-essential surgical procedures were postponed, operative cases were placed in a "depot" to be rescheduled after normal operations resumed. new teleconsults that would eventually require surgery were similarly placed in a depot for the schedulers. this process has led to hundreds of cases accruing that will need to be scheduled when the operating room schedule returns to normal. this "second surge" of elective cases will present its own set of logistic challenges and requires early planning to facilitate care of surgical patients once the covid-19 surge has passed. adding operating room staff and extending operating room hours will likely be required to accommodate the large volume of cases that will be rescheduled after the crisis. additionally, the supply chain must ensure that the necessary equipment and supplies will be available for elective cases after the crisis is over. planning with perioperative leadership is needed to prepare for these cases. a key facet of this plan is reassuring current personnel of their worth and value when their specialized services may not be needed during the crisis planning and surge. these personnel, who performed admirably during "normal" times, will be called upon greatly in the "back to business" phase after the crisis. our institution has developed redeployment and volunteer opportunities for several employees, as well as a disaster leave policy to retain key members of our team. during times of crisis such as the covid-19 pandemic, surgeon leadership in the health system is critical. major reorganization is required to manage all of the challenges imposed by covid-19, and surgeon leaders are key stakeholders in developing and implementing these radical changes. clear and frequent communication, flexibility, and careful planning are required to navigate these unchartered waters. while a sense of urgency is required, a thoughtful and collaborative approach among leaders at every level will result in practical guidelines and policies that will help the faculty to safely get through this unprecedented crisis. first case of 2019 novel coronavirus in the united states publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations conflict of interest dr. brethauer receives consulting fees from gi windows and speaking honoraria from medtronic. dr. poulose receives research support from bd interventional and advanced medical solutions and salary support from americas hernia society quality collaborative; dr. needleman has no conflicts of interest; dr. pawlik has no conflict of interest. key: cord-316126-j51dik7f authors: zhang, x. sophie; duchaine, caroline title: sars-cov-2 and health care worker protection in low-risk settings: a review of modes of transmission and a novel airborne model involving inhalable particles date: 2020-10-28 journal: clin microbiol rev doi: 10.1128/cmr.00184-20 sha: doc_id: 316126 cord_uid: j51dik7f since the beginning of the covid-19 pandemic, there has been intense debate over sars-cov-2’s mode of transmission and appropriate personal protective equipment for health care workers in low-risk settings. the objective of this review is to identify and appraise the available evidence (clinical trials and laboratory studies on masks and respirators, epidemiological studies, and air sampling studies), clarify key concepts and necessary conditions for airborne transmission, and shed light on knowledge gaps in the field. we find that, except for aerosol-generating procedures, the overall data in support of airborne transmission—taken in its traditional definition (long-distance and respirable aerosols)—are weak, based predominantly on indirect and experimental rather than clinical or epidemiological evidence. consequently, we propose a revised and broader definition of “airborne,” going beyond the current droplet and aerosol dichotomy and involving short-range inhalable particles, supported by data targeting the nose as the main viral receptor site. this new model better explains clinical observations, especially in the context of close and prolonged contacts between health care workers and patients, and reconciles seemingly contradictory data in the sars-cov-2 literature. the model also carries important implications for personal protective equipment and environmental controls, such as ventilation, in health care settings. however, further studies, especially clinical trials, are needed to complete the picture. t he world is facing a devastating new infectious disease, with only preliminary scientific data to guide policy. disagreement with the world health organization's stance on personal protective equipment (ppe), guideline changes over time (e.g., european cdc, france) , and inconsistent data on the effectiveness of medical masks have left health care workers (hcws) wondering if they are sufficiently protected. the general consensus is that sars-cov-2 predominantly transmits through droplets and contact (although precise mechanisms for both modes of transmission are yet to be fully understood), but the airborne debate is still raging. this review attempts to summarize current cumulative data on sars-cov-2's modes of transmission and identify gaps in research while offering preliminary answers to the question on everyone's mind: is the airborne route significant and should we modify our covid-19 ppe recommendations for frontline workers in low-risk settings? this review starts by investigating the differences between droplets and aerosols and goes over prerequisites for clinically significant airborne transmission. it then appraises the evidence in support of the airborne hypothesis: trials and experiments on masks, epidemiological studies, data on sars-cov-1, air sampling findings, and aerosol studies. the focus is on low-risk health care settings, in the absence of aerosolgenerating procedures (agps), with a special look at long-term-care facilities where major outbreaks occurred. national and international guidelines are compared, and alternative hypotheses for sars-cov-2's contagiousness are explored, such as presymptomatic transmission, as well as fomite and fecal routes. possible mechanisms behind high hcw infection rates are described, and the limits of the precautionary principle are addressed. finally, a revised model of inhalable particles is proposed to support ppe recommendations and guide future research. determining sars-cov-2's main mode of transmission is essential as it informs clinical guidelines for patient management, prevention practices, and hcw protection. while infectious disease precautions in health care settings are transmission-based (either airborne or droplet), in reality, the distinction is not clear-cut; instead, they are two ends of a spectrum. in the literature, respiratory droplets are usually defined as larger particles (diameter ͼ 5 m) sometimes visible to the human eye, produced during spitting, sneezing, and coughing. these droplets are thought to be the main mode of transmission of covid-19 (1), and they typically travel 1 to 2 m before landing on surrounding surfaces. however, they may be propelled further in the presence of ventilation (2) or forceful ejection (e.g., a violent sneeze) (3) and under certain environmental conditions (e.g., cool and humid) (4) . the sars-cov-2 virus is also thought to be transmitted by direct contact person to person (e.g., exchange of saliva or a handshake) or by indirect contact through intermediate objects (e.g., sharing of cups, doorknobs). generally, contact transmissions occur when contaminated hands are brought to the face and touch mucous membranes (eyes, nose, and mouth). the fate of smaller droplets may be desiccation (evaporation of the liquid) and formation of particles called droplet nuclei, or aerosols, which can contain infectious agents but also secretions, cells, surfactant, and any other product contained in the original droplet. traditionally, aerosols are defined as particles of ͻ5 m that can remain airborne for prolonged periods (several minutes or even hours) and travel long distances with air currents (several meters away). with the potential for direct entry into the lungs, they are the primary mode of transmission for tuberculosis, measles, and varicella. in other communicable diseases, such as influenza, aerosols are considered opportunistic and play a role that is of variable importance depending on the context (5) . conversely, in the field of industrial hygiene, occupational exposure of different body regions to harmful airborne agents is classified into three overlapping categories, according to the median size of penetrating particles (6): 100 m for nose and mouth (inhalable), 10 m for trachea and bronchi (thoracic), and 4 m for alveoli and air exchange regions (respirable). this aerosol classification was recently reviewed and elegantly illustrated by milton (7) . in this model, the concept of aerosol inhalability is defined as the fraction of particles capable of penetrating into the head airways or below, upon inhalation: it excludes larger droplets with ballistic behavior (since inhalation requires suspension in the air) but includes particles that are larger than the traditional 5-m definition of aerosols. throughout our review, this more nuanced conceptualization of airborne transmission will be explored, and the larger inhalable aerosols will be contrasted to the smaller respirable aerosols from the classic airborne model. finally, some procedures, such as intubation, are known to generate aerosols, while others, such as nebulizer therapy, are associated with an uncertain risk of aerosolization (8) . n95s (or similar respiratory protection devices) are unequivocally recommended for hcws working in high-risk settings with agps, although controversy still remains around which interventions constitute an agp. the design protocol for the n95, and the origin of the name, is based on its efficiency at capturing 95% of the most penetrating size range (0.3 m) of respirable aerosols (9) . by default, respirators are therefore capable of blocking the entire spectrum of airborne particles. medical masks, on the other hand, are designed to block droplets and do not undergo aerosol-filtering tests; they are therefore not considered to provide respiratory protection against airborne transmission. given that substantial disagreement persists on the importance of natural aerosol generation by covid-19 patients, and consequently, the necessary level of respiratory protection in non-agp contexts, our review will focus on transmission and ppe in low-risk health care settings. natural respiratory activities such as breathing, talking, and coughing can generate a broad range of particle sizes, from submicron aerosols to large droplets (10) (11) (12) (13) (14) . for the viral aerosols to constitute a clinically significant risk of airborne infection, three conditions are required: viral load (the concentration of infectious particles), infectivity (the ability of a virion to infect a host cell), and tropism (the specificity of a virus for a particular host cell type or tissue). since the amount of sars-cov-2 virus required to infect a host is unknown, and likely varies from one individual to another (preprint article [15] ), it is hard to determine whether typical respiratory activity generates sufficient quantities of infectious aerosols for airborne transmission. in a light-scattering study, stadnytskyi et al. estimated that 1 min of loud speaking generated at least 1,000 virion-containing droplet nuclei that remain airborne for more than 8 min (16) . however, the calculations were based on several theoretical assumptions and data from sputum load was incorrectly applied to saliva, likely overestimating aerosol viral loads. in this model, the probability that a hypothetical speech-generated droplet nucleus of 3 m contains a sars-cov-2 virion is only 0.01%, after aerosolization and desiccation. furthermore, in a mathematical modeling study on viral aerosol emissions, an individual with a high viral load was estimated to emit only modest amounts of virus with regular breathing (1,248 copies/ m 3 ) compared to coughing (7.44 million copies/m 3 ) (17). accordingly, the authors conclude that the infectious risk posed by a typical covid-19 patient is low, especially if symptoms are mild, and only a few individuals with high viral load pose a significant risk. these authors suggest that strict respiratory protection may be needed in the case of prolonged exposure to high emitters in poorly ventilated closed environments. notwithstanding, evidence of aerosol generation during natural respiratory activity or the presence of viral rna in the air are not sufficient to prove that the virus remains infectious once airborne. not all viruses are equally stable in the air, and further aerodynamic and environmental factors may inactivate viruses during aerosolization (18) . therefore, upon detecting sars-cov-2 aerosols, infectivity must then be demonstrated. evaluation of infectivity is usually done with viral cultures: researchers were able to culture rhinovirus (19) and influenza (20) from the fine particles emitted naturally by infected participants, and only recent yet unpublished research has started to achieve the same for sars-cov-2. however, it is important to note that culture methods vary between viruses and false-negative results due to the low sensitivity of commonly used sars-cov-2 cultures could have possibly underestimated infectivity from air samples until now. for instance, clinical samples (e.g., nasopharyngeal swabs) that yield positive cultures typically have low pcr cycle threshold (c t ) values of ͻ25 (samira mubareka, university of toronto, unpublished data), while c t values for environmental samples (including air samples) are often ͼ35. finally, since particles penetrate and deposit in different parts of the respiratory tract depending on size, knowledge of target locations for infection (e.g., viral tropism) can hint at typical size range and mode of transmission. sars-cov-2's main entry into host cells is through ace2 receptors, which seem to be largely expressed in the nose (21, 22) . importantly, the highest and most consistent signs of viral infectivity have been observed for nasal cells, with a gradient along the respiratory tract characterized by a marked reduction in infectivity in the distal bronchioles and alveoli. this may suggest that lower airways are not targets for infection and that transmission via respirable aerosols is not predominant. interestingly, the typical patchy bilateral pneumonia found in covid-19 patients is postulated to be caused by oropharyngeal microaspirations rather than direct viral seeding in the lungs, possibly accounting for the increased risk with age and comorbidities (22) . different types of studies suggest airborne transmission, but their levels of evidence are variable. in this review, given the focus on health care settings and hcw protection, studies are appraised according to clinical relevance: hard outcomes (e.g., morbidity) are markers of higher levels of evidence, while surrogate outcomes (e.g., pathophysiological mechanisms, modeling, and laboratory results) are considered lower levels of evidence, independent of method or design quality (table 1) . the term "mask," as used here, comprises medical masks, surgical masks, procedural masks, fluid-resistant masks, and face masks worn by hcws. the term "respirator" is used interchangeably with n95, which is the equivalent of ffp2 (european standard filtering facepiece) and kf94 (korean filter) respirators. in the absence of clinical trials on sars-cov-2, trials on other viruses with similar infection patterns (i.e., documented droplet and suspected airborne transmission) are the best available alternatives. recent systematic and narrative reviews comparing the effectiveness of respirators versus masks against common viral respiratory infections (including coronaviruses and influenza viruses such as h1n1) come to similar conclusions: both devices offer comparable protection in health care settings (23) (24) (25) (26) (27) (28) (29) (30) (31) . a few reviews (32) (33) (34) favor respirators, on the basis of two randomized controlled trials (rcts) conducted by the same lead authors, macintyre et al. (table 2 ) (35, 36) . individually and in combination (meta-analysis) (33), these two rcts report superiority of continuous n95 use over mask use for a single self-reported outcome: clinical respiratory illness (cri), defined as two or more respiratory symptoms or one respiratory symptom and a systemic symptom. no difference is found for other more rigorous outcomes: influenza-like illness (ili; defined as fever and one respiratory symptom), laboratory-confirmed viral respiratory infection (lvi), or laboratory-confirmed influenza (lci). the difference between the self-reported outcome and the laboratory results could be explained by detection bias in the absence of participant blinding and universal testing: higher symptom reporting rates in the medical mask group, rather than true infection, could have skewed cri results in favor of respirators. furthermore, selection bias is suspected to have occurred during allocation, given the surprisingly uneven distribution of major confounding variables such as agps, age, and handwashing, between the n95 and mask groups. the other two rcts (37, 38) included in the reviews had more robust methodologies and lesser risk of bias (e.g., comparable groups, test results for all participants, and longer follow-up periods). the studies did not find any significant differences between respirators and masks for clinical and laboratory outcomes, in both low and high-risk settings. a recent systematic review of observational studies suggests that "n95 respirators might be more strongly associated with protection from viral transmission than surgical masks" (39) . regrettably, of 10 studies, not a single one directly compared respirators to masks, and nine of them looked at sars or mers rather than sars-cov-2. the lone covid-19 study only compared n95s to no masks and did not include medical masks at all (40) . the researchers drew their conclusions by comparing the pooled results for n95 studies with the pooled results for mask studies, obtaining a p value for interaction by mask type that was borderline significant after partial adjustment. however, the difference between the two groups was not statistically significant (overlapping confidence intervals) and the very high heterogeneity (i 2 ϭ 88%) could have undermined the validity of the meta-analysis. also, the presence of agps was unknown in 7 of 10 studies: since all the studies were done in a hospital setting where agps frequently occur, and n95s are known to be superior in high-risk settings, failure to adjust for agps will skew the results in favor of n95s. finally, all 10 studies were observational and many did not control for important confounding factors, leading the authors themselves to rate the overall certainty for mask data as low. since many trials studied airborne viruses (e.g., influenza) and included exposure to agps, it may seem surprising that the vast majority of reviews, past and present, did not find respirators to be superior to masks. a possible explanation is that, while not designed to filter very fine particles, the medical mask might nonetheless be effective in blocking the low levels of aerosols produced in most health care contexts. a few case reports seem to support this hypothesis. for example, in a study of two severely ill covid-19 patients who were not initially isolated, contact tracing identified 421 hcws, of whom only 8 tested positive (41) . all infected hcws had close and prolonged contact without wearing the mask or ocular protection and had been present during agps. on the other hand, all of the hcws who used droplet and contact precautions did not get infected, leading the authors to conclude that there was no evidence of airborne transmission. similarly, two studies reported on 34 and 41 intensive care hcws exposed to an intubated and mechanically ventilated covid-19 patient: 50 and 85% wore surgical masks, respectively, and the others wore n95s, yet none were infected according to clinical and laboratoryconfirmed results (42, 43) . furthermore, a covid-19 patient who stayed 35 h in an open cubicle of a general ward, coughed frequently, and received high-flow oxygen at 8 liters/min, did not infect any of the 71 staff members and 49 patients, of which 7 and 10, respectively, had close contacts wearing either n95s or masks (44) . finally, strict contact and droplet precautions, as well as the use of masks rather than respirators, completely prevented nosocomial transmission from three community-infected hcws to coworkers and patients in an italian hospital (45) . as for the effectiveness of medical masks as source control (blocking particles emitted by infected individuals), clinical trials are scarce (46) (47) (48) , and they suggest a reduction of clinical but not laboratory-confirmed viral illnesses. therefore, we must turn to lower levels of evidence (e.g., laboratory studies) for further guidance. the ability of protection devices to control either source emission (e.g., infected individuals) or exposure prevention (e.g., hcws) has been the subject of several laboratory studies, whose findings are summarized in table 3 . the majority show high filtration capacity for both masks and respirators. the latter, however, are known to provide better protection against fine particles (ͻ5 m) because of a far superior fit factor. interestingly, source control with masks may be superior to exposure prevention by either respirators or masks. although these studies provide relevant information on the theoretical performances of protection devices, the experimental generation process and particle sizes may not resemble natural respiratory activity. also, many studies suffer from major limitations and inconsistencies in design: the use of different respiratory viruses with distinct behaviors, the lack of information on the size distribution of particles tested, the use of nonstandardized test particles (e.g., in contrast to standard respirator testing protocols), selection bias for ballistic behavior (petri dish sampling) rather than aerosols (air sampling), and confounding biases (e.g., fit factor and variable cough intensities). more importantly, many laboratory studies fail to account for crucial clinical and behavioral factors. for example, studies have reported lower adherence to n95 respirators compared to medical masks, due to higher rates of adverse events (35, 36, 49) . in one study on the tolerability of respirators in hcws, the probability of discontinuing respirator use during an 8-h work shift was around 50 to 70%, despite regular 15-or 30-min breaks every 2 h (50) . other studies show that one of the most challenging steps in donning and doffing is n95 use, which can result in a higher risk of contamination (51, 52) . in addition, an important, yet overlooked factor is the fitting of the device on the face (or the degree of leakage of particles around the edges). the fit factor varies between mask models and is typically very high for respirators, which is probably its main advantage. however, a poorly fitted respirator could perform no better than a loosely fitting mask (53) . seals used in some laboratory studies are poor surrogates for actual fitting on a hcw. finally, during exposure to covid-19 patients, hcws are instructed to wear ocular protection in addition to masks, and yet very few studies examine the combined effects of overall ppe. some experiments have shown that masks integrated with visors (54) and face shields individually (55) are protective not only against droplets but also aerosols (but efficiency decreases with exposure time). the vast majority of epidemiological studies that analyze sars-cov-2 outbreak patterns (case identification, contact tracing, epidemiological curves, and basic reproduction number or r0 estimates), undertaken in a variety of contexts, including health care facilities (41) (42) (43) (44) (45) , homes (56) , churches (57), fitness facilities (58), call centers (59), airplanes (60) , and company conferences and tour groups (61) , are in agreement: contact and droplets were the probable modes of transmission. rather than long-range propagation and frequent mass outbreaks typical of airborne patterns, the distribution of infected individuals was strongly correlated with close encounters and secondary attack rates were estimated be very low, around 5% (62) . rather than high r0 estimates typical of airborne viral pathogens such as chickenpox (5 to 11) (63) and measles (6 to 27) (64), community reproduction numbers fell between 2 and 4 (65, 66) and were easily lowered by droplet and contact precautions (67) . moreover, the who's largescale epidemiological analysis of 75,465 covid-19 patients did not confirm any cases of long-range airborne transmission (68) . in health care settings, the use of medical masks appears to be sufficiently protective of hcws exposed to covid-19 patients, as mentioned previously. several epidemiological reports from hospitals around the world even show little or no nosocomial transmission in the absence of recommended ppe (i.e., no n95s or masks during agps or improper mask use during close contact). combining the findings of six studies, out of a cumulative total of 295 hcws exposed to covid-19 patients without proper protection, only 5 hcws were infected. all five workers either did not wear any mask or used a mask intermittently during an agp or prolonged exposure (ͼ60 min) (69) (70) (71) (72) (73) (74) . these low levels of transmission from nonisolated covid-19 patients to nonequipped hcws are not suggestive of significant airborne transmission and support the effectiveness of basic pci measures beyond ppe. nonetheless, some epidemiological evidence is compatible with short-range airborne transmission. the washington choir outbreak is known for linking aerosolization from loud vocalization (i.e., singing) to rapid spread; however, the index case was symptomatic rather than asymptomatic as reported by the media (75), and multiple opportunities for droplet or fomite transmission were revealed in the published investigation (76) . in turn, the well-known outbreak at the guangzhou restaurant has been the subject of controversy: based on epidemiological data, one research team determined that droplets, expelled further than usual by air conditioning, were the probable source of transmission from an index patient to two neighboring tables (2); a second team, based on computer modeling and a tracer gas (a surrogate for exhaled particles), ruled in favor of airborne transmission (preprint article [77] ). moreover, a recently published study analyzed an outbreak involving two groups who rode separate buses to attend a 128-participant worship event (78) . while no transmission occurred on bus 1, 23 passengers on bus 2 were infected, some of whom were sitting up to 5 m away from the index case. seven other participants who did not ride on the buses were infected, all of whom reported close contact with the index case during the outdoor event. since proximity to source was not correlated with infection risk in the bus, but window and door seats seemed to be protective, the researchers hypothesized that bus 2's closed environment and air recirculation enabled airborne transmission to occur. furthermore, the widely studied diamond princess cruise ship outbreak is still up for debate. based on epidemiological data showing exclusive in-room transmission following imposed quarantine, as well as no correlation between infection patterns and central ventilation system, one research team concluded that close contacts and fomites were the main transmission routes (preprint article [79] ). in support of this view, an environmental study failed to detect any virus in air samples despite widespread positive surface sampling; however, passengers had disembarked at the time of sampling (80) . conversely, a modelization study simulating the cruise ship outbreak found that the epidemic models which best predicted the empirical data suggested predominant short-range and long-range airborne transmission (preprint article [81] ). finally, two studies (82, 83) analyzed the impacts of public health policies on the epidemiological curves of highly impacted regions: the first compared wuhan, italy, and new york city (nyc) while the second compared 15 u.s. states. according to the authors, mask-wearing but not social distancing (quarantine, stay-at-home, and lockdown) policies were effective in curtailing covid-19 outbreaks, suggesting that the main route of transmission is airborne rather than contact and droplets. however, the studies have come under criticism for not accounting for major confounding biases, such as differences between the three regions in terms of timing of lockdown (at ͼ9,000 confirmed cases in italy and nyc [84, 85] compared to 495 confirmed cases in wuhan [86] ), public health policy (e.g., contact tracing efficiency, testing criteria, and access), and population demographics (87) . in addition, using the date of governmentmandated mask-wearing as the start point for regression slopes is misleading, since the impacts of any new policy on epidemiological curves are delayed and nonlinear, especially given uneven compliance to mask-wearing, typically around 50% in the united states. (88) , but variable between states, compared to over 95% in asia (89) . if we further scrutinize nyc (as well as other states), it appears that the number of daily new cases, hospital admissions, and deaths started to fall before the mask-wearing order (84) , thus warranting an alternative explanation for the decline, such as an increasing proportion of immune individuals or the adoption of more aggressive testing. moreover, researchers could not explain why certain states managed to control their outbreaks without mask-wearing policies and others did not show a decline in new or cumulated cases after facemask adoption. beyond the airborne versus droplet debate, there is consensus among epidemiologists: prolonged short-range exposure is the main risk factor. interestingly, the revised airborne model presented in the conclusions: proposed model (below), involving inhalable aerosols, can accurately explain epidemiological observations as well as the dynamics of several contentious outbreaks. despite some caveats, sars-cov-1 studies may be useful to understand sars-cov-2, given that they share around 80% of their genomic sequence (66) . a well-studied outbreak at amoy gardens in hong kong, a high-rise housing estate where ͼ300 tenants were confirmed infected despite little contact between them, was studied by different teams (90, 91) . the majority agree on airborne transmission of sars-cov-1, originating from the aerosolization of feces and urine through hydraulic action (i.e., toilet flushing) of an index patient who presented with diarrhea and high viral load in excrements. this particular outbreak involved primarily environmental and engineering factors such as unsealed floor drain traps, bathroom fans causing negative pressure, bathroom fixtures contributing to drain overload or backflow, and the specific configuration of the exhaust system, which contributed to drawing aerosolized sewer droplets from the plumbing system back into the bathrooms and spreading them throughout the building (92) . the involvement of respiratory aerosols was not hypothesized. more relevant to health care settings is a hong kong hospital outbreak study on medical students exposed to an index sars patient: proximity with the patient was the main risk factor, but the duration of contact did not appear to be associated with transmission. the researchers conclude that the mode of transmission was probably through droplets and contact, but airborne transmission could not be excluded, especially given the presence of a potential agp (30-min nebulizer therapy four times a day) (93) . furthermore, in a canadian study, air samples were collected from 15 sars patient rooms in low-risk and high-risk settings, as well as four adjacent nursing support areas: 2 of the 40 wet air samples and none of the 28 dry air samples were pcr positive (94) . the two positive samples were both from the room of a single recovering sars patient where agps did not appear to be performed. subsequent viral culture; however, turned out negative. as for protection devices, a case-control study in five hong kong hospitals showed no difference in infection rates between hcws wearing a mask or a respirator, when exposed to sars patients (95) . other observational studies (96) (97) (98) done in high-risk settings (including agps) suggest possible n95 superiority, but the studies either did not adequately compare the two equipment types or did not obtain statistically significant results. other lower levels of evidence for sars-cov-1 come to similar conclusions regarding ppe. no nosocomial transmission was found in hcws from eight u.s. hospitals, despite several of them not wearing any masks and 5% of them being exposed to agps (99) . furthermore, no nosocomial transmission was found in vietnamese hcws exposed for 3 weeks to hospitalized cases, wearing only medical masks (100) . however, given the differences between sars-cov-1 and sars-cov-2 (e.g., peak viral load, asymptomatic transmission rates, and mortality rates), direct extrapolations from one virus to the other must be made with caution. similarly to the current pandemic, the significance of airborne transmission for the previous sars remains uncertain to this day, as the prerequisites (viral load, infectivity, and tropism) are not clearly met. unfortunately, sars-cov-1 seems to suffer from the same lack of rigorous clinical trials as its contemporary cousin. data from air and no-touch surface sampling studies (tables 4 and 5) conducted in covid-19 patient rooms and health care facilities are often cited to support airborne transmission. unfortunately, interstudy comparisons are complicated by the diversity of methodological approaches. for instance, positive air samples correlate with patient features (e.g., viral load and symptom intensity and duration), ventilation parameters, and cleaning procedures, but these elements are not always mentioned or detailed. moreover, large variations are reported in terms of total volume of air collected (ͻ100 liters to up to 10,000 liters), flow rates (3.5 to 300 liters/min), sampling duration, and technique (gelatin versus polycarbonate filtration, dry cyclonic sampling versus condensation sampling). furthermore, the sampling of no-touch surfaces, defined as areas typically out of reach of human contact or droplets and therefore assumed to be contaminated by aerosols only, is often poorly described and not always comparable to air samples. given that each design is associated with its own set of advantages and limitations (e.g., longer duration of air sampling may increase detection probability but decrease infectivity), there is no easy conclusion to be drawn when comparing studies. the majority of published and unpublished studies detected viral rna in the air and on no-touch surfaces (table 4 ), but some did not (table 5) . unfortunately, few positive studies included viral cultures. the main limitations of these studies were the lack of information on particle sizes and concentrations, unknown or suboptimal air sampler location, unknown time interval between aerosol production and collection (air or surface), and possible false negatives (e.g., negative pressure, open windows, and insufficient sampling volume or duration). for the studies that calculated viral concentrations from the environmental samples, various protocols, target genes (e.g., orf1ab/ rdrp, e, n, and s), and chemistry detection technology, should caution against direct comparisons. most studies were carried out in both low-and high-risk areas, and frequently in intensive care units (icus) where agps commonly occur and ventilation is optimized. many studies, however, did not specify the general risk level and did not indicate if agps were carried out during sampling. therefore, positive air and no-touch surface samples could not be clearly associated with an emission source (i.e., natural aerosolization versus agps) or risk factors (e.g., ventilation rate). this makes the results hard to generalize to most low-risk health care settings, such as long-term-care facilities. negative results from air sampling studies in home and commercial settings (80, 101) , in the definite absence of agps, also add to the uncertainty. it is worth noting that when researchers modelized aerosol emission during normal breathing, the observed concentrations of airborne particles were low, frequently under the detection limit for most air sampling approaches (102) . this could explain the negative results of many studies (table 5) . nonetheless, air and no-touch surface sampling studies support the presence of natural and/or intervention-generated aerosols in covid-19 health care facilities. however, the infectivity of these aerosols and their significance as a transmission route, beyond the mere detection of viral particles, remain uncertain. indeed, a better understanding of viral resistance to airborne stress is key to estimating infectious risk. three published studies (103) (104) (105) included viral cultures from air samples, all of which were negative; however, the santarpia et al. study (103) observed indirect signs of viral replication in two of their samples, including a mild cytopathic effect upon microscopic inspection after 3 to 4 days. on the other hand, in two unpublished studies, santarpia sars-cov-2 and health care worker protection clinical microbiology reviews et al. (106) and lednicky et al. (107) succeeded in obtaining positive cultures. the former used innovative methods such as detection of viral rna in supernatant and western blotting to yield interesting results. however, data scrutiny is impeded by the absence of c t values in the manuscript. in turn, the latter study would benefit from a thorough peer review process given that its methodology is not clearly detailed, and total and culturable viral counts seem implausible, since they are orders of magnitude higher than previously reported in the literature. the use of a condensation-based air sampler could perhaps explain the unusual results. the fact that few research teams have attempted to culture the virus, and many of those who have did not succeed, could imply that sars-cov-2 aerosols are scarce or weakly infectious. however, multiple other factors could be at play. viral cultures must be done in biosafety level 3 facilities and are therefore not easily accessible to some research teams. even when culturing is possible, viral shedding dynamics may be unpredictable or intermittent, leading to failed detection within the time frame of air sampling (108) . furthermore, the sampling process of aerosols, in itself, may induce substantial damage to viruses and alter their integrity and, consequently, their infectivity (109) . finally, current culture techniques may not be optimal for the low viral concentration found in air samples. increased sensitivity could be achieved with a bioassay or alternative methods such as electron microscopy, detection of viral proteins, and rt-qpcr in culture lysis and supernatants (106) . lastly, studies involving the in vitro generation of sars-cov-2 aerosols with jet collison nebulizers have been widely cited in support of airborne transmission. using this method, the well-known van doremalen et al. letter measured infectious titers per liter of air in a simulated aerosolized environment and showed stability of the sars-cov-2 virus in aerosols for up to 3 h, with a half-life of 1.2 h (110). another similar study made headlines because the aerosols produced were stable for up to 16 h (111) . as with all in vitro models for bioaerosols, while they provide precious information on virus properties in aerosol state, including relative stability (which seems to be high) and comparative viral behavior, it is uncertain whether the mechanically produced sars-cov-2 aerosols exhibit the same properties as naturally generated ones. therefore, such experimental studies are generally considered of low applicability to clinical settings. tragic outbreaks in long-term-care facilities (ltcs) have plagued many countries in europe (112) and north america (113) , with astonishing death tolls. some facilities report 100% resident infection rates, high hcw infection rates, as well as faulty ventilation systems (114), triggering intense debate over potential airborne transmission. while aerosols could have contributed in cases involving inadequate ventilation (115) , other explanations are also conceivable. some have justified the devastating statistics by pointing to higher viral loads (116) or longer infection periods (117) in the elderly, two phenomena likely attributable to the weakening of the immune system with age. notwithstanding, ltcs are fundamentally vulnerable to covid-19 because of an array of predisposing risk factors (118, 119) . unlike the general adult population, covid-infected residents in ltcs are not always capable of communicating their symptoms and frequently have atypical clinical presentations, such as diarrhea, delirium, or falls (120) . on the other hand, between 50 and 75% (121, 122) of them are asymptomatic or presymptomatic at the time of their positive test. these geriatric features complicate and delay case detection. the typical patient profile also leads to poor compliance with infection prevention and control (ipc) practices: most residents have neurocognitive disorders and behavioral symptoms, but some also have mental health disorders or intellectual disability, which means isolation, mask-wearing, and hand hygiene are often impossible. rates of resident noncompliance can reach almost 100% in certain special care units (e.g., wandering ward). moreover, a majority of residents with severe loss of functional autonomy requiring several hours of proximity care per day (e.g., personal hygiene and bath, urinary and bowel elimination, feeding, and medication administration), means close and sustained contact between hcws and infected patients (without source control for the most part) and consequently, higher infection risk on both sides (123) . structural and administrative impediments also come into play. some ltcs have high bed occupancy rates and tight physical spaces (e.g., shared bedrooms and bathrooms), where distancing becomes a challenge and cross-contamination an inevitability (124) . with high population density and limited space, it is very difficult to efficiently segregate patients into zones according to infectious status, leading to mixed units and high infection rates. moreover, some facilities have defective ventilation systems (115) , while others have no mechanical ventilation at all, and must rely on opening windows for air exchange. most importantly, many already understaffed ltcs were hard hit by pandemic-related absenteeism and had to resort to mobilizing staff between units and facilities or calling on lesser-trained external staff to fill in; this element exaggerated all the other risk factors because it hindered the detection and isolation of suspected cases, the deployment of covid-19 units with dedicated staff, the optimal application of ipc practices, and the overall quality of care (125) . unfortunately, despite ltcs being at the epicenter of many regions' epidemic, data are still lacking. studies on transmission modes specific to this geriatric subgroup, where various clinical, administrative, and environmental factors intersect, would be very revealing. most authorities agree with the who recommendations for droplet and contact precautions with covid-19 patients. in the united kingdom (126), canada (127), france (128) , switzerland (30), spain (129), portugal (130) , and australia (131), medical masks are indicated in most situations and respirators are required only in high-risk settings involving agps. recently, the who has acknowledged that "short-range aerosol transmission, particularly in specific indoor locations, such as crowded and inadequately ventilated spaces over a prolonged period of time with infected persons cannot be ruled out" but specifies that the significance of covid-19 airborne transmission has not been convincingly demonstrated and requires further research (1) . while the european society of intensive care medicine and society of critical care medicine (132) is also in line with who ppe recommendations, the european centre for disease prevention and control began by recommending respirators at all times, but backtracked in recent updates and now states that both equipment types are appropriate outside of agps (133) , in agreeance with the infectious diseases society of america (idsa) (134) . on the other hand, the united states (135), south korea (29), singapore (136) , and china (137) recommend respirators for routine care. the u.s. cdc states that hcws should wear an n95, but a facemask is a suitable alternative if a respirator is not available. in summary, most western countries have adopted similar guidelines in line with who recommendations, but comparisons with countries in other parts of the world were not possible due to language barriers. surprising attack rates have been reported. possible explanations include the high presymptomatic contagion of certain individuals (138) , as well as the many asymptomatic or paucisymptomatic cases (139) who seem to have similar viral loads to their symptomatic counterparts (140) . furthermore, unlike sars-cov-1 which reached peak viral load (and therefore contagion) at day 7 to 10 from the start of symptoms (141), viral load seems to peak right before the advent of symptoms (108) . given these data, certain researchers estimate that 44% of transmission happens in the presymptomatic phase (108) . finally, nasopharyngeal viral load appears to be much (up to 1,000 times) higher than that of the first sars (142) . we are therefore faced with a very contagious virus that can silently infect a large number of people. moreover, another possible mode of transmission that remains to be elucidated is through fomites. few studies look at sars-cov-2 survival on surfaces. a widely cited experiment showed that the virus could subsist between 4 h (on copper) and 72 h (on plastic) (110) . however, the study took place under experimental conditions (laboratory surface inoculation, at a stable temperature of 21 to 23°c) which do not represent droplet deposition on surfaces in clinical contexts nor the variations of typical indoor environments. nonetheless, the potentially prolonged stability of coronaviruses on surfaces (143) , as well as the extensive environmental contamination reported by many surface sample studies in health care settings (108, (144) (145) (146) (147) , needs to be confirmed by future research, including viral cultures for infectivity. possible fecal transmission is also worth considering. a significant proportion of patients declare gastrointestinal symptoms before respiratory symptoms, and it is even a predominant form of presentation in some individuals (148) . in addition, severe covid-19 cases appear to have more gastrointestinal symptoms than mild or moderate cases (149) . a meta-analysis of over 4,000 patients reported 48% pcr-positive stool samples, of which 70% remained positive even after nasopharyngeal pcr had turned negative (150) . endoscopic studies also found rna in the esophagi, stomachs, duodena, and recta of patients with severe gastrointestinal symptoms (151) . finally, two studies showed the toilet was among the most contaminated areas in indoor settings (152, 153) : interestingly, the patient who's toilet air sample was positive had a negative exhaled breath sample, warranting the consideration that detectable airborne sars-cov-2 could originate from fecal rather than respiratory aerosols. as with air, a limited number of studies have been able to culture infectious viruses from stools (154, 155) , supporting infectivity. in theory, fecal transmission could occur through different routes, including contact (e.g., while changing incontinence briefs), short-range aerosolization (i.e., inhalation), or long-range aerosolization due to toilet flushing (156) . the latter was well established in the sars-cov-1 amoy gardens outbreak and was recently considered the main mode of transmission in a sars-cov-2 outbreak involving a high-rise building in china, where the nine infected cases lived in three vertically aligned flats connected by drainage pipes in the master bathrooms (157) . hcws constitute a high-risk population for infection (158) . however, the contribution of nosocomial transmission was perhaps overestimated at the beginning of the pandemic, since recent genome-sequencing studies have highlighted the importance of community-acquired infection among hcws (159) . for instance, with epidemiological and genomic data on 50 hcws and 10 patients at hospitals in the netherlands, researchers linked these infections with three different clusters, two of which showed local circulation in the community (160) . within each cluster, "identical or near-identical sequences in health care workers at the same hospital, and between patients and health care workers at the same hospital, were found, but no consistent link was noted among health care workers on the same ward or between health care workers and patients on the same ward." the authors therefore concluded that the patterns observed were consistent with multiple introductions into the hospitals through community-acquired infections. similarly, studies are pointing to community transmission dynamics and public policies (e.g., universal mask-wearing) as the main drivers of hcws infection (161) (162) (163) . nonetheless, given that hcws can both infect patients and get infected from patients, workplace practices deserve a closer look. in the presence of a contagious virus and extensive environmental contamination in health care settings, any breach in protection, as small as it may be, can lead to infection. hcws who work regularly with covid-19 patients, especially those in close contact (e.g., patient attendants, nurse aides) can hardly maintain constant and perfect compliance with ipc practices. besides, risk exposure not only occurs with patients during ppe violations but also with other staff members in shared areas without ppe (e.g., cafeterias and changing rooms). unfortunately, few studies looked at ppe compliance during the covid-19 pandemic: one study reported very poor adherence to mask recommendations due to lack of use (almost 30%) or improper use (164) . before the pandemic, cornerstone practices such as hand hygiene were already poorly applied according to several studies in a variety of hospital departments (including icus) across different countries (165) (166) (167) . a drastic change in a short lapse of time appears improbable, especially in long-term-care facilities where the culture and philosophy are one of "home setting" rather than health care setting. moreover, hcws appear to have a false perception of their own compliance with hygiene practices: a mers-cov study showed an absence of correlation between staff's self-assessment and their observed behavior (168) . the researchers mention that most hcws understood the importance of hand hygiene but did not consistently apply it. even so, proper ppe use does not only depend on individual compliance and technique; it is a multidimensional issue with organizational, systemic, and political ramifications (169) . more importantly, ppe is neither the only nor the best way to protect hcws. in fact, when it comes to protection from occupational hazards, ppe is the last and least effective measure in the niosh hierarchy of controls (170) (see fig. 1b ). for the current pandemic and future ones, our priority should therefore be elimination strategies (e.g., decreasing bed occupancy rates, source control), engineering controls (e.g., segregated red zones and proper ventilation), and administrative controls (e.g., dedicated staff, adequate training, and strict enforcement of ipc regulations), ending with ppe (29) . unfortunately, we have seen, around the globe, many health care systems fail to meet the structural, human, and material challenges brought on by covid-19, and some hcws have paid the price for our collective unpreparedness. one final potential source for hcw infection could be the combination of risk factors for aerosol accumulation in certain exceptional circumstances, such as an overcrowded and underventilated long-term-care facility (115) , or makeshift hospitals such as we have seen built around the world (171) . while the vast majority of home and hospital environments are probably safe (172) , some care homes are located in old substandard infrastructure which relies on natural ventilation and does not allow for optimization of air exchange. it is plausible that under these specific conditions, normally minimal levels of infectious respirable aerosols could reach a threshold where classic airborne transmission becomes significant. while we wait for future research to confirm this scenario, we must strive to control what we can, eliminating physical, environmental, and administrative risk factors to protect frontline workers (173) . drawing the line between precaution and excess is a fundamentally subjective process. many experts agree that current droplet and contact precautions are adequate in low-risk settings. however, some prefer to exercise precaution by recommending respiratory protection with critically ill patients (e.g., severe desaturation or tachypnea), arguing that these clinical features predict progression to agps such as intubation (174) . others consider that the minimum precautionary practice is universal n95 use. finally, some argue that only drastic measures such as full head hoods and full-body suits, often seen in china, are sufficiently protective. in the presence of diverging opinions on the definition of so-called precaution, it seems reasonable to use an evidence-based approach to ppe recommendations. the bulk of evidence, until now, indicates that the medical mask is protective in low-risk settings and the respirator is required only for agps, although higher levels of evidence in the future may tip the balance the other way. long-term care facilities, where the risk level may at times be considered high despite the absence of agps, deserve special attention from researchers. lastly, one could argue that our collective but rather limited energy, time, and resources should be invested in the most impactful areas: proven practices that achieve broad consensus and transmission routes that appear to be predominant. for sars-cov-2, long-winded debates on the gray zones and the applicability of the precautionary principle sometimes distract from crucial measures, such as hand hygiene, source control, and optimal ventilation (175) , which are uncontroversial and highly effective, yet still unevenly applied in some settings such as long-term-care facilities. we are in favor of a return to core ipc principles, which should dominate the scientific conversation around covid-19 management. beyond the alarming statistics, several success stories around the world prove that much can be achieved quickly and efficiently with basic yet effective practices (45, (176) (177) (178) , without the need to resort to elaborate theories or equipment. this article is an in-depth literature overview attempting to answer frequently asked questions about droplet and airborne transmission. although not a systematic review, it goes deeper than current narrative reviews and has important implications for ipc practices, hcw protection, and future research. however, there are several limitations. the first is the controversial distinction between droplets and aerosols, still commonly used in much of the scientific literature, although deemed arbitrary and inaccurate by many experts. natural generation of particles belonging to a broad range of size, containing various concentrations of infectious agents, is probably concurrent rather than mutually exclusive, and transmission patterns are likely on a continuum rather than dichotomous. our proposed model addresses this issue. going forward, we are in favor of adapting public health policies and ppe recommendations to include a broader industrial hygiene-inspired definition of aerosols, as presented above, in order to lessen confusion and better represent the nuanced and complex reality of sars-cov-2 transmission. the second major limitation is the lack of clinical studies on sars-cov-2 transmission and ppe effectiveness, meaning that many conclusions are drawn from lower levels of evidence, extrapolations from other viruses, and laboratory and experimental studies. the available literature, however, is mostly consistent: while airborne transmission exists under certain conditions, there is limited direct evidence of it, especially in low-risk health care settings. given the very high viral load typical of sars-cov-2 infections, it is surprising that, after several months of pandemic, many air samples turn out negative or weakly positive, and subsequent positive cultures remain scarce. this may be attributed to the many logistical and technical limitations associated with air sampling and viral cultures, as mentioned previously, which could underestimate airborne infectivity. we must therefore rely primarily on clinical evidence (trials on masks and epidemiological studies) to study transmission; for now, it suggests that the classic airborne route is not significant. a broader airborne model, involving the short-range inhalation route, could better explain current observations. third, only a few national and international guidelines are compared because of the lack of translated documents. a thorough search of guidelines from comparable countries across different continents would allow for an unbiased comparison but is very challenging in practice. while impatiently waiting for future studies, especially clinical trials, to dispel remaining uncertainties and provide definitive answers to the questions raised here, we would like to propose a revised model for sars-cov-2 transmission, involving inhalable aerosols and favorable conditions for airborne transmission (fig. 1) . the premises of this model are based on cumulative data and clinical observations. in light of the positive air and no-touch surface samples found in health care facilities, respiratory sars-cov-2 aerosols probably occur, but many of their attributes are yet unknown; studies thus far seem to suggest these aerosols are short-range and dilute with distance (102, 103, 144) . similarly, epidemiological studies do not support the existence of long-distance aerosol propagation: the four outbreaks most often cited as evidence of airborne transmission (the washington choir, the guangzhou restaurant, the eastern chinese bus riders, and the diamond princess cruise ship) all involved individuals who were in relatively close contact for a prolonged period of time, in an enclosed space, with the presence of enabling factors (e.g., crowdedness, air currents, and poor ventilation). indeed, these conditions seem necessary for respiratory airborne transmission to occur. fecal aerosols, on the other hand, may be more common due to toilet flushing, but further studies are needed to clarify their role and distinguish them from respiratory aerosols. worst-case scenario: no protection on either the sick patient (source) or the health care worker (exposure), emission of particles of various sizes (droplets and aerosols) during natural respiratory activity (breathing, talking, and coughing), entry of infectious inhalable aerosols, and impaction in the nose where viral receptors are abundant and infectivity is greatest. (b) best-case scenario and niosh hierarchy of controls: source control (mask-wearing by the sick patient), engineering control (optimal ventilation), and exposure control (droplet-contact ppe worn by the health care worker) to prevent short-range droplet and inhalable aerosol transmission. clinical microbiology reviews moreover, to solve the mystery of particle size, we must first acknowledge that airborne transmission is not exclusive to small aerosols: some larger particles typically classified as droplets may remain airborne, especially if suboptimal airflows contribute to their preservation in suspension and reduce their dilution (179) . thus, inhalable aerosols are the ideal candidate to explain current findings, because they exhibit shorter travel distance and air suspension time than respirable aerosols while having greater potential for infection because of their higher probability of containing virions (16) . furthermore, because inhalable aerosols are larger, they are more likely to deposit proximally in upper airways compared to respirable aerosols (180) , which is in line with the robust data suggesting that nasal cells are the main portal for initial infection, with a gradient of infectivity from the proximal (nose) to the distal (lungs) respiratory tract (21, 22) . therefore, transmission of short-range airborne and inhalable aerosols could explain the seemingly contradictory finding that there are viruses in the air and transmission between individuals without contact, but lack of convincing clinical evidence of classic airborne transmission (i.e., long-distance ranges and superiority of respirators). this size range could exhibit behaviors typical of both droplets and aerosols: higher viral load, airborne behavior, inhalation, and deposition in the nose. despite relatively shorter suspension time, inhalable aerosols become especially significant in the case of prolonged exposure and close proximity. in addition, they are less likely to follow air streams through leaks in the nonfitted mask, nor make it down to alveolar space, because of larger size, but rather will remain in nasal cells due to natural impaction processes. consequently, tight seals and superior filtration would not be required in most low-risk settings, as masks (with the help of face shields) could readily block these airborne particles. however, different categories of hcws may not be exposed to the same level of risk: an attendant who spends an hour feeding, bathing and positioning a patient will be at much higher risk of inhaling aerosols compared to a doctor who questions and examines a patient for 10 min. finally, ventilation parameters (air exchange rate, flow direction, and airflow patterns) would play a role, since they could contribute to enhancing or reducing airborne suspension and transmission (181) . this model is difficult to assess given the short-range distance and the short airborne stability, as well as the alteration of particle size during most air sampling processes (desiccation and impaction in liquid). however, we believe this novel paradigm, which departs from the outdated aerosol/droplet dichotomy, more accurately portrays the reality of naturally generated viral particles and the nuances in transmission patterns. broadening the "airborne" definition to inhalable aerosol exposure in the context of proximity care, and considering inhalation as a significant route of entry for the sars-cov-2 virus, could open up new paths of exploration. in summary, traditional droplets (larger particles with ballistic behavior that deposit onto surfaces), as well as our newly defined inhalable aerosols (particles that can be suspended, breathed in, and impacted at the nose, at the location of highest infectivity), could be the predominant modes of transmission of sars-cov-2. classic respirable aerosols, even if present, seem unlikely to be significant in routine health care contexts, possibly due to insufficient quantity, inactivation during aerosolization or shortly after, inability to colonize lower airways, and/or adequate blockage by masks (especially in combination with face shields). in the light of this revised model and the cumulative data analyzed in this review, in line with several major countries' guidelines, current droplet and contact precautions appear to adequately protect hcws in most non-agp settings, with perhaps the exception of proximity caretakers in poorly ventilated settings. nonetheless, since the health and lives of hcws depend on our better understanding of sars-cov-2, further investigation into all possible routes of transmission-whether airborne, fomite, or fecal-is warranted, especially in settings where they could synergistically contribute to outbreaks (e.g., long-term-care facilities). transmission of sars-cov-2: implications for infection prevention precautions. world health organization covid-19 outbreak associated with air conditioning in restaurant turbulent gas clouds and respiratory pathogen emissions: potential implications for reducing transmission of covid-19 covid-19: effects of environmental conditions on the propagation of respiratory droplets recognition of aerosol transmission of infectious agents: a commentary air quality: particle size fraction definitions for health-related sampling a rosetta stone for understanding infectious drops and aerosols aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review niosh guide to the selection and use of particulate respirators visualizing speechgenerated oral fluid droplets with laser light scattering characterization of expiration air jets and droplet size distributions immediately at the mouth opening size distribution and sites of origin of droplets expelled from the human respiratory tract during expiratory activities origin of exhaled breath particles from healthy and human rhinovirus-infected subjects aerosol emission and superemission during human speech increase with voice loudness individual variation in susceptibility or exposure to sars-cov-2 lowers the herd immunity threshold the airborne lifetime of small speech droplets and their potential importance in sars-cov-2 transmission estimation of viral aerosol emissions from simulated individuals with asymptomatic to moderate coronavirus disease 2019 the role of particle size in aerosolized pathogen transmission: a review exhalation of respiratory viruses by breathing, coughing, and talking infectious virus in exhaled breath of symptomatic seasonal influenza cases from a college community hca lung biological network. 2020. sars-cov-2 entry factors are highly expressed in nasal epithelial cells together with innate immune genes sars-cov-2 reverse genetics reveals a variable infection gradient in the respiratory tract medical masks versus n95 respirators for preventing covid-19 in healthcare workers: a systematic review and meta-analysis of randomized trials use of n95, surgical, and cloth masks to prevent covid-19 in health care and community settings: living practice points from the american college of physicians (version 1) masks for sars-cov-2 and health care worker protection clinical microbiology reviews prevention of respiratory virus infections, including sars-cov-2, in health care and community settings effectiveness of n95 respirators versus surgical masks against influenza: a systematic review and meta-analysis medical masks and respirators for the protection of healthcare workers from sars-cov-2 and other viruses covid-19 pandemic and personal protective equipment shortage: protective efficacy comparing masks and scientific methods for respirator reuse personal protective equipment for healthcare workers during the covid-19 pandemic risk of sars-cov-2 transmission by aerosols, the rational use of masks, and protection of healthcare workers from covid-19 a scoping review of surgical masks and n95 filtering facepiece respirators: learning from the past to guide the future of dentistry a rapid systematic review of the efficacy of face masks and respirators against coronaviruses and other respiratory transmissible viruses for the community, healthcare workers and sick patients the need of health policy perspective to protect healthcare workers during covid-19 pandemic. a grade rapid review on the n95 respirators effectiveness facial protection for healthcare workers during pandemics: a scoping review a randomized clinical trial of three options for n95 respirators and medical masks in health workers a cluster randomized clinical trial comparing fit-tested and non-fittested n95 respirators to medical masks to prevent respiratory virus infection in health care workers respect investigators. 2019. n95 respirators versus medical masks for preventing influenza among health care personnel: a randomized clinical trial surgical mask versus n95 respirator for preventing influenza among health care workers: a randomized trial on behalf of the covid-19 systematic urgent review group effort (surge) study authors. 2020. physical distancing, face masks, and eye protection to prevent person-to-person transmission of sars-cov-2 and covid-19: a systematic review and meta-analysis association between 2019-ncov transmission and n95 respirator use investigation of nosocomial sars-cov-2 transmission from two patients to health care workers identifies close contact but not airborne transmission events covid-19 and the efficacy of different types of respiratory protective equipment used by health care providers in a health care setting covid-19 and the risk to health care workers: a case report risk of nosocomial transmission of coronavirus disease 2019: an experience in a general ward setting in hong kong low rate of severe acute respiratory syndrome coronavirus 2 spread among health-care personnel using ordinary personal protection equipment in a medium-incidence setting surgical mask to prevent influenza transmission in households: a cluster randomized trial pilot randomised controlled trial to test effectiveness of facemasks in preventing influenza-like illness transmission among australian hajj pilgrims in 2011 cluster randomised controlled trial to examine medical mask use as source control for people with respiratory illness short-term skin reactions following use of n95 respirators and medical masks respirator tolerance in health care workers contamination during doffing of personal protective equipment by healthcare providers cognitive load and performance of health care professionals in donning and doffing ppe before and after a simulation-based educational intervention and its implications during the covid-19 pandemic for biosafety detection of infectious influenza virus in cough aerosols generated in a simulated patient examination room effectiveness of surgical masks against influenza bioaerosols efficacy of face shields against cough aerosol droplets from a cough simulator active monitoring of persons exposed to patients with confirmed covid-19 -united states connecting clusters of covid-19: an epidemiological and serological investigation cluster of coronavirus disease associated with fitness dance classes coronavirus disease outbreak in call center potential transmission of sars-cov-2 on a flight from singapore to hangzhou, china: an epidemiological investigation novel coronavirus outbreak research team. 2020. investigation of three clusters of covid-19 in singapore: implications for surveillance and response measures airborne transmission of sars-cov-2: theoretical considerations and available evidence estimation of basic reproduction numbers: individual heterogeneity and robustness to perturbation of the contact function the basic reproduction number (r0) of measles: a systematic review estimation of the basic reproduction number, average incubation time, asymptomatic infection rate, and case fatality rate for covid-19: meta-analysis and sensitivity analysis coronavirus disease 2019: covid-19 estimation of the time-varying reproduction number of covid-19 outbreak in china report of the who-china joint mission on coronavirus disease 2019 (covid-19). world health organization covid-19 infections among hcws exposed to a patient with a delayed diagnosis of covid-19 transmission of infection from non-isolated patients with covid-19 to health care workers transmission risk of sars-cov-2 to healthcare workers -observational results of a primary care hospital contact tracing escalating infection control response to the rapidly evolving epidemiology of the coronavirus disease 2019 (covid-19) due to sars-cov-2 in hong kong illinois covid-19 investigation team. 2020. first known person-to-person transmission of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) in the usa transmission of covid-19 to health care personnel during exposures to a hospitalized patient a choir decided to go ahead with rehearsal: now dozens of members have covid-19 and two are dead high sars-cov-2 attack rate following exposure at a choir practice evidence for probable aerosol transmission of sars-cov-2 in a poorly ventilated restaurant community outbreak investigation of sars-cov-2 transmission among bus riders in eastern china transmission routes of covid-19 virus in the diamond princess cruise ship environmental sampling for severe acute respiratory syndrome coronavirus 2 during a covid-19 outbreak on the diamond princess cruise ship mechanistic transmission modeling of covid-19 on the diamond princess cruise ship demonstrates the importance of aerosol transmission identifying airborne transmission as the dominant route for the spread of covid-19 understanding transmission and intervention for the covid-19 pandemic in the united states covid-19: data summary. nyc health covid-19 dashboard estimation of local novel coronavirus (covid-19) cases in wuhan, china from off-site reported cases and population flow data from different sources formal request for the retraction of zhang 1,000 us adult citizens the role of community-wide wearing of face mask for control of coronavirus dis-sars-cov-2 and health care worker protection clinical microbiology reviews ease 2019 (covid-19) epidemic due to sars-cov-2 consensus document on the epidemiology of severe acute respiratory syndrome (sars). world health organization evidence of airborne transmission of the severe acute respiratory syndrome virus environmental transmission of sars at amoy gardens cluster of sars among medical students exposed to single patient detection of airborne severe acute respiratory syndrome (sars) coronavirus and environmental contamination in sars outbreak units effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (sars) sars among critical care nurses intubation of sars patients: infection and perspectives of healthcare workers illness in intensive care staff after brief exposure to severe acute respiratory syndrome lack of sars transmission among healthcare workers, united states lack of sars transmission among public hospital workers sars-cov-2 in environmental samples of quarantined households relative contributions of transmission routes for covid-19 among healthcare personnel providing patient care aerosol and surface contamination of sars-cov-2 observed in quarantine and isolation care investigating sars-cov-2 surface and air contamination in an acute healthcare setting during the peak of the covid-19 pandemic in london environmental and aerosolized sars-cov-2 among hospitalized covid-19 patients 2020. the infectious nature of patientgenerated sars-cov-2 aerosol viable sars-cov-2 in the air of a hospital room with covid-19 patients temporal dynamics in viral shedding and transmissibility of covid-19 methods for sampling of airborne viruses aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 persistence of severe acute respiratory syndrome coronavirus 2 in aerosol suspensions as many as half of europe's covid-19 deaths were people in long-term care facilities they're death pits": virus claims at least 7,000 lives in u.s. nursing homes. the new york times investigators look into catastrophic outbreak that infected all residents of tmr seniors' home, killing 70 outbreak of covid-19 in a nursing home associated with aerosol transmission as a result of inadequate ventilation temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by sars-cov-2: an observational cohort study viral load dynamics and disease severity in patients infected with sars-cov-2 in zhejiang province guide covid-19 pour les médecins en chsld usp ϭsharing. accessed 1 nursing homes are ground zero for covid-19 pandemic clinical characteristics of older patients: the experience of a geriatric short-stay unit dedicated to patients with covid-19 in public health-seattle & king county, cdc covid-19 investigation team. 2020. asymptomatic and presymptomatic sars-cov-2 infections in residents of a long-term care skilled nursing facility asymptomatic sars-cov-2 infection in belgian long-term care facilities lessons from mass-testing for covid-19 in long-term care facilities for the elderly in san francisco for-profit long-term care homes and the risk of covid-19 outbreaks and resident deaths restoring trust: covid-19 and the future of long-term care recommended ppe for healthcare workers by secondary care inpatient clinical setting, nhs and independent sector coronavirus disease (covid-19): for health professionals. public health agency of canada french society for hospital hygiene and the high council for public health. 2020. what face mask for what use in the context of covid-19 pandemic? the french guidelines prevención y control de la infección en el manejo de pacientes con covid-19 respiratory and facial protection: current perspectives in the context of the covid-19 pandemic national guidelines for public health units surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (covid-19) infection prevention and control and preparedness for covid-19 in healthcare settings infectious diseases society of america guidelines on infection prevention for health care personnel caring for patients with suspected or known covid-19 interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings transmission modes of severe acute respiratory syndrome coronavirus 2 and implications on infection control: a review current knowledge of covid-19 and infection prevention and control strategies in healthcare settings: a global analysis contact tracing assessment of covid-19 transmission dynamics in taiwan and risk at different exposure periods before and after symptom onset inesss. 2020. covid-19 et détection moléculaire du sars-cov-2 chez les individus asymptomatiques. inesss follow-up of asymptomatic patients with sars-cov-2 infection clinical progression and viral load in a community outbreak of coronavirus-associated sars pneumonia: a prospective study virological assessment of hospitalized patients with covid-2019 persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents aerosol and surface distribution of severe acute respiratory syndrome coronavirus 2 in hospital wards air and environmental sampling for sars-cov-2 around hospitalized patients with coronavirus disease 2019 (covid-19) air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) from a symptomatic patient environmental contamination by sars-cov-2 in a designated hospital for coronavirus disease 2019 review article: gastrointestinal features in covid᎑19 and the possibility of faecal transmission manifestations and prognosis of gastrointestinal and liver involvement in patients with covid-19: a systematic review and meta-analysis gastrointestinal manifestations of sars-cov-2 infection and virus load in fecal samples from the hong kong cohort and systematic review and meta-analysis sars-cov-2 and health care worker protection clinical microbiology reviews gastrointestinal symptoms of 95 cases with sars-cov-2 infection toilets dominate environmental detection of severe acute respiratory syndrome coronavirus 2 in a hospital covid-19 patients in earlier stages exhaled millions of sars-cov-2 per hour national health commission key laboratory for medical virology, national institute for viral disease control and prevention, chinese center for disease control and prevention, beijing, china. 2020. notes from the field: isolation of detection of sars-cov-2 in different types of clinical specimens can a toilet promote virus transmission? from a fluid dynamics perspective probable evidence of fecal aerosol transmission of sars-cov-2 in a high-rise building coronavirus pandemic epidemiology consortium. 2020. risk of covid-19 among front-line health-care workers and the general community: a prospective cohort study using virus sequencing to determine source of sars-cov-2 transmission for healthcare worker oude munnink bb, kluytmans van den bergh mfq, koopmans mpg. 2020. covid-19 in health-care workers in three hospitals in the south of the netherlands: a cross-sectional study first experience of covid-19 screening of health-care workers in england characteristics and transmission dynamics of covid-19 in healthcare workers at a london teaching hospital universal masking is an effective strategy to flatten the sars-2-cov healthcare worker epidemiologic curve rational use of face mask in a tertiary care hospital setting during covid-19 pandemic: an observational study infection prevention and control compliance in tanzanian outpatient facilities: a cross-sectional study with implications for the control of covid-19 assessing hand hygiene compliance among healthcare workers in six intensive care units systematic review of studies on compliance with hand hygiene guidelines in hospital care comparison of perceived and observed hand hygiene compliance in healthcare workers in mers-cov endemic regions committee on personal protective equipment for healthcare personnel to prevent transmission of pandemic influenza and other viral respiratory infections hierarchy of controls transmission of covid-19 virus by droplets and aerosols: a critical review on the unresolved dichotomy réduction du risque de transmission du coronavirus sars-cov-2 par la ventilation et gestion des effluents des patients. haut conseil de la santé publique how can airborne transmission of covid-19 indoors be minimised? inspq. 2020. covid-19: mesures de prévention et contrôle des infections pour les milieux de soins aigus: recommandations intérimaires. inspq it is time to address airborne transmission of covid-19 the long-term care crisis: how b.c. controlled covid-19 while ontario, quebec face disaster rapid responses in the emergency department of linkou chang gung memorial hospital, taiwan effectively prevent spread of covid-19 among healthcare workers of emergency department during outbreak: lessons learnt from sars preventing intra-hospital infection and transmission of coronavirus disease 2019 in health-care workers aerobiology and its role in the transmission of infectious diseases airborne transmission of communicable infection: the elusive pathway ventilation control for airborne transmission of human exhaled bio-aerosols in buildings grade handbook effectiveness of surgical and cotton masks in blocking sars-cov-2: a controlled comparison in 4 patients effectiveness of surgical, kf94, and n95 respirator masks in blocking sars-cov-2: a controlled comparison in 7 patients respiratory virus shedding in exhaled breath and efficacy of face masks potential utilities of mask-wearing and instant hand hygiene for fighting sars-cov-2 respiratory source control using a surgical mask: an in vitro study influenza virus aerosols in human exhaled breath: particle size, culturability, and effect of surgical masks testing the efficacy of homemade masks: would they protect in an influenza pandemic assessment the protection performance of different level personal respiratory protection masks against viral aerosol quantifying exposure risk: surgical masks and respirators a quantitative assessment of the efficacy of surgical and n95 masks to filter influenza virus in patients with acute influenza infection novel coronavirus outbreak research team. 2020. detection of air and surface contamination by sars-cov-2 in hospital rooms of infected patients aerodynamic analysis of sars-cov-2 in two wuhan hospitals is the coronavirus airborne? experts can't agree exhaled breath condensate: an overview sars-cov-2 rna detection in the air and on surfaces in the covid-19 hospital indoor air quality monitoring for the detection of sars-cov-2 (covid-19) virus environmental contamination of sars-cov-2 on surfaces, air-conditioner and ventilation systems a field indoor air measurement of sars-cov-2 in the patient rooms of the largest hospital in iran aerosol and environmental surface monitoring for sars-cov-2 rna in a designated hospital for severe covid-19 patients we thank magali-wen st-germain for the original design, creation, and development of fig. 1 , as well as patrick lane, sceyence studios, for the final version of fig. 1 . we thank stéphanie langevin, quoc dinh nguyen, luc trudel, and jean barbeau for their contribution in reviewing the original manuscript.both authors substantially contributed to the conception, design, analysis, and interpretation of data, as well as reviewing and approving the final version of the manuscript. we agree to be accountable for the contents.c.d. is holder of tier-1 canada research chair on bioaerosols. for this review article, we received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.we declare that we do not have commercial or financial relationships that could, in any way, lead to a potential conflict of interest with regard to this publication. key: cord-280419-odqo3o4w authors: gibbons, john p.; hayes, joshua; skerritt, conor j.; o’byrne, john m.; green, connor j. title: custom solution for ppe in the orthopaedic setting: retrofitting stryker flyte t5® ppe system date: 2020-10-26 journal: j hosp infect doi: 10.1016/j.jhin.2020.10.016 sha: doc_id: 280419 cord_uid: odqo3o4w the covid-19 pandemic has meant that there is growing pressure on hospital resources not least the availability of appropriate personal protective equipment (ppe), specifically, facemasks and respirator masks. within the field of orthopaedic surgery, it is a common sight to see orthopaedic surgery carried out in “space suits” (ss) which comprise of a helmet, hood and surgical gown. in this study the authors made modifications to two different ss systems to incorporate high-efficiency particulate air (hepa) filters to the inlets to the fan to assess their potential as a method of providing a reusable system for ppe for the surgeon with regard to protection from a respiratory droplet spread virus. the testing was carried out using particle counter upstream and downstream on a manikin wearing two different ss systems with and without modifications to the inlet. the results show that using a layer of hepa filter cut to size, and sealed to the inlet for the fan in the helmet will reduce the downstream particulate at the user’s mouth by over 99.5% which is equivalent to that of a respirator mask. hepa filter material is relatively cheap and can be used repeatedly making this a viable alternative to disposable, and even re-sterilized, respirator masks in the setting of a respiratory droplet spread viral pandemic. the emergence of the novel coronavirus covid-19 as a pandemic affecting most of the world's population has led to concern regarding an international shortage of personal protective equipment (ppe). the world health organisation (who), in recent guidance with respect to rational use of ppe, stated that: "the current global stockpile of ppe is insufficient, particularly for medical masks and respirators" (1). current advice from a number of bodies is that the use of ffp2 or n95 respirator masks with eye protection as well as gloves and gowns for specific procedures of which orthopaedic surgery is included (2) (3) (4) . more recently, guidance for all healthcare workers (hcws) has advised that any person working within 2 metres of any patient who is suspected or confirmed covid positive, should be using a respirator mask (4) (5) (6) . the use of respirator masks, such as n95 and ffp2 which provide at least 95% and 94% filtration of particles 0.3 μm, is advised based on the best and most broadly available masks to hcws in terms of filtration of particles and that they offer a seal to the face. it is, however, not without its own limitations, as these masks are not custom made for face-fit to the individual, and require a face-fitting procedure, which has been shown to have limitations (7) . the mean diameter of the coronavirus has been reported to be 78nm (8) . the filter efficiency of the n95 and ffp2 respirator masks relate to their ability to effectively filter submicron particles and are standardised against uncharged particles of sodium chloride measuring 300nm or airborne staphylococcus aureus (7, 9) . there are studies that have questioned the validity of using these masks in providing protection against viruses and that the performance of such masks may underestimate the penetration of nanosized virions (7) . high-efficiency particulate air (hepa) filters are standardised against the same particle size for their certification and are 99.97% efficient in their filtration, a study by nasa showed that hepa filters are also efficient for particles in the size range of virions at one magnitude less in size, c. 10nm (10) . the possibility of a global shortage of ppe, including facemasks, has led to bidding wars amongst governments to acquire ppe for the health care workers, the irish government have stated this in no j o u r n a l p r e -p r o o f uncertain terms (11). we are now very much reliant on external supplies of ppe, it is imperative that we design methods to be more self-reliant should this particular pandemic endure or resurface, and be prepared for future pandemics. there are protocols being developed with regards to the standardization of sterilization of face masks that show acceptable retention of the efficiency of the filtration after 5 cycles (12, 13) . there are limitations with regard to re-sterilization, namely, that the masks may suffer mechanical damage during the process, disposable masks are often not face-fit for the individual and the fit may be damaged by the process. sterilization of a mask is not performed if there is gross contamination of the mask, which, in the setting of orthopaedic surgery would render most masks not re-usable as there is often gross contamination of the ppe with blood spatter and splash-back from lavage. orthopaedic surgery generates aerosolised human tissue, including bone and blood, through the use of power tools during procedures. these aerosol generating procedures (agps), and the inability to re-sterilise common respirators due to contamination with blood was what prompted the current authors to look at using the existing "space-suits" (ss) used in orthopaedic surgery as an alternative for re-usable masks. the research question in this paper is if retrofitting a stryker® helmet with a hepa filter at the inlet draped in the usual hood and gown would improve the ss to a point of being comparable to a n95 or equivalent mask. this is a proof of concept study using a manikin to isolate the effectiveness of the retrofitted helmet with regard to the ability to filter air coming into the ss. the experimental set up of this research involved a manikin (head and torso mounted on a stand to measure 180 cm in height) used for cpr training as the subject in all tests. the manikin was cleaned with chlorohexidine scrub prior to the experiment, all orifices other than the mouth and nose on the manikin were sealed with 3m steri-drape™. the particle detector was placed at the mouth and sealed with leucoplast sleek tape around the detector and mouth isolating it from the internal tubing j o u r n a l p r e -p r o o f of the manikin as well as taping over the nostrils of the manikin, (see figure 1 ). the detector tubing was fed out through the bottom of the manikin and sealed with 3m steri-drape™. the testing was performed in the orthopaedic theatre initially but the background particle count was found to be too low to discern a difference at the downstream penetration detector that would be reliable. the testing was then performed in the adjoining anaesthetic room and all doors and exhaust vents were closed but not sealed. an ambient recording was made to ensure that the distribution of background particulate was equal at both points for the detector in relation to the manikin without any donned ppe, which was confirmed. the ppe systems used in this study were the stryker flyte t4® and t5® (14) . both systems have a grill over the fan inlet which prevents the hood material being sucked into the inlet. the t4 helmet has a grill overlying the fan inlet that is not amenable to removal and replacement without damaging the plastic housing for this system. the grill was cut off and a housing containing a hepa filter with a rubber gasket seal was mounted over the fan inlet (see figure 2a ). the t5 helmet has a similar grill but can be removed and replaced without damage to the housing. figure 2b illustrates the experimental set up for the modified t5 system. this allowed for a hepa filter to be placed over the inlet and sealed at the periphery to the helmet and then the grill replaced to prevent the hood being sucked onto the fan (see figure 3 ). the hepa filter material was taken from the soniq ii™ system(15). the particulate testing was carried out by a certified engineer who commissions ventilation systems for surgical healthcare infrastructure in this jurisdiction. the detection equipment used, aerotrak® handheld particle counter model 9306, (tsi, minnesota, usa), is industry standard; it generates a 2.83 l/min intake and was set to read 6 channels to enable reading of all particles in the size range j o u r n a l p r e -p r o o f 0.3-10 μm. the testing protocol for each measurement of particulate penetration recorded at the mouth detector involved 4 upstream challenge samples taken for 60 seconds each at either the inlet to the stryker hood or the same point in space relative to the head for testing without the hood on. 4 samples were taken upstream to ensure that the upstream challenge was consistent and this required that all four readings are within 15% of the mean, which they were for all tests. the downstream detector reading was also taken over 60 seconds and at least three readings were taken for each experimental set up outlined below and ten readings were taken for the configurations using the modified hoods. the particulate counts were collected and tabulated using microsoft excel® and statistical analysis was performed with comparison of test configurations using student's t-test. the test configurations were performed using the following set up: ambient test -testing of background particulate to ensure similar readings at upstream and downstream with no ppe on the manikin. this test is required to ensure no difference in ambient distribution of particles around the manikin, which was confirmed. configuration 1: a stryker t4® helmet and hood and a standard surgical gown around the neck without the fan running. configuration 6: a stryker t5® helmet with the same hepa filter material cut to fit over the inlet of the t5 fan and sealed with sealant tape to the helmet housing to prevent any filter bypass, (see figure 3 ) and then draped with hood and standard surgical gown around the neck with the fan running at medium speed. in order to investigate gas levels within the modified t5 system and the non-modified t5 system with use, the second author, j.h., wore the each of the ss with serial collection of data from a standard anaesthetic machine used in the operating theatre (ge datix ohmeda asyis & ge carescape b650, finland). the experiment was carried out in an operating theatre with a functional laminar airflow system. a narrow (1.2mm diameter) pvc co2 sample tube, connected to a multi-gas analyser (ge carescape e-caio respiratory module, finland) was placed inside the hood at the level of the participants mouth to continuously measure etco2 (end tidal carbon dioxide) and eto2 (end tidal oxygen). this side-stream gas analyser draws 150ml/minute from the user's airway gas, where the co2 concentration is calculated via absorption of infrared light, according to the beer-lambert law, and oxygen concentration is calculated using paramagnetic analysis. no additional mask was worn. measures for etco2, eto2 and fio2 were recorded at 5-minute intervals with both the modified t5 system hood and the non-modified helmet. j o u r n a l p r e -p r o o f system without filter and the two generations of stryker flyte system with hepa filters modifications were performed for total of 10 readings. table 2 presents the statistical analysis using a student ttest and the significance of the differences observed. figure 4 for the stryker flyte t5® system, the ss alone provides a similar degree of protection as the previous generation of ss at 10.9% (σ=0.3%), which was not significantly different from the t4 system. similar to the t4 system above, once the fan was turned on the penetration downstream increased to 20.54% (σ = 3.78%), again this was not statistically significantly different to the t4 system with the fan operating. with the modification of the hepa filter to the inlet of the t5 helmet as described, the downstream penetration was reduced to 0.46% (σ = 0.24%) which is significantly better than all other test configurations and offers a particulate filtration similar to ffp3 and n99 or other equivalent respirator mask. figure 5 illustrates the downstream penetration for each experimental set up for each of the 6 channels recorded by the aerotrak® particle counter, showing that there was less than 0.5% penetration at all particle sizes for the modified t5 system. an additional experiment was run with the addition of an impenetrable cover over the hood except for the area over the inlet did not significantly improve the efficiency leading one to conclude that the positive pressure experienced in the ss provides enough pressure to negate any possible infiltration of particulate though the hood material not directly over the fan inlet. the results of the gas measurement testing are outlined in table 3 and illustrated in figures 6-8. etco2 remained steady state throughout the recording. the level of etco2 was higher in the modified t5 system compared to the non-modified t5 system (see figure 6 ). fio2 appeared to be slightly lower under the modified t5 system compared to the non-modified t5 system. fico2, the inspired concentration of carbon dioxide, is normally 0. it was observed that the use of both systems results in an increase in fico2 (see figure 7) . the normal fio2 level is 21% and the readings demonstrated that there is a reduction in fio2 with both modified and non-modified ss use (see figure 8 ). the user did report mild discomfort when wearing the modified hoods however this was rated equivalent to wearing a regular ffp3 mask. the results of this study show that the ss operating without a fan offer close to 90% reduction in downstream penetration of particles, however, once the fan is turned on the downstream penetration increases to 20-25% for the t4 and t5 systems respectively. when the modifications using hepa filter at the inlet to the fans described in this study are implemented there is a significant reduction in downstream penetration, specifically, for the t5 system the downstream percentage penetration is less than 0.5% which is comparable with that offered by respirator masks. the hepa filters have a significantly greater life-span compared with respirator masks even with the potential re-sterilization of masks (12, 13) . this is a pilot study of the potential modification of ss with hepa filters and would require further testing to confirm a recommended life-span for operating, establishing timing of regular quality assurance checks on the efficacy of the filters, and possible further modification of the inlet to protect the hepa filter material (16, 17) . derrick et al previously looked at the feasibility of the ss with regards to their use as a method of ppe (18) . they had concluded that the stryker t4® suit alone was insufficient to protect the hcw in j o u r n a l p r e -p r o o f relation to submicron particles (18) which is confirmed in the results of this study for non-modified ss. their comparative was using volunteers using either a stryker t4® ss to that of a combination of a n100 filtering facepiece respirator combined with a surgical facemask and a full-face shield. in their methodology the detector was placed in the breathing zone for the ss, 1 cm below the bottom edge of the transparent face piece whilst for the facepiece respirator the probe was passed through both the respirator and covering surgical mask 1 cm to the right of the valve. there are a number of confounders to the results observed that could result from such in vivo testing, being: 1. the detector in the surgical mask is not necessarily replicating the possible true particles entering the mouth allowing for possible entrainment of surrounding air if there is even the slightest breach in the face-fit (7); 2. similarly, the detector for the ss was placed in the breathing area, not at the mouth, and their study design would not account for the possibility of particles from the subject's hair or skin counting towards the readings given that the ss offers a positive pressure environment from the top of the hood downwards. currently, for most jurisdictions, the recommendation is for the use of respirator facemasks when dealing with suspected or confirmed cases of sars-cov-2(4). a respirator mask is reliant on the adequacy of the face-fit, however, studies have shown that the adequacy of a face-fit even in controlled environments is variable and can depend on the respiratory rate of the user as well as the position of the user(7). there is previous work with regard to ss in relation to the effect of the positive pressure exerted within the suit; and the pressure that this can exert all the way down to any breach including the glove sleeve interface (19, 20) . although these tests were carried out on a static manikin, the air provided to the user is that of a highly filtered positive pressure source with less than 0.5% particle penetration which is not reliant on a face-fit, rather, the mechanical seal that is then protected by the plastic housing in the helmet that remains static. the reason that a manikin is used in this study is to assess the efficiency of the ss as a form of ppe using the detection methods for downstream penetration of the ambient environment. a manikin reduces the shedding of the millions of particles that would occur from forced air being pushed over the users head/hair/face, as well as the particles breathed out by a living person, hence changing the microenvironment within the ss, that would not be accounted for upstream and therefore give a systematic bias that could influence the findings that would pull into question the efficiency of the filtration system between the outside environment and inside the ss. we feel that this is a valid method to assess the modified ss at acting as a form of ppe for the user by reducing the confounding factor of having a person breathing and shedding particles that would inherently change the microenvironment inside the ss downstream of the hepa filter that is responsible for protecting the user. another possible benefit to the use of these modified ss in the orthopaedic setting during this pandemic and in the setting of any possible blood borne viruses is that the ss would provide further reassurance to the operating surgeon who may be cutting bone and creating aerosolised blood and tissue material. although the possibility of transmission of sars-cov-2 is not yet known, coronavirus rna has been detected in blood donation samples and there is a theoretical risk of transmission(21, a more recent study, by erickson et al. has used a 3-d printed inlet manifold with hepa filters, retrofitted to the helmet, to provide a hepa filtered airflow to the user (23) . this study did not provide details on the particulate filtered but stated that it was independently verified to meet hepa standards (23) . the system used adds to the overall volume and weight of the hoods and has two plastic hoses that exit the toga posteriorly that could jeopardise sterility of a surgical field. in contrast the setup described for the t5 system in this study does not add any further encumberment to the user and under the hood there can be no difference in the outward appearance compared to a non-modified ss. it appears that both modified stryker hoods are safe to use with no appreciable interval increase in etco2 or fico2 with time. etco2, an approximation of arterial carbon dioxide concentration, appears to be slightly higher with use of the modified t5 system, however, it does not continue to increase with time. we speculate that the increase in fico2 may be due to a reduced fresh gas flow as a result of the additional hepa filter. this does not appear to impact respiration over a prolonged period as there was no significant interval deterioration in gaseous exchange noted over the duration of the study. similarly, the normal fio2 level is 21% and the readings demonstrated that there is a reduction in fio2 with both modified and non-modified systems. however, although the fio2 is reduced in both systems the reductions are steady state with respect to time suggesting that there is adequate ventilation sufficient to keep up with the oxygen consumption of the user. the purpose of this study was to evaluate if the ss could be used as a reasonable alternative to facemask ppe. this study uses the well-established ss used in routine orthopaedic surgery to potentially provide a solution to such a shortage. by fitting a ss with a hepa filter that can be used for months at a time before needing to be assessed or changed, the orthopaedic surgeon can be one less hcw for facemask ppe requirements and use. this study is a proof of concept study and by no means rigorous in the testing and validation required for mass roll-out, but it does, validate and provide evidence that this solution could be used safely as ppe in the setting of a respiratory droplet spread, viral pandemic. the gown material without a hepa filter and not operating the fan provides some protection to the user with c. 10% downstream penetration, however, the concerns of the fan raised in previous studies are valid, whereby, the suction effect allows an increase in particulate detected downstream to 25%. the ss must be operated with the fan on and so the addition of a hepa filter at the intake significantly reduces the particulate count to less than 5% for the configuration with a hepa filter housing mounted to the helmet. the downstream penetration is even better, at less than 0.5% downstream j o u r n a l p r e -p r o o f penetration, with a hepa filter cut to the shape of the inlet and with edges sealed to the t5 helmet. the level of particulate penetration is at the level of a ffp3 mask (>99% filtration of 0.3μm particles), or equivalent can provide and greater than that of the recommended n95 respirator. for the purposes of reducing reliance on the supply of facemasks that are used in all areas of healthcare during such a pandemic the modification of the ss may present a viable alternative that would be palatable to orthopaedic surgeons. of personal protective equipment for coronavirus disease ( covid-19) and considerations during severe shortages: interim guidance management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic. british orthopaedic association intraoperative recommendations when operating on suspected covid infected patients. royal college of surgeons in ireland evaluating the national ppe guidance for nhs healthcare workers during the covid-19 pandemic guidance on the use of surgical masks in the healthcare setting in the context of the covid-19 pandemic health service executive when to use a surgical face mask or ffp3 respirator do n95 respirators provide 95% protection level against airborne viruses, and how adequate are surgical masks? ultrastructural characterization of sars coronavirus respiratory protection against bioaerosols: literature review and research needs submicron and nanoparticulate matter removal by hepa-rated media filters and packed beds of granular materials. 2016. 11. rte. hse seeks to accelerate ppe deliveries but warns supply remains challenging 2020 is there an adequate alternative to commercially manufactured face masks? a comparison of various materials and forms sterilization of disposable face masks by means of standardized dry and steam sterilization processes; an alternative in the fight against mask shortages due to covid-19 flyte personal protection system: stryker orthopaedic instruments hepa filter replacement experience in a biological laboratory survival of microorganisms on hepa filters surgical helmets and sars infection does the use of laminar flow and space suits reduce early deep infection after total hip and knee replacement? the ten-year results of the new zealand joint registry does modern space suit reduce intraoperative contamination in total joint replacement? an experimental study coronavirus disease 2019: coronaviruses and blood safety severe acute respiratory syndrome coronavirus 2 rna detected in blood donations helmet modification to ppe with 3d printing during the covid-19 pandemic at duke university medical center: a novel technique there was no funding received for the production of this paper by the present authors.j o u r n a l p r e -p r o o f key: cord-028595-p7cn71t5 authors: croser, david title: a good fit with indemnity date: 2020-07-06 journal: bdj in pract doi: 10.1038/s41404-020-0444-2 sha: doc_id: 28595 cord_uid: p7cn71t5 nan a nyone reading the bda's advice since the covid-19 pandemic began will have understood the benefit of a triage interview with patients in order to make the best use of time and resources when face to face treatment is indicated. furthermore, a risk assessment of the patient and the treatment required allows the clinician to plan the most efficient allocation of valuable surgery time between episodes of low risk procedures and higher risk aerosol generating procedures (agps) that require a higher standard of personal protective equipment (ppe). the standard operating procedure (sop) documents provided by the four chief dental officers recognise that their guidance requires local interpretation according to individual surgery premises, the layout and capacity. 1 the dental team is expected to use their clinical judgement when applying this guidance. in that respect, the choice of ppe when working with patients has to be matched to the level of risk perceived by the team. non-agp treatment of all patients involves compliance with standard infection control procedures. this will ensure there is no contact or droplet transmission of covid-19. eye protection, disposable fluidresistant surgical mask, disposable apron and gloves should be worn. although it is recommended that agps should currently be avoided where possible, there will be occasions when such treatments are in the patient's best interests and the dental team will need to prevent aerosol transmission, using a disposable, fluidrepellent surgical gown (or waterproof long-sleeved protective apron), gloves, eye protection and suitable respiratory protective equipment (rpe) such as an ffp3 respirator (or ffp2 when these are not available). the respirator worn by those undertaking or assisting in the procedure should have been previously fit-tested. fit testing of ppe may be performed by dental staff with appropriate training, or third party contractors that specialise in such services. the sop guidance advises contractors to inform their employers liability (el) insurer that all staff undertaking aerosol generating procedures are required to be fit tested for appropriate ppe, to ensure their el insurance cover is sufficient. in addition, dentists should check with their indemnity provider if they are performing the fit testing for their own staff or that of other local dental contractors, again to ensure they have adequate cover. it might be helpful if the gdc would recognise fit-testing as part of the practise of dentistry -just as they do for the management of other medical emergencies. this might allow a more uniform response from the indemnity providers who with one exception have not responded to the need for dentists and practice owners to have clarity on this matter. so it was reassuring to receive an email from the bda indemnity team confirming that they recognise fit testing as an essential part of safe dental practice together with an assurance that it is covered under the definition of dental services included in their policy and at no extra charge. 2 bda indemnity cover allows policyholders to fit-test respiratory protective equipment (rpe) for dental staff in their own and other practices. plus, the practice owner's policy will cover an employee in their own practice to do fit testing. those wishing to become a fit tester should be trained to the standards set by the british safety industry federation and be accredited as a fit tester for rpe. 3 there is an obligation to maintain your competence by regular refresher training and updates just as you would for life support. a record of rpe training should be stored as part of your continuing professional development. the bda provides more information about fit testing in its returning to work toolkit. 4 each dental practice operates in a local community and in many cases have been part of that local fabric for many years. patients build up huge amounts of trust in those practices and create strong bonds with them. this toolkit is about strengthening those bonds and reinforcing goodwill. at a time when the footfall through the practice is likely to be lower than before there will be financial implications for the patients and clinicians alike. many patients will face a degree of hardship until the uk economy recovers and there is likely to be a drop in the discretionary spend on elective treatments. in addition, there will be additional costs to the dentist from cross-infection protocols required to mitigate the risk of covid-19. let alone the drop in hourly income that will flow from treatments and the associated donning and doffing of ppe. the experience of indemnity providers during previous episodes of economic downturn has usually been a rise in the number of claims and complaints that they are asked to manage on behalf of the dental profession. hopefully things will be different in the face of this pandemic but you can probably see there will always be an element of temptation for some patients to see if they can reduce the cost of treatment by getting a refund by complaining about the work that was done or the way in which it was provided. the best way to counter those tactics is to reduce the level of patient expectations from the start. by under-promising what you know to be possible you will subsequently be seen to over-perform when you complete the patient's treatment. private hospitals may well bill their patients for all the disposable items used in their treatment, but your patient may be irritated to see an extra figure to cover two sets of disposable ppe. over time, it is likely that ppe costs will come down again whilst the requirement to wear higher grade ppe may change depending on further research into dental aerosols and immunity for dental teams either developed naturally or through vaccines. ◆ covid-19 guidance and standard operating procedure british dental association. dentists' professional liability insurance fit2fit. fit2f accreditation. available online at: www.fit2fit.org available online at: www.bda.org/advice/coronavirus/ pages/returning-to-work key: cord-302463-uw7xantz authors: ağalar, canan; öztürk engi̇n, derya title: protective measures for covid-19 for healthcare providers and laboratory personnel date: 2020-04-21 journal: turk j med sci doi: 10.3906/sag-2004-132 sha: doc_id: 302463 cord_uid: uw7xantz in the covid-19 pandemic, which affects the whole world, healthcare professionals (hcp) are at high risk of transmission due to their direct contact with patients with covid-19. therefore, how to ensure the triage of the patient with acute respiratory symptoms should be determined in advance, the contact distance should be arranged to be at least 2 m, covid-19 suspect or diagnosed patient should be instructed to wear a surgical mask. during the care of these patients, hcp should wear their personal protective equipment (ppe) in accordance with the procedure and should not neglect hand hygiene. the samples of the patient with known or suspected covid-19, patient should also be known to be risky in terms of contamination, and a risk assessment should be performed for the procedures to be performed in laboratories. the ppe should be used in accordance with the procedure to be performed. the protection of the hcp, who sacrifice at the risk of life, is possible only by complying with infection control and precautions. the novel coronavirus (covid-19) carries a high risk for society and healthcare providers (hcp) because it can be transmitted even when the disease progresses asymptomatically in some patients [1] . the main sources of infection are infected people. the virus is transmitted through droplets and close contact. it is believed that infectivity starts before the symptoms and it significantly decreases 7 days after the onset of symptoms. it is reported that the infectivity period depends on the severity and the stage of the infection of the patient. this virus can survive on nonliving surfaces in 22-25 °c and 40-50% relative humidity for up to 5 days and this increases the risk of infection. aerosol transmission is also possible [2] . in a study, it has been shown that the virus can remain alive in the aerosol for up to 3 h after aerosol generating procedures and could be detected [3] . the usage of personal protective equipment (ppe) reduces the risk of transmission but does not fully eliminate it. in china, it has been reported that 2055 hcp working in 476 different hospitals, mainly from hubei (88%), have been infected with covid-19 from december 18, 2019 to february 20, 2020 . it is emphasized that the reason for this high rate of infection among hcp stems from shifts that last more than 10 h a day due to the large number of patients and serious staff shortages. furthermore, excessive fatigue and stress weaken the immune system and therefore, increase the sensitivity to covid-19. as the infection widened rapidly, it is reported that there has been a rapid decrease in the availability of ppe, and a rapid increase in infection in hcp that resulted in a higher rate of transmission among visitors, personnel, and patients [4] . in a study with 138 patients from china, it was demonstrated that 57 patients (41.3%) were infected in the hospitals, among these patients 17 (12.3%) of them were in the hospital for other reasons and 40 (29%) of them were hcp [4] . among these infected hcp, 31 (77.5%) were working in clinical services, 7 (17.5%) in emergency service, and 2 (5%) in intensive care units (icu), respectively [5] . in order to prevent the transmission from patient to healthcare workers, the necessary precautions should be taken that comprise the whole process, which start with the admission of the patient to the hospital [6] . further, procedures like elective surgeries and routine check-ups should be postponed. for acute respiratory infection symptoms (aris) admissions triage protocols should be created [6, 7] . these protocols start with restriction of entry points to the hospitals. the patients who come to the hospitals should be given face masks and be told to wear them at all times. hcp should be fully equipped with ppe and should be ready. the patients who are suspected of covid-19 should be isolated safely and rapidly [6] . hospital entrances, patient rooms, and waiting rooms should be equipped with hand disinfectants that are 60-95% alcohol and waste containers that can be used without contact. a physical barrier made of glass or plastic should be placed in order to separate triage personnel and possible infectious patients to restrict close contact. examination rooms should be big enough so that there can be 2 m between the hcp and the patient. these rooms should also be available for ventilation [6] . hcp that has been in close contact with or work in care of a covid-19 patient is under risk of getting infected by covid-19. centres for disease control and prevention (cdc) defines close contact as, being in the same environment with an infected person without maintaining the 2 m minimum distance and being in direct contact with secretions of the infected person [6] . the national interim guideline of ireland defines close contact as being in face to face contact with a diagnosed covid-19 patient without maintaining 2 m distance for more than 15 min. the same guideline also defines performing any procedure that produces aerosol without necessary ppe or being in this room while this procedure is taking place without the necessary ppe, or any contact with the patient, bodily fluids of the patient or laboratory samples of the patient without using necessary ppe as close contact [8] . transmission from hcp to hcp is as important of a transmission way as from patient. one of the measures that will reduce the risk of transmission among hcp is creating teams among providers who work in hospitals and labs. by doing this, social distancing can be maintained, and the risk of cross-infection can be reduced. all hcp should be checked twice a day for aris symptoms, and body temperature to increase the chances of early diagnosis. if a member of the team is infected with covid-19, all close contacts should take quarantine measures [9] . hcp should take protective measures assuming that everyone is potentially infected or is colonized with a pathogen that can be transmitted in a healthcare environment [6] . in order to prevent covid-19 transmission hcp should take additional measures for contact during aerosol generating procedures (agps) alongside standard measures for droplets, close contact, and airborne transmission [10] . one of the primary measures that will reduce the transmission in health institutions is ensuring hand hygiene [1] . hcp should ensure their hand hygiene before and after contact with a patient, after contact with potentially infected material, and before and after using ppe. since bare hands can get contaminated while taking off ppe, performing necessary steps to ensure hand hygiene is of great importance. hcp should wash their hands or at least 20 s using soap and water or should disinfect their hands with 60-95% alcohol-based hand disinfectant. if the hands got visibly contaminated, they should be washed with soap and water [6, 10] . the hand hygiene should also be ensured before and after going into icus [11] . ineffectiveness of ppe may contribute to nosocomial transmission of covid-19 [12] . hcp should be educated on when to use which ppe, how to put on, take off, and change them by themselves to prevent contamination and on how to properly discard and disinfect this equipment. health institutions should have procedures and policies that describe the correct order of donning and doffing these ppe in a safe manner [6] . the order for donning the ppe after performing hand hygiene is gown, mask, goggles, face shield, and gloves; the order for doffing the ppe is gloves, face shield, goggles, gown and mask. the mask should be kept until the hcp leaves the contaminated area. the mask should be properly taken off once the contaminated area is left, furthermore it is important not to neglect hand hygiene once all of these items are removed [11] . the ppe that should be used for hcp according to the procedures have been defined by the world health organization (who) [10] . recommendations about using of ppe are given in table [ [13] [14] [15] [16] . european centre of diseases and prevention control (ecdc) states that if there is a shortage of ffp2/ffp3, if the hcp will be in contact with a diagnosed or suspected covid-19 case, if there is no risk of aerosol transmission, surgical masks (alongside eye protection, gown, and gloves) can be used. however, ecdc states that if the hcp will be performing procedures like sample collecting that will generate aerosol, they should use ffp2/ffp3 masks that provide high-level protection [7] . unless indicated by the producer, if the mask that is being used for sample collection has not been damaged, moistened, and/or soiled, it can be used for contacting multiple patients for a maximum of 4-6 h [7] . according to the covid-19 handbook prepared by the chinese colleagues, all hcp in all health institutions should wear a medical mask. all staff working in the emergency department, the outpatient department of respiratory care, the outpatient department of infectious diseases, department of stomatology, or endoscopic examination room should wear a medical protective mask such as an n95 mask [17] . the mask should be placed on your face carefully, and there should be no gap between the face and the mask [13] . it is reported that facial hair such as the beard could prevent the mask from sitting and can lessen the protective effect [10, 11] . the transmission through the eye is not certain for covid-19 but as proven with animal experiments the transmission in this way is possible. therefore, eye protection should not be neglected and should be considered as a part of ppe [18] . hcp should wear eye protection or a disposable face shield that covers the front and sides of the face when going into a patient's room. personal eye glasses or contact lenses do not protect the eye sufficiently from the transmission. the eye protection should be taken off before leaving the patient room or care areas. reusable eye protectors should be cleaned and disinfected before reuse according to the producers' instructions [6] . when entering the patient rooms or care areas hcp should wear clean unsterile gloves. if the gloves are ruptured or contaminated hand hygiene should be ensured, and gloves should be changed with new ones. when leaving the patient rooms or care areas the gloves should be removed and hand hygiene should be ensured [6] . gloves should not be washed and reused [19] . before entering the patients' rooms or care areas hcp should wear a clean isolation gown and should change it when it gets contaminated. before leaving these areas, hcp should remove the gown and should dispose it accordingly (red waste container). reusable gowns should be washed after each use. if there is a shortage of gown, the priority should be given to agps, procedures that have the risk of spatter and have a high risk of contamination of hcp due to the possibility of pathogens' contact with hcp's clothes and hands [6] . the guideline from the united kingdom recommends the usage of disposable plastic aprons to protect the contamination during patient care. long sleeved disposable fluid repellent gowns must be worn during agps [20] . during the pandemic, one of the most important problems is the availability of ppe. in order to minimize exposure of hcp and minimize the usage of ppe, a group of personnel can be designated to work in the care of these patients [6] . hcp should not touch eye protectors and masks. when the eye protector and masks got damaged, got contaminated and when the hcp leaves the unit they should be changed, and hand hygiene should be ensured [6] . medical equipment that will be used for patients should be specific to patients and they should not be taken out of the rooms or should not be used for other patients. if the equipment like stethoscope and thermometers are being used for more than one patient they should be cleaned and disinfected after every use with, for example, ethyl alcohol (70%). two medical waste containers should be available, 1 inside and 1 outside of the patient rooms so that the used ppe can be properly discarded [16] . aerosol generating procedures are intubation, extubation and related procedures, such as manual ventilation and open suctioning of the respiratory tract, tracheotomy/ tracheostomy procedures, bronchoscopy, surgery and postmortem procedures involving high-speed devices, noninvasive ventilation (niv), e.g., bi-level positive airway pressure (bipap) and continuous positive airway pressure ventilation (cpap), induction of sputum, some dental procedures (e.g., high-speed drilling), highflow nasal oxygen (hfno), high-frequency oscillating ventilation (hfov), cardiopulmonary resuscitation [20, 21] . collection of diagnostic respiratory specimens for covid-19 is considered as an agp since it can induce coughing reflex [7] . during agps, hcp should use long-sleeved disposable fluid repellent gown (covering the arms and body), higher protection masks such as n95/ffp3 mask, full-face shield or visor and gloves on suspected and confirmed cases [6, 20] . fit test should be done before starting the procedure [22, 23] . only the necessary personnel should perform the procedures and should be allowed in the area of the procedure. these procedures should be performed in respiratory tract isolation rooms, the surfaces in these rooms should be cleaned and rooms should be disinfected after every procedure [6] . after agps the surrounding can get heavily contaminated. in an enclosed area the time for the aerosol to be cleaned depends on the presence of mechanic/natural ventilation. the time for the sufficient cleaning of aerosols (the time that has to pass until an hcp can get in the room without using ffp3 masks) depends on the air change per hour (ach) in the room. it is recommended that general wards and single rooms have a minimum of 6 ach while negative pressure isolation rooms should have a minimum of 12 ach. the higher the ach, the faster the aerosol cleaning will be. it is believed that first air change reduces the contaminants in the air by 63% and after 5 times only less than 1% of the contaminants stay in the air [14] . after the patient is discharged or transferred to another room, it is recommended to leave the room empty for 20 min before cleaning if this is a negative pressure isolation room. if this is a neutral pressure room, the windows should be opened and the room should be left that way for an hour before cleaning [14] . new and emerging respiratory virus threats advisory group (nervtag) reports that the aerosol produced during nebulization is derived from the fluid in the nebulizer and does not contain viral particles that come from the patient. according to the guideline from the united kingdom; administration of pressurizedhumidified oxygen or medication via nebulization are not considered a significant infectious risk for aerosol generation [20] . however, nebulizer therapy is considered as an aerosol generating procedure by both who and cdc [15, 24] . significant environmental contamination by patients causes nosocomial transmission of virus [25] . it has been reported that cleaning environmental surfaces and patient care equipment with water and detergent and applying disinfectants at the commonly used hospital level are sufficient and effective [26] . covid-19 is sensitive to sodium hypochlorite ( 0.1%-0.5%), 70% ethyl alcohol, povidone-iodine (1% iodine), chloroxylenol (0.24%), 50% isopropanol, 0.05% benzalkonium chloride, %1 cresol soap, or hydrogen peroxide (0.5%-7.0%) (27) . all surfaces including standard floor, walls, and objects in covid-19 isolation areas should be disinfected with solutions that have 1000 mg/l chlorine. disinfection should be performed 3 times a day and should be repeated each time there is contamination [17] . hcp that is responsible for the cleaning of the environment and disposal should wear appropriate ppe [7] . although it is recommended that all laboratory samples to be considered potentially infectious, analysis of particularly unidentified covid-19 samples may pose a risk of transmission for laboratory workers [9, 28] . all personnel should be educated about the usage of biological agents and the risks that come with them. each lab should do a risk assessment before performing the planned tests. appropriate ppe should be determined after a detailed risk assessment and should be used by lab personnel. ppe should consist of gown, gloves, eye protection, shield, and a mask that will be chosen in accordance with the risk posed by the type of procedure [29] . although most laboratory analyses are carried out with automation systems, manual touchpoints that exist in the system increase the risk of transmission and contamination. all personnel working in the laboratory should be informed about the risks that may occur. during the analysis phase, procedures should be determined to minimize the formation of aerosols and droplets [9] . in order to reduce the risk of contamination, patient sample transport should not be carried with pneumatic tubing, and before sending the sample, the lab should be informed [30, 31] . when personnel is working on blood sampling including for serological tests, they should follow applications and procedures which constitute the basis of good microbiological practices and procedures (gmpp) [29] . the highlights to be followed in relation to covid-19 laboratory biosafety are specified by who. according to who; all procedures should be performed in accordance with risk assessment by personnel who can abide by the necessary protocols. before the deactivation of any samples, the first procedure should be performed in an approved biosafety cabin (bsc) or a primary containment device. suspected or diagnosed covid-19 patients' samples should be carried as un3373-"biological substance category b" and the viral cultures and isolates should be carried as category a un2814, "infectious substance, affecting human". diagnostic procedures like sequencing or naat that do not pose the risk of transmission should be performed in bio-safety level 2 (bsl-2) labs. procedures like virus culture, isolation of the virus or neutralization experiments that carry the risk of transmission should be performed in bsl-3 labs that have air inflow. suitable disinfectants with proven efficacy against covid-19 should be used [29] . for general surface disinfection of labs, sodium hypo chloride 1000 ppm (0.1%) that has proven effective for viruses that have viral envelopes and specifically for spilled blood 10,000 ppm (%1), 62-71% ethanol, 0.5% hydrogen peroxide, quaternary ammonium compounds, and phenolic compounds can be effective for covid-19. not only the type of the disinfectant that is used but also the contact duration of the disinfectant to the surface (for example 10 min), the concentration of the active compound, and the expiration date after the preparation date of the solution is of great importance and should be given great care [29] . the necessities of biosafety measures may induce stress to the laboratory personnel. however, it is possible to reduce the risk of transmission and develop a safe working environment in the laboratory by implementing these measures [9] . in conclusion, hcp experience other hardships like physical and mental exhaustion, stress that comes with triage decisions, and grief of losing their patients and colleagues alongside the risk of infection. it should never be forgotten that hcp is the most important source for public health [32] . prevention of the widening of the pandemic is only possible with healthy and effective hcp teams. the fact that the transmission speed being very high indicates that it is very urgent and necessary to protect the hcp. for this reason, it is very important that health authorities take a series of urgent measures like giving importance to the safety of the hcp, guidance on how to use ppe properly, increased support in terms of logistics and providing medical equipment, and application of developed disinfection techniques for the hotels that the hcp will reside in throughout the pandemic [4] . european centre for disease prevention and control. novel coronavirus disease 2019 (covid-19) pandemic: increased transmission in the eu/eea and the uk-sixth update transmission characteristics and principles of infection prevention and control aerosol and surface stability of hcov-19 (sars-cov-2) compared to sars-cov-1 protecting healthcare personnel from 2019-ncov infection risks: lessons and suggestions. frontiers of medicine clinical characteristics of 138 hospitalized patients with 2019 novel coronavirusinfected pneumonia in wuhan, china centers for diseases control and prevention. interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings european centre for disease prevention and control. infection prevention and control for covid-19 in healthcare settings 12 covid-19). nationa linterim guidelines for public health management of contacts of cases of covid-19 practical laboratory considerations amidst the covid-19 outbreak: early experience from singapore world health organization. infection prevention and control during health care when covid-19 is suspected: interim guidance covid-19 in intensive care. some necessary steps for health care workers aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review protecting healthcare workers from sars-cov-2 infection: practical indications reducing the risk of transmission of covid-19 in the hospital setting updated centers for diseases control and prevention. interim u.s. guidance for risk assessment and public health management of healthcare personnel with potential exposure in a healthcare setting to patients usa: cdc public health general directorate. covid-19 (sars-cov-2) infection guideline. covid-19 medical advisory committee study. ankara, turkey: republic of turkey ministry of health handbook of covid-19 prevention and treatment can the coronavirus disease 2019 (covid-19) affect the eyes? a review of coronaviruses and ocular implications in humans and animals uk coronavirus covid-19 response. infection prevention and control measures guidance covid-19 personal protective equipment (ppe) updated clinical management of severe acute respiratory infection (sari) when covid-19 disease is suspected: interim guidance 13 guidelines for changes in ent during covid-19 pandemic. london: entuk centers for diseases control and prevention. coronavirus disease 2019 (covid-19). strategies for optimizing the supply of n95 respirators world health organization. modes of transmission of virus causing covid-19: implications for ipc precaution recommendations. scientific brief air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) from a symptomatic patient interim infection prevention and control guidelines for the management of covid-19 in healthcare settings. version 1 the outbreak of covid-19: an overview clinical management of severe acute respiratory infection when novel coronavirus (2019-ncov) infection is suspected: interim guidance 13 who; 2020. 30. world health organization. laboratory testing for coronavirus disease (covid-19) in suspected human cases interim guidance covid-19 guidance for sampling and laboratory investigations version 7.2. scotland: hps covid-19: protecting health-care workers the review has not been published anywhere or has not currently being assessed for publication by any journal. all the authors contributed sufficiently in the work to take responsibility for appropriate portions of the content. the authors have no competing interests to declare. it has not been received any financial support for this review. english redaction of this article was performed by ece ağalar. canan ağalar is a member of covid-19 advisory committee of ministry of health of turkey. key: cord-329268-0zhabgkt authors: savoia, e.; gori, d.; argentini, g.; neri, e.; piltch-loeb, r.; fantini, m. p. title: factors associated with access and use of ppe during covid-19: a cross-sectional study of italian physicians date: 2020-05-01 journal: nan doi: 10.1101/2020.04.24.20073924 sha: doc_id: 329268 cord_uid: 0zhabgkt objectives during the course of the novel coronavirus (sars-cov-2) pandemic, italy has reported one of the highest number of infections. nearly ten percent of reported coronavirus infections in italy occurred in healthcare workers. this study aimed to understand physicians access to personal protective equipment (ppe) and to information about their use, risk perception and strategies adopted to prevent contracting the infection. methods we undertook a cross-sectional, online self-reported survey implemented between march 31 and april 5 2020 of italian physicians. results responses were received from 529 physicians, only 13% of which reported to have access to ppe every time they need them. approximately half of the physicians reported that the information received about the use of ppe was either clear (47%) or complete (54%). risk perception about contracting the infection was influenced by receiving adequate information on the use of ppe. access to adequate information on the use of ppe was associated with better ability to perform donning and doffing procedures [or=2.2 95% c.i. 1.7-2.8] and reduced perception of risk [or=0.5, 95% c.i. 0.4-0.6]. conclusions results from this rapid survey indicate that while ramping up supplies on ppe for healthcare workers is certainly of mandatory importance, adequate training and clear instructions are just as important. globally, as the novel coronavirus (sars-cov-2) pandemic has evolved there has been a shortage of personal protective equipment (ppe) available to the healthcare workforce. 1 2 as the world health organization has warned since the beginning of march, disruption to the global supply of ppe, has left frontline healthcare workers ill-equipped to care for their patients. 2 3 since the start of the epidemic, guidance on the usage of such equipment has continued to evolve, and has emphasized conservation of resources rather than optimizing protection of workers. 4 the coronavirus pandemic has taken a dramatic toll worldwide and especially in italy. as of the beginning of april, italy has reported one of the highest number of infections and the highest number of deaths of any european country. 5 media reports from across italy have shone a light on the burden that the coronavirus is placing on health workers. nearly ten percent of reported coronavirus infections in italy occurred in healthcare workers. 6 7 as of april 14, 162.488 cases and 21,067 deaths attributed to covid-19 were confirmed in the country, and the number of healthcare workers infected and those that lost their life due to covid-19 was 14,066 and 133 respectively. many of these infections are likely due to occupational hazard; workers becoming infected while caring for patients suggesting the shortage or inappropriate use of ppe may be at the root of part of these infections. the use of ppe has been identified as one of the biggest physical and psychological challenges experienced by physicians while responding to covid-19. 7 for example, physical burdens related to ppe include repeated donning and doffing of equipment and extended hours wearing uncomfortable masks and respirators, while psychological burdens include challenges communicating with peers and patients when wearing ppe on and operating under changed practice standards. because of ppe shortages, healthcare workers, who may have been trained on how to don and doff ppe to maximize protection from infection, have had to make ad hoc adjustments on what piece of equipment to use and when, that are not reflected in any training they have received. the additional burdens created by a shortage whereby processes for using ppe are continuously changing, has not been explored. the italian healthcare system is regionally based and organized at the national, regional, and local levels, with each region having the autonomy of managing the delivery of the healthcare services based on local needs. 8 italian national health service system certifies healthcare workers and requires continuing education and quality and standards of care are set by the regions and hospitals. training procedures for the healthcare workforce are also left to the regions and local hospitals, specifically regarding the management of ppe. such differences are expected given local needs and hospital settings differ by localities, however such differences may also have caused inconsistencies and confusion on the appropriate use of ppe in a rapidly evolving situation such as the covid-19 outbreak. currently, there is lack of literature on how the healthcare workforce in italy has adapted during the novel coronavirus pandemic in the use of equipment. this study aimed to understand physicians' access to ppe, reception of information about their use, ability to perform donning and doffing procedures, risk perception and strategies adopted to prevent contracting the infection. we believe the results of our work may be helpful in the development of policies and training related to the use of ppe in italy as well as in other countries. all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. we undertook a cross-sectional, self-reported survey, of physicians working in italy during the response to covid-19. we disseminated an online survey by the use of two social media groups (via facebook and whatsapp) created by physicians engaged in the response. we obtained an institutional review board approval to conduct this study by xyz (name omitted for blind review purposes). the survey was implemented between march 31 and april 5 2020. the population of interest included physicians aged ≥ 21 years with a valid medical license (criteria to join the social media group) and working in italy during the emergency. the questionnaire was developed through a series of meetings between the researchers and practitioners in charge of infectious control procedures and ppe training activities at the hospital level, the practitioners provided feedback on the content validity and comprehensiveness of the survey instrument before implementation. questions were designed to inform the development of training and policies in response to the crisis and included questions about the physician's work experience (years of experience, specialty, experience in covid-19 units and geographic area of work), and questions related to the use of ppe divided in four parts: 1) access to ppe and strategies to cope with shortage, 2) information received on the use of ppe, 3) self-reported ability to perform donning and doffing procedures, and 4) risk perception of contracting the disease. our analysis examines four dependent variables: 1) access to ppe, 2) use of ppe, 3) selfreported ability to perform donning and doffing procedures and 4) risk perception in the work all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. response options were coded as follows: (0=i do not know how to don or doff the piece of equipment, 1= i am not sure, 2=i know how to do it). we combined all responses for each piece of equipment into a scoring system to create a new variable named "ability to perform donning and doffing procedures" , we then dichotomized the variable into high ability when the score was 75th percentile and less than high when below the 75th percentile). finally, to measure risk perception we asked 4) what do you believe is your risk of contracting covid-19 in the work setting in the next 30 days? physicians rated their perception using a scale ranging from 0=no risk to 100=high risk, responses were coded as follows: 1= low risk (≤ 25th percentile), 2=medium risk (26th-85th percentile) and 3=high risk (≥75th percentile). we first performed descriptive statistics for each variable. we then applied ordered logistic regression to the three ordinal variables access to ppe, information on ppe use, and donning and doffing ability and logistic regression to the variable risk perception. we tested for bivariate associations between each predictor (years of experience, geographic region, type of position, working in a dedicated covid-19 unit) and the dependent variables using a p-value ≤ 0.25 as cut-off as inclusion criteria for the multiple regression model. we tested the parallel regression assumption by means all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may 1, 2020. . https://doi.org/10.1101/2020.04.24.20073924 doi: medrxiv preprint of the brant test for the ordered logistic model which resulted not statistically significant and as such the ologit command was used to run the analysis. qualitative analysis was conducted on open questions to identify how physicians coped with ppe shortages and what strategies they adopted to reduce the risk of infecting their family members. we used stata 16 software (stata, college station, tx) to analyse the data. the study was found exempt by harvard longwood medical area institutional review board. responses were received from 529 physicians, the majority of respondents were in the age category 36-50 (40%), working in the hospital setting as employees of the national healthcare system (59%), and the most frequently reported category for years of experience was 11-20 (30%). physicians from all 20 italian regions and the republic of san marino were included in our survey, most respondents were from the lombardia region (13%), the most impacted by the emergency. over 40 medical specialities were reported by the respondents, the most frequent of which being pediatrics (12%), primary care (7%) and anesthesiology/intensive care (6%) and cardiology (6%). details on the sample characteristics are provided in table 1 . when asked if they had access to ppe when they needed it, 195 (37%) of the physicians said they rarely or never did, 265 (50%) sometimes and 69 (13%) always did. ffp3 and ffp2 (equivalent to n-99 and n-95 in the usa) were the pieces of equipment most frequently reported as lacking by 59% and 56% of physicians respectively. other pieces of equipment were also reported as lacking but by a lower percentage of respondents: gown (45%), hair cups (34%), all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may 1, 2020. . https://doi.org/10.1101/2020.04.24.20073924 doi: medrxiv preprint surgical masks (27%), gloves (16%). lack of ppe forced 89% of physicians to come up with strategies to cope with the shortage. such strategies included using the same n-95 for long shifts (12 hours and beyond), disinfecting the respirator with alcohol, adding a surgical mask either under or on top of the n-95, re-using the same mask for multiple shifts, exposing the respirator to "the sun" as reported to some of them or ozone, making masks on their own at home, or buying respirators of unknown certification. in the bivariate analysis of factors that related to ppe access; working in a covid-19 unit, in the table 2 . when physicians were asked how frequently they had received adequate information regarding the use of ppe to protect themselves from contracting covid-19, 136 (26%) reported that they always did, 198 (37%) sometimes, 195 (36%) rarely or never. approximately half of the all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may 1, 2020. . https://doi.org/10.1101/2020.04.24.20073924 doi: medrxiv preprint physicians reported that the information received to date about the use of ppe was either clear (47%) or complete (54%) and approximately one quarter was unsure about clarity (28%) or completeness (27%), leaving only 25% satisfied with the information they received. when asked if the information received was useful to them, opinions were equally split between three groups: those who found it useful (33%), those who did not (35%), and those who were unsure about its usefulness (31%). as a result of the bivariate analysis years of experience, working in a covid-19 unit and in a primary care setting were associated to the dependent variable, while table 2 . when asked if they believed they could correctly execute donning and doffing procedures for specific pieces of ppe, respondents felt mostly unprepared for putting the respirators and gowns on (14% and 12% respectively) or unsure if they were doing it correctly (12% and 25%). in regards to doffing, once again, taking off the respirator and the gown were the procedures they all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may 1, 2020. . https://doi.org/10.1101/2020.04.24.20073924 doi: medrxiv preprint did not know how to do correctly (19% and 34%) or were unsure about (34% and 31%). see table 2 . as part of the survey we also presented the physicians with 12 scenarios of activities that would require the use of different types of ppe and asked them, based on their knowledge, what was the most appropriate piece of equipment for each activity. the activities included transportation of presumptive and positive covid-19 patients within the hospital or by ambulance, activities in the triage area, routine physical examination of patients with respiratory and without respiratory symptoms and administrative activities with direct contact with clients. overall respondents assigned to each activity a level of protection higher compared to what is currently recommended by current guidance. 10 for example over 90% of physicians said that a face shield is appropriate when conducting physical examination on a covid-19 positive patient while a surgical mask is what is typically recommended. similarly over 70% physicians reported that a face shield is needed when conducting the same routine examination in any patient with respiratory symptoms. interestingly gloves were reported as appropriate by over 75% of physicians for the examination all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may 1, 2020. . of any patient even if without respiratory symptoms. and over 70% reported as appropriate the use of a surgical mask when performing administrative duties. see table 2 . when physicians were asked to rate their perceived risk, on a scale from 0 to 100, of contracting the infection in the healthcare setting, they attributed a mean value of 56 (sd=22) to such risk, table 2 . interestingly, among all specialties physicians in dentistry, otolaryngology, occupational all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may 1, 2020. . https://doi.org/10.1101/2020.04.24.20073924 doi: medrxiv preprint medicine and pneumology were the ones that showed the highest risk perception based on the descriptive analysis. the lowest level of risk perception was reported by those holding a specialty in hygiene and preventive medicine which is consistent with the fact that these professionals are typically in healthcare management positions and do not directly assist patients. see figure 2 . our results present some of the first evidence on how italian physicians experienced lack of ppe, and what factors influenced their understanding of ppe procedures and use. while our results are not generalizable to the all population of italian physicians, and certainly derived from a group of physicians with high level of interest in covid-19, group differences within our sample rather than general group estimates by extrapolation, can be useful to understand predictors of behaviors and specific challenges in access and use of ppe. the majority of those surveyed reported not to have access to ppe every time they need it and at least one third of them reported not having received adequate information on the use of the equipment, nor were they consistently comfortable with donning and doffing procedures, in particular when using respirators and wearing gowns. working in a covid unit made a difference in multivariate analysis of both having access to ppe, adequate information on their use, feeling comfortable with donning and doffing procedures, and perceived risk. this likely reflects training efforts focused on educating this subset of the workforce, those actually at the highest risk of contracting covid-19 based on occupational risk. however, given the difficulties of creating 100% covid-19 free clinics as many patients may present to a clinic in a pauci-symptomatic status, the current variation in access and knowledge about ppe use, may put at a disproportionate risk those working outside covid-19 units. more specifically, our results all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may 1, 2020. . https://doi.org/10.1101/2020.04.24.20073924 doi: medrxiv preprint indicate how primary care physicians may have been neglected from informational initiatives posing them at high risk of contracting the infection. with the advancement of testing and treatment options in the months ahead more and more covid-19 patients will be diagnosed and cured outside the hospital setting. therefore, additional attention is needed to provide ppe and ppe training for this group of providers and all those working outside covid-19 units. interestingly, respondents consistently overestimated the level of ppe needed to interact with a non-symptomatic patient; reflecting they either had inadequate understanding of current guidance or regardless of the guidance they were fearful of becoming infected themselves and/or infecting the patient when a diagnosis was not confirmed. the ongoing changes to ppe guidance provided by international, national and regional public health agencies, in particular in regards to the use of respirators, likely made it more challenging to make sense of which equipment to use. standards of use evolved in mid-march, a couple of weeks prior to our survey, as a result of ppe shortages and lack of logistics planning within hospitals. limited training as well as pre-existing professional norms that lacked a culture of ppe use may have been factors that shaped challenges in developing adequate training and information material. we suggest that future efforts should be made to include ppe training in the medical curriculum so that in times of crisis physicians can better adapt to their use and differences in knowledge and practices would be less evident across categories. methods for just-in-time training including the use of video trainings may be one mechanism to improve donning and doffing procedures. 11 in times of crisis, an overuse and gauging of ppe by concerned physicians may cause as much harm as lack of supplies. we found ppe perceptions and use were also tied to perceived risk of contracting the infection in the work environment. overall, risk perception was high, but both adequate access 1 4 and ppe training decreased such perception. of concern, is also the fact that many physicians took actions in their personal lives to protect their families, limiting physical interactions and in some cases renting separate apartments. in the long term, these actions will certainly affect their emotional well being. results from this rapid survey indicate that while ramping up supplies on ppe for healthcare workers is a necessity, adequate training and clear instructions are just as important. to the extent possible instructions need to be consistent overtime and across regions, include recommendations not only on the overall safety of the workers in the healthcare setting but also on strategies to maintain their overall physical and emotional health and the health of their loved ones. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may 1, 2020. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may 1, 2020. . https://doi.org/10.1101/2020.04.24.20073924 doi: medrxiv preprint figure 2 . risk perception by specialty* *for n within each category see table 1. 9 all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may 1, 2020. . https://doi.org/10.1101/2020.04.24.20073924 doi: medrxiv preprint covid-19: the crisis of personal protective equipment in the us shortage of personal protective equipment endangering health workers worldwide rational use of personal protective equipment for coronavirus disease covid-19: phe upgrades ppe advice for all patient contacts with risk of infection covid-19) situation report -78 nearly 1 in 10 of italy's infected are health care workers: cnn; 2020 the italian coronavirus disease 2019 outbreak: recommendations from clinical practice. anaesthesia the italian health care system. international health care system profiles: the commonwealth fund medical masks vs n95 respirators for preventing covid 19 in health care workers a systematic review and meta analysis of randomized trials. influenza and other respiratory viruses indicazioni ad interim per un utilizzo razionale delle protezioni per infezione da sars-cov-2 nelle attività sanitarie e sociosanitarie (assistenza a soggetti affetti da covid-19) nell'attuale scenario emergenziale sars-cov-2 a randomized trial of instructor-led training versus video lesson in training health all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder we would like to thank for their support the administrator and all of the moderators of the facebook private group "coronavirus, sars-cov-2 e covid-19 gruppo per soli medici -https://www.facebook.com/groups/coronavirusmediciitaliani/" we are also grateful to all of the colleagues of the group which decided to compile the questionnaire giving their suggestions and point of view on this topic". key: cord-028605-ehercdou authors: merchan, cristian; soliman, joshua; ahuja, tania; arnouk, serena; keeley, kelsey; tracy, joanna; guerra, gabriel; dacosta, kristopher; papadopoulos, john; dabestani, arash title: covid-19 pandemic preparedness: a practical guide from an operational pharmacy perspective date: 2020-06-16 journal: am j health syst pharm doi: 10.1093/ajhp/zxaa212 sha: doc_id: 28605 cord_uid: ehercdou purpose: to describe our medical center’s pharmacy services preparedness process and offer guidance to assist other institutions in preparing for surges of critically ill patients such as those experienced during the coronavirus disease 2019 (covid-19) pandemic. summary: the leadership of a department of pharmacy at an urban medical center in the us epicenter of the covid-19 pandemic proactively created a pharmacy action plan in anticipation of a surge in admissions of critically ill patients with covid-19. it was essential to create guidance documents outlining workflow, provide comprehensive staff education, and repurpose non–intensive care unit (icu)-trained clinical pharmacotherapy specialists to work in icus. teamwork was crucial to ensure staff safety, develop complete scheduling, maintain adequate drug inventory and sterile compounding, optimize the electronic health record and automated dispensing cabinets to help ensure appropriate prescribing and effective management of medication supplies, and streamline the pharmacy workflow to ensure that all patients received pharmacotherapeutic regimens in a timely fashion. conclusion: each hospital should view the covid-19 crisis as an opportunity to internally review and enhance workflow processes, initiatives that can continue even after the resolution of the covid-19 pandemic. t he early weeks of response to the pandemic caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) challenged health systems to adapt and expand patient care to manage a surge of critically ill patients with coronavirus disease 2019 (covid-19). 1 nyu langone health (nyulh) is a tertiary academic medical center located in manhattan with 6 inpatient facilities and several outpatient locations throughout the new york city and long island, ny, areas. there are 19 established pharmacies throughout the nyulh enterprise. the nyulh department of pharmacy services formed and commissioned a "covid-rx" team to implement an adaptive covid-19 preparedness and response strategy. in preparation for the covid-19 pandemic, the medical center's operational bed capacity was increased from 700 to 836 beds, including an increase of 160 intensive care unit (icu) beds. all pharmacy operations were reevaluated to identify the urgency of contingency planning to ensure continuity of patient care. this article is the second of a 2-part series on pharmacist practice management preparedness during unprecedented circumstances. herein we describe the operational strategies implemented by the nyulh covid-rx team to manage the exponential increase in admissions of patients with covid-19. strategic staffing models were implemented through online conferencing and, as necessary, in-person site evaluations by individual stakeholders. 2, 3 the nyulh department of pharmacy consists of 90 pharmacists covid-19 pandemic preparedness: a practical guide from an operational pharmacy perspective and 82 pharmacy technicians. our first assessment toward building a dynamic staffing model required a full review of all pharmacy personnel across the health system and their current responsibilities. managers, pharmacists from ambulatory and inpatient care sites, technicians, and pharmacy residents assisted with all duties related to the operations of the pharmacy department. routine pharmacy tasks such as verification, compounding, dispensing, hand delivery of medications, restocking of automated dispensing cabinets (adcs) and returns processing were considered essential. ten pharmacy managers from other sites rotated through the medical center and were repurposed to perform these essential tasks during the morning, evening, and overnight shifts. the selection of pharmacy personnel to perform each of these pharmacy tasks was undertaken in consideration of the specific level of expertise required to perform them. for instance, operational pharmacy managers assisted with medication hand deliveries to allow reallocation of experienced pharmacy technicians to perform tasks that required further technician training. our pharmacy residents' training was redesigned to enable them to assist with both clinical and operational needs, including rounding in newly established units designated as "covid-icus," participating in medical code responses, and assisting with operational needs such as sterile compounding, hand deliveries, and other tasks. taking a team approach of having the entire department assist with all functions around the clock helped maximize efficiency and minimize potential interruptions in pharmacy productivity. in anticipation of the covid-19 pandemic, we developed a contingency plan to anticipate potential staff absences due to illness or the need to serve as caregivers in the setting of home isolation for an extended period of time. our plan included collapsing the pharmacy department's operational footprint and centralizing the operational model to focus on the core functions of medication preparation, verification, and delivery. it was decided that this plan would be put into effect if more than 15% of our team was on extended leave; that threshold was determined by evaluating the number of staff members required to maintain consistent decentralized pharmacy operational services. consistency was important, as we wanted patient care teams and nursing staff to have an appropriate understanding of where pharmacy support was available. (each institution is unique, and specific threshold requirements and resources for decentralized pharmacist staffing will vary accordingly). other staffing models, such as implementing a 3-day work week (ie, three 12-hour shifts) in order to keep staff healthy and limit sars-cov-2 transmission, were considered but not adopted at our institution. 2,3 as a major medical center in the us epicenter of the pandemic, nyulh experienced exponential increases in the rate of admissions and patient census, which did not allow us to reduce the number of pharmacy staff on-site for patient care activities. however, that is a strategy we would encourage other institutions to consider if it is deemed feasible. an additional approach to consider is a pharmacist work-fromhome model (state law permitting); this would involve remote completion of tasks such as medication order verification through the electronic health record (ehr) or review and approval of intravenous (i.v.) medication compounding via electronic i.v. workflow management systems. our top priority was to ensure the safety of the entire pharmacy department. the infection prevention and control (ipc) department provided guidance for the use of personal protective equipment (ppe) and ppe conservation strategies. at the start of the pandemic we rapidly identified team members who would require n95 face masks and coordinated mask-fit testing promptly. we wanted to ensure that our team was protected with the appropriate ppe in areas where ppe use was required. this is vital to consider in order for a pharmacy team to execute the full array of operational and clinical tasks, such as delivering medications and restocking adcs, working in decentralized pharmacy areas, and responding to medical internal emergencies in a safe manner. moreover, we assessed our ability to implement social distancing measures in the central pharmacy. unfortunately, full implementation of a robust social distancing protocol was not practical due to the increased volume of medication dispenses and the presence of large automated dispensing systems, medication storage carousels, and refrigerators. however, the pharmacy staff used appropriate ppe, maintained clean work areas, and performed hand washing. we encourage other institutions to • a hospital at the us epicenter of the coronavirus disease 2019 (covid-19) assembled an interdisciplinary team to forecast and allocate medication supply in order to ensure continuity of care. • optimization of automated dispensing cabinets (adcs) to minimize staff virus exposure and ensure ready medication access, with regular review of par levels and adc inventory, was essential in meeting increased medication demand on patient care units. • order templates within the computerized prescriber order entry and smart infusion pump systems were optimized to help ensure appropriate prescribing and effective medication supply management. implement social distancing strategies if feasible. open communication was essential throughout this process to drive accountability, consistency, safety, and trust. a dedicated covid-19 guidance document was created as a single source for all pharmacy-related information pertaining to covid-19, including clinical and operational needs. this document facilitated realtime sharing of updates and served as a reference for our pharmacy staff on the following topics: medication handling, storage and disposal, ppe requirements, designated covid-19 units, verification queue assignments, clinical pharmacotherapy assignments, and covid-19 clinical protocols. the guidance document was updated daily due to the dynamic nature of the pandemic. it is imperative to educate the pharmacy team about internal guidelines and ensure that the most up-todate information is relayed in a timely fashion. placing all relevant information in a single web-based location allowed us to efficiently relay information to our team. the guidance document served as our department's real-time strategy and was frequently updated as new evidence emerged. the volume of critically ill patients admitted with sars-cov-2 infection led to increased utilization of healthcare resource and supplies such as hospital beds, ppe, ventilators, and dialysis machines and also had an immediate impact on the use and procurement of medications. successful implementation of an adaptive covid-rx team included designating team members to anticipate the health system's needs and ensure the sustainability of medication supplies and resources. [4] [5] [6] [7] in preparation for the initial surge of critically ill patients infected with sars-cov-2, our covid-rx team reviewed all essential medications needed to treat the projected number of patients, created necessary storage space for these items, and anticipated supply chain interruptions. this anticipatory stock was procured from drug wholesaler partners, manufacturers, nonprofit generics manufacturer civicarx, and 503b outsourcing vendors. adequate communication was essential in coordinating with distributors and manufacturers in order to provide justification for large inventory purchases; this was especially important in placing orders for controlled substances that were on allocation and orders for quantities higher than the institution's previous average usage. other essential medical supplies to be purchased and monitored included isopropyl alcohol, adapters for connecting medication vials to i.v. diluent containers, and diluents for compounding of i.v. bags. additional storage space was acquired within the hospital to accommodate the increased inventory, and proper security measures were arranged. a number of dedicated refrigerators were resourced to enable storage of essential medications and extension of the beyond-use dates (buds) of batched infusion bags of opioids and sedatives. the inventory application in the ehr was used by the pharmacy staff to keep track of pertinent information relating to each medication stored in overstock, such as quantity, lot numbers, and expiration dates. 8 electronic dashboards were developed to allow oversight of medication utilization and projection of estimated usage on a daily basis. these electronic dashboards were developed by retrieving data from adcs, inventory carousels, and administration records from the ehr. for continuous infusions, supplemental infusion pump administration data was collected from third-party data analytics software. these dashboards were valuable resources for the covid-rx team to use in generating reports on average daily utilization of medications and predicting which medications might be subject to shortages. the dashboard also helped in prioritizing adaptive changes to medication utilization patterns by informing rounding clinical pharmacotherapy specialists when to recommend therapeutic alternatives to their healthcare teams. for example, the dashboard would display midazolam infusion characteristics (the number of patients receiving infusions, as well as the concentration and rate of each infusion and their location within the hospital); if a comparison of these variables to the current inventory on hand indicated an unsustainable usage pattern, the clinical pharmacotherapy specialists were informed to create an alternative sedation strategy. at the peak of the pandemic response, nyulh experienced a nearly 10-fold increase in the use of i.v. infusions of opioids (fentanyl and hydromorphone), sedatives (ketamine, propofol, dexmedetomidine, and midazolam), and vasopressors (norepinephrine and vasopressin). daily virtual meetings were held with inventory personnel from each represented hospital pharmacy site within the health system. these meetings helped pharmacy personnel identify medications that were in short supply, redistribute overstocked medications between locations, and coordinate medication deliveries. with the increased demand for compounded infusions, we looked to nyulh outpatient care sites for support with sterile compounding. as outpatient sites were closed and workloads decreased, outpatient pharmacy personnel, including pharmacists and technicians, assisted with batching of compounded sterile preparations (csps) that were used in high volume in icus. the health system's ambulatory care centers delivered csps to the medical center twice per day. the flexibility to use ambulatory infusion centers located more than 1 mile from the medical center was made possible by the food and drug administration (fda). on april 6, 2020, fda waived the 1-mile radius requirement specified in the agency's "hospital and health system compounding draft guidance" document. 9 additionally, on april 11, 2020, the united states pharmacopeia compounding expert am j health-syst pharm | volume xx | number xx | xxxx xx, 2020 note covid-19 pandemic preparedness committee (usp cmp ec), in recognition of the increased demands on sterile compounding operations at compounding entities due to the covid-19 pandemic, issued an operational strategies document authorizing bud extensions. 10 as described by the usp cmp ec, we assigned a 4-day bud for compounded products stored at controlled room temperature and a 10-day bud for refrigerated compounded products. the extension of buds allowed us to manage the drug supply and ensure consistent availability of compounded products to patients. adjustments to compounding procedures were made in order to conserve ppe for sterile compounding activities. compounding staff were instructed to use no more than 2 facemasks per shift and to store them in paper bags to prevent moisture buildup. coverall suits were worn throughout the entire shift and stored in the anteroom. in addition, polyethylene-coated chemotherapy gowns were used for the entire shift and stored inside the hazardous sterile preparation room. due to ppe conservation strategies for sterile compounding activities, the frequency of surface environmental sampling of primary engineering controls was increased to once monthly to ensure appropriate quality of compounded products. newly designated covid-19 units, including both icu-level and acute care units, were rapidly established to accommodate the projected surge of patient admissions. as these units were announced, the covid-rx team proactively maximized the use of adcs by creating a standardized covid-19 medication list based on reports of medications identified as investigational therapies for the treatment of sars-cov-2 infection and the medications necessary to manage mechanically ventilated patients with acute respiratory distress syndrome (ards), as listed in the appendix. both clinical and operational pharmacists evaluated utilization of adc-stocked medications on a daily basis. 11 stock-out reports were assessed to develop par numbers for medications, determine how often to stock adcs, and establish critical low levels for restocking purposes. optimization of and increased reliance on adcs were critical to a structured response to managing the rapid development of new covid-19 units. 12, 13 our approach relied on several strategies, including adc reorganization, expansion of the adc-only medication list, stocking of batched i.v. opioid and sedative infusions, increasing the number of adc restocks for covid-19 units, and medication formulation interchangeability at the point of dispensing. optimizing the adc content and removing medications with expected low utilization allowed for greater capacity for frequently utilized medications. the development of an adc-only medication list was done in collaboration with nursing staff. this list consisted of supportive care medications such as bronchodilators, mucolytics, medications with a frequency of daily or as needed, anticoagulants, sedatives, and some antivirals suggested for off-label use as anti-covid-19 therapies. use of the adc-only medication list was successful in decreasing medication delays and cartfill volumes. additionally, certain units were converted to a "cartless" distribution model wherein an adc was used as the primary source of medications, with only non-adcstocked medications delivered to patients by other means. due to the increased demand for i.v. opioids and sedative infusions, these medications were batched daily and restocked up to 3 times a day on all covid-19 icus. medication utilization reports on these batched medications prevented waste, allowed medications to be readily available on icu floors, and provided insights to inform purchasing of stock. redeployment of staff resources to support additional adc restocks was also critical. adc restocks for covid-19 units were increased from once per day to 3 times per day by redeploying pharmacy technicians from closed units (operating rooms and postanesthesia care units) and units with a lower census and/or capacity (pediatrics units). the additional restocks were critical to maintain sufficient supply in adcs, particularly with regard to controlled substances and continuous infusions. lastly, an "adc dose equivalent" process was implemented due to the sporadic availability of parenteral medications. a medication dose equivalent option exists if an item is available in the same drug concentration in containers of multiple sizes and interchanging these items is both clinically and operationally acceptable. therefore, if the default product is out of stock, the adc interface automatically redirects the user to an equivalent that is in stock at that adc location. this adc functionality allowed for greater product flexibility within an individual adc and decreased the number of unavailable products. specific strategies were implemented for the handling of formulary medications, patients' own home medications, and cardiopulmonary arrest "code carts." medication deliveries and adc restocking were performed primarily by pharmacy technicians, and the amount of ppe required depended on the location of entry (eg, a hallway outside of a negative pressure room vs a "respiratory isolation zone" in the emergency department). in highrisk isolation areas with pharmacy staff already present, the pneumatic tube system was used whenever possible to reduce overall virus exposure, preserve ppe, and expedite delivery. in order to minimize staff exposure to medication items possibly contaminated with sars-cov-2, we updated the hospital's policy on the use of home medications. 14 the frontline pharmacists used their clinical judgment to determine whether a home medication could be converted to a formulary alternative or withheld or whether it was absolutely essential for inpatient use. if continuation of a home medication was deemed necessary, a nurse wiped down the medication package with a cleaning agent and placed it in a bag for handoff to the pharmacy, where it was again decontaminated, identified, and verified. for formulary medications that entered the rooms of patients with covid-19 but were not ultimately used, similar precautions were taken, and medication packages were cleaned and reused when possible. as the number of covid-19 units increased, there was a corresponding increase in the demand for code carts. our hospital's interdisciplinary resuscitation committee determined that during the covid-19 pandemic, carts were to be positioned directly outside of patient rooms during emergencies to ensure that any unused content did not need to be discarded or decontaminated. this measure was especially important in light of critical shortages impacting nearly all essential emergency medications. at the time of a cardiopulmonary arrest, required medications were prepared by pharmacists outside the patient's room and passed to the resuscitation nurse through the door for immediate use. the code response pharmacist's ppe requirement was in accordance with the guidance provided by the nyulh ipc department. upon completion of a code response, the cart was extensively decontaminated by the response team using sterile wipes prior to the return of the cart to the pharmacy for cart exchange. while this workflow was effective for our team, another strategy could be to make bags of a small supply of commonly used emergency medications readily available on all hospital floors; this could potentially prevent the opening and potential contamination of code carts during every emergency. we ultimately did not implement that strategy due to uncertainty as to whether it would decrease the number of carts actually accessed and due to the additional pharmacy technician labor required. a complete evaluation of medication administrations was performed to characterize smart pump infusions and timing of medication administrations. we assessed the number of smart infusion pumps on hand and obtained addi tional pumps in order to maintain the best practice of using smart infusion pumps for all i.v. infusion administrations. 14 smart pumps were positioned outside of single-bed icu patient rooms through the use of magnetic resonance imaging (mri) extension tubing. this strategy was adjusted based on the availability of mri tubing, the number of icu patients, and the number of required i.v. continuous infusions per patient. therefore, we had to reevaluate this process for patients receiving multiple continuous infusions requiring frequent dose titrations. the clinical pharmacotherapy specialists rounding in covid icus were instrumental in guiding nurses on whether a smart pump could feasibly be kept outside of a patient room. for instance, a decision to keep a smart pump inside a patient's room included consideration of the following: a need for frequent dose titration (ie, intervals of <6 hours), a need for frequent line exchanges (as with infusions of propofol or clevidipine), and use of continuous-infusion medications not requiring dose titration by a nurse (eg, amiodarone, neuromuscular blockers). another component of our smart pump strategy was to revise our system-wide policy requiring independent double checks of continuous infusions for adult patients. the revision to the independent double check policy decreased the number of interruptions to nurses' workflow, and each continuous infusion was discussed during icu rounds with the clinical pharmacotherapy specialists. alternative strategies that organizations may consider for smart pumps include redistributing pumps throughout the healthcare system by relocating off-site ambulatory pumps to inpatient facilities, expanding the list of medications approved for i.v. push administration, preferentially administering medications as intermittent vs continuous infusions, considering gravity administration for selected low-risk infusions, and encouraging the use of alternative medication administration routes. 14 another strategy proposed to decrease the frequency of nurse entry into patient rooms include adjusting medication administration times to enable bundling of patient care tasks. this strategy may not be feasible for critically ill patients with ards requiring frequent lifesaving interventions and medications. communication between nursing personnel and rounding clinical pharmacotherapy specialists was essential to help coordinate timing of medication administrations within the icu environment. the coordination of medication timing was balanced with consideration of the severity of illness of the patient, planned or potential procedures, the need for clinical imaging, and the nurse-to-patient ratio. for patients admitted to acute care floors with covid-19, specific attention was focused on minimizing the potential for postdischarge public virus exposure by allowing these patients to be discharged home for self-isolation. we were able to leverage the patient discharge process by using an onsite ambulatory care pharmacy to provide these patients with discharge medications. prescriptions were sent electronically to the pharmacy and delivered to each patient's room prior to hospital discharge. pharmacy staff coordinated with nursing personnel to ensure that patients received their medications, as well as necessary education, prior to discharge from the emergency department or an acute care unit. the covid-19 pandemic created a need to strategize alternative medication management processes. careful am j health-syst pharm | volume xx | number xx | xxxx xx, 2020 note covid-19 pandemic preparedness consideration and planning is required for evaluation of new formulary additions, addition to the formulary of standard drug concentrations appropriate for short-term infusions and/or larger-volume or more concentrated continuous infusions, institutional i.v. push policy, and expansion of clinical indications for use of a particular agent. developing dosing guidelines, order sets, and alternative-option alerts within a computerized prescriber order entry (cpoe) system can help to ensure compliance with clinical updates and drive alternative medication selection when needed. 15, 16 when building these new medication order records, it is important to validate drug-drug interaction data, dosing limits, and pregnancy warnings provided by the drug database vendor to ensure that displayed clinical alerting and drug interaction severities are appropriate. the covid-rx team quickly identified an increase in alerts associated with pharmacist-recommended covid-19 therapies and quickly implemented a number of changes to limit nuisance alerts and ensure clinically meaningful alerting of ordering clinicians. despite the large number of organizational changes and strain that occurred throughout the pandemic response, nyulh experienced a significant decrease in the number of reported medication errors. in times of turbulence and influx of newly hired or travel staff, the importance of reporting observed and experienced medication safety risks throughout an institution should continue to be emphasized. each health system is unique and has or may face different obstacles in combating the covid-19 pandemic; the strategies outlined here can be implemented to varying degrees in other institutions. a dynamic and flexible staffing model is essential in order to anticipate and manage new obstacles. cross-training in routine pharmacy tasks among pharmacists, managers, and technicians is recommended in preparation for any future similar event. the participation of the pharmacy leadership in daily frontline clinical and operational activities provided us with a unique exposure and allowed for added opportunities for communication with staff. each hospital must view the current crisis as an opportunity to internally review and enhance workflow processes, which can continue even after the resolution of the covid-19 pandemic. appendix-example of automated dispensing cabinet stocking list for covid-19 intensive care unit at nyu langone health a acetaminophen 325 mg tablet, 325 mg liquid, 500 mg tablet acetylcysteine 10% and 20% 4 ml vial albuterol sulfate mdi and 2.5 mg/3 ml nebulizer world health organization. coronavirus disease (covid-19) pandemic pandemic assessment tool for health-system pharmacy departments field/surge hospital and icu bed expansion responses to covid-19 drugs supply and pharmaceutical care management practices at a designated hospital during the covid-19 epidemic pharmacy administration and pharmaceutical care practice in a module hospital during the covid-19 epidemic drug shortages ashp guidelines on managing drug product shortages the future of data, analytics, and information technology compounding policy clarifications -drug information update pharmacopeial convention. operational considerations for sterile compounding during covid-19 pandemic covid-19 bi-weekly pharmacy resources survey results a comparison of automated dispensing cabinet optimization methods ashp statement on the pharmacist's role in clinical informatics institute for safe medication practices ashp guidelines on the design of database-driven clinical decision support: strategic directions for drug database and electronic health records vendors monitoring clinical decision support in the electronic health record vancomycin i.v. formulations (premixed or nurse-assembled products) the authors thank and acknowledge the entire staff of the nyulh department of pharmacy services for their support during the pandemic. the authors have declared no potential conflicts of interest. key: cord-316063-9bg2dm8e authors: morgan, marcus title: why meaning-making matters: the case of the uk government’s covid-19 response date: 2020-10-15 journal: am j cult sociol doi: 10.1057/s41290-020-00121-y sha: doc_id: 316063 cord_uid: 9bg2dm8e through analysis of the uk government’s management of the covid-19 outbreak, this paper offers an empirical demonstration of the principle of culture’s relative autonomy. it does so by showing how the outcome of meaning-making struggles had impacts on political legitimacy, public behaviour, and control over the spread of the virus. ultimately, these impacts contributed to the avoidable deaths of tens of thousands of uk citizens. dividing the crisis into phases within a secular ritual passage or ‘social drama’, it shows how each phase was defined by struggles between the government and other actors to code the unfolding events in an appropriate moral way, to cast actors in their proper roles, and to plot them together in a storied fashion under a suitable narrative genre. taken together, these processes constituted a conflictual effort to define the meaning of what was occurring. the paper also offers more specific contributions to cultural sociology by showing why social performance theory needs to consider the effects of casting non-human actors in social dramas, how metaphor forms a powerful tool of political action through simplifying and shaping complex realities, and how casting can shift responsibility and redefine the meaning of emotionally charged events such as human death. 'any important disease, whose physical etiology is not understood, and for which treatment is ineffectual, tends to be awash in significance' (sontag 1978) . this paper demonstrates the real-life impacts of meaning work through an analysis of the sense-making struggles that took place around the uk government's response to the covid-19 crisis. it argues that events fell roughly into three periods, understood as a succession of phases in a secular ritual passage or 'social drama' (turner 1969 (turner , 1980 fig. 1) . these phases were defined by changes in the moral coding of events, modifications in the casting of actors involved, and alterations in the dominant narrative genre within which events were to be understood. this dynamic chronology therefore constituted a conflictual effort to define the meaning of what was going on. it will show how the outcome of these struggles over meaning-making ultimately impacted not only government legitimacy but also the avoidable deaths of tens of thousands of uk citizens. during the first period (early january to mid-march), the viral threat was identified, but little was done to counter it. events were narrated in a low mimetic mode that cast the virus as an object of routine and mundane political management. banal measures, such as handwashing, were recommended to control the disease, and the prime minister instructed the public that 'they should, as far as possible, go about business as usual' (quoted in calvert et al. 2020, may 24) . british social structure remained intact, and the virus was presented as one amongst a number of problems to be dealt with. this response allowed the virus to spread unobstructed throughout the population. as this period progressed, however, and especially from early march onwards, polarisation grew, government legitimacy declined, narrative inflation took place, and the viral antagonist increasingly became cast as a mortal enemy. pressure-much of it from outside government-eventually succeeded in forcing a ritual breach to occur, and a crisis to be declared in order to deal with the deadly 'invader'. though changes in the government's conception of the virus were underway from early to mid-march, significant practical measures of redressive action only arrived on 23rd march when lockdown came into effect and the uk properly entered its second, liminal period. during this period, routine social life was suspended, antistructure became the norm, and significant measures to control the spread of the disease finally, and belatedly, arrived. government legitimacy rose during this period and focussed ritual expressions of communitas occurred in which social solidarity was expressed with those working on the 'frontline' in fighting the virus. as we shall see, these secular rituals did not, however, magically resolve various significant social cleavages within british society, and in many ways ended up dramatising these latent divides in more vivid light. this second period was narrated in the high mimetic mode of tragedy that drew upon the highly polarised, and occasionally even apocalyptic, language of warfare. one important episode in this period-boris johnson's illness-even reached into the lofty genre of romance and legend, in which the pm-as-hero was cast as possessing preternatural powers of agency in his personal capacity to fight off the virus. the government also attempted to recast, or interpellate, a range of other actors from both within and beyond the government during this middle period, with varying degrees of success. attempts, for instance, were made at redistributing responsibility by recasting senior medical and scientific advisors as ultimately accountable for the government's policy decisions, and the general public as liable for following them. nhs staff and other frontline workers were recast as 'heroes' and eulogised in that role in ways that profoundly reframed the meaning of their mounting deaths. attempts at co-opting external actors to play along with one's intended direction are, however, inevitably unpredictable and the paper will explore phases in the uk's c-19 social drama the failures of these casting efforts, showing how at various junctures uninvited actors inconveniently pushed their way onto the public stage in ways that threatened to undercut the government's intended drama. the third and final ritual phase was announced on 10th may, came into effect from the beginning of june, and is ongoing. turner makes clear that 'social dramas, especially under conditions of major social change, might not complete [their] course ' (1988, p. 35) . this period has so far been characterised by ambiguity and incompleteness. attempts at narrative deflation have been uneasily combined with the inflated moral coding that prevailed during the previous phase, and strong elements of liminality have also remained. it will be shown how the government's ability to successfully narrativize this period has been thrown into jeopardy by contradictions in government actors' own public performances, typified by revelations of a major political scandal involving the pm's top advisor. the effect of these failures is evidenced by a stark decline in government legitimacy during this period, and widespread confusion over government rules and guidance around covid-19. since covid-19 has spread throughout the globe, and different nation-states have responded in different ways, with differing health outcomes, the pandemic therefore presents social science with a large-n dataset that can be used for comparative purposes. this means that a large number of different cases can be observed empirically, without the need to imagine speculative counterfactuals. placed within this international comparative context, it is hard to escape the conclusion that whichever way you measure it, and especially in light of the uk's relatively advanced warning of the virus, the uk's response has been woeful, resulting in tens of thousands of avoidable deaths (aljayyoussi and cross 2020) . a primary contention of this paper is that this abysmal public health outcome was in part an effect of the efforts to fix meaning around the virus by the politicians who directed the response. different constructions of the virus's meaning by powerful political players became quite literally a matter of life and death for many. the paper therefore wishes to illustrate the real-life (and more to the point, realdeath) causal impacts of culture, identifying, with some degree of specificity, 'just how culture makes a difference' (alexander and smith 2003, p. 14) . it intends to show how cultural analysis is not condemned to producing vague descriptions of social life that skirt around the edges of specifying explanatory mechanisms. despite what some of its critics may claim, cultural analysis need not remain stuck on some destabilising merry-go-round of ever-undercutting hermeneutic circles but is instead able to come good on dilthey's (1972 dilthey's ( [1900 , 2002) original goals for interpretive enquiry. these goals never intended to banish explanation from the human sciences, but instead aimed to reconstruct meanings in such a way as to build explanations appropriate to the human sciences. in order to effectively render meaningful 'forms of life', narrative reconstructions ought to rely upon, and take seriously, the categories used by social participants themselves (tsilipakos 2020; winch 1958, pp. 40-65) , though this does not mean they need not remain inside such categories in offering their explanations. the case of covid-19 reveals how struggles over sense-making-such as fixing the genre under which events are understood, or the effective casting of human and non-human actors-can affect whether or not populations find themselves exposed to mortal risk. culture, in other words, is revealed in this paper to act as a mechanism through which the sovereign power to 'expose to death'-what mbembe (2003) has called necropolitics-is able to function. methodologically, these explanatory pathways are traced through an historical reconstruction of dominant meanings that were projected-with variable degrees of success and contention-from centres of power. the paper shows how these meanings shaped interpretation, behaviour, policy, public legitimacy, and ultimately the spread of infection and death rates. to do this, it draws its empirical data from transcripts of the government's daily press conferences, recorded media appearances of politicians and scientists, press briefings, investigative tv, newspaper journalism and media reports that provided the 'first rough draft of history', social media posts, open letters, and newspaper front-page headlines. the information sources are limited, and a full picture would require declassification of internal downing street communications that ought to become the focus of any future public enquiry. nevertheless, to unpick the public messaging itself, and the responses it received, no such data are required. it will also use political polls as imperfect proxies for measuring government legitimacy at various moments. another limitation in the data has been the difficulty of accurately tracking the variation in infection rates at different periods, which is itself a consequence of the lack of a systematic testing system. rather than a comprehensive overview of events, it focuses in on shifts in messaging and symbolic action, moments where sudden change can be detected. it will tell two stories: one of a national public health catastrophe, in which over 57,600 deaths have so far been registered in the uk where c19 was mentioned on the death certificate; another of a public relations exercise, in which casting, narrative, and performance were deployed in an effort to shield the government from responsibility, with the frequent effect of exacerbating the crisis. it will therefore focus on efforts to contain two types of contagion: one viral, the other symbolic, and examine the dangers of treating public policy around matters of life and death as a matter of political communications; of managing a public health crisis as though it were a public relations one. given the openness and complexity of social systems, unlike stage dramas, the genesis and termination of social dramas, as well as the identification of the relevant parties involved, is a matter to be determined, and justified, by social analysts themselves. the events described below unfolded within other, more panoramic social dramas, and themselves contained many smaller, more focussed social dramas. in presenting my own narrative, i am conscious that i am both adding another layer to the storytelling and smuggling in my own account of the appropriate analytic forms and categories through which to understand these extraordinary events. a physical virus, and the substantive suffering involved in the death it causes, might seem to somehow spontaneously contain its own interpretation. this paper intends to demonstrate how nothing could be further from the truth. as we shall see, the meaning of the virus, the performance roles of those who acted to control it, and the significance of the death it caused, were all subject to highly contested meaning work. certain conventional understandings of a pandemic's meaning, derived from historical and popular artistic representations (wald 2008) , no doubt influenced the interpretation of c19, as did even more generalised and generic narrative forms. nevertheless, the crisis also offers a stark example of an 'unsettled time' (swidler 1986) , in which the field of meaning was thrown open for interpretation and struggles to define its symbolic significance ensued. the control that directors exert over conventional stage plays allows them to construct a 'relatively contrived illusion' involving 'the maintenance of a single definition of the situation' (goffman 1959, p. 246) . in contrast, real-life social dramas are obliged to work with highly contingent and often radically uncontrollable actors and conditions. rarely do preformed, coherent, and consensually coordinated 'performance teams' exist at the outset of a social drama (goffman 1959, p. 104; morgan and baert 2015, pp. 36-37) , and this is one feature that renders social dramas more akin to improvisational theatre than the conventional stage play that the dramaturgical tradition has typically used as its referent. as all experienced improv actors know, audience participation-which might be thought of as an implicit casting of the audience into an intended projection of meaning-always operates within a 'horizon of risk' (white 2013, pp. 73-94) . this risk derives from the fact that audience members do not always play ball. stubborn inductees have their own ways of answering the question of 'what is it that's going on here?' (goffman 1974, p. 8) , which rarely align perfectly with the intentions of those directing the show. to increase the likelihood of conformity, one influential manual suggests that audience 'volunteers must be treated with love and generosity' (johnstone 1981, p. 14) , a matter that will be shown to be important later on in this paper. other clues as to how external actors can be successfully enlisted into a particular drama come from the radical tradition of social theory. althusser famously explored how states, and their varied institutions, effectively maintain social control through ideological processes that help reproduce social subjects as beings who tend to naturally identify themselves with those institutions. those experiencing the effects of ideology, whether capitalist or otherwise (althusser 2014, pp. 227-228) , come to see themselves as spontaneously at one with certain categories and ways of thinking and acting. when this occurs, such subjects have, in his parlance, become 'interpellated as subjects' (ibid., pp. 267). 'interpellation' refers here to the process of being hailed and-identifying yourself as the subject who is being addressed-turning around to acknowledge that the call was indeed meant for you (ibid., p. 164, p. 191 ). althusser's account rests upon an elevation of the theoretician of ideologiekritik as capable of penetrating illusion in a context in which mere mortals are assigned no such powers. more importantly though, in spite of his favoured use of the term 'subject', once althusser is done with her, this figure has very little of what we would conventionally identify as 'subjectivity' left. these problems, alongside various others, provoked a particularly vociferous critic of structural marxism to dismiss interpellation as a 'grotesque notion' (thompson 1978, p. 148) . nevertheless, even flawed concepts have their uses when adapted or applied in contexts other than those for which they were designed, and i intend to both adapt and resituated althusser's concept here. i intend to adapt it by offering far greater agency to subjects in refusing to be interpellated in the roles assigned to them, 1 and to resituate it by transplanting it into the wider field of social drama, where it comes to be seen as similar to the attempts at audience participation or 'casting' introduced above. this latter term is useful in allowing us to speak sensibly of how the virus itself was cast in a particular dramatic role at different periods within the drama, since a virus can hardly be said to be interpellated given its incapacity to subjectively recognise itself in its assigned role. whereas most of the studies following the performance turn in cultural sociology, as well as turner's own account, have assumed that the characters that populate social dramas are human agents, in these events, the virus itself became cast as an antagonist with varying powers of agency assigned to it at different phases in the drama. recognising this, need not entail hyperbolic post-humanist claims concerning nonhuman 'actants' (latour 1996, pp. 373-379; cf. morgan 2016, pp. 38-42) , but simply implies an acknowledgment that objects other than human beings serve functional roles in storytelling processes. however, whilst useful for capturing the ability of an actor to resist enrolment, and also for the capacity of non-human entities to become enlisted in a story, the relatively neutral term 'casting' proves inadequate for capturing the power relations involved in many of the ways that actors are often dragooned into their roles. the power of the government's intended casting of the scientists who advised them, for instance, was shored up by the status of many of those scientists as employees of that same government. such power relations did not, however, automatically determine casting outcomes, and as well as identifying conformity, the paper will also review those moments in which scientists rebelled against their assigned roles and blew the whistle on the government's mishandling of the crisis. role casting is only effective to the extent that actors conform to a broader storyline and a more focussed script, which are by definition extended through time. the same is true of the moral coding of objects and events as good or evil: coding's efficacy, which may be thought of as the organisation of events and objects in conceptual space, is only realised once a diachronic movement is introduced to plot these objects and events in evolving narrative time (alexander 2006, pp. 60-62) . getting at this dynamism, ricoeur describes a story as 'a sequence of actions and experiences of a certain number of characters, whether real or imaginary … represented in situations which change … [and to] which they react' (ricoeur 2016, p. 239) . english studies scholars have looked at the way in which popular stories of communicable disease are shared across different outbreaks and circulate within populations very much like diseases themselves do. it has been shown how these stories can then go on to influence responses to outbreaks, both by authorities and by those affected by the disease (wald 2008) . sociologists have examined the role of personal narratives in making sense of the lived experience of pandemics (e.g. davis and lohm 2020), and historians have also applied dramaturgical models to show how epidemics are constructed through narratives that share particular motifs and metaphors (e.g. rosenberg 1989 rosenberg , 1992 . tracking similar lines to van gennep's and turner's tripartite account of the ritual passage explored here, rosenberg, for instance, identifies how epidemics 'follow a plot line of increasing and revelatory tension, move to a crisis of individual and collective character, then drift toward closure ' (1989, p. 2) . salmon (2017, p. 6 ) is correct to point out that narrative has often functioned 'as a technology of communications, control, and power', even if he incorrectly characterises this development as a relatively recent phenomenon. his account also tends to neglect that what plummer (2019) calls 'narrative power' can be used to challenge as well as legitimate authority (e.g. polletta 2006; alexander 2011; olsen 2014) . whilst dominant powers tend to have greater access to, and control over, 'means of symbolic production', alternative stories can and do get voiced in the public sphere, and authorities are often forced to adapt their own stories in response (davis 2002) . whilst the covid-19 outbreak is ripe for sociological analysis of the various speech genres deployed at different phases of its management (bakhtin 1986) , the aspect of genre theory relied upon most here will instead be that concerned with narrative genres (barthes 1977) , both in their ability to account for a mechanism of the exercise of power, and their affording the possibility of a 'structural hermeneutics', which enables 'the construction of models that can be applied across cases and contexts but at the same time provid[ing] a tool for interrogating particularities' (alexander and smith 2003, pp. 25-26) . adapting northrop frye's (1957) classic aristotelian statement on literary criticism, smith (2005) has shown how locating one's narrative in the appropriate archetypal genre can help politicians justify exceptional policy and mobilise dramatic forms of social action. this is because narrative genre helps organise both the cognitive and emotional response to events. for social narratives to be effective, politicians must not only plot them in an appropriate way, but, citizen-audiences must of course be willing to read and experience them in that same way. plotting events in one genre rather than another expands or contracts the possibilities for action that we might expect from both protagonists and antagonists, encouraging certain beliefs about their character whilst discouraging others. the focus here will be on what turner calls the 'star groupers' of the public sphere, those 'main protagonists … who develop to an art the rhetoric of persuasion, who know how and when to apply the pressure and force, and who are most sensitive to factors of legitimacy ' (1980, p. 152) . this group therefore excludes individuals who circulate stories in private discussions during pandemics (davis and lohm 2020) , the content of which may be used to index the efficacy of the star groupers' own interventions, but who nevertheless fail to define a situation in any significant way for broader social groups. politicians form the most prominent element of this star group and though their interventions are far from infallible, and though their public utterances may be characteristically carefree with it comes to meeting truth conditions, they are typically hyper-aware of the felicity conditions that need to be met for their performative acts and utterances to come off effectively in front of enfranchised public audiences. other contributors to this symbolic public sphere included journalists, scientists, doctors, nurses, and organised or disorganised members of the public who in open letters, tweets, television appearances, and op-eds tried to impose their own narrativization of the events and attempted to cast various actors, including the virus itself, in ways that often diverged from the government's own efforts at fixing meaning. smith's (2005) focus is on the way that governments drum up support for the extreme act of war, with all its attendant human sacrifice. given that war is typically considered in realpolitik terms of the clash of instrumental powers, material competition, or violence, it provides an excellent test case for a cultural sociological approach to explanation, since the proposed hypothesis is considered improbable within conventional social science (popper 1963, p. 77) . theories of 'perpetual war' notwithstanding (keen 2006) , taken as a discrete event, war is an extraordinary occurrence that in most contemporary societies requires justificatory work for governments to avoid becoming enveloped in a 'legitimation crisis' (habermas 1988) . to motivate a population to engage in exceptional acts such as war, politicians must plot real-life events in a convincing sequence that is usually characterised by a highly charged apocalyptic struggle between protagonists, coded as absolutely good, and antagonists, coded as absolutely evil. the consequence of this struggle must be presented as the fate of a society's highest ideals. whether or not base and material motivations-imperial expansion, resource extraction, military-industrial complexes, etc.-are in fact driving states to wage war, in national democratic contexts, and international contexts governed by conventions and treaties, war narratives must be pitched in such a way that evil forces come to be seen as threatening what a society holds most dear. in such scenarios, it must come to be seen that without war liberty or justice, for instance, will be banished; with war they will be protected or extended. stories must be told in such a way that blood sacrifice is considered an acceptable price for a society to pay in order to protect its most treasured ideals. drawing directly upon aristotle (1996) , frye (1957) describes five 'fictional modes' on the basis of the hero's role vis-a-vis the audience. (1) the dramatic mode most removed from the mundane is the mythic, in which the hero 'is superior in kind both to other men and to the environment of other men'. such a hero therefore occupies the realm of the divine. (2) slightly closer to earth, in the romantic mode, the hero is 'superior in degree to other men and to his environment' (ibid., p. 33). such a hero therefore 'moves in a world in which the ordinary laws of nature are slightly suspended: prodigies of courage and endurance, unnatural to us, are natural to him' (ibid.). the romantic hero is the protagonist we find not in myth, but in legend. (3) touching down to earth, the hero of the high mimetic mode is 'superior in degree to other men but not to his natural environment ' (ibid., pp. 33-34) . such a hero is therefore bound by the same mundane constraints as others but is more capable than most in his ability to bend and overcome them. frye associates this mode with great leaders, and it is the hero we find in the genre of tragedy that preoccupies aristotle's poetics. in using this term 'mimetic', aristotle draws upon plato's notion of art as mimêsis, or imitation, of life. aristotle stressed that in tragedy, there must be both a closeness and a distance between life and its imitation in order for art to achieve a 'purification of … emotions' (katharsis), especially those of 'pity and fear', and it is from this emotional purging that the audience's pleasure in dramatic tragedy was derived (aristotle 1996, pp. 10-12) . the closeness to real life allows the audience to identify with, and be moved by the characters, whilst the distance from real life allows them to rest assured that it is not them who are undergoing ill. ricoeur introduces another function of art's mimetic distance from reality in his observation that storytelling 'refers to reality not in order to copy it' in any direct sense, 'but in order to prescribe a new reading' (ricoeur 2016, p. 255) . in this sense, a good tragedy is never entirely realist, but always involves a certain stylisation. it is 'a kind of metaphor of reality', that imitates reality 'in accordance with its magnified essential features' (ibid.). (4) firmly rooted in the world of the everyday is the low mimetic hero. such a protagonist is 'superior neither to other men nor to his environment'. in realist fiction in the low mimetic mode, we are moved by such a hero precisely because they are one of us; in low mimetic comedy, we are amused by them because we recognise their flaws in the worst aspects of ourselves. (5) finally, we find a hero who is 'inferior in power or intelligence to ourselves' (frye 1957, p. 34) in the ironic fictional mode. here, the protagonist-hardly any longer a hero, and certainly not in the modern sense of that term-is a frustrated, pathetic, or absurd figure, and readers of such literature can rest assured of their superiority in being capable and conscious in ways that this protagonist is not. as we move down this hierarchy of narrative modes, it is important to point out that the powers of the hero to act on the world around them-to manage or resolve a crisis, for instance-are progressively diminished. smith (2005, pp. 21-22) adds three additional dimensions to frye's generic schema. first, as narrativization moves away from the ironic and towards the mythic mode (a process he calls 'narrative inflation'), heroes' motivations become less base, and more ideal. second, it is not only the protagonist's perceived powers to act that are expanded, but also those of the antagonist. as acts of good and evil become more momentous and dramatic, moral polarisation between the hero and the enemy is therefore also increased, and the antagonistic characters take on an increasingly emblematic appearance. finally, as we move up the narrative hierarchy, the 'issues' at stake also grow in significance and gravity, 'the future of kingdoms and even the world may be at stake and transcendental themes relating to the need for salvation and redemption become increasingly significant'. a key insight of cultural pragmatics is that culture structures both enable and constrain action, which is one way of establishing culture's relative autonomy. whilst agency is key, e.g. in attaching particular real-life events to generic narrative forms, at the same time, culture structures inhibit agency, blocking various possibilities as they open up others. i will try to show how at different points in the uk's c19 crisis, culture workers exerted agency in attaching events to different generic narratives, which both facilitated various forms of action, but simultaneously foreclosed others. once, for instance, the antagonist-virus was successfully narrativized in high mimetic terms as an 'unprecedented', even 'devilish', threat to society, this opened the door to interventionist state action, at the same time as it closed the door to inaction in the face of a morally inflated threat. where smith (2005, pp. 232-233, n4) chooses to neglect the significance frye places on the use of metaphor, this article will address metaphor directly, showing how the dynamics of the real wars that smith analyses offered important narratological functions when used as symbolic metaphors for fighting disease, for as bruner (1990, pp. 59-60) points out, 'narrative is not just plot structure or dramatism … "historicity" or diachronicity. it is also a way of using language [that] relies upon the power of tropes -upon metaphor, metonymy, synecdoche, implicature, and the rest'. it will also try to show how literary theories of narrative genre can complement, and be interwoven with, anthropological theories of ritual process and social drama, the utility of which has already been demonstrated elsewhere (e.g. jacobs 1996) . social drama itself is, after all, a kind of narrative, a story composed of a 'sequence of social interactions of a conflictive, competitive, or agonistic type' (turner 1988, p. 33) . ritual, and the contemporary pseudo-rituals we find in social dramas, are also processes that when successful are, like good tragedies, able to 'achieve genuine cathartic effects' (turner 1974, p. 56) . elsewhere, turner (1980, p. 153 ) makes clear that 'there is an interdependent, perhaps dialectic, relationship between social dramas and genres of cultural performance in perhaps all societies. life, after all, is as much an imitation of art as the reverse … genres … serve as paradigms which inform the action of important political leaders … giving them style, direction, and sometimes compelling them subliminally to follow in major public crises a certain course of action, thus emplotting their lives'. turner's (1969) account of the ritual process drew upon van gennep's (2004) model of rites of passage and his own ethnographies of traditional, tightly integrated and non-differentiated societies such as that which he found amongst the ndembu of zambia. however, he later adapted his concepts to fit complex, non-traditional societies too. modernising turner's approach a step further, cultural pragmatics has emphasised the difficulties-though not impossibilities-of achieving the kinds of ritualistic 'fusion' that were common in more simple societies, due to the highly contingent, reflexive, and 'de-fused' nature of the modern world (alexander 2004; morgan 2020) . this argument mirrors others that we find in literary theory. whether or not one accepts the 'cambridge thesis' concerning the origins of theatre in ritual (cornford 1914; cf. schechner 1988, pp . 1-6), frye's description of the high mimetic mode of greek tragedy emphasised its integrated unity of focus, in which the hero becomes the 'cynosure' of the audience (1957, p. 58) , just like the totem forms the centre of attention for rites of worship in certain indigenous societies. recall that in tragedy, mimesis works in such a way that the fictional hero is also cast as higher in powers than the mortals that he or she imitates in ordinary life, just as for durkheim 'the images of totemic beings are more sacred than the beings themselves' (durkheim 1995, p. 134) . in this respect, unlike the low mimetic mode, which involves fictional forms that 'deal with an intensely individualized society' the 'centripetal gaze' of the higher mimetic modes seem to share something with ritual, for it 'seems to have something about it of the court gazing upon its sovereign, the court-room gazing upon the orator, or the audience gazing upon the actor' (frye 1957, pp. 58-59) . as we work up the narrative ladder to the realm of myth, we are quite explicitly dealing with the sacred realm of the gods. lukács's theory of the novel reveals something similar in its tracking the decline of both epic poetry and dramatic tragedy, which he tells us emerged from the 'integrated civilisation' of the ancient greek world (1971, pp. 29-39) , and the rise of the novel, as a modern attempt to recapture some of this unity in a socially fragmented, and individually alienated, contemporary setting (ibid., pp. 56-93). the novel, for lukács, was an expression of our striving for something more universal in the tensions it exhibits between the way the world is and our idealistic motivations to overcome reality's constraints. for cultural pragmatics, the pseudo-ritual process in contemporary societies is similarly strained between on the one hand, disenchanted conditions of de-fusion and differentiation, and on the other, a striving for re-enchantment, shared meanings, and collective solidarities. under such conditions, culture can still bind social groups together, but it does not come about with such ease and spontaneity. participation cannot be assumed, and the different 'elements of performance' need to be actively brought together and made to work in synchrony. fusion therefore relies upon the artistic skill of actors and directors in successfully orchestrating social performance. in what follows, this paper will describe efforts at such orchestration, and the ways in which such efforts were routinely undermined, both by the inartistic skills of their authors, and the refusal of actors to be interpellated. it will show how conceiving the handling of the uk's covid-19 outbreak as progressing through the stages of a secular ritual process sheds light on how crises are triggered, how they are elevated to dramatic heights, and how they are lowered back down again. this section will describe how the uk government ignored various alarming warnings that suggested the immediate necessity of initiating a social drama around the virus. instead, throughout the first three months of the year, the government chose to narrativize the outbreak in 'low mimetic' terms which disallowed the possibility of an effective response being taken to control its spread and prepare the health service for the severe outbreak that was brewing. 'low mimetic' narrativization barred recognition of the virus as a tragic threat, and therefore prohibited extraordinary action being taken to avert it. ritual breach into an anti-structural state was, in other words, foreclosed, and the everyday routines and structures of british society remained intact, allowing the deadly virus to disperse throughout the population and eventually kill an extraordinary number of uk citizens in the weeks and months ahead. this section will describe how all this was enabled under the banner of 'herd immunity'. it will describe how such symbolic labels were connected to the narratives through which the public were being encouraged to understand the meaning of the virus and show how these culture structures did not only exist at the level of ideas but were also communicated in concrete acts of political performance. finally, this section will show how these sense-making efforts from above proved ultimately ineffective in imposing their intended meanings, as public institutions and individuals took matters into their own hands, rebelled against the government's laissez faire approach and began taking their own prohibitive measures towards the viral threat. these actions 'from below' led to narrative inflation, paving the way for the belated casting of the virus as a tragic threat that was to define phase ii of the national drama. january, 2020 began with china reporting its first death from the novel coronavirus in wuhan, and concluded with the uk leaving the european union. the latter event was marked by prime minister johnson delivering a public address in which he declared that 'the dawn breaks and the curtain goes up on a new act in our great national drama'. similarly to 1918, when woodrow wilson was so distracted by wwi that he failed to recognise the emerging threat posed by the so-called 'spanish flu', the uk government were later criticised for being too involved in their promise to deliver brexit, and deal with other domestic issues such as severe winter flooding, to adequately acknowledge the far more momentous drama that was looming on the horizon. the day prior to johnson's use of theatrical metaphor, the who had declared that covid-19 constituted a public health emergency of international concern, advising governments of 'all countries' to take immediate action, readying themselves 'to contain any introduction of the virus and its spread through active surveillance, early detection, isolation and case management, contact tracing and prevention' (who 2020a, b) . the who's announcement, and many subsequent warnings, could have provoked the government into initiating a social drama around the virus much earlier, as occurred in many comparable nations. this would have involved acknowledging a 'breach' and coding the virus not merely in mundane technical terms, but in extraordinary moral terms, as a threat to cherished values, such as life and livelihood. such coding could have spurred public legitimacy for the rapid declaration of a 'crisis' that would demand radical redressive measures. if this had occurred in good time, the deadly scale of the crisis might have been 'sealed off quickly within a limited area of social interaction' (turner 1974, p. 38 ) as occurred in for instance, in new zealand. rather than conjecturing about counterfactuals though, this section will describe what in fact happened: how throughout january, february, and into early march, the uk government narrativized the covid-19 outbreak in 'low mimetic' terms which prohibited a timely breach, prevented dire coding, and barred the possibility of consequential action being taken to avert it. smith talks about how '[c]risis situations involve a genre guess made from a few events and then ongoing efforts to check this as things develop' (smith 2005, p. 31) . in some ways, the periodic revisions that the uk government made in its generic narrativization of the developing covid-19 situation are accurately described by this notion of a 'genre guess'. in other ways, however, the phrase does not quite fit. this is because politicians were not simply guessing at what genre most accurately fit the unfolding events, but instead-in a context in which other imperatives, such as economic and political motivations shaped decision-making-they were attempting to actively impose their chosen narrative, to which they hoped the reallife events themselves might be made to conform. contagious disease has long been narrativized in the literature and film in apocalyptic terms, and in the book of revelation, plague is indeed one of the four horseman of the apocalypse. this would seem to suggest that if politicians were simply guessing what genre to place events under, conventionally, a deadly pandemic would scream out for narrativization in an apocalyptic, or at least a high mimetic, narrative mode. this was not, however, forthcoming, until a large degree of damage had already been done. instead, the government decided upon low mimesis, a narrative mode that 'takes life exactly as it finds it' (frye 1957, p. 41) , and which whilst involving the resolution of some weak level of binary conflict lacks the dramatic potency of tragedy, let alone the apocalyptic contradictions of good and evil necessary for acts of war. smith describes how the weak character polarisation of the low mimetic mode leads it to 'understand crises as fixable through prudence ' (2005, p. 25) , and in this case, the virus was initially cast as a mundane hazard to be overcome by prosaic forms of individualised action, rather than the coordinated and enforced measures that were to be belatedly introduced in the second period. the uk health secretary was first alerted to covid-19 on 3rd january and on 21st january, neil ferguson provided a report to cobra showing how the infectivity rate was certainly higher than seasonal flu and could be higher than the spanish flu (calvert et al. 2020, april 19) . on 23rd january, the uk department of health's first press release on the new virus described its risk to the public as 'very low' (dhsc 2020). a different narrative genre had clearly taken hold amongst political leaders in china, who the next day placed wuhan, which contains over 11 million inhabitants, into complete lockdown. soon the whole of the surrounding hubai province was placed under the same measures. if this event was registered at all in the uk's official communications, it might be detected in the modifier 'very' having been removed when the chief medical officer, chris whitty, issued a government press release reiterating that 'we all agree that the risk to the uk public remains low' (whitty 2020a). the same phrasing was repeated by the health secretary on 24th january (reuters 2020) , and again in various government communications on 27th january (e.g. hancock 2020a). on 3rd february, johnson made a speech in greenwich that played on familiar themes of british exceptionalism in order to justify keeping the country open for trade. in it, he argued that other nations' overreactions to coronavirus threatened the global market economy, and explained that he intended the uk, which he compared to superman, to buck this trend: 'there is a risk that new diseases such as coronavirus will trigger a panic and a desire for market segregation that go beyond what is medically rational to the point of doing real and unnecessary economic damage, then at that moment humanity needs some government somewhere that is willing at least to make the case powerfully for freedom of exchange, some country ready to take off its clark kent spectacles and leap into the phone booth and emerge with its cloak flowing as the supercharged champion of the right of the populations of the earth to buy and sell freely among each other … i can tell you in all humility that the uk is ready for that role'. (gov.uk 2020e) on 10th february, a slight shift appears to have taken place, with the secretary of state declaring that 'the incidence and transmission of novel coronavirus constitutes a serious and imminent threat to public health' (gov.uk 2020a). nevertheless, mandatory screening was still not taking place at borders-in fact only 273 out of the 18.1 million people arriving in the uk in the three months prior to the lockdown were quarantined (grieirson 2020)-and as late as 20th february, downing street was continuing to reassure the public that 'the risk to individuals remains low' (rawlinson et al. 2020 ). on 12th february, an exeter university study warned that 45 million people in the uk could become infected if the virus was left to spread. on 14th february, johnson was apparently so relaxed about the developing situation that he took a holiday for almost a fortnight in the kent countryside with his new fiancé, during which time he seems to have finalised his divorce, and aides were told to 'keep their briefing papers short' (calvert et al. 2020, april 19) . richard horton, editor of the lancet was later to point out that 'we knew in the last week of january that this was coming, the message from china was absolutely clear … we wasted february when we could have acted' (in evans 2020). later in february, studies emerged that showed that a large percentage of those infected were asymptomatic, and on 2nd march, another alarm bell was sounded after two consensus statements were reported to sage, alerting them to the high likelihood of 'sustained transmission of covid-19 in the uk at present', and warning them that without more 'stringent measures' an estimated 80% of the population would become infected, and that their 'best estimate of the infection fatality rate is in the range of 0.5-1%' (spi-m-o 2020). this translated into an almost unthinkable death toll of between 250,000 and 530,000 british citizens. however, this warning was apparently insufficient to budge the government from its low mimetic reading of events, which they continued to project for two further weeks. that same day johnson's final words in a video address to the nation were strangely edited out of the version that was published on the government's social media accounts. he stated: 'i wish to stress that, at the moment, it's very important that people consider that they should, as far as possible, go about business as usual' (in calvert et al. 2020, may 24) . the day following this sage meeting, johnson held his first press conference, televised to the nation. flanked by the scientific authorities of chris whitty and the chief scientific advisor, patrick vallance. this opening scene would be an opportunity to set the tone for the ensuing drama and define the characteristics of its narrative genre. whitty's relaying of the 80% infection rate might have provoked some gesture towards 'narrative inflation', the process 'through which ramping up … of threats is achieved' (smith 2005, p. 29) . however, any increase in the 'weighting' (alexander 2012, pp. 35-39) offered to the coding of the virus as a significant threat was quickly undone by whitty's reassurance that 'the proportion of the population who get infected is likely to be lower than that and probably a lot lower than that … even for the highest risk group, the great majority of people will survive this … if you're talking about the low-risk groups, the rate of mortality is well below 1 per cent' (in menendez 2020). the general performance that day was coherent, and johnson reassured the gathered journalists that this was 'overwhelmingly a disease that is moderate in its effects' (in calvert et al. 2020, may 24) . if these efforts at retaining a deflated narrative had failed to achieve their end, and any of the assembled journalists risked leaving the conference with the impression that the story to be reported was anything more than routine political management, johnson's memorable subsequent intervention left no room for doubt. 'i was at a hospital the other night where i think there were actually a few coronavirus patients and i shook hands with everybody', he declared, offering the relaxed advice that 'we should basically just go about our normal daily lives', and that 'the best thing you can do is wash your hands with soap and hot water while singing happy birthday twice' (in crace 2020). frye uses 'domestic tragedy' as another term for the low mimetic mode, and it would be difficult to contrive a more mundane and domestic proposal than washing one's hands with soap and water. a concerned downing street source was later quoted in the sunday times telling them: 'the handshake-you can't minimise how important that is' (in calvert et al. 2020, may 24) , and a sage member was quoted in the guardian saying that at this point it became clear that a gap had emerged between 'the scientific advice and political messaging. "the prime minister was going around shaking people's hands to demonstrate that there wasn't a problem. there was a disconnect at that point. we were all slightly incredulous that that was happening"' ). on 28th february, the first death of a british national occurred on the quarantined diamond princess cruise ship, and the sunday times reported that around the same time dominic cummings (johnson's chief advisor, and former director of the successful vote leave campaign) had 'outlined the government's strategy' for the uk's national response to the virus 'at a private engagement', quoting those present as claiming that it was 'herd immunity, protect the economy, and if that means some pensioners die, too bad' (shipman and wheeler 2020) . given the subsequent prominence of this 'herd immunity' term-and given the government's later denials that it was ever informing their strategy-it is worth briefly reviewing its presence in the uk's response, and how neatly it fit with their initial low mimetic narrativization of events. it's not possible stopping everyone in the population getting it. and it's also, actually, not desirable, because you want some immunity in the population -prof. patrick vallance, chief scientific advisor to the government, 12th march, 2020. following cummings's reported private outlining of a herd immunity strategy, it wasn't until early march that the idea was launched into the public sphere and became subject to the mechanisms of civil discourse. its most (in)famous airing was johnson's memorable reference to the concept on itv on the 5th march, the same day that confirmed infections exceeded 100 and the first covid death on uk soil occurred. asked by the presenter whether the plan was 'to spread this out so it doesn't all happen at once and overwhelm the nhs', johnson revealed that 'one of the theories is that perhaps you could take it on the chin, take it all in one go and allow the disease, as it were, to move through the population, without taking as many draconian measures' (this morning 2020). actions, of course, speak louder than words, and johnson put this 'theory' into performative practice by shaking the presenter's hand (who had intentionally kept it by his side to see if johnson would offer his own) on entering the studio. when asked about this during the interview, johnson responded 'i've been going around hospitals as you can imagine and always shake hands. people make their own decisions' (in ng 2020; mason 2020d). background representations (low-mimetic generic narrativizations of the virus) were being converted into concrete scripts (mast 2013, p. 10) , which were then being made to walk-and-talk on the public stage provided by a daytime tv show. performance, in other words, was being creatively deployed to communicate the government's intended meanings for the virus. johnson's symbolic actions (burke 1966) continued to accord with the 'theory' he had shared with the nation when two days later he was photographed at a six nations rugby match at twickenham, with tens of thousands of fans in attendance, after which he retweeted a video of himself again shaking hands with the england team (england rugby 2020). it was later revealed by the times that johnson had failed to attend any of the five crisis response cobra meetings that took place in january and february (calvert et al. 2020, april 19) , 2 and which are typically chaired by the pm at times of national crisis (a. walker 2020; walker 2020a, b). on a bbc broadcast on 11th march, david halpern, a behavioural psychologist and sage member who leads whitehall's behavioural insights team-commonly known as the 'nudge unit'-first offered the public a label to attach the 'theory' that johnson had both verbally explained and then performatively acted out. halpern's unit draws upon 'nudge theory', used by many liberal democratic governments as a way of 'nudging' citizens towards 'better' choices (such as handwashing during the c19 outbreak) in a way that avoids legislative intervention. whilst it raises its own civil liberties issues, it is a mode of applied behavioural psychology that lends itself well to civil libertarian modes of government. on the bbc news that day, halpern described a strategy of 'cocooning' vulnerable groups, for a period of time during which the virus could spread, so that 'by the time they come out of their cocooning, herd immunity [could have] been achieved in the rest of the population' (in easton 2020). the idea was to avoid a second, possibly worse, outbreak in the autumn or winter if too few had developed immunity by then. two days later, on the bbc's most popular radio news broadcast, the today programme, patrick vallance reiterated that 'our aim is to … not suppress it completely; also, because the vast majority of people get a mild illness, to build up some kind of herd immunity so more people are immune to this disease and we reduce the transmission' (in stewart and busby 2020) . later that day he told sky news that 60% of the population (approximately 40 million people) would need to become infected in order to reach herd immunity, accepting that this would involve 'an increasing number of people dying' (vallance 2020) . it is worth noting how death is presented here in regrettable but hardly highdramatic tones. frye associates low mimetic drama with pathos (1957, p. 38) , and pathos allows death to be framed as regrettable, though not something that actors have a great deal of agency to control. as boltanski (1999) has argued, feelings of pity for those that suffer or die might move us, but they rarely evoke action towards ending the causes of that death or suffering. death was being framed here as unfortunate, but ultimately unavoidable. the dominant signification of a 'herd' is livestock, and whatever the technical meaning, the popular semantic implication was that human health was being managed equivalently to cattle. this risked evoking eugenicist connotations that are clearly distasteful to many. lawrence freedman (2020) wrote that the term 'lent itself to accusations that the government was preparing to let the disease rip through the community as part of a cold-blooded experiment in social engineering'. moreover, the science was not clear that long-term antibody resistance was viable, an assumption that was based upon the idea that this new virus would operate in a similar way to influenza . although new influenza viruses keep mutating, they are somewhat predictable in that individuals are known to develop immunity through vaccination or exposure. less is known, by contrast, about how the human immune response to c19 functions, and how long it lasts, so deciding not to suppress or track it involved far higher levels of risk. on 13th march, two other sage members confirmed that herd immunity was the only available option. prof john edmunds told chanel 4 news that there were two approaches to stopping a virus: 'you can stamp out every case in the world', but, 'we haven't managed to do that … when the genie is out of the bottle, the virus is all around the world and spreading, the only other way that the epidemic is going to come to a stop is achieving herd immunity'. prof graham medley, interviewed for the bbc, stated that 'we're going to have to generate what we call "herd immunity", so that's the situation where the majority of the population are immune to the infection, and the only way of developing that in the absence of a vaccine, is for the majority of the population to become infected' (on newsnight 2020). however, it was not only the scientists' references to the idea, or johnson's conspicuous actions in accordance with that idea, but also wider policy decisions during this period that offered an overall unity to the government's initial narrativization. all three of these elements were working performatively in concert with the others. on 10th march, the same day that nadine dories, a health minister, tested positive for the disease, the government claimed that there was no scientific basis for suspending sporting events or other large gatherings. many looked on in disbelief as the cheltenham horse racing festival-an event that was cancelled in 2001 due to the foot-andmouth-disease outbreak (a virus that can in only very rare conditions infect humans)took place unabated. one-quarter of a million racing enthusiasts attended from 10th to 13th march. local cases 'increased several-fold' soon afterwards (tucker and goldberg 2020; sabbagh et al. 2020) . most attendees travelled to cheltenham from other areas of the country, where they of course returned following the event, an unknown number carrying the pathogen with them. two horse-racing fans who had attended cheltenham died with c19 symptoms on the same day at the end of that month (calvert et al. 2020, may 24) . on 11th march-the same day that the director general of the who formally declared a 'pandemic' and expressed that the organisation was 'deeply concerned by …. the alarming levels of inaction' exhibited by some governments (who 2020b)-approximately 3000 atletico madrid fans flew from madrid-a coronavirus hotpot, which was itself already under partial lockdown-into liverpool to attend the champions league tie (proctor 2020) . this was at a time when atletico madrid had been forced to close its home ground due to the virus (dispatches 2020). liverpool soon becomes another uk infection hotspot (nuki 2020) . giant stereophonics gigs were held in glasgow (11th march), manchester (13th march), and cardiff (14th march)-in arenas with a combined capacity of over 40,000-producing memorable images of tightly packed fans. all these areas subsequently experienced spikes in cases, but for the time being, this large-scale imagery served to provide manifest symbols of the government's narrative that there was little high drama in this outbreak, no need for ritual to redress it, and that life should continue as normal. contrast heightens dramatic effect and the sense of doing nothing during this period was exaggerated by news that comparable countries were actively intervening to halt the virus's spread. this was a pandemic, not a local epidemic, and the british story was merely a subplot in a global drama. the domestic audience had access to a global media to inform their judgement of how convincing the government's narrative was. east asian nations had demonstrated the efficacy of mass testing, contact tracing, and stockpiling protective equipment, and equivalent european governments were projecting divergent stories that refused to countenance the enormous death toll associated with a 'herd immunity' strategy. italy, denmark, ireland, norway, and spain had all entered lockdown in early march. germany had heeded the successful south korean experience, carrying out comprehensive testing and contact tracing. by 12th march, france had announced school closures, and banned large public gatherings. 3 on 13th march, the behavioural advisors to sage put the case that public trust in the government's response would be lost 'if measures witnessed in other countries are not adopted in the uk' (quoted in freedman 2020). much of the public and many private institutions clearly felt the dominant national narrative was not changing quickly enough and legitimacy in the government's story appears to have diminished around mid-march. 4 polling published on 14th march revealed that 41% felt that the government was underreacting to the situation, and only 36% trusted what johnson said on the subject (helm 2020) . internal government polling showed that a majority was now in favour of cancelling large sporting events (freedman 2020) . preceding government instructions to do so, the premier league, the football league, and the women's super league all suspended their fixtures indefinitely on 13th march, in spite of the enormous financial cost of these moves (macinnes 2020). financial services professionals were told to work from home after outbreaks appeared in their offices (clarke 2020; reuters 2020) , anxious parents kept their children away from school (murphy 2020), employees began simply refusing to show up to work, and universities began cancelling face-to-face teaching from 13th march, advising students who could do so, to return home as soon as possible (bbc 2020f) . large sectors of the public were refusing to act out their roles in the low mimetic narrative in which they had been cast. after lockdown finally arrived, the telegraph quoted a cabinet member claiming that they 'didn't want to go down this route in the first place-public and media pressure pushed the lockdown' (rayner et al. 2020) . leadership and agency were emerging from below, and the government risked being inadvertently cast as a follower, rather than a leader. on 14th march, a who scientist criticised the 'herd immunity' approach on radio 4′s today programme, emphasising the need to escape the notion that events should simply run their course, and instead pleading the importance of becoming actors in the unexpected drama: 'we can talk theories, but at the moment we are really facing a situation where we have got to look at action' (in financial times 2020; also cockroft 2020). that same day, an open letter, signed by over 500 scientists was published, pressing the government to recognise its capacity to resist the enveloping disaster: 'the growth can be slowed down dramatically, and thousands of lives can be spared … "herd immunity" at this point does not seem a viable option … additional and more restrictive measures should be taken immediately, as it [sic.] is already happening in other countries across the world' (open letter 2020a). another open letter signed by almost 700 behavioural scientists had been published the day previously, likewise, highlighting the country's 'unique window' for action. this letter took aim at the assumption that 'behavioural fatigue' could justify failing to implement lockdown, arguing that 'essential behaviour changes that are presently required (e.g. handwashing) will receive far greater uptake the more urgent the situation is perceived to be. "carrying on as normal" … undercuts that urgency' (open letter 2020b). all these interventions were united in their linking narrative inflation with an increase in perceived agency over unfolding events. on 12th march, a highly significant sage meeting took place in which the development of the virus in italy-which the uk was tracking in terms of case and death rates-was put under focus, and the extraordinary consequences of sticking to a 'herd immunity' approach were apparently acknowledged. in turner's typology, this moment at last marked recognition amongst those in power that the viral breach had developed into a crisis (turner 1980, p. 150) . in aristotle's language, this was the moment of 'recognition', the moment of 'change from ignorance to knowledge' (aristotle 1996, pp. 18-19) . dominic cummings was present at this meeting and was reported by the sunday times to have suddenly realised that 'he had helped set a course for catastrophe', resulting in what the newspaper described as a 'domoscene conversion" (shipman and wheeler 2020) . that same day, johnson, in a much more sombre mood, and seemingly uncomfortable with having to share the bad news, made a striking announcement that signalled a radical break from his previous public communications. he stated that 'this is the worst public health crisis in a generation… it is going to spread further, and i must level with you, i must level with the british public: many more families are going to lose loved ones before their time' . he announced that the government would be moving from its 'contain' to its 'delay' stage (gov.ac.uk 2020b). acting against who advice to 'test, test, test' it was also announced that testing those with symptoms and the minimal efforts that had taken place to contact trace would be abandoned. additional advice was offered, but it was modest, and still merely advice-those exhibiting symptoms should stay at home for 7 days, over 70s were advised not to go on cruise ships, and schools should not take their pupils on trips abroad . levels of human agency, in other words, remained low: though recognition had occurred, and a crisis had been inaugurated, a reversal in action and an initiation of redress was yet to come. that saturday, 14th march, the cabinet met and agreed to escalate the response. an attendee reported that the 'mood in the room was astonishing. you could tell that something very significant had shifted' (in shipman and wheeler 2020). that same day, denials began of what had, a few days earlier, appeared transparent. the department of health issued a statement that 'herd immunity is not part of our action plan, but is a natural by-product of an epidemic' (ghosh 2020) , and the health secretary wrote an article for the sunday telegraph claiming that '[h]erd immunity is not our goal or policy; it's a scientific concept; our policy is to protect lives' (hancock 2020b) . 5 even though the uk epidemic was doubling every three to four days at this point, it was nine more days until lockdown-a policy that jarred with johnson's libertarian impulses-was enacted. this decision to delay had demonstrably fatal consequences for many, as the government's own advisors identified (mason 2020b) . modelling from imperial and oxford universities (in calvert et al. 2020, may 24) suggests that if lockdown had commenced on 3rd march, when the initial dire warnings concerning 'mitigation' were presented to sage, infections would have needed to be brought down from around 14,000. by saturday 14th march, when the decision to change approach arrived, around 200,000 people were infected. by the time lockdown was enforced on 23rd march, infections were estimated to be around 1.5 million. another piece of research for channel 4 suggests that locking down on 12 march would have led to 13,000 fewer deaths, and on 16th march, 8,000 fewer (dispatches 2020) . the starkest estimate, however, has come from the epidemiologist and mathematical biologist neil ferguson, a former sage member who heads the imperial college covid-19 response team that has advised the government throughout the crisis. on 10th june, ferguson told a house of commons science committee that if the government had locked down a week earlier, 'we would have reduced the final death toll by at least a half' (stewart and sample 2020) . 5 further evidence of the brazen nature of these denials comes from the following: the italian health minister reported that johnson had phoned the italian pm on 13th march, telling him explicitly that herd immunity was the strategy (dispatches 2020); an author of a paper widely credited with influencing the government's change of approach (ferguson et al. 2020 ) explained at its launch that 'we were expecting a degree of herd immunity to build up … we now realize it's not possible to cope with that in the current health system, and it may not be acceptable in terms of the numbers' (in conn et al. 2020) ; interviewed on 25th march on bbc breakfast, the former health secretary stated that the government changed 'from a herd immunity approach to a suppression approach about ten days ago'. this section will describe how the government's belated recognition that they had made a catastrophic miscalculation led to narrative inflation to a high mimetic mode. most of this new narrativization took place within the genre of tragedy, which aristotle describes as 'an imitation of action that is serious, complete, and of a certain magnitude ' (1996, p. 10) . a central motif of this inflation was the increasing use of militaristic metaphors, which lent themselves to moral polarisation by magnifying the threat presented by the virus to the level of a belligerent invader. this legitimated the need for the extraordinary state intervention required to enter the liminal lockdown phase on 23rd march. it also provided a thematic frame for ritual activity by recasting those who were charged with directly tackling the virus into the role of national 'heroes', apparently willing to risk sacrificing their lives for the health of the nation. at the same time, the government attempted to recast the scientists as more responsible for government policy than the government itself. this narrative inflation reached its peak with johnson's admission into hospital with the virus, a moment that moved the story from the tragic genre of drama, to the even higher romantic genre of legend, imbuing johnson with superhuman powers to fight off the viral antagonist. the end of this section will describe how relatively soon after johnson's release from hospital, signs of narrative deflation emerged, paving the way for a slow and incomplete return to an ambiguous low mimetic mode, characterised by anticipations of both partial reintegration and schism. on 19th march, dominic cummings met with the government's communications director, the general election campaign director, the election's social media strategist, a pr boss, and various figures from the vote leave campaign, to devise the government's main slogan to define the second high mimetic period of the covid drama (hope and dixon 2020; shipman and wheeler 2020). this group had been involved in the famously effective 'take back control' mantra for the 2016 brexit referendum, and the tory's similarly successful 'get brexit done' slogan for the 2019 general election. the new slogan they created to form the centrepiece of the messaging for the lockdown period was 'stay home. protect the nhs. save lives.', and it was released on friday 20th march, two days before lockdown was officially enforced. in announcing lockdown on 23rd march, johnson emphasised the final element of the slogan: 'i must give the british people a very simple instruction: you must stay at home'. this announcement constituted what aristotle called peripeteia, or reversal, the moment in a plot in which 'there is a change to the opposite in the actions being performed ' (1996, p. 18) . in turner's schema, this reversal in actions initiated the most important period of a social drama, that of redress, in which various mechanisms-such as closure of businesses and public buildings, but most centrally an unambiguous order to the public to 'stay home'-were brought into operation to resolve the crisis and bring the recently elevated viral antagonist to heel. the tripartite slogan was repeated over and over again in speeches and government messaging on television, the radio, billboards, and across social media, including being plastered on the front of the lecterns from which the daily press conferences were held (fig. 4) . on the second day of lockdown (24th march), for the first time in british history, an sms with the slogan was sent to every uk mobile phone, and later that week, a letter from the prime minister containing the slogan was sent to every household in the uk. its appearance was typically surrounded in 'emergency' red and yellow chevrons, signifying the seriousness and urgency of the instruction. emphasising the inflation of agency intended by the slogan, hope and dixon (2020) quote a senior downing street source as explaining that it 'was built around the concept of emergency so people could appreciate how stark times were. we needed action'. the action called for, however, was not action from the government, but from the public, and as will be explored below, this contributed to an attempt at shifting responsibility that was to define this high mimetic lockdown period. ironically enough, other than for those few engaged in essential services, the action called for was also a kind of inaction: 'stay home' was how this invisible antagonist was to be fought. like the casting that takes place in situated performances, and the narrative genres that social dramas yoke themselves to, metaphors are another method of meaningmaking, and the metaphor of war was increasingly used by the government and media in discussions of how the virus would be 'fought'. all this 'war talk' (roy 2003, pp. 1-7) served the purpose of narrative inflation, justifying the extraordinary state powers required to enter lockdown. the war alluded to most frequently was that war that currently holds pride of place in the fractured british conscience collective. this was of course wwii, and the fact that the 75th anniversary of ve day fell within the crisis no doubt primed the receptiveness with which this allusion was met. turner has pointed out that 'the culture of any society at any moment is more like the debris, or "fall-out," of past ideological systems, than it is itself a system, a coherent whole ' (1974, p. 14) , and the collective memory of wwii-a war which the vast majority of living people in the uk never experienced first-hand-has become an established culture structure within the british nationalist mythopoeia, capable of conjuring formidable feelings associated with overcoming adversity, and just victory over evil. sometimes sentimental, sometimes jingoistic, this reference is typically backward-looking 6 or even melancholic (freud 1917, pp. 243-258; gilroy 2005, pp. 88-89) and follows the same route of binary polarisation demanded by genre inflation. as gilroy has put it, the imaginative invocation of wwii allows brits to 'know who we are as well as who we were, and then become certain that we are still good while our uncivilised enemies are irredeemably evil' (ibid.). in the c19 'war', non-human agency featured in the form of the 'invisible enemy' being cast as the antagonistic virus itself. the following words/phrases are all taken from newspaper front-page headlines referring to c19 during the period under study: 'the blitz', 'army', 'victory, 'bulldog spirit' (accompanied by an image of churchill giving the victory sign), 'betrayal', 'battle', 'war footing'. the top five ministers of the government have repeatedly been referred to as the 'war cabinet', words like 'threat', 'battle', 'fight', 'invisible enemy', were used repeatedly in the press conferences, during which johnson also described the nhs as 'unconquerable' (12th april). once lockdown was imposed, these martial binaries were used to identify 'traitors' flouting its rules (the mirror 2020). however, the war imagery was not always bellicose: the hospitals built to deliver extra icu capacity were called 'field hospitals', volunteers producing ppe were described as working on the 'home front' (blackall 2020) , and during an extraordinary televised speech to the nation, the queen alluded to vera lynn's famous wwii song 'we'll meet again'. some of the metaphors, whilst not quite subliminal, were less explicit, so that even if they were not always consciously recognised, they nevertheless retained their power to strike the 'symbolic imagination in more or less the same way' (baudrillard 2002, p. 41 n1) . references, for instance, to the sites where infections were understood to have originated as 'epicentres', or the routine description of those staff dealing directly with infected patients as 'frontline' seemed to operate in this way. war did not only feature in language, but also in ceremonial actions that became the focus of media attention and public celebration or censure. a veteran wwii british army officer, captain tom moore, walked 100 laps around his 25-m garden in the run up to his 100th birthday to raise money for the nhs during lockdown. moore, who completed his circumambulations using a walking frame and adorned with his war medals, provided an immaculately preformed icon for the broader sense of wartime spirit the government was working to evoke. he went on to record a version of lynn's 'we'll meet again' to raise further money for charity, and johnson sent him a recorded birthday greeting from downing street, referencing the 'heroic efforts' he had made to complete his 'mission', later recommending him for a knighthood. more contrived attempts at military ceremony were not so successful, such as the health secretary's announcement on 16th april that a lapel badge would be provided to care workers, describing it as 'a badge of honour in a very real sense, allowing social care staff to proudly and publicly identify themselves' (in wood 2020). in a situation in which deaths were mounting amongst these workers, ersatz medals were perceived by many as an insulting substitute for adequate ppe provision, and the scheme was widely ridiculed (woods 2020) . successful wars are typically good for political fortune, but unsuccessful ones can spell ruin for a government's authority. deploying these affective metaphors as ciphers through which to understand the virus therefore simultaneously opened up political risk, since references to the same civil code could be used to critique, as well as to defend government policy. one consultant cardiologist who contracted the disease but could not access testing complained that 'there is policy of surrender' (in boseley 2020a). an epidemiologist suggested that if we were at war, the government needed to do better, in 'commissioning, or commandeering supplies, and delivering those supplies under fire … appoint a commander and give them powers to requisition equipment and laboratory space … make a battle plan on who should be tested first' (hunter 2020) . critics pointed out that the government's newfound martial courage was effectively locking the stable door after the horse had bolted, recasting them from war heroes to appeasers. as one critical website put it, johnson was 'not churchill. he's chamberlin' (www.appea semen t.org). of course, there is nothing particularly new about politicians and the media using war metaphors ('trade wars', 'war on drugs', 'war on poverty', etc.). they are perhaps the most frequently used metaphors of all, and their ubiquity means we often fail to detect them. their popularity is no doubt due to their readily understandable nature, and their tried-and-tested ability to trigger emotions and summon symbolic boundaries between us (the allies) and them (the enemies) (lamont and molnár 2002) . moreover, these metaphors have a long association with illness and disease in particular (sontag 1978) , entering our consciousness from a young age (sick children are frequently told to 'be a brave soldier'). nerlich (2020) suggests that war metaphors are 'the go-to metaphors used in almost all reporting on infectious diseases' in particular, where pathogens are said to 'invade' cells, 'colonise' their host, and our natural 'defences' are said to become 'compromised', 'conquered', or 'overwhelmed'. one explanation for this strong association might be that infectious diseases operate on a microscopic scale, invisible to the naked eye. metaphors provide a vivid visual imagery that allows us to assimilate and structure our understanding of these invisible but highly consequential forces, to make sense of how they operate, but most importantly, what they mean, since ' [m] etaphor is, at its simplest, a way of proceeding from the known to the unknown' (turner 1974, p. 25) . nevertheless, such metaphors do not arise spontaneously, and there was nothing inevitable about the truculent imagery that was attached to the c19 events. the doctor in camus's la peste notes that a plague is similar to other human evils in that it 'helps men to rise above themselves' (camus 2002 (camus [1946 , p. 96). given the extraordinary outpouring of community solidarity in response to the covid threat, metaphors of cooperation and mutual support might just as easily have been adopted. despite historical associations and factoring in the mores that shape and socialise our decision-making, the choice of war metaphors must ultimately be considered just that: a choice. it should also be noted that just as tying real-life events to generic narratives simplifies a complex reality, metaphors likewise tend to conceal whilst they simultaneously reveal. this is because 'metaphor selects, emphasizes, suppresses, and organizes features of the principal subject by implying statements about it that normally apply to the subsidiary subject' (turner 1974, p. 30) . whilst rhetorically effective, metaphor can at the same time therefore curtail and distort our comprehension of the principal subject. wars, for instance, are fought via top-secret strategies laid out by the commanders of sovereign nation-states. pandemics are not. containing and eliminating viral outbreaks requires cooperation, transparency, and maximal sharing of information. rendering pandemics symbolically as if they were wars allows national governments to avoid transparency, to suspend normal democratic accountabilities, and to ignore the experiences and advice proffered by other nation-states, or by global health organisations. nevertheless, in spite of all these reductions and misrepresentations-and perhaps in fact because of them-metaphor remains a potent symbolic resource. the choice to use warfare as the primary figurative representation of fighting the covid threat had the important effect of inflating the sense of danger, and therefore expanding the powers available to the government to control it. a cultural intervention, in other words, enabled a public health intervention. in war-whether real of metaphorical-as in tragedy, heroes come to the fore, and the following section will explore the role that the figure of the hero played in meaning-meaning during this phase of the crisis. in ancient greece, heroes were considered somewhere between the gods and the mortals, and their memories were often kept alive via ritual forms of worship, including offerings and sacrifices that took place around their burial mounds or shrines (farnell 1921) . heroes were of course also the main protagonists of greek drama in the high mimetic mode; they were the 'somebody doing something' (frye 1957, p. 33) , typically presented as struggling against adversity, often driven by higher moral motives. the great greek tragedies frequently centred around, or concluded with, the hero's death, even if those deaths were rarely represented directly to the audience (pache 2009 ). very soon into the covid-19 outbreak, nhs and other key workers-many of whom had previously been referred to in derogatory terms as 'low-skilled', 'inefficient', 'greedy', and 'selfish' (e.g. mckinstry 2011)-were recast as honourable 'heroes' throughout the british media and in speeches and press briefings issued by the government. this section will discuss how this recasting enabled a reframing of the meaning of these workers' deaths. rosenberg notes how epidemics tend to take 'on the quality of pageant, mobilizing communities to act out proprietary rituals that incorporate and reaffirm fundamental social values and modes of understanding' (rosenberg 1989, p. 2) . various secular rituals sprung up around the newly cast heroic healthcare workers in the uk, included children drawing rainbows, often accompanied by slogans of thanks to nhs staff, and sticking them in their windows to be seen by passers-by. there was also a minute's silence held on 28th april for what the bbc described as 'fallen key workers' (bbc 2020a). the choice of a minute's silence, and the description of those that had died as 'fallen' is lifted directly from war commemoration, and in ritualised memories of war, death is dramatised as heroic, but casualties are nevertheless considered inevitable. as one nhs worker bluntly put it 'calling us heroes makes it ok when we die' (panorama 2020) . similar metaphorical work was at play in the us, where trump usefully spelled out what british leaders intimated. in an off-script section of a speech delivered in pennsylvania, trump observed that 'healthcare warriors' were 'running into death just like soldiers run into bullets', adding-as if savouring the moral aesthetic-that 'it's an incredible thing to see, it's a beautiful things to see'. it scarcely needs stating that no healthcare worker entered their career on the understanding that they may be required to sacrifice their lives. durkheim (1995) discusses how intensely emotional interactions focused around sacred objects arise in response to symbolic threats to a community, their functional purpose being to reconfirm collective bonds at moments when their solidity is waning or placed in danger. this approach to ritual spawned an influential paradigm in british anthropology (e.g. radcliffe-brown 1965), but one that in its focus on collective solidarity, weighed too heavily towards the explanation of ritual's functional role in maintaining stasis rather than triggering change, or at least limited its conception of change to immanent systemic causation. turner (1969) , by contrast, whose ethnographies of the ndembu exposed extraordinary levels of conflict amongst these village communities, placed more emphasis on ritual's-and eventually social drama's-role in not only reconfirming but also transforming social structure. in this sense, turner is perhaps best conceived as a conflict theorist, who developed the metaphor of social drama to explain how conflicts resolved themselves through socially patterned processes. nevertheless, although turner's preoccupation is with the management of outbursts of social conflict, he nonetheless studied such phenomena to gain deeper insights into the ongoing 'deep structures' that are revealed through analysing the surface ruptures (1974, p. 34) . the rituals that took place during the uk c19 outbreak were both triggered as responses to a collective threat, but nevertheless expressed social division as much as solidarity, and anticipated change as much as conservation. the most prominent ritual that arose, for instance, was one initiated by annemarie plas, who imported the practice of regularly clapping for healthcare workers that she had seen take place in her home-country, the netherlands. successful cultural practices tend to 'reproduce themselves' (wagner-pacific and schwartz 1991, p. 413) , and the ceremony was rapidly and widely adopted in the uk, with hundreds of thousands of participants clapping key workers from their windows, balconies, or doorsteps during lockdown, celebrating and consolidating their heroic status in the national imaginary. durkheim had observed the importance of periodically repeating rituals 'to renew their effects ' (1995, p. 420) , and 8 pm on thursday evenings quickly establishing itself as the time in which the rite would be enacted. during the structureless, liminoid days of lockdown, the ritual also provided a way of connecting with neighbours in a collective expression of shared sentiment. reminiscent of prison protests, participants who were not necessarily able to see one another in person, could nevertheless hear each other in cacophonous waves of sound that spread an audible 'bond of communitas' across residential centres (turner 1969, p. 105) . collective participation, however, did not miraculously resolve the contradictions that underlay this ritual. for many on the political left of british society, the nhs has been a sacred object of veneration since its postwar foundation, and its staff have been consecrated as folk heroes by those who have relied upon their care. participation in such public reconfirmations of sentiment were therefore unsurprising when expressed from these quarters. what was surprising was the public participation of some quite unlikely sectors of british society. johnson, for instance, had on multiple occasions backed private provision of healthcare, and in 2002 attacked the idea of sacralising the nhs in a speech in which he called for its 'reform', stating: 'i don't see why it should be sacrilegious to say that the nhs is failing … it's all very well to treat the nhs as a religion but it's legitimate for some of us to point out that insofar as it is a religion it is letting down its adherents very very badly' (in bartlett 2019 ). yet johnson made sure he was filmed every thursday evening engaging in the clapping sacrament. other tory mps who had voted through legislation defunding the nhs for almost a decade when the virus hit had also been filmed cheering in the house of commons after successfully voting down an amendment that would have given nhs nurses a pay rise. they too, however, advertised their enthusiastic participation in the clapping ritual on social media with hash tags such as #youareheroes (e.g. helen whately 2020). even within the c19 crisis, on 18th may, tory mps backed an immigration bill denying so-called 'low-skilled' workers-which included many of the 'heroes' they had been clapping-being granted uk work visas. the same month it was revealed that the £60,000 provided to families of bereaved nhs workers would not be extended to families of care home workers or hospital cleaners who had lost loved ones. the daily mail, who had dedicated various front pages in 2016 to attacking junior doctors striking over unsafe working conditions (12th february; 25th, 28th april; 31st august; 3rd september), and in 2014 had felt it necessary in another front-page headline to inform the public that '4 in 5 nurses on nhs wards are foreign' (dec 17th 2014), similarly joined in the public thanksgiving, boasting of the £1million it had raised via a charity for what it described as the 'nhs heroes' in its 29th april front-page headline. one way of explaining this apparent ritual convergence is that the nhs has successfully been raised to a sacred status within the british civil sphere, and its positive coding has been established as a 'common-sense' across the mainstream political spectrum (gramsci 1971, p. 326 f5). as a result, politicians who care about their careers must be seen to be protecting and supporting it. this is especially so at a time of national crisis in which healthcare workers were narrativized as primarily responsible for fending off the collective threat. another element of an explanation might come from narrative inflation having meant that the virus was successfully coded as the primary antagonistic enemy, and as any war-mongering leader knows, external threats can temporarily and precariously galvanise internal solidarities. finally, griswold (1987) recognises that successful cultural expressions allow their consumers to project diverse meanings upon them, whilst simultaneously retaining some overall coherence. the same is evidently true of cultural practices: those that enjoy widespread participation in complex societies with deep political divides need to function somewhat like rorschach inkblot tests, allowing varied participants to read their own meanings into them, whilst maintaining some broader sense of formal unity. getting at the same thing from a different angle, laclau (1996) might have described the functional role of such practices as akin to 'empty signifiers'-signifiers without firm signifiedswhich in their openness to resignification become focussed sites for political struggles over meaning. in the case of the thursday #clap4carers, participants often creatively moderated the rite in order to emphasise the particular meaning it held for them. an ex-mining union leader and labour mp, for instance, was filmed banging a saucepan, chanting 'pay them properly; give them ppe'. as wagner-pacific and schwartz (1991, p. 417) point out, rituals 'do not resolve historical controversies; they only articulate them, making their memory public and dramatic'. this insight was on display most clearly on the event of the uk's final #clapforcarers, on 28th may, for which a group of healthcare workers gathered outside the downing street gates. as the pm emerged to clap from the steps of no. 10, the group turned their back on him, holding a sign reading 'doctors, not martyrs', and stood in silence for 237 s, one second for each of their colleagues who had died from the disease. 7 the narrative inflation brought about through the use of these war metaphors functioned both to excuse the death of healthcare workers and to increase legitimacy for the interventionist policies that the government had belatedly chosen to deliver. another function, though, was to distribute responsibility for dealing with the crisis away from elected officials. although wars are directed by generals, they are fought by troops, and johnson made clear that it was the british public who were being called up for national service: 'in this fight we can be in no doubt that each and every one of us is directly enlisted. each and every one of us is now obliged to join together, to halt the spread of this disease' (johnson, 23rd march) . thanking others for their role in delivering an outcome implicitly casts these flattered inductees into some degree of responsibility if that outcome turns out to be wanting. here, as in the casting of nhs workers as 'heroes', interpellation can be seen most clearly in the use of gratitude and adulation as a mechanism of power. if we recall the improv advice that 'volunteers must be treated with love and generosity' (johnstone 1981, p . 14), we can see how thanks and praise increases the likelihood that an actor will recognise themselves in their assigned role, and that casting will be effective. when faced with criticism, government statements would be issued defending their own actions in the same breath as thanking the public for theirs. for instance, in response to whether the government had any regrets concerning their handling of the crisis, one downing street spokesperson insisted: 'we have taken the right steps at the right time to combat it, guided by the best scientific advice. we are so grateful for the response of the public, who have helped us to slow the spread of the virus' (in conn et al. 2020) . unlike cruder versions of scapegoating, the implicit-and indeed structuralcorollary of the idea that it was the public's responsibility for winning the war was that it was also, at least in part, the public's responsibility if the war was lost. politicians can typically rely upon the mass media to amplify deviance, and such reports often tend not so much to inform the public of actual news, as to provide them with periodic reminders of society's moral boundaries (erikson 1966) . just as convenient 'folk heroes' had been discovered in figures such as captain tom moore, 'folk devils' were quickly identified too (cohen 1972) . this more sinister element of the framing borrowed from another dramatic genre-the 'open conflict of good and evil' (frye 1957, p. 290) found in the medieval morality play. 8 pulling against any superficial galvanising force found in the ritual processes described above, this allowed for identification of 'enemies within', and the coding of these figures as morally corrupt. news reports focussed on the public's flouting of the lockdown rules (e.g. goorwich 2020; bbc 2020b; osborne 2020), encouraging transgressions to be reported to authorities (e.g. higham 2020). sun bathers in public parks, for instance, were attacked by the government and the media for undermining the fight against collective suffering and paraded in the media as public examples of one of 'the shapes that the devil can assume' (cohen 1972, p. 10) . asked on bbc radio 4 why people were ignoring the government advice, the health secretary responded, 'well i don't know, because it's very selfish' (mason 2020a) . as we shall see, these assertions came back to haunt the government when it was discovered that their senior advisor had himself spectacularly breached the rules. on 9th may, just prior to the second major shift in genre, johnson tweeted 'thanks to you, the plan is working, let's keep going' (fig. 2 ). this 'keep going' refrain was repeated in various other social media posts from johnson's personal and official accounts. beyond shifting responsibility onto the public's shoulders, a climate of 'free-floating responsibility' (bauman 1989, pp. 161-163; cohen 2000, p. 88 ) was established in other ways too. the health secretary shifted responsibility to nhs medical staff for over-using ppe (stewart and campbell 2020) , 'huge global demand' was held responsible for ppe shortages (lay and wright 2020) , 'chinese culture' was responsible for creating the virus (liu 2020), but most consistently and explicitly, scientists were held responsible for the overall strategy of the response. turner (1969, pp. 166-203) discusses how liminal periods allow for changes in traditional status and role distinctions, which is in part how ritual processes are able to deliver social transformation. the 'following the science' mantra allowed mps who had been elected to bear responsibility for public decision-making to shift this responsibility by recasting themselves as simply servants to science. interviewed on sky news about the alarming levels of infection in care homes following revelations that 1,500 elderly hospital patients had been transferred into care homes and the community without being tested, the work and pensions secretary said 'if the science was wrong, the advice at the time was wrong, i'm not surprised if people will then think we then made a wrong decision' (in merrick 2020). hume (1985, pp. 507-521) famously argued that you cannot derive an 'ought' from an 'is', and it is clear that prescriptive policy cannot be read directly off descriptive science. to turn science into policy, interpretation and decisionmaking must intervene, and interpretation is a fundamentally cultural matter (taylor 1971; geertz 1977) , just as political decision-making is a fundamentally normative matter. during the outbreak, significant-and for many, deadly-lags took place between evidence appearing and evidence being acted upon, suggesting that it was not scientific calculations, but political and economic ones-themselves deeply embedded in the normative worldview of those politicians making them-that were leading the response. different 'sciences' were also played off against one another. 'behavioural science', for example, was used as a justification for ignoring measures that epidemiological science might have suggested necessary. in early march, johnson had chaired his first cobra meeting of the crisis, in which he was presented with the shocking 500,000 deaths scenario, following which, many members of the medical science team were shocked that tougher restrictions were not immediately introduced (dispatches 2020). chris whitty justified delaying such measures on the basis that 'if we go too early people will understandably get fatigued' (in cohen 2020), and hancock later delivered the same line adding that 'social science and the behavioural science are a very important part of the scientific advice that we rely on' (in conn et al. 2020) . however, the behavioural scientists advising the government strongly rejected this notion of 'fatigue' (ibid.), as did other independent behavioural scientists (open letter 2020b), placing a question mark over its origins as part of the government's strategy. 'guided by the science' was usually shorthand for the fact that they were relying on the scientific advisory group for emergencies (sage), a body charged with providing impartial scientific advice to the government. the daily press conferences were staged in such a way that there was almost always a scientist from this group, or usually two, on a podium by the mp or pm who was fielding the questions. at first, the composition of sage was kept secret, but its membership was later revealed by the guardian newspaper. anthony costello, a doctor and ex-director of the who, critiqued the group not only for drawing upon too narrow a range of expertise, but also for the fact that 13 of its 23 members were directly employed by the government (costello 2020) . it was soon revealed that the top government advisor, dominic cummings, was also sitting in on sage meetings, alongside another younger political protégé of his . costello (2020) argued that this vastly reduced the likelihood of free disagreement. sir david king, the former chief scientific advisor, was 'shocked' by the revelation that political advisors had attended, stating that 'if you are giving science advice, your advice should be free of any political bias' (in carrell et al. 2020 ). vallance had claimed on 13th march that 'i speak scientific truth to power' (sky news 2020), yet available evidence does not seem to bear this claim out. minutes from a sage subcommittee meeting on 3rd march (spi-b 2020) stated that they had reached 'agreement that government should advise against greetings such as shaking hands and hugging' (in payne and cookson 2020; mason 2020d ). vallance then stood by johnson's side in the press conference that same day whilst he boasted of being 'at a hospital where there were a few coronavirus patients and i shook hands with everybody … i think the scientific evidence is, well, i'll hand over to the experts', johnson said, gesturing towards vallance. vallance failed to correct the pm, simply advising, 'wash your hands'. rifts had apparently developed between the government and the scientists when on 19th march, johnson had-in the absence of any scientific evidence-claimed that they could 'turn the tide' of the virus within 12 weeks, a statement that had apparently 'appalled' the experts (shipman and wheeler 2020). prof. neil ferguson (the lead author of the imperial paper that it was claimed provoked the government's shift in approach) made clear that 'it was the politicians, not the scientists, who decided on policies to pursue' (in conn et al. 2020) . another key sage member, prof graham medley, claimed that although the scientists advised the government, action was ultimately 'a political decision', agreeing with the interpretation that johnson and hancock have sometimes been 'passing the buck' onto the scientists (in con et al. 2020). the former examples in this section showed the role of flattery in the exercise of interpellative power in shifting the responsibilities inherent in democratic office onto the shoulders of the public or healthcare workers. these latter examples, by contrast, show the role of office itself in moving the locus of responsibility from elected and democratically accountable officials to unelected and unaccountable experts. the claim of simply 'following the science' allowed mps to cast themselves in what bauman, drawing upon milgram, called an 'agentic state', a heteronomous condition in which actors present themselves as simply 'carrying out another person's wishes ' (1989, p. 162) . on 10th march, nadine dorries, a health minister, tested positive for covid-19. on 25th march-two days after lockdown had come into effect-so too did heir to the throne, prince charles. on 27th march, prime minister johnson also tested positive, alongside the health secretary, matt hancock. chris whitty, the chief medical officer, also started experiencing symptoms the same day. on 5th april, johnson was admitted to hospital where he would spend seven nights, three of them on an intensive care ward where he was not intubated but was given oxygen treatment. three days later, dominic cummings also developed symptoms. the fact that the virus had penetrated the inner sanctums of the symbolic 'centres' (geertz 1977) of british society, infecting almost all the top officials charged with controlling it, naturally generated enormous media attention. this fuelled genre inflation further, to the point that the suspense story of johnson's 'fight for life'-as the 7th april front pages of both the daily mirror and daily star described it-was eventually elevated to the romantic mode. the romantic mode presents the hero as superior not in kind but in degree to other mortals, and 'the ordinary laws of nature [as] slightly suspended', so that 'prodigies of courage and endurance, unnatural to us, are natural to him' (frye 1957, p. 34 ). on 8th april, the daily mail and the daily express both ran with a front-page headline lifted from a speech made by foreign secretary dominic raab asserting that 'boris is a fighter… he'll pull through'. raab, who was deputising for johnson, had declared the day earlier that 'i am confident he will pull through because if there is one thing i know about this prime minister, he is a fighter'. 9 heads of foreign states echoed raab's claims, narendra modi asserted that 'you are a fighter, and you will overcome this', and donald trump reassured everyone that 'he's very strong, resolute. doesn't quit, doesn't give up'. on 9th april, the sun, pointed to various political elections johnson had won, editorialising that he 'has overcome the odds before and can do so again' (dunn and dathan 2020) . there was, of course, nothing automatic about this construction of meaning, and it is worth comparing it with the initial agentless narrativization of the uk's response to the virus described above, and even the predominant tragic narrative of this period. in the former mode, death was a regrettable inevitability for which pathos was the dominant 'structure of feeling' (williams 1977, pp. 128-135) ; in the latter, the disease might be challenged on a policy front, but death could hardly be warded off through individual force of will. frye describes how the romantic mode is characterised not only by 'the suspension of natural law' but also 'the individualizing of the hero's exploits ' (1957, p. 36) , and this new spotlighting of johnson as capable of somehow fighting the virus by sheer strength and courage, cast a shadow over the agency of the nhs staff who were treating him. it also implied that others who had died from the virus were simply not resolute enough in their 'battle'. sontag describes how this notion of a patient beating disease through individual effort is a common theme especially for cancer patients, and emphasises the added turmoil it can cause for the sufferer. 'widely believed psychological theories of disease assign to the ill the ultimate responsibility both for falling ill and for getting well' (1978), she wrote. interestingly, the responsibility for falling ill-given johnson's previous handshaking gambles-was rarely assigned to him, but the responsibility for getting well certainly was. smith's (2005, p. 20) claim that heroes' motivations become more ideal as narrative inflation takes hold is also borne out in this example. on 4th may, the sun's front page reported on an exclusive interview with the headline 'baby gave me will to live', in which johnson-who has refused to publicly disclose how many children he in fact has-described how 'the fear of never seeing his unborn son gave him the strength to beat coronavirus' (wooding 2020) . another theme of the narrativization of these events was that of democratisation: the notion that key public figures contracting the virus indicated its acting as a great social leveller. a downing street source claimed that the 'stay home' slogan's 'success was to communicate a message that "we are all in this together"' (in hope and dixon 2020). in the daily press conference on 27th march (the day of johnson's diagnosis), cabinet office minister michael gove suggested that the 'fact that both the prime minister and the health secretary have contracted the virus is a reminder that the virus does not discriminate'. on 28th march, the mirror's front-page headline ran 'virus at heart of govt. nobody's safe'. on 17th april, the telegraph's front page was a full spread reading 'all in, all together', calling on readers to stay at home. again, there was nothing inherent in the events that necessarily determined these meanings-when iran's deputy health minister had contracted the virus, it was widely reported in the uk press as signalling the incompetence of the iranian government in managing the outbreak. the government's reading of events quickly found themselves subject to dispute. on bbc's newsnight on 9th april 2020, for instance, the presenter began the show with a segment that quickly went viral on social media: 'they tell us that coronavirus is a great leveller. it's not. it's much much harder if you're poor…. those working on the frontline right now, bus drivers and shelf-stackers, nurses, care home workers, hospital staff and shopkeepers are disproportionately the lower paid members of our workforce. they are more likely to catch the disease because they are more exposed'. she added that 'you do not survive the illness through fortitude and strength of character, whatever the prime minister's colleagues will tell us … this is a myth that needs debunking'. the presenter's views were backed up by evidence. the crisis has been experienced in radically different ways depending upon one's housing, employment, and income situation. the wealthier have been more likely to be able to work from home, enjoy household and garden space, and the ifs has shown that richer households have actually increased wealth during lockdown through spending less on luxuries; an effect that has not been seen for poorer households (crawford et al. 2020 ). there has also been a starkly disproportionate number of bame deaths from c19 in the uk (pareek et al. 2020) . even johnson's particular episode was a poor emblem for social levelling: he was tested when others in his condition and age group had no access to testing, and a source in the hospital even claimed that since he had not required a ventilator, he 'was taking up an icu bed when he didn't need it' (in harding et al. 2020) . once he was released from hospital, the travel restriction that applied to everyone else apparently did not apply to him, and he spent his recovery in a grace-and favour 16th century manor house outside of london, with an indoor pool, surrounded by 600 acres of land. perhaps contrary to what might be expected, the episode of johnson's illness coincided with the second largest increase in support for the government's handling of the crisis during the outbreak (yougov 2020a, b; opinium 2020; fig. 3 ). legitimacy was high throughout this middle period of redress, partly because government opinium and yougov polling on public perception of the government's handling of the crisis actions appeared to be conforming to their projected definition of the situation, which itself coincided with dominant public answers to the question of 'what is it that's going on here?'. this specific uptick in legitimacy in a prevailing climate of high legitimacy can in part be explained through the romantic narrative around johnson's illness, and the consequent recalibration of the level of agency available for dealing not only with johnson's personal health, but with the public health crisis more broadly. jacobs and smith (1997, p. 68) identify how within civil societies, romantic narratives 'encourage maximal participation, solidarity, and trust in a common political culture' promoting the assumption of 'powerful and overarching collective identities'. tying groups together in collective projects, driven by shared sentiments and generative of communal identities are processes that are likely to overshadow the more mundane dissensus that might rise to the surface of political life under less elevated narrative genres. as with civil ceremony and ritual, the dramatisation of external threats can serve to temporarily increase internal solidarities, but such solidarities are fragile and time-bound, and cannot be assumed to hold under altered narrativizations. as incoherencies emerged between the government's definition of the situation and their public performances, as their casting of the primary antagonistic threat shifted, and as the narrative pitch was wound down again, dissensus would soon reappear, and with it, legitimacy would soon fall. in johnson's first speech on emerging from hospital, after claiming that the government's response had been a 'success' (exactly one week before britain's death toll became the second highest in the world), he referred to the virus in criminal terms, as a 'physical assailant, an unexpected and invisible mugger', claiming that 'we have begun to wrestle it to the floor' (28th april). 10 in evoking this 'mugger' imagery, a deflation of tone was inaugurated. the signification of the virus as an unpleasant threat remained, but it was no longer the grand foreign invader that had animated the military metaphor. the virus was being recast in the government's projection as once again a more mundane antagonist that could be-indeed was being-wrestled to the floor. the object of struggle was once again becoming more localised and domesticated, and the powers of action ascribed to the virus-with the structural correlate being also those powers necessary to tackle it-were losing their extraordinary force. johnson's particular emphasis on this mugger as 'unexpected' was latched onto, provoking some angry public responses. on social media, a clip from a popular channel 4 tv programme, gogglebox, in which participants are filmed reacting to tv broadcasts, went viral. responding to 10 much of johnson's political charisma is built upon his figurative and-to his admirers-entertaining, use of language. during the crisis, flattening the infection curve became 'squashing the sombrero', avoiding an infection peak was travelling through a 'vast alpine tunnel', and johnson referred to the regional lockdowns as 'whack-a-mole'. this often-clownish use of imagery has alienated as much as it has entertained though, as occurred in his reported use of the phrase 'operation last gasp' during a meeting to source extra hospital ventilators (blanchard 2020 ). johnson's 'unexpected mugger' comment, one viewer asks rhetorically, 'it wasn't really that unexpected though, was it?', another reacts that 'we saw this coming over the hill from china, so i don't think it was that much of a surprise'. 'if we're going to use that simile, that's like a mugger skipping down the street, doing a little dance number, and a twirl, singing "i'm going to mug yooou!"', says another viewer in the clip, with his sofa companion adding, 'that's like saying jack the ripper was unexpected after he'd killed his fifth prostitute'. these viewers were undoubtedly correct in their assessments. c19 was unprecedented in all sorts of ways, but its arrival-or the arrival of something similarwas certainly not unexpected. since 2008, the government's own national risk register had ranked pandemic influenza as one of the highest national risks to the uk, stating that 'experts agree that there is a high probability of another influenza pandemic occurring', and that 'one half of the uk population may become infected and between 50,000 and 750,000 additional deaths' (cabinet office 2008, p. 13 ). an updated version of the same register in 2017 put pandemic influenza in both the highest risk category, and the most likely civil societal risk to take place (cabinet office 2017). the newer report stated that 'emergency responders have personal protective equipment for severe pandemics and infectious diseases' and that there are 'protocols in place for infection control both before and during an incident ' (ibid., p. 35) . in 2016, however, a secret government simulation had been carried out for a hypothetical influenza pandemic, codenamed exercise cygnus, which had instead shown that the nhs would collapse under lack of resources including inadequate levels of ppe (nuki and gardner 2020) . although c19 is not an influenza virus, the ppe required is identical, and that the government were supposed to have been stockpiling this equipment in accordance with their own risk assessment. they failed to do so. stock went out of date without being replaced during the austerity years (malik 2020) , and fell in value by 40% (£325million) . at the end of 2019, there were also 43,000 nursing vacancies in the nhs (gallagher 2019) . no protective gowns at all were included in the government's stockpile when covid hit, even though the government's own advisors had recommended stockpiling in 2019 (panorama 2020) . nor did the government buy any visors, swabs, or body bags (bbc 2020c). even in the absence of this stockpile, however, there was still time to source what was necessary and build up ventilator capacity. on 7th february, the european centre for disease control had issued clear guidance about the levels of necessary protective equipment required (ecdc 2020) meaning that if the uk had acted then, they could have sourced what was needed. british companies who made ppe had written to the government offering their services but received no response (bbc 2020d), so many of these companies actually began exporting their products to foreign governments, such as the usa (panorama 2020) . the uk failed to join two rounds of eu schemes to bulk-buy ppe, and one to buy ventilators, claiming that that they had missed the invitation emails (boffey and booth 2020; mason and o'carroll 2020) . johnson had promised that 'we'll give them [nhs staff] all the support that they need; we'll make sure that they have all the preparations, all the kit that they need for us to get through it' (this morning 2020) but images of nhs staff re-using disposable gear, wearing old swimming goggles, 'dinner lady' aprons instead of the recommended long-sleeved gowns, and making protective head gear from bin-liners and plastic shopping bags quickly surfaced (e.g. staton et al. 2020) . families of nhs workers and volunteers dug out old sewing machines and began making scrubs for their loved ones, and members of the public with 3d printers began producing masks (blackall 2020; itv 2020) . the government then explicitly ordered coroners not to investigate lack of adequate ppe in the inquests into nhs workers' deaths (booth 2020). most alarmingly perhaps, on 18th march (i.e. following the government's decision to inflate the narrative and introduce far more interventionist social isolation measures), a press release from public health england announced that as of '19th march, 2020, covid-19 is no longer considered to be a high consequence infectious disease (hcid) in the uk ' (gov.uk 2020c) . this was an extraordinary decision to make at the height of the deadliest viral outbreak in living memory, especially four days prior to lockdown coming into effect, and at a period where deaths were mounting exponentially (calvert et al. 2020, april 19) . the classification had direct implications for ppe guidance-for a hcid, medical workers should be supplied with an appropriate long-sleeved gown, a respirator mask, and a visor-and it appears that this downgrading was the government attempting to protect itself from litigation, conscious of inadequate ppe supplies (bbc 2020c). on 5th may, even on the official figures released by the government-which have almost certainly vastly underestimated the real death toll (giles 2020)-british deaths from the virus became the highest in europe, and the second highest in the world, with a higher proportion of deaths than the country with the worst overall death toll in the world. only five days after these ignominious rankings however, narrative de-escalation began translating into policy. this final section describes the third phase of the government's response to the virus, which entailed a winding down of the drama back to an ambiguous low mimetic mode. this involved a significant and much-criticised shift in the government's official slogan, and a change in its policy towards the easing of lockdown restrictions and the encouragement of a return to work. at the level of meaning, where the antagonistic threat had previously been focussed purely on the virus itself, the threat was now broadened to also include the consequences of over-responding to the virus through a 'long period of enforced inactivity'. this section will describe how public approval dropped markedly during this period, arguing that this resulted in large part from generic and performative incoherence. the final subsection describes the most spectacular instance of this performative incoherence by recounting the story of how the architect of the 'stay home' slogan found himself caught in the act of failing to stay home whilst infected by the virus. on 5th may, the telegraph reported a senior adviser to the prime minister as claiming to have 'a phase two messaging plan pretty much ready to go. … we are going to remove "stay at home" because that is not going to be the main focus of things. it is about moving people onto the second part of the journey' (in hope describing what i have chosen to define as the third phase of the response, as 'phase two' or the 'second part of the journey', was a presentation later repeated by johnson, and one that conveniently removes the government's failure to act during the initial period from view. on 10th may, johnson released a speech from downing street in which he announced a loosening of lockdown restrictions, including requesting those who could not work from home to return to their workplaces, the removal of any limitations on outdoor exercise, and the announcement that certain school classes could return from 1st june (gov.uk 2020d). though not entirely coherent, this announcement appeared to signal the beginning of the end of the liminal period of redress, and a movement back towards structural reintegration. in his speech, johnson introduced the new tripartite slogan that would define this third period: 'stay alert. control the virus. save lives.'. the shift in the design of the slogans was also notable (fig. 4) . whereas the old one had been surrounded by red chevrons, the new slogan was surrounded by green ones; the semiotics of the message was clear-the country was shifting from 'stop' to 'go'. the new messaging was immediately criticised as confusing and incoherent (bush 2020; tolhurst 2020; sheridan 2020; a. walker 2020; walker 2020b) , and the devolved scottish, welsh, and northern irish governments all refused to shift from the original slogan. public health communications during a deadly viral outbreak need to be clear and comprehensible and this new slogan was evidently not (mendick 2020) , since it was unclear what the public were being asked to 'stay alert' to. polling showed that whilst 91% of the public understood the old slogan, only 30% understood the new one (yougov 2020b). this was arguably not a communications error, as many pr experts were quick to claim (hickman 2020), but instead an extension of the free-floating responsibility theme mentioned above, achieved through a successful communication of an intentionally incoherent message. the purpose, in other words, was arguably to encourage a loosening of restrictions whilst passing responsibility for the possible consequences of that loosening further onto individuals. evidence for this reading comes from the multiple times during johnson's address that he thanks the public-it was 'thanks to your effort' that the death rate was coming down, and 'thanks to you' that thousands of lives were saved (gov.uk 2020d; johnson 2020). the speech included a clear pivot to recasting the antagonistic threat from being not only the disease itself, but also the consequences of radical responses to the disease: 'there are millions of people who are both fearful of the disease, and at the same time fearful of what this long period of enforced inactivity will do to their livelihoods and their mental and physical wellbeing … this campaign against the virus has come at colossal cost to our way of life' (ibid.). this recasting of the virus introduced an ambiguity that had not previously been present over what exactly it was that the public should be 'fearful' of. after all, johnson continued to describe the virus in the morally polarised terms of high mimetic tragedy as a 'vicious threat', and even used the apocalyptic and religious imagery of 'sacred-evil' (alexander 2012, pp. 56-59) at one point, referring to 'this devilish illness' (gov.uk 2020d). these proclamations, however, were contradicted by the broadening out of the metaphors used to describe the antagonist (from 'foreign invader' to 'mugger'), the ambiguity as to what the primary threat in fact was (was it the virus, or the 'cost to our way of life' incurred by controlling the spread of the virus?), and by the rolling back of the restrictions that had previously been in place. in spite of the continuing refrain that the new plans were 'driven by the science' (gov.uk 2020d), the shift again appears to have been led by politics. the top scientific advisors were never asked to sign off on the slogan , and prof. john dury, who sits on the behavioural subcommittee of sage typically tasked with devising public communications during emergencies asked 'who is advising on the current messaging? unfortunately, it's not us', criticising the 'stay alert' messaging as 'too vague' (in ibid.). later in may, another prominent sage advisor, prof. john edmunds, issued a warning that 'with relatively high incidents, and relaxing the measures, and with an untested track and trace system, i think we are taking some risk here' (in boseley 2020b). the day following johnson's announcement of the lockdown loosening, teachers unions spoke out against sending classes back on 1st june, and a petition asking for parents to retain the right to keep their children at home gathered 390,000 signatures (lovett 2020) . on 15th may, the daily mail front-page headline attacked 'militant unions' for standing in the way of teachers wishing to return to work, and in continuity with the sacrificial-heroic coding of the previous period declared 'let our teachers be heroes'. four days later, the guardian reported that 1,500 primary schools were intending on defying the government's orders to open at the beginning of june (weale et al. 2020) . three days after johnson's lockdown loosening speech, polls indicated a 9-point plunge in public approval of the government's handling of the crisis, with disapproval (42%) for the first time during the crisis exceeding approval (39%) (opinium 2020a ; fig. 3) . a repeat poll on 21st may showed this disapproval with the handling of the crisis growing, as well as johnson's personal approval rating being overtaken by the opposition leader (opinium 2020b) . the same polling found that 47% of the public believed that the government were underreacting to covid-19, compared to 34% who believed they were reacting proportionally, and that 43% of parents felt anxious sending their primary-aged children back to school, compared to 20% who felt relieved; 53% felt anxious sending their secondary school children back, with only 13% reporting relief (ibid.). it is important to ask why it was, during this third period in which the government attempted to move the country back towards structural reintegration, that public legitimacy fell below the levels seen even at the end of the initial period when institutions and individuals were leading the government towards lockdown (fig. 3) . one important factor was a lack of both generic and performative coherence. in terms of genre, whilst many successful dramas are based upon blending (tragicomic, romantic-comedy, etc.), and whilst genres can be shifted from one mode to another, genre constraint nevertheless exists, since genres are indeed generic and therefore do not exhibit unlimited plasticity or boundless synthetic potential. this genre constraint might be thought of as one of the ways in which the relative 'autonomy of culture' functions. the ambiguities described above-in narrativizing what the real threat was (was it still the virus? was it now the effects of countering the virus?), at what level of gravity this threat should be understood, what powers of agency existed to fight the virus, and indeed what the new messaging condensed in the revised slogans in fact meant-flouted generic rules leading to broad confusion as to the kind of story the government was trying to tell. during the initial low mimetic period, a growing proportion of the public may not have found the government's narrative genre convincing, but there was at least coherent projection to disagree with. no such coherence reigned during this third period. on the performative level, in the first period johnson had acted in accordance with low mimesis by shaking hands and allowing sporting events to go ahead, communicating that it was 'business as usual' (calvert et al. 2020, may 24) . in this third period, johnson was mixing the rhetoric of one genre (the high mimetic claims that this was a 'devilish disease ' [gov.uk 2020d] ), with the actions of another (the low mimetic loosening of lockdown restrictions so as to 'reopen society ' [ibid.] ). such incoherence threatened the possibility of widespread fusion, and less of the public seemed prepared to suspend their disbelief and go along with the confused narrative they were being told. such contradictions between word and deed reached their most spectacular apogee in an episode revealed near the end of may. this episode, which occupies the focus of the following and final subsection, further eroded the dramatic force of the government's intended projection, damaging legitimacy even further. on 22nd may, a joint investigation by the guardian and the mirror revealed that dominic cummings had breached the lockdown rules he had helped write after being spotted at the end of march on the grounds of his parent's home in durham, a county in the north of england, 264 miles away from his london home (crerar and armstrong 2020; weaver 2020) . his presence in durham would have violated lockdown rules if he had been feeling well, but the transgression was considered particularly serious since both cummings and his wife had written about their coronavirus illnesses during this period, omitting to mention their extensive trip (wakefield 2020) . at the height of the lockdown, and exhibiting symptoms, they had apparently travelled the majority of the length of the country from the most infected zone to an area with a relatively low infection rate at the time. by this point, the official advice had been tattooed into the public's consciousness by the extraordinary communications campaign cummings himself had designed: stay home, and if you showed symptoms, you should self-isolate for seven days. the next day, a government minister, grant shapps, made clear that although the cummings family had made the cross-country trip, he had 'stayed put' once there (bland 2020) . the following day, however, a member of the public reported spotting the cummings family at barnard castle, 45 min from cummings's parents' home (weaver and dodd 2020) . rather than apologise for the incident, the government chose to double-down, using an appeal to the higher moral motive of love for one's child, as the alibi. downing street issued the following statement on the day the story broke: 'owing to his wife being infected with suspected coronavirus and the high likelihood that he would himself become unwell, it was essential for dominic cummings to ensure his young child could be properly cared for' (in stewart and weaver 2020) . the public had by this point spent weeks restricting their movements. thousands who had contracted the virus had been confronted with the same childcare issues but nevertheless conformed to the lockdown instructions. for many others adhering to the lockdown rules had meant foregoing saying goodbye to dying loved ones and being unable to conduct funeral ceremonies. many scientists, and even tory mps were furious with the official response, and began joining calls from the opposition benches for cummings to resign or be sacked. the following day, a remarkably similar chorus of messages in support of cummings appeared on cabinet ministers' social media accounts. an instance of this came from the health secretary tweeting that 'it was entirely right for dom cummings to find childcare for his toddler, when both he and his wife were getting ill'. on 3rd april, whilst cummings was away in durham, that same health secretary had presided over the daily press conference, behind a podium with the inconspicuous words 'stay at home' emblazoned upon it and stated that 'we cannot relax our discipline now. if we do, people will die', warning that 'this advice is not a request, it is an instruction' (bbc 2020e). the government's narrative risked appearing as though it had been devised only to apply to the public and not to the government itself, a case of 'do as we say, not as we do', which undermined the earlier 'we're all in it together' framing of the outbreak. since the media seemed unprepared to let the story die, the following day johnson held a press conference claiming that cummings had 'acted responsibly, legally and with integrity', again deploying the higher moral motive argument in claiming that 'any parent would understand'. many parents did not understand though, and the headlines that day were the worst since johnson's premiership began. the mirror had headshots of cummings and johnson, with 'a cheat & a coward' splashed across their front page. even the daily mail-typically unwavering in its automatic support for the government-ask incredulously of the pair, 'what planet are they on?'. prof. stephen reicher, a member of the sage behavioural subcommittee, tweeted that 'in a few short minutes tonight, boris johnson has trashed the advice we have given on how to build trust and secure adherence to the measures necessary to control covid-19′. dr adam kucharski, of sage's modelling subcommittee, tweeted that for the contact tracing measures 'to work, we need public adherence to isolation/quarantine to be very high. but i fear it's now going to be far more difficult to achieve this'. as the pressure mounted, it was announced that cummings would give his own press conference the following day (25th may) from the downing street rose garden, an unprecedented move for a senior advisor, which the bbc described as an 'extraordinary piece of political theatre'. in a gesture that no doubt did little to help generate sympathy and diffuse the impression of arrogance, cummings kept the audience waiting for half an hour, pushing back the day's tv scheduling. when he finally emerged, remorse was nowhere to be seen: 'i believe in all the circumstances i behaved reasonably and legally'. to a journalist's question of whether he regretted his actions, he responded 'no, i don't regret what i did'. to a question about whether he had considered resigning, the answer again was 'no'. precedent had been set by the scottish chief medical officer and the author of the imperial paper, both resigning from their roles for far less serious transgressions of the government's rules. cummings justified his journey due to the 'exceptional circumstances' around his childcare, but tens of thousands of people had found themselves in far worse circumstances, and nevertheless kept to the rules. he also confirmed his trip to the scenic town of barnard castle, which, entirely coincidently, had fallen on his wife's birthday. he claimed he had made the journey to test his eyesight, which had apparently been damaged by the disease, to see if he was fit to drive back to london. this decision to operate machinery for an hour and a half in lieu of an eye-test would have been odd if it had only meant putting himself at risk, but having done so with his family in the car, in the same defence in which he claimed that his overall actions were driven by the higher moral motives of love for his child, tried the credulity of many observers. after it was revealed that cummings's wife also held a driving licence, a reader wrote to the guardian suggesting that the reason her licence had not been used to drive the family home was probably that the dog had eaten it (guardian letters 2020). a poll published in the daily mail the following day revealed that whilst 8% believed cummings's eye-test story, 78% took it to be false (hussain 2020) . the same poll suggested that 59% of tory voters thought he came across as arrogant, and a staggering 80% of conservative voters believe he had broken lockdown rules. 70% agreed with the statement that johnson's government believes 'it's one rule for them and another rule for everyone else', with 65% predicting it was less likely that others would now follow the lockdown rules. a yougov poll the same day revealed that 52% of leave voters believed cummings should resign, contradicting claims that the scandal had been artificially concocted by disgruntled remainers as revenge on the man they believed manipulated the referendum result. as the scandal deepened, 44 tory mps called for cummings to resign or be sacked (mason 2020c ). johnson's approval ratings plunged 20 percentage points in the four days following the revelations to their lowest levels ever (from 19% to 1%), and government approval dropped 16 percentage points (from 14% to 2%) in a single day (savanta 2020) . once again, an explanation for this precipitous fall in legitimacy can be found in word and deed failing to align. the high mimetic narrativization of events, in which the 'stay home' message was communicated not as 'a request', but as an emergency 'instruction' (bbc 2020e), was suddenly being presented as open to interpretation. the government appeared to be saying that if one's motives were high enough, one could flout the rules, the importance of which they had spent weeks establishing. for public performance to be effective, narratives need to be acted out in accordance with the 'genre constraints' described above, since 'no matter how intrinsically effective [they are], collective representations do not speak themselves' (alexander 2004, p. 530) . government actions had failed to conform with the genre under which they were narrativizing the crisis, revealing a de-fused performance that wreaked havoc on the coherence of their drama. drawing upon a range of tools for cultural analysis-including narrativization and its link to genre, ritual process and social drama, casting and interpellation, scripting and performance-this paper has tried to specify the ways in which shifts in meaning-making resulted in changes in the political fortune of powerful actors, alterations in public behaviour, and ultimately in life and death outcomes for tens of thousands of uk citizens. it has mapped out specific turning points at which cultural changes in the management of the crisis can be shown to have had often dire impacts on health outcomes. in other words, it has tried to demonstrate why meaning-making matters, and why sociologists ought to pay attention to it. precisely because these mechanisms of sense-making can be shown to impact spheres of social life beyond the cultural, their functioning should be of interest not only to cultural analysts, but also to those concerned with public health and administration more broadly. the lesson, in other words, is that viral threats cannot be treated merely from a medical science perspective of the most technically efficacious ways to halt the spread of a disease, or even from a narrowly political perspective of how to represent, govern, legislate, and manage an organised polity in the midst of an outbreak. nor should we stop short at the important point of underlying the social origins of covid-19 (horton 2020). cultural processes should also be recognised as lying at the heart of both public health and statecraft, since culture composes the media through which these other practices are necessarily transacted. as well as demonstrating culture's relative autonomy and offering an empirical illustration of the potential of the strong program in cultural analysis, this paper has also made a series of other contributions to cultural sociology. for instance, in showing the effects of casting the virus as a sometimes more, sometimes less, threatening antagonist, it has demonstrated how social performance theory needs to take more seriously the way in which non-human actors become inducted into social dramas. by analysing the ritual behaviour that took place around the sacralised nhs, it has shown ritual's role in rendering social conflicts and divisions to public audiences, as much as its more familiar role in affirming consensus and social cohesion. in showing how metaphor simplified a complex reality, redefined the form and gravity of the crisis, and reshaped the meaning of healthcare workers' deaths so as to shift responsibility away from the government, it has revealed mechanisms through which culture (in the form of figurative expression) is able to directly impinge on political process. in showing how flattery can operate as a kind of hailing, it has shown how expressions of praise and gratitude can function as a mode of interpellative power, similarly capable of shifting responsibilities. finally, in charting the progression of the crisis through the stages of a secular ritual process, it has not only shown how anthropological theories of ritual can be productively interwoven with literary theories of narrative to provide hermeneutic forms of explanation, but has also shed light on the meaning work that lies behind how crises are triggered, how they are elevated to dramatic heights, and how they are lowered back down again. though the focus here has been on the diachronic evolution of a single case, future research in this vein would benefit from taking a comparative multi-case approach. this would enable tracing the impact of meaning-making processes synchronically across national contexts, showing how differences in governmental sense-making shaped divergent public health policies in ways that resulted in differences in behaviour, and infection and death rates. studying the c19 pandemic in this way is particularly promising for the further demonstration of culture's relative autonomy in that unlike in many other cases of sociological interest, one of the key variables to be monitored is the behaviour of an indifferent pathogen, rather than that of reflexive human beings, capable of their own internalising, interpreting, and performing processes. this ability to bypass what giddens (1987) called the 'double hermeneutic', in other words, bolsters the possibility of specifying more direct mechanisms of the causal impacts of culture. turner's fourfold schema of the passage of a social drama concludes with either 'reintegration', typically involving some change in the social structure into which that reintegration takes place, or else schismogenesis-the initiation of a permanent 'breach between contesting parties ' (1980, p. 151) . reintegration might be said to have occurred if and when the virus has become an accepted part of everyday life in the uk and considered something like seasonal flu, perhaps through the development of more successful means of treating its symptoms, and the emergence of a shared consensus on reading it in low mimetic quotidian terms. alternatively, a conclusion signalling schism might arise if and when the virus is somehow overcome and separated from the field of view as a present threat, perhaps through a successful vaccination programme leading to a critical mass of immunity within the population. another event around which schism may arise is the ritual management of political sanction-through ballot or public enquiry-for the government's failure to shift from a low mimetic to a tragic narrativization of events early enough and maintain its coherent projection in both rhetoric and action for long enough, or in response to some mismanaged future second wave. a complete manifestation of any these outcomes is clearly not yet present, though aspects of all remain latent and virtual possibilities. another conclusive possibility is also worth noting. turner emphasises that 'during attempts to redress conflict', '[n]ew norms and rules may have been generated… old rules will have fallen into disrepute and have been abrogated ' (1974, p. 42) . if this social drama follows the pattern of many others before it, the social disruption brought about by the anti-structural lockdown period of redress may lead to a makeover of social relations. though lockdown experiences have been highly variable, a recent poll revealed that only 9% of the uk public want things to return to normal after lockdown ends (yougov 2020a). sanguine voices have speculated that the war metaphors that gave figurative expression to the height of the redressive period might be mobilised towards demands for a more egalitarian social dispensation in the uk, such as occurred following wwii (bakewell 2020) . turner saw the interim liminal or liminoid periods in social life as a wellspring of social transformation, since members are granted the exceptional ability to stand aside from rule-bound social roles and both reflect upon and actively involve themselves in, alternative social arrangements. during such periods, settled standards of behaviour and order are subject to criticism and imaginative reinterpretation. frequently enough, turner wrote, '[y]esterday's liminal becomes today's stabilized, today's peripheral becomes tomorrow's centred ' (1974, p. 16) . given the radical contingency of events, making any confident predictions about the content of possible social changes resulting from the uk's c19 social drama remains foolhardy, but asserting the likelihood of change itself appears less so. the civil sphere performative revolution in egypt: an essay in cultural power. london: bloomsbury academic trauma: a social theory the strong progam in cultural sociology: elements of structural hermeneutics revealed: how, on every measure, britain's response to the covid pandemic has been woeful on the reproduction of capitalism: ideology and ideological state apparatuses origins of the present crisis ve day was the spark for change. coronavirus could be too speech genres and other late essays introduction to the structural analysis of narratives boris johnson urges break up of 'top-down monopolistic' nhs in the spirit of terrorism modernity and the holocaust minute's silence for fallen key workers dozens flout lockdown rules for park 'rave uk failed to stockpile crucial protective kit government 'has 8,000 offers from ppe suppliers staying at home this weekend 'not a request more universities halt teaching and exams the volunteers making ppe on the homefront for uk health workers. the guardian politico london playbook: the age of corona-rishi leads the fightback-commons rule change dominic cummings timeline: what we know about his movements. the guardian uk missed three chances to join eu scheme to bulk-buy ppe. the guardian nhs staff coronavirus inquests told not to look at ppe shortages. the guardian there is a policy of surrender': doctor on uk's covid-19 failures. the guardian covid-19 spreading too fast to lift lockdown in england-sage advisers. the guardian acts of meaning language as symbolic action: essays on life, literature, and method the government's "stay alert" slogan is working too hard coronavirus: 38 days when britain sleepwalked into disaster the sunday times 22 days of dither and delay on coronavirus that cost thousands of british lives top experts not asked to approve 'stay alert' coronavirus message. the guardian the plague. penguin the origins of attic comedy revealed: dominic cummings on secret scientific advisory group for covid-19 canary wharf bankers are 'sleepwalking' into coronavirus crisis uk's 'herd immunity' approach to tackling coronavirus questioned by world health organisation the british charlatan style has been sent packing by too much reality | nick cohen. the guardian folk devils and moral panics: the creation of the mods and rockers states of denial: knowing about atrocities and suffering revealed: the inside story of the uk's covid-19 crisis the government's secret science group has a shocking lack of expertise. the guardian boris fails to convince with sanitised take on coronavirus. the guardian household spending and coronavirus. london: institute for fiscal studies ifs dominic cummings investigated by police after breaking covid-19 lockdown rules. the mirror revealed: value of uk pandemic stockpile fell by 40% in six years stories of change: narrative and social movements pandemics, publics, and narrative response to sunday times insight article-department of health and social care media centre the rise of hermeneutics. new literary history. winter the formation of the historical world in the human sciences coronavirus did the government get it wrong? bounding back: boris johnson 'sitting up in bed' and improving as he fights coronavirus in intensive care the elementary forms of the religious life care home residents could be 'cocooned' over virus personal protective equipment (ppe) needs in healthcare settings for the care of patients with suspected or confirmed novel coronavirus wayward puritans: a study in the sociology of deviance question time: medical expert richard horton says uk 'wasted february' when it should have been preparing nhs for coronavirus cases greek hero cults and ideas of immortality impact of nonpharmaceutical interventions (npis) to reduce covid-19 mortality and healthcare demand the real reason the uk government pursued "herd immunity"-and why it was abandoned mourning and melancholia anatomy of criticism: four essays number of gps has fallen while nursing vacancies hit 43,000 amid nhs crisis the interpretation of cultures some scientists say uk virus strategy 'risks lives social theory and modern sociology uk coronavirus deaths more than double official figure, according to ft study after empire: melancholia or convivial culture? abingdon: routledge. goffman, e. 1959. the presentation of self in everyday life covid-19: government announces moving out of contain phase and into delay pm speech in greenwich uk government under fire after 'big influx' of covid-19 cases from europe revealed. the guardian the fabrication of meaning: literary interpretation in the united states, great britain, and the west indies testing questions on the drive to barnard castle | letters. the guardian legitimation crisis wuhan coronavirus: health secretary's statement to parliament we must all do everything in our power to protect lives. the telegraph boris johnson and coronavirus: the inside story of his illness only 36% of britons trust boris johnson on coronavirus, poll finds. the observer pr pros lambast new government 'stay alert' slogan as 'unclear' and 'unhelpful lockdown breach: how to report people ignoring lockdown rules the story behind 'stay home, protect the nhs, save lives'-the slogan that was 'too successful'. the telegraph comment: covid-19 is not a pandemic a treatise of human nature: being an attempt to introduce the experimental method of reasoning into moral subjects coronavirus: if we are in a war against covid-19 then we need to know where the enemy is. the conversation tory voters say dominic cummings should resign over 'lockdown breach'. daily mail 15-year-old uses 3d printer to make masks for frontline nhs workers | meridian-itv news civil society and crisis: culture, discourse, and the rodney king beating romance, irony, and solidarity pm address to the nation on coronavirus impro: improvisation and the theatre endless war? hidden functions of the 'war on terror why do empty signifiers matter to politics? the study of boundaries in the social sciences on actor-network theory: a few clarifications coronavirus: only use the ppe you need, hancock tells healthcare workers. the times blaming china for coronavirus isn't just dangerous. it misses the point. the guardian 000 sign petition demanding parents given choice to keep children at home. the independent the theory of the novel: a historico-philosophical essay on the forms of great epic literature premier league, football league and wsl suspended until april. the guardian in this crisis, the tory cuts can no longer be hidden by empty gestures. the guardian hancock accuses those still socialising in uk of being 'very selfish'. the guardian uk failure to lock down earlier cost many lives, top scientist says. the guardian tory anger at dominic cummings grows as 61 mps defy boris johnson. the guardian boris johnson boasted of shaking hands on day sage warned not to. the guardian no 10 accused of putting 'brexit over breathing' in covid-19 ventilator row. the guardian the performative presidency: crisis and resurrection during the clinton years coronavirus belgium: 'outraged' medics turn their backs in protest at pm's handling of pandemic no surrender to these greedy and selfish strikers the government's mixed messages mean british workers do not know whether to stay or go up to 80% of people in uk could catch coronavirus in worst-case scenario scientists to blame if government made coronavirus mistakes, cabinet minister says. the independent social movement spillover pragmatic humanism: on the nature and value of sociological knowledge. abingdon performance and power in social movements: biko's role as a witness in the saso/ bpc trial movement intellectuals engaging the grassroots: a strategy perspective on the black consciousness movement conflict in the academy: a study in the sociology of intellectuals coronavirus: concerned parents vow to keep kids off school with covid-19 walkout the british political elite coronavirus: can herd immunity protect the population? -bbc newsnight philip schofield tries to avoid shaking boris johnson's hand, but pm does it anyway. the independent revealed: the three uk sporting events that may have led to a coronavirus death spike exercise cygnus uncovered: the pandemic warnings buried by the government telling our stories: narrative and framing in the movement for same-sex marriage open letter to the uk government regarding covid-19 public request to take stronger measures of social distancing across the uk with immediate effect public opinion on coronavirus -13th may the political report, 21st may police wake up caravan tourists flouting lockdown rules in newquay. the independent the hero beyond himself: heroic death in ancient greek poetry and art panorama-has the government failed the nhs? bbc ethnicity and covid-19: an urgent public health research priority boris johnson shook hands 'continuously' despite science panel warnings narrative power: the struggle for human value it was like a fever: storytelling in protest and politics conjectures and refutations: the growth of scientific knowledge liverpool v atlético virus links 'interesting hypothesis', says government scientist. the guardian structure and function in primitive society who plays down pandemic fears after seventh person dies in italyas it happened cabinet ministers admit there is no lockdown exit plan as they wait for boris johnson's return. the telegraph coronavirus risk to british public remains low: health minister the narrative function what is an epidemic? aids in historical perspective explaining epidemics war talk experts call for inquiry into local death toll after cheltenham festival. the guardian storytelling: bewitching the modern mind coronavirus data trackers chaos over government's 'stay alert' slogan as scotland coronavirus: ten days that shook britain-and changed the nation for ever. the sunday times coronavirus: enforcing uk lockdown one week earlier 'could have saved 20,000 lives'. the guardian coronavirus: 'i speak scientific truth to power' says chief scientific adviser for england why war?: the cultural logic of iraq, the gulf war, and suez disease as political metaphor spi-b return to sage on the use of behavioural and social interventions on a covid-19 epidemic in the uk spi-m-o: consensus statement on 2019 novel coronavirus (covid-19 why the nhs is struggling to protect staff from coronavirus coronavirus: science chief defends uk plan from criticism. the guardian nhs workers angered at hancock's warning not to overuse ppe. the guardian johnson: many more people will lose loved ones to coronavirus. the guardian grant shapps backs dominic cummings over lockdown breach. the guardian culture in action: symbols and strategies interpretation and the sciences of man the mirror boris johnson on priti patel, coronavirus and changing nappies the peculiarities of the poverty of theory: an orrery of errors confidence in government's handling of coronavirus crisis drops amid confusion over 'stay alert' slogan descriptive accuracy in history: the case of narrative explanations sports events 'shut down too late to save lives the ritual process: structure and anti-structure dramas, fields, and metaphors: symbolic action in human society social dramas and stories about them the anthropology of performance coronavirus: 'i speak scientific truth to power' says chief scientific adviser for england the rites of passage the moro morality play: terrorism as social drama the vietnam veterans memorial: commemorating a difficult past getting coronavirus does not bring clarity | the spectator. the spectator contagious: cultures, carriers, and the outbreak narrative alert for what?': manchester confused by new government slogan. the guardian boris johnson missed five coronavirus cobra meetings, michael gove says. the guardian coronavirus lockdown: what are the new rules announced by boris johnson? the guardian no 10 retreats as rebellion over schools gathers pace. the guardian pressure on dominic cummings to quit over lockdown breach. the guardian dominic cummings facing possible police investigation as pressure mounts. the guardian audience participation in theatre: aesthetics of the invitation 2019-ncov outbreak is an emergency of international concern who director-general's opening remarks at the media briefing on covid-19 the idea of a social science and its relation to philosophy coronavirus: matt hancock ridiculed after announcing badge to support care sector workers. the independent boris johnson says fear of never seeing his new son gave him strength to beat coronavirus the care home crisis won't be solved by handing out some badges. the telegraph perception of government handling of covid-19 | yougov brits split on changes to coronavirus lockdown measures | yougov publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations movement intellectuals engaging the grassroots: a strategy perspective on the black consciousness movement acknowledgements thank you to the ajcs editors and anonymous reviewers for their generous comments on earlier drafts of this article, and to anne marie champagne for all her help in the production of this article. key: cord-316682-4360s2yu authors: fischer, william a.; weber, david j.; wohl, david a. title: personal protective equipment: protecting health care providers in an ebola outbreak date: 2015-11-01 journal: clinical therapeutics doi: 10.1016/j.clinthera.2015.07.007 sha: doc_id: 316682 cord_uid: 4360s2yu abstract purpose the recent ebola epidemic that devastated west africa has infected and killed more health care providers than any other outbreak in the history of this virus. an improved understanding of pathogen transmission and the institution of strategies to protect health care providers against infection are needed in infectious disease outbreaks. this review connects what is known about ebola virus transmission with personal protective equipment (ppe) designed to arrest nosocomial transmission. methods articles pertaining to filovirus transmission and ppe in filovirus outbreaks were reviewed and findings are presented. in addition, studies that evaluated ppe and donning and doffing strategies are presented. findings ppe is one step in a comprehensive infection prevention and control strategy that is required to protect health care providers. given that the ebola virus is primarily transmitted through direct contact of mucous membranes and cuts in the skin with infected patients and/or their bodily fluids, it is necessary to cover these potential portals of infection with ppe as part of a structured and instructed donning and doffing procedure. implications current recommendations about ppe and the donning and doffing processes are based on anecdotal experience. however, the use of non-human viruses can help provide evidence-based guidelines on both ppe and donning and doffing processes. the recent ebola epidemic that devastated west africa evolved within months from a regional humanitarian crisis to a global public health emergency. as of may 27, 2015, 27 ,049 cases and 11,149 deaths from ebola were reported by the world health organization (who), an underestimate that already eclipses the numbers of infections and deaths in all previous outbreaks combined. 1 with fewer than 0.1 physicians per 10,000 people in liberia, sierra leone, and guinea, the infection of 869 health care providers and the death of 507 in this epidemic alone has depleted an already precious resource. 2 although the rate of confirmed cases has declined dramatically in west africa, the loss of health care providers will continue to affect the people of this area for decades to come. despite major advances in the prevention and treatment of infectious diseases in general, there are currently no licensed vaccines, proven effective antiviral therapies, or proven postexposure prophylaxis strategies for ebola virus disease (evd). personal protective equipment (ppe) plays a critical role in mitigating the risk of health care personnel (hcp) exposure to contaminated body fluids in the care of patients with communicable infectious diseases, including evd. the importance of ppe was recognized during the outbreak of severe acute respiratory syndrome (sars), in which hcp accounted for $ 20% of persons who were infected with sars. 3 evidence of continued sars transmission despite the use of droplet, contact, and airborne precautions drew attention to the possibility of nosocomial transmission during ppe removal or doffing. 4, 5 in addition, recent studies suggest that viruses, including ebola, have the potential to remain infectious on ppe for longer than it is typically worn, creating an opportunity for transmission during doffing. historically, development of ppe strategies has been driven by the paradigm that infectious agents are transmitted by 1 of 3 routes: contact, droplet, or airborne. however, the consideration of self-inoculation in the removal of ppe is emerging as a major potential route of hcp infection. 6 to this end, we reviewed the major routes of ebola virus transmission and the use of ppe to prevent hcp exposure and infection. once the ebola virus enters the human population, outbreaks are sustained through human-to-human transmission, which is facilitated by the presence of the virus in every body fluid, including blood, diarrhea, vomit, sweat, breast milk, vaginal secretions, and semen. 7, 8 ebola virus increases logarithmically in the blood during acute infection, and often the highest levels of viremia are achieved at the time of death. 9 in addition, patients in the later stages of disease have more severe symptoms, including diarrhea, vomiting, and bleeding complications, thus increasing the potential of spread via infectious body fluids. this coupled with limited health care infrastructure in the areas where most ebola outbreaks occur contribute to the outbreak amplification that is often seen in health care settings. [10] [11] [12] epidemiologic studies suggest that the virus is spread primarily through direct contact with the patient and virus-laden body fluids, especially late in the clinical course of disease. 11, 13, 14 of 173 household contacts of 27 infected patients, 28 (16%) developed evd. 13 all 28 cases reported direct physical contact with the index patient (risk ratio ¼ 3.6; 95% ci, 1.9-6.8). 13 importantly, none of the 78 household members who reported no direct contact with the index patient developed evd. in a separate study those family members who provided direct nursing care to the index patient had a 5.1-fold increased risk of infection, highlighting the importance of direct contact. 11 the risk of secondary transmission, in a separate study, increased with exposures that continued through the later states of illness (crude prevalence proportion ratio [ 15 given the high levels of virus in body fluids and on the skin of patients at the time of death, postmortem contact is also associated with an increased risk of infection (adjusted risk ratio ¼ 2.1; 95% ci, 1.1-4.2). 13, 16 the increased potential for transmission during contact with a dead body, as occurs during traditional burial practices, can be partly attributed to the durability of virus in body fluids even after death. in a nonhuman primate study of viral persistence after death, replication competent virus was detectable in oral, nasal, and blood samples from dead animals. blood contained the highest concentrations of viable virus (2 â 10 5 median culture infectious dose/ ml) and remained positive for the longest duration, 7 days postmortem. 17 viral rna was detectible from oral nasal and blood swabs for up to 3 weeks postmortem. 17 together, these data highlight close contact with a dead body, as is custom during preparing a body for funeral, is a potential route of transmission. of 316 people infected in the kikwit outbreak (in 1995) only 5 reported no physical contact with a confirmed patient, suggesting that alternative routes of transmission, including droplet or fomite-mediated transmission, may be possible but are unlikely events. 18 theoretically, fomite transmission is possible, but the conditions, including the environmental surface and ambient temperature, affect the viability of the virus. in 1 study, filoviruses, including ebola, were found to remain infectious in liquid media at room temperature for at least 46 days, but infectious virus could not be isolated when allowed to dry on a plastic or glass substrate at room temperature. 19 reports from the current outbreak indicate that multiple environmental samples obtained from an ebola treatment unit were positive for polymerase chain reaction. 10 however, when sampling occurred after routine cleaning in a separate study, all 31 environmental samples were negative, suggesting that routine sanitation, as part of environmental control, can decrease the potential of fomite transmission. 20 recently, the potential for airborne transmission has received considerable attention. 10, 21 although animal studies suggest that this is possible when virus is experimentally aerosolized, epidemiologic studies of household contacts indicate that this is not a primary means of transmission. 11, 13, 14, [22] [23] [24] in addition, the institution of barrier protection with the use of surgical masks that do not protect against airborne transmission has historically been sufficient to eliminate nosocomial transmission and hcp infection. 25 higher risks of airborne or droplet transmission is likely to occur in health care settings during aerosolgenerating procedures such as induced sputum procedures and/or intubation. the combination of high viral loads, the ubiquitous presence of virus in all body fluids, and the low inoculum required for infection substantially increases the risk of hcp, family members, and loved ones who provide direct care to ebola-infected patients. 26 in addition, patients infected with evd often present with nonspecific symptoms that frequently mirror more common, but less contagious, infectious diseases. for this reason it is imperative that hcp implement the use of standard precautions consistently when providing care to all patients. 27, 28 the strict adherence to standard precautions before the identification of an ebolainfected patient is paramount to preventing nosocomial transmission to hcp. key elements of standard precautions include the following 27,29,30 : (1) hand hygiene, (2) risk assessment for appropriate ppe, (3) respiratory hygiene, (4) prevention of needle-stick and injuries from other sharp instruments, (5) proper waste management, and (6) environmental cleaning and disinfection of patient care equipment and environmental surfaces. although a disproportionate amount of attention and debate have been directed to the components of ppe, the most effective means of reducing health care-associated infection include the implementation of environmental and administrative controls. 31 environmental controls include not only the construction and maintenance of appropriate facilities for isolating potentially infected patients but also the establishment of clean water and sanitation and effective waste management that reduce environmental contamination and serve to limit hcp exposure at the source. similarly, administrative controls alter the delivery of care to mitigate potential exposures such as implementation of infection control precautions, patient triage for rapid identification of suspect cases of evd with immediate isolation of the patient in a single room, establishment of specific donning and doffing protocols, the presence of donning and doffing monitors, and policies on medical procedures. during the ebola outbreak in kikwit, zaire, in 1995, 67 hcps were infected while providing care in an isolation unit plagued by a lack of water and electricity, a shortage of ppe, and an absence of appropriate waste disposal. 25 after the implementation of environmental and administrative controls in the establishment of a properly functioning ebola treatment unit the rate of hcp infections decreased dramatically. 25 collectively, environmental and administrative controls are critical infection control measures that work to arrest potential chains of transmission in health care settings. despite the lethal nature of this virus and the potential ease of transmission, infection can be prevented. although the most effective interventions to protect hcp are those that physically separate hcp from infectious patients and body fluids, mortality rates of ebola-infected patients can be decreased with more aggressive care that requires close contact with these patients. 32 in this setting, ppe serves as the last physical barrier between a health care provider and infectious body fluids. in prior outbreaks, infection of hcp was substantially reduced with the institution of barrier precaution. although the actual ppe is the most visible aspect of infection control, it must be used as part of a larger infection prevention and control strategy that incorporates environmental and administrative controls, including the establishment of physically separate donning and doffing areas from the space in which actual clinical care is provided, training on the correct use of ppe, sufficient supply of all ppe components, and the use of a trained doffing instructor. designated areas that allow for clear separation between donning and doffing is critical because doffing involves potential exposure to contaminated body fluids on the outside of used ppe. moreover, clear delineation between high-and low-risk areas and when ppe is needed and not needed are paramount to ensuring that ppe is used appropriately to mitigate risks of exposure to sources of infection. secondly, training in the use of ppe before providing care for suspect or confirmed patients is crucial because there is a learning associated with providing routine tasks in unfamiliar situations. in addition, the heat stress associated with the use of ppe in tropical climates is an occupational hazard that, in some instances, can increase the risk of accidents and thus exposure if not recognized early. behavioral controls are also a fundamental aspect of infection control strategies. on average a person will touch his or her eyes, lips, and nostrils at a rate of 15.7 times per hour. 33 in ebola endemic countries during this epidemic, there was a policy of no touch in which people do not hug, kiss, or shake hands to avoid potential transmission outside of ebola treatment units. refraining from touching one's face and frequent handwashing is encouraged to reduce the potential of self-inoculation. collectively, the logistics of ppe are also necessary to protect health care providers. although there is no consensus on each of the specific components of ppe among the major organizations providing care to infected patients in the field, all agree that it should uniformly protect the major portals of virus entry, including mucous membranes and breaks in the skin. centers for disease control and prevention (cdc) guidelines, which are directed toward the use of ppe in us hospitals, recommend mucous membrane coverage with either an n-95 particulate respiratory or a powered air-purifying respirator (papr) that incorporates a full-face shield, helmet, or headpiece. 34 if an n-95 respiratory is used, it must be accompanied by a single-use surgical hood that extends to the shoulders and a full-face shield. similarly, if a papr is used with a helmet or headpiece, it also must be used in combination with a disposable hood that extends to the shoulders and fully covers the neck. the who recommendations, which pertain to care of ebola-infected patients regardless of location, include the use of a face shield or goggles to protect conjunctival membranes and either a fluid-resistant medical/surgical mask that does not collapse against the mouth (eg, duckbill or cup shape) or a fluid-resistant particulate respiratory if aerosol-generating procedures will be performed. 35 in both cases, the who offers a conditional recommendation that health care providers also wear a separate head cover that protects the head and neck. this recommendation is conditional because there is no evidence to support the use of a head cover or hair cap for preventing infection. 35 although the use of a papr provides enclosed protection and full visualization of the provider's face, the logistical obstacles of disinfection after each use, need for reliable electricity to power the unit, and the cost limit these from being widely used in the field. similarly, because ebola does not appear to be efficiently transmitted via an aerosol route, a surgical mask can be used to protect against droplet transmission, although an n-95 if available provides better protection against airborne agents. however, given the length of time it takes to don and doff ppe and the inability to change components of ppe while inside a high-risk area, many in the field enter with a particulate respirator in case a patient is coughing, aggressively vomiting, or undergoing a procedure that could generate secondary aerosolization. no evidence is found of increased efficacy of either face shields or goggles in the prevention of ebola virus transmission, but both have advantages and disadvantages. goggles offer complete enclosure around the eyes, preventing inadvertent touching with potentially soiled gloves, but they provide a more limited range of view compared with face shields. however, face shields allow more of the hcp's face to be visible during patient care, which facilitates communication and potentially decreases patient anxiety. although fogging affects both face shields and goggles, reducing visibility, it may affect face shields to a lesser degree. both the cdc and the who recommend the use of 2 pairs of gloves with at least the outer pair having an extended cuff that reaches beyond the wrist. 34, 35 the inner pair of gloves rests against the hcp's skin and underneath the gown/coverall (described in the body and skin protection section), whereas the outer pair is worn on top of the gown/coverall to effectively protect the wrist from contamination. this also allows the outer glove to be changed between patients to mitigate risks of nosocomial transmission between patients. the use of 2 pairs of gloves also protects against damage to the outer glove by disinfectants such as chlorine and may reduce the risk of parenteral exposure from sharp injuries while the loss of tactile sensation is minimal. as described in the next section, the use of double gloves has also been used to decrease the incidence of hand contamination particularly during ppe removal. no evidence suggests that 42 pairs of gloves allots additional protection but instead may increase risk as the doffing sequence becomes more complicated. given the high risk of transmission through direct patient contact, the cdc and the who recommend the use a single-use fluid-resistant gown or coverall to prevent contamination of underlying skin and surgical scrubs. although it is not known if the ebola virus can penetrate intact skin, the presence of virus on skin or clothing could be a source of self-inoculation. the resistance of commercially available gowns/coveralls is assessed by their ability to prevent passage of a nonenveloped dna virus, phix174, under different degrees of pressure. 36 resistance, however, must be balanced by tolerance of use by health care providers who work in tropical conditions because increased resistance impairs evaporative cooling and may decrease the time hcp can provide care. if a fluidresistant gown is worn, it should extend beyond the top of the footwear or shoe covers (see foot protection). the integration of thumb loops may be beneficial in securing complete protection of the wrist area. the who guidelines recommend against the use of tape to attach gloves to gowns/coveralls because this may increase the risk of tearing the gown/coverall and complicate the doffing procedure at a time when health care providers are potentially most vulnerable. 35, 37 the use of a waterproof or impermeable apron worn over the gown/coverall is recommended to provide further protection against infectious body fluids. both the cdc and the who recommend using a disposable apron if feasible because a reusable one will require decontamination after each use. given the high degree of environmental contamination due to substantial diarrhea and vomiting, hcp are advised to wear waterproof boots or shoe covers if used with a coverall that has integrated socks. 32 in addition to being easier to decontaminate, waterproof boots offer some protection against sharps injuries. 35 the feasibility of such an approach in the field must be considered however because the countries in which most ebola outbreaks have occurred are among the poorest in the world with the least developed health care infrastructure available. in sierra leone, a country already among the countries with the lowest health care expenditures (ranked 141 of 192 nations) and devastated by the current epidemic, the use of full containment ppe as recommended by the cdc and who was deemed neither affordable nor practical in peripheral health care units that were visited initially by many patients infected with evd. 38 although the various forms of ppe recommended by the who, cdc, and medecins sans frontiers (or doctors without borders) all mitigate risks of exposure to infected body fluids while caring for ebolainfected patients, the presence of ppe alone is not enough. ppe must be donned correctly before entry into a high-risk area, must remain in place while inside a high-risk area, and must be removed safely when leaving the high-risk area to be effective. ppe must not be adjusted during patient care because adjusting goggles or a face shield can lead to mucous membrane exposure and potential infection. risk of indirect exposure to infected bodily fluids is likely highest when removing ppe because, depending on the step, the major portals of entry may be exposed in close proximity to clothing contaminated with infected bodily fluids. these risks may be decreased by implementing a systematic process of instructed doffing in which safe removal of contaminated clothing is directed by a trained and rested doffing instructor. this is different than the buddy system of donning. when donning, it is sufficient to have the person you are entering with check to ensure that your ppe is intact and on correctly. however, given that doffing is the highest risk activity, it is critical that the person guiding you through the process of removal has not been inside the high-risk zone recently, is well rested, and is solely focused on getting you out of the high-risk area safely. the variability in recommended ppe by different organizations and hospitals necessitates variation in donning and doffing order because the order will change with each ppe item added or removed. it is imperative that this order is established, optimized, and taught before it is being used to ensure feasibility and success. although ppe in its various forms and designs cover the major portals of virus entry, the efficacy of actual protection is unknown and remains poorly studied. a nonpathogenic nonenveloped bacteriophage, ms2, has been used to assess safety of ppe and donning and doffing protocols in non-ebola settings. 39 although filovriuses are single-stranded enveloped rna viruses, the use of ms2 is a conservative surrogate because the absence of an envelope likely improves the ability of this virus to maintain its infectiousness in the environment. in addition, the current cdc recommendations for environmental decontamination of an ebola care area are consistent with those needed to decontaminate nonenveloped viruses. the use of ms2 allows for the systematic evaluation of ppe and processes to ensure they have been optimized for health care provider safety. after the sars outbreak the cdc sequence for removing ppe was evaluated with the use of a nonenveloped, nonpathogenic rna virus and glogerm (glo germ company, moab, utah) fluorescent synthetic beads. 40 the fluorescent tracer was found not to be a reliable indicator of virus contamination because virus was recovered from both areas that fluoresced and areas that did not fluoresce. in this study, virus was recovered from the scrub shirt of 100% of participants, the nondominant hand in 80%, and scrub pants in 75%. 40 the highest virus titer was recovered from the scrub shirt. the use of fluorescent tracer provided false confidence because it was found on the shirt, nondominant hand, and scrub pants in 10%, 10%, and 0% of research participants, respectively. 40 the use of double gloving, however, significantly reduced not only the incidence of hand contamination with virus but also the quantity of virus that was transmitted to hcp hands, thus providing better protection against viral contamination during ppe removal. a comparison of 2 personal protective systems found that the papr system that included a second outer layer was less likely to experience contamination than an enhanced respiratory and contact precautions system that lacked a second outer layer. 5 in the papr ppe set hcp wore a tyvek (dupont, wilmington, delaware) suit, shoe covers, a surgical gown, and a large hood, whereas the enhanced respiratory and contact precautions system included only a surgical gown, indicating that a second covering significantly reduced exposure to contaminated body fluids and provided evidence for the use of aprons on top of gowns or coveralls in the care of ebola-infected patients. areas that were more likely to be contaminated included the anterior neck, forearm, hands, and wrists. however, those persons donning the papr system were more likely to commit donning procedure violations, highlighting the increased difficulty of donning and doffing with more complex ppe. fortunately, there were no significant differences in doffing procedure violations between the 2 groups. 5 although ppe is often only worn for short periods of time, pathogenic viruses such as influenza, sars, and ebola can survive for extended periods of time on surfaces and be sources of transmission via surface-tohand and hand-to-face/mucous membrane contact. despite 2 layers of protective clothing and 2 pairs of gloves, hand hygiene remains an essential aspect of ppe because previous studies have reported that organisms can spread from gloves to hands after glove removal. 41 outbreaks of evd, with the exception of the reston subtype, have occurred exclusively in central sub-saharan africa and more recently in west africa where the climates are known for high ambient temperatures and humidity throughout the year. ppe worn in these settings significantly increase the risk of heat stress and pose yet another risk to the hcp. the risk of heat stress when wearing ppe depends on a number of factors, including length of work shift, ambient temperatures, hydration status, and preexisting medical conditions among others. strategies to mitigate the risk of heat stress for hcp must be implemented such as the use of buddy systems to monitor the health of providers inside the high-risk area, hydration breaks in between shifts, and consideration of time limitations in staffing determinations. in addition, other strategies were used in the current outbreak, including the use of cooling vests and air conditioning, which have extended the time that providers can spend with patients. ongoing studies by the national institute for occupational safety and health are evaluating the effect of different types of ppe on core body temperature. 42 recommendations from the cdc for reducing heat stress-related complications include the following 43 : (1) educate hcp how ppe places them at a higher risk of heat-related illness, (2) acclimatize hcp to ppe conditions by gradually increasing their time working in ppe, (3) stay well hydrated, (4) watch for signs and symptoms of heat-related illness, and (5) ensure adequate breaks in between shifts to rest and cool down. the devastation in west africa exacted by ebola will be felt for decades to come. in addition to the unprecedented numbers of infections and deaths, this epidemic has also decimated the hcp population that will leave an already susceptible region at risk well beyond the end of this epidemic. in this epidemic 869 hcp were infected and 507 died to date, more than any other ebola outbreak and likely more than all previous outbreaks combined. protection of hcp who bravely work on the front lines must be a priority. although the use of ppe is an integral part of hcp safety, it must be used as part of a universal infection prevention and control strategy that incorporates environmental and administrative controls, sustained logistical support, and the use of scientific evidence to back current recommendations. there have been 25 outbreaks since the ebola virus was discovered in 1976, and they are occurring with increased frequency. the question is not whether another outbreak will occur, but when. improved ppe and evidencebased recommendations are a priority. drs. fischer, weber, and wohl contributed equally to this work. the study was supported by funds from the national institutes of aging r03ag045088 (wf), north carolina translational and clinical sciences institute (nc tracs) kl2tr001109 (wf), infectious disease society of america young investigator award in geriatrics, and a national institutes of health k24 da037101 (dw). the funders had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; and preparation, review or approval of the manuscript. statement on the 1st meeting of the ihr emergency committee on the 2014 ebola outbreak in west africa physicians (per 1,000 people). http:// data.worldbank.org/indicator/sh.med.phys.zs?order= wbapi_data_value_2010þwbapi_data_value&sort=asc lessons learned: protection of healthcare workers from infectious disease risks cluster of severe acute respiratory syndrome cases among protected health care workers-toronto contamination: a comparison of 2 personal protective systems uncertainty, risk analysis and change for ebola personal protective equipment guidelines ebola haemorrhagic fever persistence and genetic stability of ebola virus during the outbreak in kikwit, democratic republic of the congo rapid diagnosis of ebola hemorrhagic fever by reverse transcription-pcr in an outbreak setting and assessment of patient viral load as a predictor of outcome transmission of ebola viruses: what we know and what we do not know ebola virus disease in southern sudan: hospital dissemination and intrafamilial spread report of a who/international study team transmission of ebola hemorrhagic fever: a study of risk factors in family members ebola hemorrhagic fever transmission and risk factors of contacts lethal experimental infection of rhesus monkeys with ebola-zaire (mayinga) virus by the oral and conjunctival route of exposure schmiedel s. a case of severe ebola virus infection complicated by gramnegative septicemia postmortem stability of ebola virus ebola hemorrhagic fever, kikwit, democratic republic of the congo, 1995: risk factors for patients without a reported exposure the survival of filoviruses in liquids, on solid substrates and in a dynamic aerosol assessment of the risk of ebola virus transmission from bodily fluids and fomites what we're afraid to say about ebola. ny times (print) ebola virus transmission in guinea pigs transmission of ebola virus (zaire strain) to uninfected control monkeys in a biocontainment laboratory transmission of ebola virus from pigs to nonhuman primates interventions to control virus transmission during an outbreak of ebola hemorrhagic fever: experience from kikwit, democratic republic of the congo clinical recognition and management of patients exposed to biological warfare agents centers for disease control and prevention. infection prevention and control recommendations for hospitalized patients under investigation (puis) for ebola virus disease (evd) in u.s. hospitals infection prevention and control (ipc) guidance summary: ebola guidance package basic infection control and prevention plan for outpatient oncology setings world health organization. standard precautions in health care centers for disease control and prevention. workplace safety and health topics: hierarchy of controls clinical presentation of patients with ebola virus disease in conakry, guinea centers for disease control and prevention. guidance on personal protective equipment to be used by healthcare workers during management of patients with ebola virus disease in u.s. hospitals world health organization. personal protective equipment in the context of filovirus disease outbreak response personal protective equipment for filovirus epidemics: a call for better evidence protecting health care workers from ebola: personal protective equipment is critical but is not enough ebola infection control in sierra leonean health clinics: a large cross-agency cooperative project methods for the recovery of a model virus from healthcare personal protective equipment virus transfer from personal protective equipment to healthcare employees' skin and clothing removal of nosocomial pathogens from the contaminated glove. implications for glove reuse and handwashing fighting ebola: a grand challenge for development -how niosh is helping design improved personal protective equipment for healthcare workers interim guidance for healthcare workers providing care in west african countries affected by the ebola outbreak: limiting heat burden while wearing personal protective equipment (ppe) key: cord-284484-oak1lfmi authors: barratt, ruth; gilbert, gwendolyn l.; shaban, ramon z.; wyer, mary; hor, su-yin title: enablers of, and barriers to, optimal glove and mask use for routine care in the emergency department: an ethnographic study of australian clinicians date: 2019-12-04 journal: australas emerg care doi: 10.1016/j.auec.2019.10.002 sha: doc_id: 284484 cord_uid: oak1lfmi background: the risk of healthcare-acquired infection increases during outbreaks of novel infectious diseases. emergency department (ed) clinicians are at high risk of exposure to both these and common communicable diseases. personal protective equipment (ppe) is recommended to protect clinicians from acquiring, or becoming vectors of, infection, yet compliance is typically sub-optimal. little is known about factors that influence use of ppe—specifically gloves and masks—during routine care in the ed. methods: this was an ethnographic study, incorporating documentation review, field observations and interviews. the theoretical domains framework (tdf) was used to aid thematic analysis and identify relevant enablers of and barriers to optimal ppe use. results: thirty-one behavioural themes were identified that influenced participants’ use of masks and gloves. there were significant differences, namely: more reported enablers of glove use vs more barriers to mask use. reasons included more positive unit culture towards glove use, and lower perception of risk via facial contamination. conclusion: emerging infectious diseases, spread (among other routes) by respiratory droplets, have caused global outbreaks. emergency clinicians should ensure that, as with gloves, the use of masks is incorporated into routine cares where appropriate. further research which examines items of ppe independently is warranted. healthcare-associated infections are an ongoing threat to patients and clinicians, resulting in significant morbidity and economic cost [1] . the risk of infection, for vulnerable hospital patients, their family members and healthcare professionals, increases during outbreaks of novel and re-emerging infectious diseases, such as the highest-risk healthcare professionals for exposure to bloodborne viral infections [8] and respiratory diseases such as influenza [9] . hunter et al. [10] reported an estimated 16% rate of mers among ed clinicians in abu dhabi and, of those infected, 93% had been exposed before the diagnosis was made. personal protective equipment (ppe), including gowns, gloves, masks and protective eyewear, is crucial for protecting clinicians from acquiring, or acting as a vector of infection to other staff and patients [11] . in addition to appropriate use of ppe, as part of transmission-based precautions (contact, droplet or airborne), standard precautions indicate use of ppe when there is a risk of exposure to pathogens: non-sterile disposable gloves if hands are likely to become contaminated and a surgical mask and eye protection when at risk of exposure to aerosols or direct splash with blood and body fluids. n95/p2 masks are usually reserved for a few diseases (chickenpox, measles, tuberculosis) in which pathogencontaminated droplet nuclei (residue from evaporated droplets) or dust particles can remain suspended in air for long periods and enter the upper and lower respiratory tracts. sub-optimal use of ppe (i.e. contrary to the indications for standard and transmission-based precautions) by clinicians has been reported in different hospital settings [12] [13] [14] . while gloves are the most frequently used item, masks are less appropriately used [15] . although clinicians' use of ppe has been shown to increase when an outbreak is declared [3, [16] [17] [18] , routine compliance is typically suboptimal [19, 20] which increases the risk of occupationally-acquired infection and disease. there is limited recent literature examining the use of ppe in eds. following the introduction of universal precautions in the early 1990s [21] , a number of studies reported poor compliance with these measures in the ed [22] [23] [24] . more recently, singh et al. used self-administered questionnaires to determine compliance with (what are now referred to as) standard precautions in the ed, and found that gloves were frequently used, but there was poor compliance with other ppe, especially eye protection [15] . evanoff et al. [25] observed video footage to assess compliance with ppe during 304 invasive procedures in an ed and reported 96% glove use for trauma patient encounters, compared with 68% and 78%, for use of mask and protective eyewear, respectively. in a trauma centre study, the compliance rates for use of masks and eye protection, after an educational intervention, were 16% and 44%, respectively [26] . ed clinicians are regularly at risk of facial contamination during invasive procedures, intubation and other resuscitative measures [27] . they are also exposed to both seasonal and emerging respiratory infectious diseases. in one paediatric ed setting, only 1-12% of clinicians reported that they always or usually wore a mask or eye protection, while assessing febrile respiratory patients during winter [28] . although gloves are worn frequently, patient safety may be compromised by misuse, such as not changing them between dirty and clean tasks on the same patient or between different patients and/or failing to comply with hand hygiene before and after use, which often contaminates the clinician's hands [29] [30] [31] . commonly cited factors contributing to sub-optimal compliance with ppe in healthcare include inadequate knowledge and training, perception of risk, organisational culture and environmental barriers [32, 33] . reid et al. [28] identified knowledge, access to ppe, patient diagnosis and unit culture, in the ed context, as factors influencing ppe compliance. healthcare transmission of novel infectious diseases can occur prior to recognition of an outbreak [10] . while it is difficult to plan in advance for such a rare event, staff who are competent in the principles and practice of routine infection prevention and control (ipc) and ppe use are more likely to be better protected from the start and more prepared to implement high-level precautions rapidly and safely. in this area there is a paucity of literature which examines factors that facilitate or hinder the use of ppe during routine clini-cal care in the ed. most previous studies have focused primarily on compliance with standard precautions during procedures that pose a high risk of exposure to blood and body fluids [25, 26] or on overall compliance with ppe use, without elucidating determinants of those behaviours [15] . they have described 'how' clinicians use ppe, whereas the present study aimed to shown 'why' ppe is, or is not, used by exploring the factors that influence the use-specifically of gloves and masks-during routine care, in one ed. we employed methods that allowed close engagement with clinicians so as to understand their choices and behaviours and utilised the theoretical domains framework (tdf) [34] to assess the relevant enablers and barriers. a better understanding of these practices in this context could assist managers, educators and clinicians to optimise enablers and address barriers, locally, and inform health policy and pandemic planning more widely. this qualitative study used ethnography to explore the use of gloves and masks by clinicians in an ed. this is a suitable methodology for the study of complex social and clinical interactions in the context of healthcare quality and safety [35] as it involves direct observation of the behaviour of people and their social environment using varied data collection methods. the theoretical underpinnings of this research are grounded in behavioural science, in particular the tdf, which was used to inform the interview guide and subsequent data analysis. the tdf synthesises multiple theories of behaviour and behavioural change into 14 domains which provide a framework for examination of cognitive, affective, social and environmental determinants and influences on behaviour [36] . it has been used widely in patient safety research [37] , including clinicians' ipc practices [38] and is particularly useful for informing policy and planning practice improvement. the setting was a busy ed with over 72,000 presentations per year in a major tertiary hospital in sydney, australia. departmental staff were informed about the study through a staff e-newsletter and during several morning staff meetings which are attended by all staff on duty that day. a purposive snow-ball sampling technique [39] was used to recruit clinical and non-clinical staff working in the department for semi-structured interviews, so as to obtain a crosssection of professional roles, experience and clinical expertise. approval for this study was given by the western sydney local health district human research ethics committee. written consent for interview was obtained by the researcher after negotiation with each participant in accordance with the approved study protocol. the researcher attended the ed during day shifts for one to two hours at a time, observing and taking notes on activities directly related to the aim of the study. local and hospital policies, signage, and other documentation relating to use of ppe in the ed context, were examined. reflexive review of field observations and documentation, was used to inform the interview guide [40] but not included in the analysis reported here. twenty-two face-to-face, semi-structured interviews, lasting 10-45 min (average 28 min), were conducted with clinicians (nurses and doctors) and non-clinical support staff at times and places convenient for them during the day. interviewees comprised five senior doctors (dr), seven nurses in senior roles (clinical nurse consultant [cnc]/ nurse manager [nm]/ nurse practitioner [np]), two registered nurses (rn), one enrolled nurse (en), two nurse graduates (ng), two support workers (sw) and two senior external clinicians from the ipc (cnc) and infectious diseases (dr) departments. the questions were guided by the 14 domains of the tdf and focused on the desired behaviours of optimal compliance with glove and mask use. interviews were audio-recorded and subsequently transcribed verbatim. interviewees were invited to review their transcripts for accuracy. the data was analysed using a content and thematic approach in order to gather an in-depth understanding of factors affecting optimal glove and mask use. transcripts were reviewed independently by two researchers, the content was coded into tdf behavioural domains relating to the target behaviours [36] and analysed thematically. no data were lost in the transcription or the interpretive analysis. thirty-one behavioural themes were identified that influenced participants' use of protective masks and gloves. these were mapped against the theoretical domains (table 1 ) and further analysis allowed them to be classified as enablers and barriers to optimal use. the data revealed interdependency between some domains, resulting in natural grouping of the findings. for example, "participants' beliefs about the consequences" (tdf6) of glove and mask use were linked to "emotion" (tdf12) such as anxiety; therefore, the findings are described together. there was also mirroring of themes whereby one could be either an enabler or barrier within the same domain. for example, "knowledge" (tdf1), was an enabler of glove use but a barrier to appropriate mask use. findings are reported under tdf domain titles within the categories of enablers and barriers. in this study, enablers of optimal ppe use were represented in all domains; however, there were more enablers of optimal glove, than protective mask, use. enablers include a variety of factors that encourage, facilitate or are likely to increase glove or mask use (not necessarily appropriately) including internal/personal factors such as self-protection and/or external factors, as detailed next. participants' knowledge and skills, self-efficacy and confidence in the equipment, were interconnected as key enablers of optimal ppe use. all participants reported having received instruction in the use of ppe during either their professional or induction training. optimal use of gloves and masks was further enabled through education provided by the hospital ipc team or by some other clinicians with broader knowledge and/or interest in ipc. participants please cite this article in press as: barratt reported that high-level ppe skills had also been enhanced in recent years through simulation exercises for ebola virus disease. 'look, whenever there's attention to something, like the ebola, we had a lot of in-services regarding donning and doffing.' (doctor [dr] 2) most clinicians' perceived knowledge of ipc policies supported their use of gloves as appropriate for standard and transmissionbased precautions. optimal ppe use had been further promoted recently through the introduction of an ed-specific poster that identified ppe required for specific diseases, which was attached to isolation trolleys and positively received by staff as helpful, particularly in choosing the correct mask. the majority of participants reported they were confident with the protection provided by the equipment and in their ability to correctly don and doff gloves and protective masks. 'i got taught that fitting of the mask, when the ebola . . .. was out. i remember being taught properly then how ppe should be worn.' (enrolled nurse [en]1) the participants' understanding and abilities in ppe use were consistent with their professional responsibilities as described in the next section. an important enabler of optimal glove and mask use was the professional responsibility some clinicians felt towards protecting patients from infections. for example: 'so yeah, the staff should also then be taking on some of that ppe responsibility, infection prevention responsibility.' (dr4) another associated professional responsibility that influenced appropriate glove use was the perception, by several doctors, that when there was no obvious risk of contamination, not wearing gloves facilitated a better doctor/patient relationship. this professional role identity was interconnected with the participants beliefs about the consequences of not using ppe, as outlined next. protecting themselves and not taking infection home to their family were reported to be strong motivators of ppe use. this belief in the negative personal consequences of not using ppe was often emotive: 'my concern is (a) infecting me and then taking it home to my family.' (dr3) glove use in particular was determined by the perception of personal risk, as summarised by this participant: 'personally, i will put gloves on if obviously there's blood, patient's got blood on them, so a trauma patient, i would generally put gloves on. patients who are a bit unhygienic, i'll put gloves on. so, both of these instances are to protect myself.' (dr3) for others, their use of ppe was influenced by previous experiences, such as working in the early days of hiv or having a urine splash to the face. the many participants who described a personal motivation for ppe use may have influenced the overall social culture within the department. the departmental norms and peer behaviour in the ed both reinforced and positively enabled clinicians' use of gloves, but less so for masks. glove use was reported to be embedded in routine tasks and patient encounters and clinicians would wait for, or remind, colleagues to don gloves when attending a patient: 'there's definitely a culture of these are the tools that we use to do our work. . . . and what i do notice is that people wait for you to put your gloves on.' (cnc 1) during the winter respiratory virus season, visual signals such as patients wearing surgical masks or an increase in boxes of masks in clinical areas helped to reinforce mask use. staff were also expected to wear a mask when caring for a neutropenic patient: 'just the only other time when i think about wearing masks, is in patients who are in neutropenic. because that's the other setting where we say that it's required.' (dr1) the behavioural norms within the ed also influenced the individual's routine and habitual practices related to gloves and masks. although some medical staff reported using risk assessment to determine the need for gloves, as described above, the entrenched habit of most staff using gloves routinely for patient contact had the positive effect of facilitating their use when it was indicated as part of standard precautions. as this nurse explains: 'it's an autopilot thing, as soon as they go and get a new patient, straightaway grab a set of gloves and start doing what they need to do.' (registered nurse [rn] 4) while glove use was almost automatic for the participants from the department, clinicians reported making a conscious decision to wear a mask. medical staff in particular reported making a risk assessment for mask use which was prompted by visual cues such as isolation trolleys and signs by the bedside or certain clinical information handed over about the patient: 'like the measles or something along those lines. that would prompt me to think, i need a mask and then let [the] nursing staff as well know. or a tb patient.' (dr2) support staff also chose to wear masks and gloves on occasions when they deemed there to be a risk of infection to themselves, as described by the following support worker: within the physical environment of the ed, staff were generally satisfied with the brand of gloves provided and noted that they were very accessible, which was an enabler of optimal use. the recent introduction of isolation trolleys, for patients in transmission-based precautions in curtained bed spaces, facilitated please cite this article in press as: barratt the support staff also found the isolation trolleys useful to alert them to the infectious status of a patient: 'if they go to enter a room and see the trolley outside they won't bother 99% of the time as not urgent enough to do so. or if they really have to they will put on the type of mask that is on the trolley.' (sw1) behaviour towards ppe was also influenced by the organisational ipc requirements for hospital accreditation. although no specific ppe monitoring was in place, annual training was encouraged. 'so we're trying to instil that they need to do an annual [ppe] competency. it's available, we're definitely not there yet.' (cnc ipc) the introduction of hospital-wide hand hygiene audits helped to promote correct hand hygiene behaviour around glove use and was reported to be an enabler. 'i am more compliant with hand washing prior to glove use than i probably was when i first trained.' (dr1) as illustrated, a range of factors were identified by participants as enablers of optimal ppe behaviour, primarily for glove use. within the same tdf domains, barriers to mask and gloves use were also described. unlike enablers, which mainly related to glove use, barriers to protective mask use were more frequently described by participants. as noted earlier, knowledge of policy was an important enabler of optimal ppe use. however, despite the ready availability of ppe policies and educational resources, participants described mask and glove practices that did not adhere to policy. thus, in this department, information resources and policy were sometimes a barrier because they were confusing. one clinician pointed to the various posters and guidelines as 'information overload', while others suggested that hospital-wide policies were not clear or did not work well in the ed context. 'i think that some of our bad practices, or some of our practices that, where you find someone wearing the wrong mask is all due to the fact that when we're educating and when we're following policy, the policy has been very, very ambiguous.' (cnc1) indications for which type of mask to use are described in the ipc policy relating to transmission-based 'airborne' and 'droplet' precautions. however, as the following participants describe, these terms were not always well understood and indicated a knowledge gap around the functionality and usage of the different types of masks. consequently, both medical and nursing staff reported choosing whichever mask was handy, not necessarily the one required, as the following nurse participants reported: 'if you said droplet or airborne you'd just mostly get a blank face and look at you and they might come up and go, well, maybe i need for the airborne the orange but i'm not sure . . . ' despite a knowledge of hospital policy towards masks, several participants preferred to apply their own professional autonomy in relation to mask use. professionally, some medical staff felt that using a mask restricted their ability to provide good clinical care, as it hindered communication and empathy with patients. the following participant felt that the mask interfered with their clinical assessment: 'the problem is, if you need to communicate with people, the mask can, particularly the n95, can muffle your voice as well.' (dr5) another doctor perceived the mask as an obstacle to establishing a good understanding between themselves and the patient: 'but i don't want to be the one that's wearing the mask and making the patient feel like there's a barrier. (dr6) these aspects of the use of ppe that clinicians presented as barriers to their use, because it interfered with their professional role, were interconnected with their beliefs about the consequences of not using ppe, as outlined next. as described previously, an exaggerated perception of infection risk, leading to overuse, was a potential barrier to appropriate use of gloves: 'i'm probably not the best person because i think i probably overdo gloves. i do not even feel comfortable shaking hands with a patient without gloves.' (dr6) by contrast, minimal concern towards the risk of respiratory infection was a barrier to mask use. one clinician attributed this to her own immunity, while another suggested that he was as likely to get a cough or cold as a member of the general public as when working. 'i never wear a mask during the flu season unless obviously i felt like i had the flu. you know, my view of the flu is i get immunised. i catch a train and everyone coughs on me anyway. and i'm more likely to have immunity against things like that because i never get sick.' (dr2) 'so, yes, if they have a respiratory symptom, if they have a fever, there is a history of overseas travel and i'm suspecting some unusual organisms, yeah then i will . . . but if it's like cough and cold, just minor symptoms, probably not because we get exposed to it when we are out in public and in the shopping centre, anyway, and i wouldn't.' (dr6) another participant suggested that in the absence of visual reminders for infectious respiratory diseases such as a productive cough, they did not perceive enough risk to wear a mask. similarly, participants also felt a lack of personal risk if the patient was wearing a mask, although they acknowledged that it was often not worn correctly by the patient. however, potential consequences for other patients were not reported as a motivation for ppe use outside of caring for the immune-compromised patient. '. . . gloves are really more for our protection, especially, way more than they are for the patient's protection.' (rn2) these common perceptions of risk were re-enforced within the social setting of the unit. unlike glove use, there was no departmental norm for wearing protective masks, except when attending to immunosuppressed patients. although there was a general consensus that mask use could be improved, peer influence or role modelling was limited to a few senior nurses and doctors. 'i mean part of your ppe, you probably should put a mask on, but we generally don't.' (dr3) 'i guess, in general we don't use masks.' (rn3) the absence of a departmental culture of wearing protective mask impacted on the clinicians' intentions and decision-making, as described below. one of the barriers to optimal mask use was the lack of habitual mask use in daily care requiring the individual to make a conscious decision to use a mask as illustrated in this excerpt: 'but because it's not business as usual the only thing that would prompt me initially would be to think, oh i could get a splash here, so therefore i'll wear a mask.' (cnc1) conversely, although glove use was prompted by unconscious behaviours, this could lead to unnecessary glove use: 'but i've noticed that's something that happens a lot nowadays, that just to touch a patient, people will put gloves on, and i encourage them not to do that; that they don't need to, that the patient is not dirty.' (rn2) the individual's decision-making processes were also related to the environment within which they worked, as outlined next. the busy, chaotic context of an ed, was reported by many participants to be a barrier to optimal ppe use: 'and it's just so busy that sometimes you can see that, yeah, something might not be quite by the books because of the pressure and the stress of the environment and the amount of people coming in and out.' (enrolled nurse [en]1) participants cited urgency of care as barriers to performing hand hygiene prior to donning gloves (it took too long for the hands to dry) or mask. 'the fit test can be a bit of a deterrent in a busy environment, to have to make sure it's fitted properly.' (cnc1) '. . . the time to put it on and off, particularly if someone's sick.' (cnc3) there was also a belief that the differences between the ed environment and an inpatient unit allowed for different ppe practices. 'it's culturally acceptable in an emergency to doattend your cares of a patient without those precautions where it's not in the ward.' (np1) the lack of a designated place for boxes of masks -other than isolation trolleys -sometimes made it difficult to locate a mask and was a barrier to the use of masks for standard precautions. the open-plan layout of the department, with only two single isolation rooms, was also identified by several participants as a deterrent to implementing good ipc practices. 'so once they're not in those [isolation] rooms and they're just out in the general acute area, i think [staff are] much less so likely to adhere to those precautions.' (dr3) compared to general satisfaction with the gloves provided, participants described more undesirable qualities with using the masks. some participants reported that the n95/p2 masks were more difficult to don, while others described discomfort and fogging of their glasses or protective goggles when wearing a mask. for one participant the discomfort of wearing a mask interfered with her ability to provide clinical care. 'like i really think it does make me abridge my assessment and examination because my desire to get the mask off is great.' (dr3) unlike hand hygiene audits, participants reported other external ipc monitoring as a barrier to optimal ppe use. this participant changed her behaviour with masks due to expectations of ppe audits: 'i think it's a bit of a throw-back from infection control. they will teach us about this mask and that mask, and then come and audit you, and then you're always afraid you're using the wrong one. so you just choose the higher one.' (cnc1) this ethnographic study explored the behaviour of clinical staff towards use of gloves and protective masks in a busy ed. analysis using the tdf elucidated factors that either promote or impede (occasionally both, in different circumstances) optimal ppe use, some of which have been identified previously in the literature [6] . however, we also revealed ed-specific determinants of glove and mask use that have not been previously described. in addition to providing emergency care of patients, front-line clinicians play a central role in the initial screening, detection and ipc management of suspected but undifferentiated infectious diseases. this role inevitably puts them at personal risk of infection. therefore, protective barriers such as ppe are essential to minimise the risk both to themselves and to other patients. although occu-pational health and safety is important, clinicians should be aware of their professional duty towards patient safety. an important finding in our study was a significant difference, in use, between gloves and masks in that there were more reported enablers of use of the former and barriers to use of the latter. existing research has demonstrated that gloves are the most frequently used item of ppe, much more so than masks [15] . a significant factor associated with frequent glove use idenitified in this study was some participants' motivation to use them for their own protection as a routine precaution. glove use was even more prevalent when there was a higher risk of blood and body fluid contamination, such as in the trauma and resuscitation areas. this aligns with the literature which reports compliance rates of 93-99% for glove use during trauma encounters in ed [25, 26] . less obvious contamination risks, such as an unrecognised mro-colonised patient, were also identified by participants as reasons for glove use. these patients present a significant risk in the ed for environmental contamination and staff acquisition [41] . some participants argued that habitual use of gloves was a barrier to optimal use. it is difficult to ascertain whether the glove use was excessive as there is no published research that explores the indications for and use of gloves in an ed. a recent systematic review of glove use and transmission of infection in other inpatient departments concluded that gloves were often overused and misused [42] . the published literature related to hand hygiene auditing provides some indication of ed rates for glove use. during a hand hygiene observational study in an ed, carter et al. [43] reported that only 32% of hand hygiene opportunities, whether or not hand hygiene was performed, were associated with glove use, indicating that in this setting, the majority of patient encounters did not incur the use of gloves. nevertheless, when optimising behaviour for cross infection, attention should also be focused on hand hygiene practices associated with the use of gloves [29] . in comparison, participants described fewer enablers of mask use, which reflects that they are used much less so than gloves [15] . the apparent under-use of protective masks in this study reflects literature reports of low rates (3-25%) for mask compliance in the ed setting [25, 26, 44] . the optimal use of protective masks by healthcare workers has been shown to reduce transmission of sporadic and epidemic infectious diseases. during the global sars outbreak in 2003, sars-cov transmission in a vietnamese hospital was significantly reduced when protective mask use among clinical staff increased [45] . skowronski et al. [46] attributes the prevention of sars transmission within a vancouver hospital to the prompt implementation of ipc measures, including ppe, in the ed for a traveller returning from asia with severe influenza-like illness. this is in contrast to the outcome for a similar case in toronto, when droplet and airborne precautions were not put in place in the ed for over 21 h, resulting in 14 further cases of cross infection [4] . many participants blamed the chaotic, fast-paced ed environment, as a significant barrier to using a mask. while this argument has been reported previously [44] , the same contextual reasoning could also apply to gloves, which are in fact regularly used and take longer to don and doff-at least if hand hygiene is included. thus, other factors may be more influential determinants of mask use, such as the team behavioural norms in the department or the individual's perception of risk of infectious diseases. one barrier to optimal mask use demonstrated in our research was the strong personal belief about ppe use of some senior medical staff, which overrode ipc policy. this is reflective of a recent study which found that the clinical autonomy of doctors was a significant factor in their ipc practice [47] . in an ed where there are numerous 'leaders', different role models and aberrant behaviour can impact negatively on the ipc culture of the department. participants identified a lack of positive role modelling and leadership which has been shown elsewhere to influence individual behaviour towards ppe [26, 47, 48] . in contrast to our findings, a recent qualitative study that utilised focus groups with nurses and assistants, reported a positive peer culture for encouraging respirator mask use [49] . this may indicate a greater perception of risk associated with diseases that required an n95/p2 respirator mask. in our study, a clinician's reduced perception of risk of infection from facial exposure was a barrier to wearing a mask. furthermore, clinicians perceived less risk to themselves when the patient was wearing a protective mask for a potential respiratory disease and felt protected enough not to wear a mask. public health guidelines recommend that symptomatic persons in hospital waiting rooms and other public spaces are given a mask to wear to prevent transmission of respiratory infection [50, 51] . this measure is largely accepted by the public and has had some success in community settings [52] [53] [54] . however, research is limited on its protective effect for clinicians engaging in direct patient care. the literature also reports the problem of noncompliance with mask use by the public [55] . this risk may increase in the ed setting, where, as identified by participants in our study, patients are unwell and often non-compliant in correct mask use. to prevent early transmission of either routine or outbreak infectious diseases, frontline staff must be vigilant and adhere to routine ipc measures [51] . this study identified the barriers to implementing effective protective mask use, which can be difficult in facilities with few isolation rooms or where staff rely on visual or verbal cues to instigate appropriate precautions [56] . in addition, the placement of boxes of masks was a practical barrier. poor access to masks is also a common finding in the literature [44, 57, 58] . in our study setting the introduction of ten isolation equipment trolleys addressed some of these barriers. applying human factors design principles is one method to address some of the contextual environmental barriers to optimal ipc behaviour such as difficult access to ppe [14, 59] . it is worth noting that in this study an exclusively policy-driven approach to ppe use was not a consistent enabler of optimal practice. although normally viewed as a facilitator, policy in this setting was viewed as a barrier to optimal mask and gloves use. bouchoucha and moor [60] suggest that deviating from ipc guidelines and policy can have serious consequences for patient safety. on the other hand, other authors have recognised that the unique complexity of an ed environment can challenge conventional ipc protocols and practices. for example, liang states that overcrowding, multiple clinician-patient encounters, limited isolation facilities and other factors unique to an ed are barriers to good ipc practice [61] . chen et al suggests that, compared to inpatient settings, it is more difficult to implement ipc measures in an emergency or outpatient department [62] . the study has some limitations. it reports participants' perceptions of the enablers of and barriers to optimal ppe use for routine care in one australia ed. this is a single-site study, and the findings are not expected to be representative in their totality of other eds. other eds will inevitably have characteristics which mediate enablers or, and barriers to, optimal ppe use, although it is expected that those identified in this study have resonance. the study design did not permit verification or otherwise of these findings beyond what was possible to observe during the field immersion. our findings have demonstrated that the determinants of ppe behaviour in an ed differed significantly between gloves and masks. the spread of emerging infectious diseases that have been responsible for global outbreaks recently, has included respiratory droplets. ed clinicians should therefore ensure that, as with gloves, the use of masks is incorporated into routine care where appropriate. these results support the need for further research which examines items of ppe independently. rb, glg, sh and mw conceived and designed the study and prepared the study protocol. glg supervised all data collection and study procedures. all authors contributed to interpretation of the results, preparation of the manuscript and approval of the final version. this work is supported by the australian partnership for preparedness research on infectious diseases emergencies (apprise) of which author glg is a chief investigator and author rb is recipient of a doctoral scholarship. the research presented in this article is solely the responsibility of the authors and does not reflect the views of apprise. rs is editor-in-chief of australasian emergency care but played no role in the peer review or editorial decision-making of the manuscript whatsoever. the authors declare no other conflict of interest. report on the burden of endemic health care-associated infection worldwide scope and extent of healthcare-associated middle east respiratory syndrome coronavirus transmission during two contemporaneous outbreaks in riyadh, saudi arabia healthcare-associated infections: the hallmark of the middle east respiratory syndrome coronavirus (mers-cov) with review of the literature responding to the severe acute respiratory syndrome (sars) outbreak: lessons learned in a toronto emergency department risks to healthcare workers with emerging diseases recognizing and managing emerging infectious diseases in the emergency department a descriptive analysis of occupational health exposures in an urban emergency medical services system risk and management of blood-borne infections in health care workers exposure to influenza virus aerosols during routine patient care transmission of middle east respiratory syndrome coronavirus infections in healthcare settings australian guidelines for the prevention and control of infection in healthcare national health and medical research council compliance with standard precautions: results of a french national audit a review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions improving healthcare worker adherence to the use of transmission-based precautions through application of human factors design: a prospective multi-centre study incompliance in use of universal precautions as a safety measure in emergency department evaluation of respiratory protection programs and practices in california hospitals during the 2009-2010 h1n1 influenza pandemic lack of compliance with basic infection control measures during cardiopulmonary resuscitation-are we ready for another epidemic? facial protective equipment, personnel, and pandemics: impact of the pandemic (h1n1) 2009 virus on personnel and use of facial protective equipment self-reported use of personal protective equipment among chinese critical care clinicians during 2009 h1n1 influenza pandemic. santin m severe acute respiratory syndrome (sars) and healthcare workers centres for disease control and prevention. guidelines for prevention of transmission of human immunodeficiency virus and hepatitis b to health-care and public-safety workers compliance with universal precautions in a university hospital emergency department substantial improvement in compliance with universal precautions in an emergency department following institution of policy a comparison of observed and self-reported compliance with universal precautions among emergency department personnel at a minnesota public teaching hospital: implications for assessing infection control programs compliance with universal precautions among emergency department personnel caring for trauma patients trauma team utilization of universal precautions: if you see something, say something occupational exposure during emergency department thoracotomy use of personal protective equipment in canadian pediatric emergency departments predictors of hand hygiene in the emergency department hand hygiene before donning nonsterile gloves: healthcareworkers' beliefs and practices clinical glove use: healthcare workers' actions and perceptions a review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions instruments for evaluating compliance with infection control practices and factors that affect it: an integrative review validation of the theoretical domains framework for use in behaviour change and implementation research applying ethnography to the study of context in healthcare quality and safety: table 1 a guide to using the theoretical domains framework of behaviour change to investigate implementation problems applying the theoretical domains framework to identify barriers and targeted interventions to enhance nurses' use of electronic medication management systems in two australian please cite this article in press as: barratt r, et al. enablers of, and barriers to, optimal glove and mask use for routine care in the emergency department: an ethnographic study of australian clinicians australasian emergency care xxx (2019) xxx-xxx hospitals does the use of a theoretical approach tell us more about hand hygiene behaviour? the barriers and levers to hand hygiene social research methods coding, sorting and sifting of qualitative data analysis: debates and discussion emergency department environmental contamination with methicillin-resistant staphylococcus aureus after care of colonized patients glove utilization in the prevention of cross transmission: a systematic review environmental factors and their association with emergency department hand hygiene compliance: an observational study behind the mask: determinants of nurse's adherence to facial protective equipment factors associated with nosocomial sars-cov transmission among healthcare workers in hanoi coordinated response to sars the politics and ethics of hospital infection prevention and control : a qualitative case study of senior clinicians' perceptions of professional and cultural factors that influence doctors' attitudes and practices in a large australian hospital nursing students' intentions to comply with standard precautions: an exploratory prospective cohort study health care workers' perceptions and reported use of respiratory protective equipment: a qualitative analysis assessment of hospital emergency department response to potentially infectious diseases using unannounced mystery patient drills the great influenza centennial-what have we learned about the epidemiology and prevention of transmission? mask use, hand hygiene, and seasonal influenza-like illness among young adults: a randomized intervention trial prevalence of preventive behaviors and associated factors during early phase of the h1n1 influenza epidemic impact of non-pharmaceutical interventions on uris and influenza in crowded, urban households facemasks for the prevention of infection in healthcare and community settings respiratory protection policies and practices among the health care workforce exposed to influenza in new york state: evaluating emergency preparedness for the next pandemic current practices and barriers to the use of facemasks and respirators among hospital-based health care workers in vietnam barriers to the use of face protection for standard precautions by health care providers interventions to improve hand hygiene compliance in emergency departments: a systematic review infection prevention and control: who is the judge, you or the guidelines? infection prevention for the emergency department interpretation and clinical practice of regulation for prevention and control of healthcare associated infection in outpatient and emergency department in healthcare facilities key: cord-270348-5804ffwx authors: angelino, andrew f.; lyketsos, constantine g.; ahmed, m. shafeeq; potash, james b.; cullen, bernadette a. title: design and implementation of a regional inpatient psychiatry unit for asymptomatic sars-cov-2 positive patients. date: 2020-07-02 journal: psychosomatics doi: 10.1016/j.psym.2020.06.018 sha: doc_id: 270348 cord_uid: 5804ffwx patients with psychiatric illnesses are particularly vulnerable to highly contagious, droplet spread organisms like sars-cov-2. patients with mental illnesses may not be able to consistently follow behavioral prescriptions to avoid contagion, and they are frequently found in settings with close contact and inadequate infection control, such as group homes, homeless shelters, residential rehabilitation centers, and correctional facilities. further, inpatient psychiatry settings are generally designed as communal spaces, with heavy emphasis on group and milieu therapies. as such, inpatient psychiatry services are vulnerable to rampant spread of contagion. with this in mind, the authors outline the decision process and ultimate design and implementation of a regional inpatient psychiatry unit for asymptomatic sars-cov-2 infected patients, and share key points for consideration in implementing future units elsewhere. a major take-away point of the analysis is the particular expertise of trained experts in psychosomatic medicine for treating sars-cov-2 infected patients. modern inpatient psychiatry is different from medical and surgical inpatient services in several ways. psychiatric units are designed to be therapeutic communities that provide "milieu therapy" providing a normalizing, structured day. they have communal spaces for group therapies, social and recreational activity, and meals. patients are encouraged to be up and out of their rooms throughout the day, participating in the milieu. many units begin and end each day with a community meeting when patients and staff share their goals and progress. when safe, patients are encouraged to wear their own clothing rather than hospital attire, as long as it is not disruptive the community (e.g., not provocative, sexually or socially inappropriate). in contrast, patients in general hospital rooms wear hospital gowns, mostly stay in bed and eat in their rooms. medications are brought to them in bed. they are taken around the hospitals for tests, therapies, and procedures, at least at first. this promotes rest and focus on physical recovery. psychiatry recovery focuses on resumption of autonomous direction of activities, through participation in a normal day of work (therapy) with relaxing engagement in social activity. furthermore, many psychiatrists today specialize in the care of patients with comorbid psychiatric and medical disorders. the branch of psychosomatic medicine encompasses not only experts in consultation-liaison psychiatry, but includes subspecialists in psycho-oncology, hiv psychiatry, hepatitis psychiatry, perinatal psychiatry, and functional gastroenterologic disorders, to name a few. these consultation-liaison and subspecialty psychiatrists often undergo extra fellowship training and board certification, and are well-suited to care for complex patients with medical and psychiatric comorbidities. additionally, some hospitals have developed special medical-psychiatric units to manage acute patients with comorbid disorders. the models vary somewhat, but typically involve some form of co-management process with psychiatric and somatic providers, as well as specialized nurse training to manage patient comorbidities. in this era of integrated care and services, such units, and the specialists who staff them, provide key resources to the healthcare system. with this background in mind, it is easy to see how a highly contagious, droplet and contact spread virus, like sars-cov-2, could run rampant through a standard psychiatric unit 1,2 . personal isolation is anti-therapeutic to many psychiatric illnesses like depression and schizophrenia. severely psychotic and manic patients are vulnerable to inappropriate behaviors, such as intrusiveness and disregard for behavioral rules, like wearing a mask or hand washing. removal of therapy from the environment in psychiatry would eliminate a significant aspect of recovery, relying only on medications to treat illnesses. while medications are often necessary for recovery, without the practice of new thoughts and skills recovery is incomplete. as such, when confronted with the care of psychiatric inpatients infected with sars-cov-2 but asymptomatic of its illness, the idea of closing or significantly changing inpatient psychiatry services, or treating such inpatients in medical units, was not accepted at our institution. instead, we sought to preserve our established methods of treating patients, while finding a way to reduce or eliminate the threat of contagion. as soon as tests were available, all hospital patients in our system with covid-19 symptoms were being tested, either in emergency departments or on inpatient medical units. everyone who tested positive for viral rna was admitted to an inpatient medical unit. at first, our psychiatry inpatient focus was monitoring for symptoms and preventing the spread of infection, transferring symptomatic patients to medicine units to be ruled out or treated. we attempted to create distances between psychiatric inpatients by implementing single occupancy rooms where possible, moving from family style to tray meals, and moving furniture in our day areas so that they were placed 6 feet apart. we adopted novel practices, such as shared online rounding, with the doctor and patient in one room and staff in their individual offices connected by synchronous video. we began requiring all staff and patients to wear face masks, to avoid droplet spread. these were improvements, but as patients and clinical staff share many spaces at different points in time, we still risked exposure, especially between cleanings of common areas and items. to prevent covid-19 outbreaks in our units, we next decided to require universal nasal swab testing for sars-cov-2 for all medically asymptomatic patients being admitted to psychiatric units 3 . with universal testing, two challenges remained. first, false negative tests do occur, usually due to inadequate sample collection. we thought that the rate of this was low enough that with frequent symptom screening, distancing, masking, and systematic cleaning we would likely have safe environments. second, we realized that we needed to decide where to care for sars-cov-2 positive, medically asymptomatic patients with mental illnesses who required hospitalization-those without symptoms of covid-19. one option was to admit such patients to medical units in negative pressure rooms, provide medications and virtual therapies via our consultation services 4 . while attractive, this idea had a few problems. our patients would be taking up negative pressure rooms best assigned to patients with covid-19 who required medical care. further, medical unit covid-19 rooms are not "psychiatrically safe" as most have many ligature points that would require 1:1 oversight with all patients to mitigate the risk of self-injury. we also faced a legal challenge: our legal team informed us that in maryland it is unlawful to involuntarily commit a patient to a "medical bed." although we could not find a specific statute prohibiting involuntary psychiatric commitment to a medical facility, we found other language saying that practices involving committed patients do not pertain to facilities without specific psychiatric treatment units 5 . thus inpatient medical admission can only be an option for voluntary patients. if they chose to leave against medical advice, we would not have a good legal way to detain them for psychiatric care. some of us argued that it could be declared that the patient lacked capacity to decide to leave and we could detain them. besides being legally questionable, this argument fell flat because we have a strong commitment to patient autonomy and use involuntary certification as a last resort. as such, we had strong opinion against anything that would expand involuntary treatment without due process to protect patient rights and autonomy. in light of the above, we concluded it would best serve our patients if we developed an inpatient psychiatric unit capable of accepting sars-cov-2 infected patients without covid-19 symptoms, or with mild enough symptoms that they would not require medical hospitalization. the next question was where in our system to do this, and what resources would be required. as the unit would have to be able to accept involuntary patients, only two of our hospitals, johns hopkins hospital and howard county general hospital, were eligible sites -johns hopkins bayview medical center, suburban hospital and sibley memorial hospital are voluntary only for psychiatric admissions and do not have the ability to hold administrative law hearings on site. as we developed our thoughts as to how to design and implement this unit, we contacted colleagues around the country to see if anyone else was taking this approach. in late march, we only found one source in israel. we sought guidance from dr. mark weiser, head of the psychiatric division of sheba medical center tel hashomer in tel aviv, israel. dr. weiser had opened a psychiatric unit at his hospital to receive sars-cov-2 infected patients without covid-19 patients from all other hospitals in israel 6 , just as we sought to do for maryland. that unit was designed rapidly, with safety in mind, and an emphasis on minimizing staff presence on the unit to decrease exposures. he detailed for us the installation of cameras in all rooms to monitor patients for decompensation, and a remote ability to lock a patient's room door, allowing staff time to don ppe to be able to enter and intervene for an acutely agitated patient. we also discussed use of medications for these patients, and our mutual idea was to try to get to full doses of medications as quickly as safely possible, to avoid outbursts, especially in psychotic and manic patients. fortuitously, howard county general hospital had just opened a new psychiatric unit, with major safety and cosmetic upgrades. in so doing, the old 20-bed unit had been decommissioned, and had not yet been remodeled into something else, but had undergone renovations in the year prior to mitigate ligature risk. it has 10 semi-private rooms, and was a medical unit before a psychiatry unit, thus having available oxygen and suction in all rooms. it has a large day room for groups and activities, and there is a sally port (air lock type) entrance with two sets of double doors providing security for visitors and space to prepare prior to entry to the unit. after discussion, we decided that the old unit at howard county would become the site for the johns hopkins inpatient psychiatry unit for sars-cov-2 infected patients without covid-19. we would have 1 bed per room to begin, expanding as necessary to meet need, with a maximum of 20 patients. [insert table 1 here.] for most medical units treating droplet-borne contagious illnesses, negative pressure rooms are the norm. to ensure droplet precautions, providers don personal protective equipment (ppe), i.e., mask, face shield, gown and gloves, in the hallway, enter the room, provide service, doff gown and gloves, exit the room and have assistance with wiping hard surface equipment, i.e., face shields, from a safety officer in the hallway. for our psychiatry unit, we wished to normalize behaviors. to this end, we decided to make the entire unit a negative pressure space and use the sally port entrance as the donning/doffing area for staff (see figures 1 and 2 ). this was accomplished by our engineering department in a matter of days. three large blowers were installed. the first blows air into the sally port area, making it a positive pressure clean space. any droplets on the new unit would be kept from entering by positive pressure behind the doors. this area was divided into a "clean" and "dirty" side, so that donning ppe happens on the clean side prior to entry, while doffing takes place on the dirty side after exit. a safety officer is stationed in the space to assist with donning, doffing and cleaning. the second and third blowers were installed at the ends of the unit, each blowing air outside through windows that were converted to vents. these blowers are secured behind vented walls. in this way, airflow from the unit itself is vented outside to dissipate to a very low transmission density, and the entire unit becomes a negative pressure space, including the rooms, hallways, showers, and the day room/activity space. it is important to note here that with this design decision, the unit would accept only sars-cov-2 infected patients, and not patients awaiting sars-cov-2 test results, so called puis or patients under investigation. placing a pui in the space might expose them to sars-cov-2, so we have to have a positive nasal swab result before the patient arrives. the nursing station, being attached to the sally port, was maintained as a positive pressure, clean space. this allows staff to wear only standard precautions in the clean space, which is a surgical mask, without face shield or other eye protection. in the nursing station, medications are kept in the dispenser machine, there are several workstations for documentation, and there is a break room for rehydration and snacks. in the negative pressure space on the unit, there is a single workstation on wheels, for documentation by the nurse on the unit. as wearing ppe for long periods of time is uncomfortable and adds stress to staff, it was decided to staff the unit with enough nurses that they could swap out after every 2 hours of being on the unit -2 hours in, 2 hours out. our standard nurse-to-patient ration is 1:6, so we staffed for 6 beds to start-even though we have 10 rooms-with 2 nurses, 1 patient care technician, and 1 security guard. security typically sits in the nursing station, while the nurses and technician take turns entering the unit with the patients. security is trained in donning ppe quickly to respond to urgent issues. as we have only 4 psychiatrists and 1 psychiatric nurse practitioner at howard county general hospital, and we still have to staff our other inpatient unit, our consult service, our outpatient clinic, and provide support to the emergency department, we chose to staff the covid unit with a single dedicated psychiatrist with a plan for back-up with psychiatrists from our other hospitals if needed. to best support the staff through this effort, the howard county general hospital department chair (aa) decided to personally attend to patients on the unit, following the idea that leaders go first in difficult tasks. further, so as not to overburden other weekend call providers, and to provide continuity, we chose to have the same psychiatrist cover covid unit rounds on the weekend. we had a discussion about the best ways to see patients in "hot zone" areas. other systems had elected to remove the psychiatrist from the in-person experiences, opting to use telehealth solutions exclusively. while we have adopted use of telepsychiatry for seeing some patients on the consultation service who have covid-19, the method is problematic at times. some patients cannot keep the camera on themselves, there are frequent volume issues with microphones and speakers, and less frequently, connectivity problems disrupt the flow of conversation. one advantage to telepsychiatry is that the provider can be in an area where s/he can remove the mask, allowing the patient to see a human face with all its expressions. a second point, however, relates to the division of labor and risk among members of the treatment team. having providers exclusively use telepsychiatry while nurses and technicians have to wear ppe to enter the infectious area created a discussion for us about fairness. ultimately, we decided for our inpatient covid unit, providers would use ppe and round in-person on the patients daily, as on our other inpatient psychiatry units. in thinking about the patients' needs, we realized that a high degree of medical sophistication would be necessary for daily assessments. our department is fortunate to have expert trained and certified psychosomatic medicine psychiatrists, with experience in managing patients with serious mental and physical comorbidities. as we wished to describe the staffing needs for this paper, we thought about how best to convey this to other systems needing to develop such a unit. we recommend that the psychiatrists and nurses staffing the unit be well-versed in the assessment and treatment of covid-19 disease and have a high comfort level with physical examination and provision of medical treatments, such as oxygen, fluids and coagulation prophylaxis, in order to best serve patients with mild disease in situ on the psychiatry unit. further, it is highly beneficial for continuity of care if the patient requires transfer to a medical covid-19 unit that the psychiatrist be able to follow them there and maintain the psychiatric treatments as indicated. thus the covid psychiatry inpatient unit should be the equivalent of a medical psychiatry unit, with the ability to manage mild covid-19 disease, and the gold standard for psychiatrist staffing is a trained psychosomatic medicine or consultation-liaison psychiatrist who has knowledge of covid-19 disease. our initial staffing plan with the chair at howard county general demonstrated this, as he is a specialist in hiv and hepatitis psychiatry and consultation-liaison psychiatry, and thus he is able to provide the medical expertise needed to effectively manage these patients. patient assessment for transfer to the covid inpatient psychiatry unit also involves a degree of expertise about covid-19 disease. in our system, one expert consultation-liaison psychiatrist assesses all requested transfers to determine the level of care required on the unit. some medically hospitalized covid-19 patients may be physically recovering from the respiratory illness and require psychiatric intervention for a separate mental illness. while there is some information that such patients may no longer be infectious, we suggest either viral load testing if it is available, or the recent practice of 2 negative nasopharyngeal swab tests 24 hours apart if they are to be transferred to a regular psychiatry unit 7 . it is our practice that if the patient has a positive nasopharyngeal swab test, they be admitted to the covid psychiatry inpatient unit to prevent any chance of spreading virus to non-infected patients and staff. further, some patients develop a protracted delirium after serious covid-19 illness, especially if a long intubation and intensive care unit stay was involved, and a trained consultationliaison psychiatrist would best be suited to assisting in the treatment of these patients on the medical unit, rather than transferring them to inpatient psychiatry. the infection control experts recommend several options for ppe. in areas with many sars-cov-2 infected persons, we can choose between n95 or drager masks, with a face shield, or a papr (powered air purifying respirator) hood. we were test-fitted for n95 masks and dragers, and trained on papr use. all persons wear a gown and two pairs of gloves, one under the gown sleeves and one over. there is a process for donning and doffing. the first decision is mask + face shield or papr. the papr can be worn without a mask, allowing the patient to see the provider's face, which we think is comforting to psychiatric patients, so we most often use paprs on the unit. however, there was concern that if a patient becomes violent, during the response to the violence, a clinician might have the papr torn off, exposing the face openly if no mask is worn underneath. thus, some staff in some situations wear a papr with a mask and glasses underneath. this approach is also used on dr. weiser's unit in israel. on the subject of violence with ppe, we have several different options for gowning. most common and cost efficient are yellow paper gowns, often worn by providers making quicker visits to the unit to see patients, such as the rounding psychiatrist. nurses and technicians, who spend more time on the unit, often wear surgical gowns that provide more coverage around the body and are more tear-resistant should a physical hold be necessary. finally, we have tear-resistant jumpsuits, most worn by security, who have the most hands-on in a violence situation. a final word about ppe. it is very difficult and far higher risk for an individual to don and doff ppe without help, especially for the wiping down after exiting the unit or room. this requires extra staff to be present. further, as mentioned above, we staff 2 nurses per 6 patients, rather than 1, so as to be able to give relief to the nurse wearing the ppe -this was done in 2 hour shifts as ppe is very uncomfortable to wear for periods longer than 2 hours. it is also important to remind staff to maintain hydration once they are out of ppe, as they do not have the ability to take fluids while on the unit in ppe. we have ascom phones for nursing staff. one phone is handed off from nurse to nurse inside the unit. for quick communications, we have a small white board and dry-erase marker to share messages through the window to the nurses' station. most longer communications are from the ascom phone to the landline in the nursing station. medications, meals, snacks, and supplies are passed through the entrance to the unit by the safety officer. there is no donning, but the safety officer wears a mask and shield at all times, and uses gloves to pass objects through the entrance. we use disposable items for as much as possible -meal trays, utensils, scrubs for patients. linens are handled in the normal way. we allow patients to wear some regular clothes, provided they are safe and the patient is clinically ok to do so. there is a washer and dryer on the unit for patients' personal laundry. we have ipads on the unit, encased in strong protective cases, for patients to have video visits with providers and family members, to watch videos or play games. these are swapped out when they need to be charged, and wiped down by the safety officer in the sally port before and after charging. the unit has television and a video game system can be attached for recreation. the most challenging aspect of care is the provision of anything other than 1:1 therapy. we do not have occupational therapy providers on the unit, and we have only 1 nurse at a time, so there is no one available to lead groups. patients with alcohol and drug problems attend online meetings using ipads. for one patient who was struggling with coming out as gay to his family, we were able to find online support groups through an lgbtq support organization's website. we are investigating using video connections to the groups already happening on our other inpatient unit, but as of this writing, the logistics are not fully worked out. we have had several art/craft sessions led by our patient care technicians. activities are easier to accomplish. we have games and puzzles for patients, and staff assist in playing them. we allow patients to watch online content on ipads, provided it is appropriate, and there is a tv room. there is a phone bank so patients may call family. we do not allow in-person visitors at this time. as mentioned above, we have a unit that accepts both voluntary and involuntary patients. according to maryland law, involuntary patients must have a hearing with the administrative law judge (alj) to determine commitment to treatment within 10 days of admission. for both our regular psychiatric units and our covid unit, these hearings are currently conducted via secure video conference. the public defender meets with the patient via video conference prior to the hearing to prepare a position, and the hearing is conducted via group video conference. we monitor vital signs every 6 hours, including pulse oximetry. nurses screen thrice daily for cough, shortness of breath, chest pain, nausea and vomiting. every patient has a physical exam by an internist, laboratory testing for coagulopathy and inflammation, and follow up daily by the internist. our observation thus far has taught us that serious covid-19 symptoms usually arrive in the first week of infection, and our only transfer out of the unit to medicine happened 4 days after his positive test. most patients have been completely asymptomatic on the unit, while a few have developed mild complaints of cough or subjective shortness of breath. we manage mild complaints symptomatically, and have the ability to provide oxygen on the unit. our medical colleagues are invaluable in determining which patients are sick enough to require transfer to a medical bed -usually this takes the form of an oxygen requirement beyond 2 liters by nasal cannula. all other medical care is as usual, with a general rule of thumb being that we manage any chronic medical illness that would be managed as an outpatient, e.g., controlled hypertension, controlled diabetes, etc. one area that is a bit tricky is the monitoring of patients requiring detoxification from alcohol or opioids on the unit. we provide active withdrawal protocols, using benzodiazepines for alcohol withdrawal and buprenorphine for opioid withdrawal, and in general, monitor vital signs and symptoms closely, concentrating on respiratory symptoms and pulse oximetry to guide intervention for covid-19. there are three ways someone can be discharged from the unit. first, and most undesirable, a patient is transferred to a medicine unit if s/he decompensates medically and requires acute medical attention beyond what is available on the unit. while we can provide oxygen, if the person requires >2 l of oxygen by nasal cannula, it is unsafe for them to stay on the unit where there is not a medical provider nearby 24/7. we did have one patient so far leave this way, but he did well with medical treatment and returned to our unit after a few days on medicine. second, patient can be discharged if they get better psychiatrically and no longer require inpatient care. this proves challenging if they are still positive for sars-cov-2. many placements, e.g., group homes, assisted living facilities, residential rehabilitation facilities, shelters, etc., require patients to be tested negative before they can enter. some patients have homes to go to, and are discharged home with instructions on maintaining quarantine until it is safe for them to stop-according to cdc guidelines 8 . although this discharge-to-quarantine process has a different feel for the social worker arranging aftercare, there is actually not much difference in follow up care. many providers are using telepsychiatry visits, so we can get appointments while patients are still in quarantine. intensive outpatient and partial hospitalization programs in maryland are currently closed or providing only telepsychiatry options, so this does not differ for sars-cov-2 positive patients from non-infected patients. our only real concern was acquiring medications after discharge, as quarantined patients picking up prescriptions from a pharmacy proved a challenge. we address this by having a 2-week supply of medicines filled before discharge by our pharmacy and delivered to our unit so patients can leave with medications in hand. transport home as well proves an issue. to decrease exposure of family members due to close proximity on the ride home, we use a medical transport van that allows for distance from the driver and have the patient wear a mask home. to sign discharge paperwork we bring the patient into the sally port wearing a mask, ask them to put on gloves, have them sign the paperwork and give them a copy. the hospital copy is kept in the nurses' station for 1 day in a secure area before being taken to health information technology (medical records) to be scanned into the record, in order to decrease possible contamination. third, a patient may be discharged is if they are on the unit long enough to clear sars-cov-2 virus and can be transferred to a regular psychiatric unit, a residential program or group home or to their own home. we have had only one experience of a patient requiring continued psychiatric care after clearing the virus, and we have had a couple on the unit long enough to merit testing at time of discharge, who were discharged to group homes or programs after testing sars-cov-2 negative. we closely follow cdc guidelines as they are updated with new information, so as to best decide on timing of testing and how to handle patients with prolonged positive pcr results. we are fortunate to have a very dedicated, highly experienced staff of physicians, nurses, patient care techs and security. all staff working on the unit voluntarily. as mentioned above, the chair of the department personally staffs the unit daily, which also was advised by dr. weiser in israel, as it boosts morale to see leaders working alongside everyone. we frequently check in with unit staff, and the hospital as a whole, to be alert for signs of fatigue, stress, anxiety, depression. on the whole, our psychiatry staff are open about their feelings and well-being, as we have created an environment in which expressing such is safe from repercussion or retaliation. we focus efforts on recognizing everyone's vital contribution to the team and our interdependence on one another, creating trust in our culture that everyone is valued and will be supported in our efforts. our department has teamed with other support systems within the johns hopkins system, including our r.i.s.e program (resilience in stressful events), which provides confidential, trained-peer support 24/7. additionally, our faculty and staff assistance programs provide professional counseling and psychotherapy treatments for our employees. finally, the department of psychiatry added urgent appointments for psychiatric evaluation by faculty members for employees with more serious issues, including requirement for medications. in addition to this spectrum of care, one of our faculty implemented daily virtual mindfulness video conferences, available to all johns hopkins employees to participate. we have held video meetings with hospital managers from every department, presenting warning signs of burnout, as well as a tiered approach to referrals of employees for help. community support is widespread and tremendous. from meals and snacks to personal care products such as lotion for chapped hands, many individuals and organizations have contributed to staff support throughout the hospital. staff from non-isolation units and administrative areas have been very kind to deliver things to the isolation units for staff who cannot easily and safely get away to collect them from drop-off points. we present this account of our efforts to inform those faced with a similar problem. when we opened the unit on april 21, 2020, we did not know of any similar units in the united states. we are now aware of several, and have learned that their processes are very similar to ours. most recently, an account of principles that guided the planning of a covid+ unit in california were published online. 9 as the practices at our institution and those we have found are compared and discussed, best practices will be defined in this area, and support the development and implementation of units everywhere they are required. we recommend that such a unit would be best implemented in a medical psychiatry unit, but if none is available, the unit would be best placed inside a general hospital that has ability to care for covid-19 ill patients should they become too acute to be managed safely on the inpatient psychiatry unit. further, we feel the gold standard of psychiatrist staffing for such a unit be a trained psychosomatic medicine psychiatrist with knowledge of covid-19 illness, for reviewing appropriateness of patients referred for admission to the unit, and for daily monitoring of psychiatric and medical signs and symptoms and management of mild covid-19 illness. systems issues a. how does the system process sars-cov-2 testing for admitted patients? i. 1 test, 2 tests separated by 24 hours, rapid tests or regular-time tests, etc.? b. how will sars-cov-2 positive patients be admitted? i. does the system have a plan for admitting sars-cov-2 negative patients to a different facility, or a different unit within the same facility? c. what is the best location for a sars-cov-2 positive asymptomatic psychiatry unit in the system? i. medical capabilities, consultations, icu access, etc. ii. voluntary v. involuntary patients ii. unit design a. how many beds? single or double rooms? b. will there be communal spaces for treatment/activity? c. will patients eat in their rooms? d. if patients are in their rooms with doors closed for negative pressure, how will they be monitored? e. how will the unit handle seclusion/restraint events? f. does the unit have adequate wifi for video conferences as required? g. where will be the clean zones for donning/doffing ppe? iii. staffing a. is there a consultation-liaison psychiatrist or other psychiatrist with knowledge of covid-19 illness and comfortable with managing minor disease? b. how many nursing staff per patient? c. will staff be required to wear ppe for extended periods or only while interacting with patients in their rooms? d. will providers see patients face to face or via telepsychiatry? e. how many assistant staff will be required for donning/doffing ppe? iv. ppe a. what ppe is available for your unit? b. how will staff be trained in use of ppe? v. activities and groups a. what therapies will be offered and how? b. what activities will be available for recreation? c. how will the unit handle visitors? vi. involuntary patients a. will the unit accept involuntary patients? b. how will legal conferences and hearings be handled? vii. medical monitoring a. who will be responsible for vital signs and pulse oximetry and how often? b. what processes are in place for rapid intervention for patients developing illness? c. what is the transfer process? d. how will repeat sars-cov-2 testing be done to determine negativity, if required? viii. discharges a. how will aftercare be arranged? b. are medicines available for patients being discharged into quarantine? c. how will sars-cov-2 positive patients be transported to their discharge site? ix. staff support a. what systems are in place to monitor staff for symptoms of stress? b. what resources are in place to help staff deal with stress? c. how do staff access higher levels of evaluation or treatment if necessary? advance it was a medical disaster': the psychiatric ward that saw 100 patients with new coronavirus covid-19 testing and patients in mental health facilities covid-19 diary from a psychiatry department in italy annotated code of maryland cautionary tale spurs 'world's first' covid-19 psychiatric ward -medscape virological assessment of hospitalized patients with covid-2019 discontinuation of transmission -based precautions and disposition of patients with covid-19 in healthcare settings (interim guidance). decision memo 2020 planning for a psychiatric covid-19-positive unit -medscape sally port doffing area (dirty) nurses' station (clean) occupational therapy/art room 10. seclusion suite 11. nutrition 12. quiet/reading room 13. shower 14. interview room 15. clean supply 16. patient belongings 17. staff bathroom 18 the authors would like to thank drs. mark weiser, patrick triplett, karin neufeld, erica richards, cynthia lewis and ashley bone, as well as ryan brown, jennifer baldwin, angela mckay, kelly caslin, laurie burdock, zahra parva and susan webb for their contributions to this process. key: cord-266905-j9ljwqv0 authors: ecker, jeffrey l.; minkoff, howard l. title: laboring alone?: brief thoughts on ethics and practical answers during the covid-19 pandemic date: 2020-05-15 journal: am j obstet gynecol mfm doi: 10.1016/j.ajogmf.2020.100141 sha: doc_id: 266905 cord_uid: j9ljwqv0 nan condensation: to minimize risk of exposure to health care workers, some have proposed eliminating 4 spouses, partners and other visitors to support women during their labor and delivery. an ethical and 5 pragmatic approach argues that with appropriate limits and safeguards, including personal protective 6 equipment, the option of having one support person in labor can be preserved for almost all patients. 7 8 9 10 the iconic image of mid-twentieth century childbirth is a woman's partner----always a man, always her 11 husband----pacing in a waiting room until a nurse in white bursts through the door to announce that his 12 wife (always again) had given birth to a boy or a girl. this is followed by much back slapping and cigar 13 smoking with the other expectant fathers until, hours later, the new father peers through a nursery glass 14 to pick out his child from the assembled rows of newborns. 15 such has not been the norm for decades, and obstetricians and midwifes would have thought that the 16 days of sequstering partners outside labor and delivery units were long past. yet these are 17 extraordinary times, and during the current covid-19 pandemic, hospitals have been eliminating 18 patient visitors in an effort to promote social distancing and protect the health of their work force and 19 patients. we understand that asymptomatic individuals can carry and transmit covid-19 infection, and 20 this recognition makes banning visitors from accompanying patients to their cardiologist's office and 21 banishing a partner from the bedside of a patient recovering from an mi in the ccu seem prudent. 22 in most institutions, however, labor and delivery units have been rare exceptions to the "no-visitor" 23 rules, for visitors there are felt to have, in the words of the new york department of health, an 24 "essential" role in process of care, and not having a partner present for the birth of a child seems 25 unimaginable,unkind and, for some, even traumatic. and yet as the pandemic grows, challenging and 26 sometime humbling the capacity of units to accommodate, some have begun to rethink this exception. 27 several hospitals and systems in new york city, hit hard by an overwhelming number of covid-19 28 patients, enacted a ban on labor and delivery visitors, hoping to reduce unnecessary staff exposures that 29 were challenging their ability to maintain a needed complement of providers and support staff. the 30 ensuing reaction and concern---a mix of grief, incomprehension and outrage---was both local and 31 national. many worried that such policy would push women, including many with risks not conducive to 32 such, to plan home deliveries or uproot themselves during a time of quarantine and seek care and 33 delivery at hospitals elsewhere that still permitted an accompanying support person. responding to the 34 publicity and controversy, the new york city department of public health published guidance declaring 35 a support person in labor to be, as noted above, "essential," and the governor of new york issued an 36 executive order requiring hospitals to allow (healthy) visitors. 37 38 as a matter of medicine, policy and ethics, what is right here? in this commentary, we will briefly 39 outline the considerations important to answer those questions. unlike many choices in medicine, this 40 policy decision affects not just the patient but other individuals including the patient's family and the 41 health care team. accordingly, the issue may be best considered from the perspective of the 42 community rather than just the individual. we recognize that to some the arguments laid out and 43 conclusions we reach may seem long settled or obvious, yet we still regularly hear questions 44 from others---providers, staff, hospital leaders and administrators, patients and the public--45 wondering why we don't allow more visitors or, conversely, why we allow any at all. those this piece will consider visitor policy from an ethical perspective. it is important to understand, as this 51 conversation progresses, that ethics is not strictly an abstract or ethereal art. it is informed by facts. so, 52 for example, if an obstetrician is wrestling with the ethical question of whether to accede to a patient's 53 request for a cesarean section for a fetus at 22 and a half weeks, the ethical conundrum would be quite 54 different and perhaps vanish entirely if a sonogram revealed that the fetus was in fact only 19 weeks. in 55 this article the facts that are contributory are the risks and benefits of visitor policies, and as we will 56 discuss, those can vary widely based on technology and policy. emotion is another factor that flavors 57 ethical positions. in phillipa foote's and judith jarvis thomson's classic thought experiments about an 58 out of control trolley racing toward several innocent children, participants are asked whether they 59 would push a man onto the tracks in order to stop the train and save the children. when this thought 60 experiment is offered to a subject lying in a flow mri, the decision to "kill" the man varies depending on 61 whether the emotional (save the man) or intellectual (kill the man) part of the study subject's brain 62 lights up. hence, fears of contagion will undoubtedly play a role in how the issues discussed here are 63 viewed. as we have previously written, "the strength of the physician-patient bond is dependent, at 64 least in part, on patients' belief in their physicians' altruism, i.e., their willingness to do what is in the 65 best interests of patients (i.e., to fulfill their fiduciary obligation) and, historically, to occasionally do so 66 at some risk."(1) while those words-written in the context of the ebola epidemic-focused on patients, 67 not partners, it is not extreme to recognize that the best interests of patients include having their 68 partners present. while partner issues cannot supersede substantive risks of contagion, they should not 69 be dismissed out of hand. 70 the patient and her partner 73 74 in times free of covid-19, having one or more visitor is important for all patients. we have been taught 75 the words of hippocrates since medical school, "cure sometimes, treat often, care always." facilitating 76 ongoing contact with loved ones is a critical component of caring. this is even more important in the 77 context of childbirth. having individuals present to attend and support a woman during her labor and 78 delivery is not just expected but is, in fact, generally encouraged. these visitors/support people serve 79 many important roles: 80 • they provide emotional support and encouragement, distraction and just plain company to 81 speed the passing of what, in some case, can be many hours. such support, especially when 82 knowledgeable and trained, has been associated with improved outcomes separate from a 83 patient's happiness and sense of well-being. 84 • they can contribute to decision making especially as parent-couples work to align choices with 85 shared values. a partner-visitor can often help patients process information and choices, 86 serving as a valuable second set of ears, articulating questions the patient may struggle to offer 87 and explaining key points in ways that are more readily heard and understood. 88 • they provide help during the process of labor and delivery, whether lifting a leg, obtaining water 89 or other appropriate hydration and nutrition and, on the postpartum unit, assisting in newborn 90 care and maternal recovery. among other realities, removing these invited "assistants" would 91 challenge nurses' time and nursing staffing needs. 92 • as attendants they experience the joy of welcoming a new child, whether as a genetic or 93 intended parent, other relative or friend. 94 95 in short not having a partner present during labor seems both detrimental and unkind. yet we must 96 acknowledge that the same could be said for end of life circumstances, and covid-19 in some settings 97 has left patients dying without the comfort and presence of loved ones. these are extraordinary times. 98 some have raised concerns that having visitors present risks the visitor's health by reducing physical 99 distance and exposing visitors to many in a hospital's halls and rooms, including the patient herself. as 100 noted above, the process of labor and delivery requires close quarters, but it is difficult to estimate the 101 true incremental risk that comes with accompanying and supporting a patient, especially if members of 102 the health care team are symptom free and wearing appropriate ppe. it also should be recognized that 103 most patients and their visitors will soon be sharing similarly close quarters at home as they recover and 104 care for a newborn. 105 the health care worker 108 both for the sake of their own well being, and so they will be available to care for current and future 109 patients with and without covid-19 illness, health care workers (hcw's) have an interest in decreasing 110 their chance of unprotected exposures to those who are infected. the infectivity (r0) of covid is 111 approximately twice that of the flu, and the mortality rate is apparently much higher as well. 112 • decreasing the risk of exposure may be accomplished by screening patients and visitors (using a 113 questionnaire regarding symptoms and travel, and taking temperatures), but transmission from 114 asymptomatic but infected individuals has been recognized as a key avenue for spread both in 115 china and on u.s. labor and delivery units(2). furthermore, screening for symptoms relies on 116 the honest and transparent reporting from a visitor who, eager to be present, may consciously 117 or unconsciously fail to disclose an early tickle in the throat, waning sense of smell, flushed 118 feeling or other early and/or subtle symptoms of infection. the risks of transmissions from 119 visitors will clearly diminish if and when viral or serologic screening of partners can be instituted. 120 the former is already in place in some sites. 121 • use of appropriate hand hygiene, distancing and other health practices (not touching one's face) 122 are important in limiting risk of infection, but keeping one's physical distance is difficult in most 123 labor rooms, particularly when supporting a woman during the second stage. all who have 124 managed the second stage have experienced the tight huddle of provider at the perineum, a 125 nurse on the mother's one side with the partner on the other: the diameter of that circle is 126 often much less than six feet. 127 • appropriate use of ppe is an important step in mitigating risk of close exposure, but in many 128 places individual elements of ppe have been in short supply. in many settings, it is not possible 129 to approach every patient and visitor as if they were covid-19 positive and use enhanced ppe 130 (gown, gloves, mask of at least some kind, and face shield). while supplying and requiring 131 visitors to use masks themselves would limit their risk of their spreading infectious droplets, 132 even that may not be possible in systems with limited supplies. in such situations or if providing 133 ppe for visitors would compromise access to ppe for frontline workers, then the ethical balance 134 shifts away from supporting visitors in labor and moves towards honoring the societal 135 commitment to protect the health of physicians and other healthcare workers. 136 limiting the number of people in the room would as a matter of simple math, limit the potential 137 exposure of hcw's. there are certainly other situations in which we accept limitations to a patient's 138 right to have visitors or limit their autonomy in choosing them. individuals who are verbally or physically 139 abusive of staff or otherwise risk a provider's well-being are not permitted to attend their partner's 140 delivery, for example. it is also difficult to imagine that someone symptomatic with active tb would be 141 welcomed. when risk is manifest, whether as a cough or verbal challenge, the chance to exclude 142 provides an opportunity for keeping hcw's safe. when risk may be present without symptoms or other 143 warning, the risk is more insidious and there is not such a ready opportunity to identify and exclude 144 those who bring risk. 145 while in all these considerations, it is important not to dismiss these risks to those providing care, it may 146 be useful to contextualize them. when the health care worker leaves work and goes to shop for 147 essential goods in the local grocery mart, they will stand six feet away from someone who has not had 148 their temperature taken or filled out a questionnaire, and are likely not be wearing the type of ppe that 149 would be distributed in a hospital. in the delivery room, when the provider, patientand partner have 150 donned appropriate garb and make good faith efforts to maintain a distance, the risks would have to be 151 considered substantially reduced. 152 153 what is to be done? where does best balance lie 154 155 as laid out above, the dilemma here appears to be of conflicting interests and outcomes: the 156 unhappiness, potential trauma and other challenges of giving birth alone for the patient, the risk of 157 exposure and possible infection for the hcw. but this simple sketch ignores the shared goals important 158 to each: navigating the process and events of labor and delivery with a healthy mother and child at the 159 end. moreover, eliminating risks by banishing all visitors is likely to discomfort, at least in some regard, 160 most providers, who would be asked to serve as agents in inflicting this unkindness. separately, 161 eliminating visitors may impede the process of labor and delivery and post-partum recovery. 162 accordingly, instead of pushing to eliminate all visitors/support, we suggest two menus of measures: the 163 first is designed to limit the chance that a visitor presents a risk; the second, recognizing that all visitor-164 risk cannot be eliminated, is designed to moderate any residual impact on hcw's. 165 166 a first step in limiting risk of exposure is to screen all visitors for symptoms of covid-19 infection or a 168 known ongoing infection, and only allow those who are asymptomatic and infection free onto labor and 169 delivery units. this is consistent with hospital practice during times of other infections (flu season) and 170 the approach to individuals who at other times have highly communicable illness (e.g. active tb). the 171 utility of visitor screening, as with screening of the patient herself, relies on honest answers from the 172 individual screened. some will see this as a key weakness, but appealing to the virtue of truthfulness 173 while emphasizing the implications for the health of the individual hcw's as well as the other patients 174 who require their continued health and care should find traction with many. verbal screening can also 175 be supplemented by objective criteria, such as checking a visitor's temperature at intervals (once a shift 176 might be a practical option) and monitoring for readily observed symptoms such as cough. 177 ideally, the screening process will yield to viral or serologic screening in the not too distant future. 178 when testing becomes more readily available, screening might include testing a visitor for viral rna 179 either at the time of admission (tests that allow for very rapid resulting have already been rolled out in 180 some clinical settings) or at some point in the final weeks of pregnancy as the time for delivery nears 181 (although this latter approach cannot preclude incident infection subsequent to testing). serologic 182 testing (i.e. testing for covid-19 antibodies) can also identify individuals who have tested positive in the 183 past but are no longer shedding virus, and who therefore are appropriate to accompany a patient. 184 testing may also be useful in reducing the risk from a visitor who, though asymptomatic, has had an 185 identified significant exposure to an individual known to be covid-19 infected. 186 if a planned visitor/partner needs to be excluded, whether due to symptoms or concerning test results, 187 a patient should be permitted to turn to an asymptomatic substitute: mother for husband, sister for 188 partner, second best friend for best friend. discussing or otherwise communicating visitor policy and 189 restrictions in advance will allow patients to understand when such substitution will be needed and to 190 prepare accordingly. 191 the spread of coronavirus from those not undergoing aerosol generating procedures is through 192 droplets. as such, requiring visitors to wear an appropriate mask supplied by the health care facility for 193 as much time as possible can be part of a visitorcontract. requiring visitors to remain with their patient-194 partner in their room throughout the course of labor and delivery and postpartum recovery should be 195 another key stipulation in limiting staff exposure. in addition, limits on the number of visitors should also 196 be instituted. given the extraordinary current circumstances, and the work and resources involved in 197 the measures proposed above, allowing just one visitor who cannot be swapped for another throughout 198 the course of labor and delivery seems appropriate and is, in fact, where many have settled. some have 199 argued that a policy of one, impacts those who have planned to use a doula or an experienced family 200 member or friend to provide support that a partner/father may be less able to offer or comfortable 201 offering. allowing exceptions and extra visitors for some, however, would push against the virtue of 202 providing care that is equitable, and, as just noted, allowing more for all would be a significant 203 additional strain on resources. an appropriate solution may be to encourage additional support and 204 participation by using phones and other technology to share conversation and images. facilities should 205 consider relaxing any rules limiting live communication and streaming during the process of labor, 206 delivery and recovery. equity in this virtual solution might be facilitated by loaning needed devices and 207 technologies to interested families who do not have such access. 208 as is true when an individual provider is caring for a woman with known or suspected covid-19 211 infection, the risk for being infected by a visitor-partner will be mitigated by appropriate use of ppe. the 212 availability and type of ppe has varied widely across health care settings. some require and provide 213 masks for continuous use by hcw's and may be able to provide similar masks to patients and their 214 partners and require that they use them continuously as well. other facilities may limit use to partners 215 of those patients with symptoms or known covid-19 infection. in cases in which masks are not worn, 216 encouraging or even requiring distancing of the partner may offer another route of mitigation. such 217 distancing may be undertaken, as room architecture permits, by assigning a visitor a space appropriately 218 distanced from where a nurse, midwife and/or physician will be stationed for needed clinical care. 219 clinicians will recognize the limits of this latter approach given the close quarters of the labor room and, 220 especially, the huddle of patient, providers and visitors that often is the reality of second stage pushing. 221 given these concerns and real-world limitations and, as suggested above, some may judge the overall 222 balance of adding a labor support person to be unacceptable when ppe cannot be available to visitors. 223 224 none of the suggestions above is perfect, and admittedly there may be chinks in the armor of 225 protection. as with medical care and protocols in general, all will need to be tailored thoughtfully to 226 individual circumstances, including the circumstances of individual facilities where supplies, space and 227 staffing may limit implementation of some proposed steps for risk mitigation. used in combination, 228 however, the measures suggested here will contribute to promoting the goals that patients and 229 providers share and hold paramount: promoting healthy maternal and neonatal outcomes, protecting 230 the safety and health of all involved in patients' care, and creating an experience of childbirth as 231 satisfying as possible to all. a recent article (3) discussed intrusions on civil liberties in times of rampant 232 infection noting that, "to respect civil liberties, courts have insisted that coercive restrictions must be 233 necessary; must be crafted as narrowly as possible -in their intrusiveness, duration, and scope -to 234 achieve the protective goal… "(4) with appropriate ppes and screening, we believe that in most settings 235 and circumstances, that mandate would allow women to have a chosen partner, spouse or support 236 person present with them without posing undo risks to their providers. 237 238 239 physicians' obligations to patients infected with ebola: echoes of acquired 241 immune deficiency syndrome 244 pregnancy: early lessons disease control, civil liberties, and mass testing -calibrating 249 restrictions during the covid-19 pandemic covid-19 -the law and limits of quarantine key: cord-021907-omruua6n authors: hick, john l.; thorne, craig d. title: personal protective equipment date: 2009-05-15 journal: disaster medicine doi: 10.1016/b978-0-323-03253-7.50043-1 sha: doc_id: 21907 cord_uid: omruua6n nan c h a p t e r 3 6 personal protective equipment john l. hick and craig d. thorne personal protective equipment (ppe) recently has become a rather common acronym in the lexicon of healthcare providers, even though it has been common in the fire services, emergency medical services (ems), and military for quite some time. essentially, ppe helps ensure that individuals are safe from physical hazards that they may encounter in their work environment. ppe may be used to protect workers from general environmental threats (e.g., temperature extremes, noise), specific work-related threats (e.g., falling objects, falls from heights), or threats faced in an emergency situation (e.g., hazardous chemical and infectious agents). no equipment is appropriate for all individuals and threats, but it must be selected and properly used according to the setting of use and the level of risk. the critical problem with most ppe, particularly in regard to chemically protective suits and respirators, is that with higher levels of protection come not only higher prices and required training levels, but also a higher physiological and physical burden to the user. thus, a structured approach to assessment of risk and selection of proper equipment is important to achieve a reasonable level of protection in relation to the hazard. this chapter reviews the concepts of ppe, recent lessons learned in regard to ppe, types of respirators, key regulations, and issues in the selection of ppe for emergency medical care and decontamination operations. until recently, ppe for medical providers received little attention short of the "standard precautions" of gloves, with the addition of simple masks and barrier precautions, when needed. the 2003 severe acute respiratory syndrome (sars) pandemic, the 1995 tokyo subway sarin attack, the 1995 murrah federal building bombing in oklahoma city, and the terrorist attacks of september 2001 are some examples of situations in which the lack of proper ppe resulted in adverse health effects for healthcare providers and thus focused attention on ppe as a critical issue in disaster response. in march 1995, a crude form of the nerve agent sarin was released in the tokyo subway system on separate cars bound for a common downtown station. this attack resulted in 12 deaths and more than 4000 persons presenting to the hospital for medical evaluation. none of the casualties was decontaminated before treatment or transport. retrospectively, 135 prehospital and 100 hospital personnel reported symptoms consistent with nerve agent exposure. fortunately, none required emergency treatment. 1, 2 eleven physicians caring for the sickest victims (including one in cardiac arrest and one in respiratory arrest) were most affected, and six of them required antidotal therapy. fortunately, all recovered fully and did not have to cease their patient care efforts due to symptoms. 3 approximately 80% of victims self-referred to hospitals, which is consistent with u.s. experiences indicating that few victims of chemical contamination events undergo decontamination before arrival at a medical facility. 2, 4 this has caused most jurisdictions to reconsider historical plans that contaminated patients would not be in contact with medical care personnel until they were "clean." ems and hospital personnel need to be prepared for contaminated patients presenting directly to them and to recognize that in certain situations, ppe may be required to safely provide care. sars posed unique risks and challenges to healthcare workers. this novel viral agent with incompletely defined transmission characteristics was controlled in 2002 with aggressive quarantine measures and use of ppe. in the first wave of sars in toronto, 79.2% of all cases were acquired in a healthcare setting. 5 aggressive use of ppe, including n95 masks, barrier precautions, and gloves, was generally effective at preventing spread, although during one difficult and prolonged intubation attempt, at least six providers contracted sars from a patient despite complying with ppe recommendations. 6 this case led to recommendations that higher levels of ppe may be required during procedures that are likely to generate aerosols or provoke coughing, such as intubation, airway suctioning, positive pressure ventilation, and nebulization treatments. 7 the national institute for occupational safety and health (niosh) and the rand corporation produced a comprehensive "lessons learned" report summarizing issues from the 2001 terrorist bombings at the world trade center (wtc), anthrax incidents, and the 1995 oklahoma city murrah federal building bombing. the report, titled "protecting emergency responders: lessons learned from terrorist attacks" describes in detail many of the challenges responders faced (box 36-1). 8 it is clear from the wtc events that a large number of jurisdictions responding, conflicting messages regarding use of ppe and safety of the environment, and lack of a plan to implement respiratory precautions can complicate a response and potentially place providers at risk. wtc responders continue to suffer respiratory symptoms attributable to exposures at "ground zero." 9 selection of appropriate ppe begins with an analysis of the hazards that responders may encounter and an assessment of responders' roles and responsibilities. hazard vulnerability analyses (hva) are required for community emergency planning grants and are required of healthcare facilities that are accredited by the joint commission on accreditation of healthcare organizations (jcaho). 10 the hva uses a numerical ranking of factors for specific threats (e.g., chemical release), including the risk of the event occurring, the current preparedness for the threat, and the risk to life. the numerical score determines the gravity of each threat to the community. each community's hva will reflect the unique risks that must be considered by its emergency responders. choice of ppe may be affected by factors within the hva such as: • population density of the community and surrounding area • high-or moderate-risk terrorist targets in the community (e.g., government buildings, centers of commerce, or another symbolic site) • chemical hazards posed by community industry (e.g., use of cyanide and hydrofluoric acid in the electronics industry) • risk of transportation incidents and major transportation routes, particularly highways and railroads • proximity of healthcare facilities, schools, or other key locations to these potential targets and industrial and transportation hazards • frequency of hazardous materials (hazmat) incidents in the community • resources available to respond to hazmat incidents (e.g., rapid access to on-site decontamination may decrease, but not eliminate, contaminated persons leaving the scene) stakeholders in emergency response, including ems and healthcare facilities and fire and rescue, emergency management, and law enforcement agencies, must clearly define the responsibilities of each entity and the support and resources that each may need or offer during an emergency, particularly one involving a hazmat release. ems roles in a hazmat event vary depending on jurisdictional planning. fire services personnel may or may • physical hazards including fires, burning jet fuel and explosions, rubble piles with sharp rebar and heated metal, falling debris (which resulted in the death of a nurse in oklahoma city), hazardous materials, electrical hazards, structures prone to collapse, heat stress, exhaustion, and respiratory irritants • heat-related seizures while wearing chemically protective suits • eye injuries (usually related to particulate exposure), which accounted for 12% of all wtc disaster response worker injuries • potential for secondary hazards, including explosive devices and chemical, biological, and radioactive agents • ppe shortcomings: • heavy helmets hindered performance • self-contained breathing apparatus (scba) was heavy and cumbersome • scba face pieces fogged (reducing visibility), and the equipment hindered verbal and radio communication • scba air bottle made it difficult to enter small spaces, and the limited air supply (up to 1 hour) necessitated leaving the operation to exchange the air bottle • air tanks and/or filters were not interchangeable between teams, and teams worked under different standards • powered air-purifying respirator (papr) filters became clogged and were uncomfortable for long duration use. many workers instead opted to use dust masks (which offered little protection and caused nose-bridge chafing) or to wear the masks/hoods around their necks ("neck protectors") • use of respirators made it difficult for workers to communicate with each other, often resulting in users breaking the face seal to talk • turnout gear (the common protective garments used by firefighters) increased heat stress and physical fatigue • at the wtc, the rubble pile was so hot in places that it melted the soles of workers' boots; providing wash stations to cool the boots resulted in wet feet and serious blisters for many workers; some 440 wtc disaster response workers sought treatment for blisters • steel-reinforced boots (soles and toes) protected against punctures by sharp objects but conducted and retained heat, which contributed to blisters and burns • structural firefighting gloves worked well until they got wet and hardened, reducing their dexterity • wtc disaster response workers did not consistently protect their hands against potential hazards such as human remains and bodily fluids • safety glasses were readily available but often were open at the sides and did not offer adequate protection against airborne particles • goggles were uncomfortable, hindered peripheral vision, tended to fog, and did not fit well in conjunction with half-face respirators • many disaster response workers at the wtc (especially law enforcement officers) did not consistently use hearing protection, even around heavy machinery, because they needed to hear their radios and voices and listen for tapping when they were searching for survivors • most volunteers at the wtc, pentagon, and oklahoma city did not receive pre-event training on ppe and hazardous materials • although firefighters generally received detailed pre-event training, this was less true for law enforcement officers • accurate "real-time" hazard information was not readily available, especially during the anthrax incidents • protection from falls was available at some sites (in the form of ropes and harnesses) but was inconsistently used not be able to provide treatment in a "warm zone" (i.e., the area of reduced contamination outside of the immediate release zone) depending on their training. non-fire based ems personnel may require ppe to triage and treat victims in the warm zone. in the event of a mass chemical exposure, victims will likely self-refer to visible ambulances, call 911 from sites removed from the site of release, or make their way to hospitals, by-passing organized ems and fire services. this movement of contamination on the bodies of patients essentially causes a "migrating" warm zone, causing contamination of previously clean ("cold") areas. this migrating contamination may require protective equipment for ems responders, and appropriate plans and equipment should be in place. the roles and responsibilities of the responders, as well as the equipment required, need to be defined and drilled in advance of an incident. hospitals, until very recently, usually relied on fire services for patient decontamination at the hospital. these resources, however, are often deployed to the scene of the event and are thus unavailable to support the hospital. most hospitals have now recognized the need for at least some internal capacity for patient decontamination and are equipping their teams with ppe appropriate for decontaminating self-referred contaminated patients. a few hospital teams integrate with community hazmat teams, necessitating additional training and equipment as the mission then changes from a defensive decontamination response to an offensive response at the scene of release. hazmat releases seldom cause serious injury, but the potential exists for both scene responders and hospital receivers to suffer serious consequences of exposure. the agency for toxic substance and disease registry (atsdr) maintains a multistate voluntary accounting of hazardous substance releases, excluding petroleumrelated incidents. the hazardous substances emergency events surveillance (hsees) database currently involves 15 states. 11 from 1993 to 2001, 44,015 events were recorded: 3455 (7.8%) of the incidents caused injuries, and 74% of victims were transported to a healthcare facility. 4 in another analysis of hsees data, only 5% of victims required admission to a healthcare facility. 12 the vast majority had self-limited respiratory symptoms. in 2001, the chemicals with highest potential for injury were chlorine (injury occurred in 18.8% of releases), ammonia (18.2%), acids (14.2%), and pesticides (17%). 13 hsees data from 1996 to 1998 show 348 responder injuries in 126 incidents out of a total of 16,986 incidents (0.7%). law enforcement officers and firefighters accounted for the vast majority of responder injuries, which usually consisted of nausea and respiratory irritation. hospital admission occurred in 6.6% of cases. no deaths were reported in this 3-year period. 4 hospital personnel were injured in 0.3% of the total hazmat events and represented 0.1% of the victims. 4 six events involved emergency department staff contact with contaminated patients, and five events were hazmat releases at the healthcare facility itself. no provider required hospital admission, and no chemical ppe was used. other reports of emergency department evacuation and/or provider illness due to off-gassing from contaminated patients have been summarized. [14] [15] [16] [17] [18] [19] the most serious of these incidents involve patients with suicidal ingestions of organophosphate pesticides. [14] [15] [16] exposures to these patients caused at least one provider to require intubation and receive aggressive antidotal therapy due to contact with pesticide in emesis and vapors during patient resuscitation. 14 patients who have ingested organophosphate may off-gas for days and present an ongoing risk to healthcare workers. 16 niosh has documented 46 healthcare worker injuries from pesticide agents between 1987 and 1998. 14 in conjunction with the information from the tokyo subway sarin attack and the chemical terrorism risk posed by these agents, it is clear that these pesticides present a substantial risk of toxicity from secondary exposures. limited research is available to document the degree of the off-gassing that occurs from the bodies and clothing of contaminated patients. 20, 21 clothing removal and control may be expected to remove 90% of the contaminant and thus should be a priority. 21, 22 ideally, this should take place in an open-air environment. providers may not initially recognize a chemical release when they arrive at a scene. even though structural firefighting ensembles with self-contained breathing apparatus (scba) offer some chemical protection that may be sufficient for victim rescue, 23 the incident commander must determine what actions are appropriate for the situation. protective suits, gloves, and boots and appropriate respiratory protection must be donned as soon as possible when a chemical threat is recognized. the occupational safety and health administration (osha) and environmental protection agency define four basic levels of ppe for hazmat scene responses ( 29 cfr 1910 .120, appendix b). generally, as the level of protection increases (a being the highest level), so do the weight, cost, and physiological burden. increasing protection also generally means decreasing mobility, dexterity, and scope of vision. inherent risks to ppe include trip and fall hazards; a reduced ability to complete tasks; heat stress 19,24-27 ; anxiety 28 ; and seizures, which, although rare, have been reported. 19 cardiovascular demand is dramatically increased as ensemble weight and heat retention increase. ppe must be selected on the basis that it does not impose unnecessary risks on the provider while at the same time offering an appropriate margin of safety against the chemical hazard. because the selection of ppe usually revolves around the selection of the respiratory component, various types of respirators must be reviewed. each respirator has an assigned protection factor that reflects the degree of protection afforded to the user. simply put, 1/protection factor equals the amount of exposure for the wearer. for example, a provider wearing a powered air-purifying respirator (papr) with an assigned protection factor (apf) of 1000 is exposed to 1/1000 the level of contaminant as compared with wearing no protection. atmosphere-supplying respirators provide breathable fresh air to the user independent of the environment via an air supply hose and/or tank and thus offer a high level of respiratory protection. this type of respirator is required for entry into environments where the identity of and/or the potential quantity of a hazardous substance are unknown or where the quantity of oxygen in the air is unknown. scba is the most common atmosphere-supplying respirator for emergency responses. it provides air via a tank, usually worn on the back. the operational time is limited by the capacity of the tank (usually less than 1 hour). fire services personnel routinely use this form of respiratory protection, and fire-based ems services personnel generally incorporate this ppe into their chemical protection planning. limitations include the equipment's weight (approximately 25 to 30 pounds), cost, need for fit-testing, duration of air supply, and need to refill air bottles. even though scba provides excellent protection, its limitations make it inappropriate for many situations (e.g., caring for a patient with an infectious disease, providing hospital-based decontamination, or securing a perimeter in the warm zone). scba has an apf of about 10,000, the highest of any type of respirator. 29 supplied-air respirators (sars) provide air via a hose line from a nearby clean air source (e.g., compressor or hospital supply line). to meet osha requirements for level b, respirators must have a tight-fitting face piece and an emergency supply of air in case of line failure or problems. 30 loose-fitting hoods with a supplied air source do not meet level b standards but are used by some decontamination teams when an additional level of protection is desired due to institutional preference or local hazard profile. advantages include a potentially unlimited supply of fresh air and longer duration of use. limitations are primarily mobility and thus flexibility of response. these respirators are best suited to healthcare provider use in a decontamination room or a welldefined area in which the air lines are unlikely to be tangled, stretched, or a tripped hazard. the apf of a typical tight-fitting face piece sar is 1000, although there may be variability among models and types (e.g., tight-fitting mask versus loose-fitting hood). 29 air-purifying respirators (aprs) have cartridges that filter the air in the user's environment to remove particulate matter and specific chemicals that the filter is designed to capture. these filters do not affect the oxygen concentration of the ambient air and thus cannot be used in potentially oxygen-deficient environments. only those chemicals for which the filter is designated are removed. also, the capacity of the filter can be exceeded by large amounts of contaminant, thus these respirators are designed for situations in which the concentration of the agent is either established to be or assumed to be below the threshold for the canister. nonpowered aprs use the wearer's work of breathing to pull ambient air through the filter. examples include dust masks and military and civilian "gas masks."the apf of a nonpowered full face piece apr is 50 when appropriate quantitative fit-testing is performed. 29 of note, this type of mask is used by the military for battlefield protection against lethal levels of nerve and other chemical agents. advantages include low cost and long duration of use. disadvantages include increased work of breathing and physiological stress, mask fogging, and the need for fit-testing. a papr uses a motor to pull air through the filter canisters, thus decreasing the work of breathing and the risk of air entrainment around the respirator face piece.paprs are often supplied with a loose-fitting disposable or reusable hood that eliminates the need to perform fit-testing and allows use by a broad range of individuals. hooded paprs with "stacked" canisters that offer protection against com-personal protective equipment 249 mon hazardous chemical and biological agents encountered by first responders and hospital personnel are in widespread use due to their relatively low cost,weight,and the increased flexibility of response allowed. dependence on battery power,shelf life of the filters,and the need to be able to match the filter to the agent are limiting factors. the currently proposed apf for a papr is 1000. 29 directions for use must be carefully followed; one particular model provides a protection factor of 20,000 when properly donned, but when the inner hood is not tucked in, the protection level declines to 1000 and less 31,32 (personal communication, 2001) . battery packs are usually either single-use or rechargeable. rechargeable battery packs require ongoing attention to ensure a proper charge, but they offer the flexibility of allowing papr re-use during an infectious disease event. particulate filter masks such as those commonly used for patient care to protect against tuberculosis and other organisms are also considered aprs. masks are classified n (not oil resistant), r (oil resistant), and p (oil proof). n95 refers to a filter (the entire mask) that removes 95% of a particulate challenge in the 3-to 5-μm range. n100 respirators filter 100% of the same challenge, yet simple half-face respirators offer an apf of only 10 due to the entrainment of air around the mask and other factors; therefore, changing from an n95 to an n100 offers little additional protection unless a more robust mask ensemble, rather than a simple half-face mask, is used. 33, 34 respiratory protection technologies are rapidly evolving, and respiratory program administrators should make sure they are familiar with the available options and their relative advantages/disadvantages. regional cooperative planning and purchases may be helpful to allow for sharing of resources during an incident. chemically protective suits must be tailored to the type of use. suits for hot zone entry where direct contact with a hazardous material is likely must be much more robust than suits for patient decontamination activities. selection should be guided by national fire protection association (nfpa) standards 1992 and 1994 for site-ofrelease response activities and by recent osha guidance for hospital decontamination activities. 35,36 chemicals commonly found in local transit, agriculture, or industrial use should also guide selection. appropriate ppe for perimeter control and ems warm zone operations remain topics of debate at this time. generally, suits should be sized far more generously than standard work clothing to prevent tearing during squatting and other activities (e.g., an average 70-kg man should plan to wear a size xxl suit). many suit configurations are possible, and the optimal configuration will depend on the mission and other equipment in the ensemble. for example, suits without "feet" are preferred when worn with boots (to allow taping over the boot) but those with integrated bootie "feet"are preferred when pull-on "sock"type butyl booties are to be used. these integrated feet should not be used as primary footwear at any time because they have poor abrasion resistance. boots supplied in sizes medium, large, and extra large rather than fitted sizes may be preferred when equipment is purchased for a group (e.g., hospital decontamination team) rather than being purchased for an individual responder (e.g., firefighter). butyl or other rubber boots probably afford appropriate protection for warm zone operations. butyl "sock" type booties may be used on very low abrasion surfaces (e.g., internal hospital decontamination room) but are not generally appropriate for outside use. nitrile undergloves with butyl overgloves provide protection against a broad range of hazards for warm zone activities. silver shield gloves are more expensive but may be better suited for particular compounds when the agent is known. overglove selection should balance the need for abrasion resistance with dexterity required to perform tasks (e.g., to administer intramuscular antidotes). the u.s. army center for health promotion and preventive medicine (usachppm) recommends 14-mm thickness butyl gloves (standard examination gloves are 4 mm) as a minimum for working with patients contaminated by chemical warfare agents or toxic industrial chemicals. 37 very few situations require physical decontamination of patients exposed to biological agents. an exception would be patients who present after contamination with biological agents (e.g., anthrax spores) from a dissemination device. ppe for decontamination should consist of the same chemical protective suit and high level of respiratory protection, including a high-efficiency particulate (hepa) or sar, that would be used for chemical decontamination activities. ppe for biological agents in relation to care of patients who are already infected and symptomatic is discussed in the following. categories of ppe for biological agents include 38 : 1. standard precautions: use of gloves and proper hand hygiene to prevent disease transmission for any potentially infectious patient. gowns and eye protection are added only when patient care activities are likely to result in splashing or soiling. 2. contact precautions: standard precautions plus use of barriers during all patient care activities to protect face, arms, and front torso to prevent contact with secretions, emesis, feces, etc. (e.g., enteric infections, many hemorrhagic fever viruses). 3. droplet precautions: standard precautions with the addition of a droplet respirator (e.g., surgical mask) when working within 3 feet of the patient to prevent transmission of infectious agents that travel by large droplet spread (e.g., cirborne precautions are used against plague); may not be protective against all droplet nuclei. 4. airborne precautions: standard precautions with an n95 or higher protection respirator to prevent transmission of infectious agents that are spread by aerosols (e.g., airborne precautions are used against chickenpox, smallpox, and tuberculosis). 5. "special pathogen precautions": based on the sars experiences, a high-risk pathogen with respiratory spread probably requires greater levels of protection than previously recommended. constant use of both contact and airborne precautions has generally been advised with the optional use of a papr rather than an n95 mask during "high-risk" interventions likely to generate aerosols or provoke coughing (e.g., suctioning, intubation, positive pressure ventilation). 6, 7 these precautions are the subject of current discussion. patient care providers should have routine access to nonsterile examination gloves, barrier gowns that protect the arms and front torso, standard surgical (droplet) masks, and a face shield that provides adequate splash protection (which may be integrated with the mask, a separate face shield, or goggles) according to the osha bloodborne pathogens standard. 39 providers should have ready access to higher levels of protection when needed."bad bug bags"may be assembled with appropriate gowns, gloves, face shields/goggles, n95 or papr respirators, and other supplies so that healthcare providers do not have to assemble the recommended components. instruction sheets for donning/doffing and disinfection procedures can be included in the bag. 40 practitioners fitted for n95 respirators may use these for patient care, and others should have access to a papr until they are fitted for an n95 respirator. plans to rapidly fit-test additional employees during an event that might require prolonged use of airborne precautions (e.g., sars) should be in place. all ppe must be part of an ongoing program of respiratory protection and hazmat/decontamination response within the agency or institution to ensure that employees who are expected to use these protections are competent and comfortable with the indications, use, and limitations of their equipment. numerous regulations apply to the selection and proper use of ppe. all persons using ppe must conform to osha standards on respiratory protection (29 cfr 1910.134) ,ppe (29 cfr 1910 .132),eye and face protection (29 cfr 1910.133) , hand protection (29 cfr 1910 .138), hazard communication (29 cfr 1910 (29 cfr .1200 , and bloodborne pathogens (29 cfr 1910 (29 cfr .1030 ). state osha agencies may have stricter requirements than the federal standards. most occupational or employee health services of agencies/facilities where ppe is used are very familiar with these standards and their application to employees. the nfpa has numerous standards for the training and equipping of responders (including ems personnel) to a hazmat incident (e.g., nfpa standards 471, 473, 1981, 1992, 1994, and 1999) . specific guidance is also provided for urban search and rescue teams (nfpa standard 1951) . 35 responders to hazmat releases are covered by osha's hazwoper (hazardous waste operations and emergency response) standard 29 cfr 1910 .120, which is perhaps the most comprehensive standard guiding hazardous materials responses. osha requires use of a minimum of level b equipment (i.e., an atmosphere-supplying respirator and chemically protective suit with sealed seams) during a response into a contaminated environment until the concentration of the agent is shown via air monitoring to be below the threshold required for the safe use of an apr or other lesser degree of protection. 41 this requirement presents difficulty for ems and hospital providers because the agent is often unknown at the time that medical care is provided in the warm zone (i.e., an area where the level of contamination is minimal and controlled). particularly for hospitals, confusion existed as to what constituted appropriate protection for decontamination team members who provide medical care for contaminated patients and to what degree the hazwoper standard applied to community responders geographically separate from the site of release. osha clarified this issue for healthcare facility providers in two letters of interpretation 42, 43 and a comprehensive guidance document on ppe and training released in 2004. 36 in this document, osha codifies use of paprs as the minimum level of respiratory protective equipment for hospitals under certain conditions: • the facility acts as a "first receiver" for self-referred contaminated casualties, not as a responder to a release zone. • the facility itself is not the site of the hazardous substances release. • an hva has been conducted to identify specific hazards to the community and facility. • the victims must present at least 10 minutes after exposure (to allow time for some of the contaminant to evaporate or dissipate). it will usually take at least this long to get personnel into ppe at the facility. • the victims' clothing must be rapidly removed and contained. • decontamination must occur in a well-ventilated area, preferably outdoors. when these conditions are met, and absent any particular threats within the community that require higher levels of protection (such as close proximity to a specific chemical production, storage, or disposal site), the minimum level of respiratory ppe is a papr with a protection factor of 1000 or greater, which filters organic vapor, acid gas, particulate matter, and biological agents (at the hepa level). 36 hazwoper also defines training requirements for responders. 44 the application of these regulations to hospital decontamination teams was also clarified in recent osha guidance. 36 awareness training is required for individuals involved in a hazmat response who will not be using ppe or taking actions beyond recognizing and reporting an incident (emergency department staff, law enforcement officers). 43 at a minimum, all responders who will use chemical ppe must be trained to the operations level (8 hours or to competency) 43 so that each responder can: • understand his or her role in the response and the emergency response plan. • identify the presence of a hazardous substance through signs and symptoms of exposure. • assess site safety, including risks to self. • select and safely use appropriate ppe. • understand decontamination procedures. hazmat awareness educational competencies must also be met by providers trained to the operations level. the awareness competencies may be included in the 8 hours of operations training or conducted separately. 36 in addition, any personnel using respiratory protective equipment must be in compliance with osha's respiratory protection standard (29 cfr 120.134). key features of this standard are: • respirator selection procedures. • proper use of respirators in routine and reasonably foreseeable emergency situations. • medical clearance before use (at minimum, a screening questionnaire; see appendix c of the standard). • fit-testing before use and annually thereafter (see appendix a and b1 of the standard). • inspecting, cleaning/disinfecting, storing, repairing, and maintaining the equipment. • training and education on topics such as the types of respiratory hazards they might be exposed to, proper use (including donning and doffing), limitations, and maintenance. most medical facilities and response agencies have a respiratory protection program in place. this existing foundation and the subject matter experts in occupational safety and health, infection control, or other related disciplines can assist with implementation of new technologies and protocols. ppe technology continues to change rapidly. hopefully, technologies that are lighter weight, less expensive, and less heat-retaining can be developed. technology change is occurring far more rapidly than the current approvals process and new standards that have arisen in the wake of the events of 2001. clear guidance on appropriate technologies for warm zone activities is lacking at this time. this can lead to confusion and difficult choices for agencies and facilities, knowing that their ppe selection may be either too much or too little to satisfy future standards. currently, there is no recommendation or consensus on the level of ppe that is required for hospital-based personnel, much to the consternation of hospital preparedness leaders. some have proposed a ppe level "h" to meet this need. more research is clearly needed regarding safe but comfortable ppe, methods of decontamination, modeling of airborne concentrations of specific agents, and ppe selection. further, detection technologies are needed that can provide better environmental screening for a wide range of hazardous substances and quantitative assessment of agent concentration. currently, incident commanders may remain confused about appropriate ppe, and this may result in ppe selection that is overly conservative (which risks provider noncompliance and adverse effects from the ppe) or overly liberal (which risks provider injury from the contaminant). finally, providers need to be educated about the consequences of not using ppe appropriately, including acute chemical effects and delayed pulmonary effects. in general, communities and regions can help to reduce issues of ppe interoperability by planning, purchasing, and training together whenever possible. this also allows for caches of materials to be deployed that are true replacements for usual materials and thus will be better accepted and require minimal training. for too long, jurisdictions have been reluctant to share their problems, issues, and roadblocks in the area of ppe, lest the agency be seen as having problems protecting its responders. better dialogue and sharing of best practices and lessons learned are of immense value to better hazmat response planning and should be encouraged. the recent niosh/rand report 8 and release of select after-action reports are welcome changes in this history. defining hazards in this age of potential chemical terrorism is fraught with peril because we are unable to truly assess the scope of the threat. thus, ppe must be chosen that will protect appropriately against a broad range of threats without being so restrictive that in the heat of the moment, the provider decides to forgo the ppe and is at risk of becoming a casualty of the event. balancing cost, ease of use, and scope of protection concerns are delicate decisions with few answers at this time, particularly for those who may have long-duration job tasks in a warm zone environment. we can only hope that we are not forced to learn too many more harsh lessons about ppe use in the future. in the meantime, however, we should strive to prepare our communities by selecting appropriate protective technologies in relation to perceived threats and practicing our responses so that our personnel are comfortable using their ppe and understand the consequences of not doing so. the tokyo subway sarin attack: disaster management, part 1: community emergency response the tokyo subway sarin attack: disaster management, part 2: hospital response secondary exposure of medical staff to sarin vapor in the emergency room secondary contamination of emergency department personnel from hazardous materials events public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in toronto cluster of severe acute respiratory syndrome cases among protected healthcare workers-toronto, canada public health guidance for community-level preparedness and response to severe acute respiratory syndrome (sars) version 2: supplement i: infection control in the home, healthcare, and community settings protecting emergency responders: lessons learned from terrorist attacks physical health status of world trade center rescue and recovery workers and volunteers joint commission accreditation manual for healthcare facilities ec 1.4 and 1.6 (rev) hazardous substances emergency events surveillance risk factors for adverse health events following hazardous materials incidents hazardous substances emergency events surveillance (hsees) annual report 2001: victims nosocomial poisoning associated with emergency department treatment of organophosphate toxicity-georgia malathion overdose: when one patient creates a departmental hazard prolonged toxicity of organophosphate poisoning hospital response to a chemical incident: report on casualties of an ethyldichlorosilane spill dangerous bodies: a case of fatal aluminum phosphide poisoning personal protective equipment for healthcare facility decontamination personnel: regulations, risks, and recommendations simulated exposure of hospital emergency personnel to solvent vapors and respirable dust during decontamination of chemically exposed patients joint publication of the u.s. army soldier and biological chemical command, environmental and occupational health sciences institute, and veterans health administration (vha) weapons of mass destruction events with contaminated casualties: effective planning for healthcare facilities guidelines for incident commander's use of firefighter protective ensemble with self-contained breathing apparatus for rescue operations during a terrorist chemical agent incident impact of the chemical protective ensemble on the performance of basic medical tasks the effect of full protective gear on intubation performed by hospital medical personnel emergence of real casualties during simulated chemical warfare training under high heat conditions the effect of chemical protective clothing and equipment on army soldier performance: a critical review of the literature biopsychosocial responses of medical unit personnel wearing chemical defense ensemble in a simulated chemical warfare environment occupational health and safety administration. hazardous waste operations and emergency response. code of federal regulations domestic preparedness: sarin vapor challenge and corn oil protection factor (pf) testing of 3m be10 powered air-purifying respirator with ap3 cartridge technical data bulletin #155:test criteria for the 3m cartridge fr57 against various military and industrial chemical agents aerosol penetration and leakage characteristics of masks in the health care industry characteristics of face seal leakage in filtering facepieces osha guidance for hospital-based first receivers of victims from mass casualty incidents involving the release of hazardous substances (final draft) personal protective equipment guide for military medical treatment facility personnel handling casualties from weapons of mass destruction and terrorism events. technical guide 275. aberdeen proving grounds, md: u.s. army center for health promotion and preventive medicine guideline for isolation precautions in hospitals. the hospital infection control practices advisory committee respiratory protective devices: final rules and notice minnesota department of health chapter association for practitioners of infection control. personal protective equipment for smallpox and viral hemorrhagic fever patient care code of federal regulations 1910.120(q)(3)(iii-iv) standard interpretations. training and ppe requirements for hospital staff that decontaminate victims/patients standard interpretations. respiratory protection requirements for hospital staff decontaminating chemically contaminated patients hazardous waste operations and emergency response key: cord-296306-xcomjvaa authors: rivett, lucy; sridhar, sushmita; sparkes, dominic; routledge, matthew; jones, nick k; forrest, sally; young, jamie; pereira-dias, joana; hamilton, william l; ferris, mark; torok, m estee; meredith, luke; curran, martin d; fuller, stewart; chaudhry, afzal; shaw, ashley; samworth, richard j; bradley, john r; dougan, gordon; smith, kenneth gc; lehner, paul j; matheson, nicholas j; wright, giles; goodfellow, ian g; baker, stephen; weekes, michael p title: screening of healthcare workers for sars-cov-2 highlights the role of asymptomatic carriage in covid-19 transmission date: 2020-05-11 journal: elife doi: 10.7554/elife.58728 sha: doc_id: 296306 cord_uid: xcomjvaa significant differences exist in the availability of healthcare worker (hcw) sars-cov-2 testing between countries, and existing programmes focus on screening symptomatic rather than asymptomatic staff. over a 3 week period (april 2020), 1032 asymptomatic hcws were screened for sars-cov-2 in a large uk teaching hospital. symptomatic staff and symptomatic household contacts were additionally tested. real-time rt-pcr was used to detect viral rna from a throat+nose self-swab. 3% of hcws in the asymptomatic screening group tested positive for sars-cov-2. 17/30 (57%) were truly asymptomatic/pauci-symptomatic. 12/30 (40%) had experienced symptoms compatible with coronavirus disease 2019 (covid-19)>7 days prior to testing, most self-isolating, returning well. clusters of hcw infection were discovered on two independent wards. viral genome sequencing showed that the majority of hcws had the dominant lineage b∙1. our data demonstrates the utility of comprehensive screening of hcws with minimal or no symptoms. this approach will be critical for protecting patients and hospital staff. despite the world health organisation (who) advocating widespread testing for sars-cov-2, national capacities for implementation have diverged considerably (who, 2020b; our world in data, 2020) . in the uk, the strategy has been to perform sars-cov-2 testing for essential workers who are symptomatic themselves or have symptomatic household contacts. this approach has been exemplified by recent studies of symptomatic hcws (hunter et al., 2020; keeley et al., 2020) . the role of nosocomial transmission of sars-cov-2 is becoming increasingly recognised, accounting for 12-29% of cases in some reports . importantly, data suggest that the severity and mortality risk of nosocomial transmission may be greater than for community-acquired covid-19 (mcmichael et al., 2020) . protection of hcws and their families from the acquisition of covid-19 in hospitals is paramount, and underscored by rising numbers of hcw deaths nationally and internationally (cook et al., 2020; cdc covid-19 response team, 2020) . in previous epidemics, hcw screening programmes have boosted morale, decreased absenteeism and potentially reduced long-term psychological sequelae (mcalonan et al., 2007) . screening also allows earlier return to work when individuals or their family members test negative (hunter et al., 2020; keeley et al., 2020) . another major consideration is the protection of vulnerable patients from a potentially infectious workforce (mcmichael et al., 2020) , particularly as social distancing is not possible whilst caring for patients. early identification and isolation of infectious hcws may help prevent onward transmission to patients and colleagues, and targeted infection prevention and control measures may reduce the risk of healthcare-associated outbreaks. the clinical presentation of covid-19 can include minimal or no symptoms (who, 2020a). asymptomatic or pre-symptomatic transmission is clearly reported and is estimated to account for around half of all cases of covid-19 (he et al., 2020) . screening approaches focussed solely on symptomatic hcws are therefore unlikely to be adequate for suppression of nosocomial spread. preliminary data suggests that mass screening and isolation of asymptomatic individuals can be an effective method for halting transmission in community-based settings (day, 2020) . recent modelling has suggested that weekly testing of asymptomatic hcws could reduce onward transmission by 16-23%, on top of isolation based on symptoms, provided results are available within 24 hr (imperial college covid-19 response team, 2020). the need for widespread adoption of an expanded screening programme for asymptomatic, as well as symptomatic hcws, is apparent (imperial college covid-19 response team, 2020; black et al., 2020; gandhi et al., 2020) . challenges to the roll-out of an expanded screening programme include the ability to increase diagnostic testing capacity, logistical issues affecting sampling and turnaround times and concerns about workforce depletion should substantial numbers of staff test positive. here, we describe how we have dealt with these challenges and present initial findings from a comprehensive staff screening programme at cambridge university hospitals nhs foundation trust (cuhnft). this has included systematic screening of >1000 asymptomatic hcws in their workplace, in addition to >200 symptomatic staff or household contacts. screening was performed using a validated real-time reverse transcription pcr (rt-pcr) assay detecting sars-cov-2 from combined oropharyngeal (op) and nasopharyngeal (np) swabs (sridhar et al., 2020) . rapid viral sequencing of positive samples was used to further assess potential epidemiological linkage where nosocomial transmission was suspected. our experience highlights the value of programmes targeting both symptomatic and asymptomatic staff, and will be informative for the establishment of similar programmes in the uk and globally. between 6 th and 24 th april 2020, 1,270 hcws in cuhnft and their symptomatic household contacts were swabbed and tested for sars-cov-2 by real-time rt-pcr. the median age of the hcws was 34; 71% were female and 29% male. the technical rt-pcr failure rate was 2/1,270 (0. 2% see materials and methods); these were excluded from the 'tested' population for further analysis. ultimately, 5% (n = 61) of swabs were sars-cov-2 positive. 21 individuals underwent repeat testing for a variety of reasons, including evolving symptoms (n = 3) and scoring 'medium' probability on clinical covid-19 criteria (tables 1-2) (n = 11). all remained sars-cov-2 negative. turn around time from sample collection to resulting was 12-36 hr; this varied according to the time samples were obtained. table 3 outlines the total number of sars-cov-2 tests performed in each screening group (hcw asymptomatic, hcw symptomatic, and hcw symptomatic household contact) categorised according to the ward with the highest anticipated risk of exposure to high; 'amber', medium; 'green', low; . in total, 31/1,032 (3%) of those tested in the hcw asymptomatic screening group tested sars-cov-2 positive. in comparison, 30/221 (14%) tested positive when hcw symptomatic and hcw symptomatic household contact screening groups were combined. as expected, symptomatic hcws and their household contacts were significantly more likely to test positive than hcws from the asymptomatic screening group (p<0. 0001, fisher's exact test). hcws working in 'red' or 'amber' wards were significantly more likely to test positive than those working in 'green' wards (p=0. 0042, fisher's exact test). all users of ffp3 masks underwent routine fit-testing prior to usage. cleaning and re-use of masks, theatre caps, gloves, aprons or gowns was actively discouraged. cleaning and re-use of eye protection was permitted for certain types of goggles and visors, as specified in the hospital's ppe protocol. single-use eye protection was in use in most scenario 1 and 2 areas, and was not cleaned and re-used. all non-invasive ventilation or use of high-flow nasal oxygen on laboratory-confirmed or elife digest patients admitted to nhs hospitals are now routinely screened for sars-cov-2 (the virus that causes covid-19), and isolated from other patients if necessary. yet healthcare workers, including frontline patient-facing staff such as doctors, nurses and physiotherapists, are only tested and excluded from work if they develop symptoms of the illness. however, there is emerging evidence that many people infected with sars-cov-2 never develop significant symptoms: these people will therefore be missed by 'symptomatic-only' testing. there is also important data showing that around half of all transmissions of sars-cov-2 happen before the infected individual even develops symptoms. this means that much broader testing programs are required to spot people when they are most infectious. rivett, sridhar, sparkes, routledge et al. set out to determine what proportion of healthcare workers was infected with sars-cov-2 while also feeling generally healthy at the time of testing. over 1,000 staff members at a large uk hospital who felt they were well enough to work, and did not fit the government criteria for covid-19 infection, were tested. amongst these, 3% were positive for sars-cov-2. on closer questioning, around one in five reported no symptoms, two in five very mild symptoms that they had dismissed as inconsequential, and a further two in five reported covid-19 symptoms that had stopped more than a week previously. in parallel, healthcare workers with symptoms of covid-19 (and their household contacts) who were self-isolating were also tested, in order to allow those without the virus to quickly return to work and bolster a stretched workforce. finally, the rates of infection were examined to probe how the virus could have spread through the hospital and among staff -and in particular, to understand whether rates of infection were greater among staff working in areas devoted to covid-19 patients. despite wearing appropriate personal protective equipment, healthcare workers in these areas were almost three times more likely to test positive than those working in areas without covid-19 patients. however, it is not clear whether this genuinely reflects greater rates of patients passing the infection to staff. staff may give the virus to each other, or even acquire it at home. overall, this work implies that hospitals need to be vigilant and introduce broad screening programmes across their workforces. it will be vital to establish such approaches before 'lockdown' is fully lifted, so healthcare institutions are prepared for any second peak of infections. clinically suspected covid-19 patients was performed in negative-pressure (à5 pascals) side rooms, with 10 air changes per hour and use of scenario 2 ppe. all other aerosol generating procedures were undertaken with scenario 2 ppe precautions, in negative-or neutral-pressure facilities. general clinical areas underwent a minimum of 6 air changes per hour, but all critical care areas underwent a minimum of 10 air changes per hour as a matter of routine. surgical operating theatres routinely underwent a minimum of 25 air changes per hour. viral loads varied between individuals, potentially reflecting the nature of the sampling site. however, for individuals testing positive for sars-cov-2, viral loads were significantly lower for those in the hcw asymptomatic screening group than in those tested due to the presence of symptoms (figure 1) . for the hcw symptomatic and hcw symptomatic contact screening groups, viral loads did not correlate with duration of symptoms or with clinical criteria risk score (figure 1 -figure supplement 1 and data not shown). three subgroups of sars-cov-2 positive asymptomatic hcw each individual in the hcw asymptomatic screening group was contacted by telephone to establish a clinical history, and covid-19 probability criteria ( table 1) were retrospectively applied to categorise any symptoms in the month prior to testing ( figure 2 ). one hcw could not be contacted to obtain further history. individuals captured by the hcw asymptomatic screening group were generally asymptomatic at the time of screening, however could be divided into three sub-groups: (i) hcws with no symptoms at all, (ii) hcws with (chiefly low-to-medium covid-19 probability) symptoms commencing 7 days prior to screening and (iii) hcws with (typically high covid-19 probability) symptoms commencing >7 days prior to screening ( figure 2 ). 9/12 (75%) individuals with symptom onset >7 days previously had appropriately self-isolated and then returned to work. one individual with no symptoms at the time of swabbing subsequently developed symptoms prior to being contacted with their positive result. overall, 5/1032 (0.5%) individuals in the asymptomatic screening group were identified as truly asymptomatic carriers of sars-cov-2, and 1/1032 (0.1%) was identified as pre-symptomatic. box 1 shows illustrative clinical vignettes. for the hcw asymptomatic screening group, nineteen wards were identified for systematic priority screening as part of hospital-wide surveillance. two further areas were specifically targeted for screening due to unusually high staff sickness rates (ward f), or concerns about appropriate ppe usage (ward q) ( figure 3 ). interestingly, in line with findings in the total hcw population, a significantly greater proportion of hcws working on 'red' wards compared to hcws working on 'green' wards tested positive as part of the asymptomatic screening programme ('green' 6/310 vs 'red' 19/ 372; p=0.0389, fisher's exact test). the proportion of hcw with a positive test was significantly higher on ward f than on other wards categorised as 'green' clinical areas (ward f 4/43 vs other 'green' wards 2/267; p=0.0040, fisher's exact test). likewise, amongst wards in the 'red' areas, ward q showed significantly higher rates of positive hcw test results (ward q 7/37 vs other 'red' wards 12/335; p=0.0011, fisher's exact test). ward f is an elderly care ward, designated as a 'green' area with scenario 0 ppe (tables 4-5) , with a high proportion of covid-19 vulnerable patients due to age and comorbidity. 4/43 (9%) ward staff tested positive for sars-cov-2. in addition, two staff members on this ward tested positive in the hcw symptomatic/symptomatic contact screening groups. all positive hcws were requested to self-isolate, the ward was closed to admissions and escalated to scenario 1 ppe ( table 5) . reactive screening of a further 18 ward f staff identified an additional three positive asymptomatic hcws (figure 4 ). sequence analysis indicated that 6/9 samples from hcw who worked on ward f belonged to sars-cov-2 lineage b. 1 (currently known to be circulating in at least 43 countries [rambaut et al., 2020] ), with a further two that belonged to b1. 7 and one that belonged to b2. 1. this suggests more than two introductions of sars-cov-2 into the hcw population on ward f (figure 4-figure supplements 1-2, table 6 ). it was subsequently found that two further staff members from ward f had previously been admitted to hospital with severe covid-19 infection. ward q is a general medical ward designated as a 'red' clinical area for the care of covid-19 positive patients, with a scenario 1 ppe protocol (tables 4-5). here, 7/37 (19%) ward staff tested positive for sars-cov-2. in addition, one staff member tested positive as part of the hcw symptomatic screening group, within the same period as ward surveillance. reactive screening of a further five staff working on ward q uncovered one additional infection. 4/4 sequenced viruses were of the b. 1 lineage (figure 4-figure supplements 1-2, table 6 ; other isolates could not be sequenced due to a sample ct value >30). all positive hcws were requested to self-isolate, and infection control and ppe reviews were undertaken to ensure that environmental cleaning and ppe donning/doffing practices were compliant with hospital protocol. staff training and education was provided to address observed instances of incorrect infection control or ppe practice. ward o, a 'red' medical ward, had similar numbers of asymptomatic hcws screened as ward f, and a similar positivity rate (4/44; 9%). this ward was listed for further cluster investigation after the study ended, however incorrect ppe usage was not noted during the study period. the majority of individuals who tested positive for sars-cov-2 after screening due to the presence of symptoms had high covid-19 probability ( table 7) . this reflects national guidance regarding self-isolation at the time of our study (uk government, 2020a). through the rapid establishment of an expanded hcw sars-cov-2 screening programme, we discovered that 31/1,032 (3%) of hcws tested positive for sars-cov-2 in the absence of symptoms. of 30 individuals from this asymptomatic screening group studied in more depth, 6/30 (20%) had not experienced any symptoms at the time of their test. 1/6 became symptomatic suggesting that the true asymptomatic carriage rate was 5/1,032 (0.5%). 11/30 (37%) had experienced mild symptoms prior to testing. whilst temporally associated, it cannot be assumed that these symptoms necessarily resulted from covid-19. these proportions are difficult to contextualise due to paucity of table 4 . the hospital's traffic-light colouring system for categorising wards according to anticipated covid-19 exposure risk. different types of ppe were used in each ( table 5) . red (high risk) amber (medium risk) green (low risk) areas with confirmed sars-cov-2 rt-pcr positive patients, or patients with very high clinical suspicion of covid-19 areas with patients awaiting sars-cov-2 rt-pcr test results, or that have been exposed and may be incubating infection areas with no known sars-cov-2 rt-pcr positive patients, and none with clinically suspected covid-19 point-prevalence data from asymptomatic individuals in similar healthcare settings or the wider community. for contrast, 60% of asymptomatic residents in a recent study tested positive in the midst of a care home outbreak (arons et al., 2020) . regardless of the proportion, however, many secondary and tertiary hospital-acquired infections were undoubtedly prevented by identifying and isolating these sars-cov-2 positive hcws. amber + red wards, for example intensive care unit, respiratory units with non-invasive ventilation facilities. all operating theatres, including facilities for bronchoscopy and endoscopy. 12/30 (40%) individuals from the hcw asymptomatic screening group reported symptoms > 7 days prior to testing, and the majority experiencing symptoms consistent with a high probability of covid-19 had appropriately self-isolated during that period. patients with covid-19 can remain sars-cov-2 pcr positive for a median of 20 days (iqr 17-24) after symptom onset (zhou et al., 2020) , and the limited data available suggest viable virus is not shed beyond eight days (wö lfel et al., 2020) . a pragmatic approach was taken to allowing individuals to remain at work, where the hcw had experienced high probability symptoms starting >7 days and 1 month prior to their test and had been well for the preceding 48 hr. this approach was based on the following: low seasonal incidence of alternative viral causes of high covid-19 probability symptoms in the uk (public health england, 2018), the high potential for sars-cov-2 exposure during the pandemic and the potential for prolonged, non-infectious shedding of viral rna (zhou et al., 2020; wö lfel et al., 2020) . for other individuals, we applied standard national guidelines requiring isolation for seven days from the point of testing (uk government, 2020b). however, for hcw developing symptoms after a positive swab, isolation was extended for seven days from symptom onset. our data clearly demonstrate that focusing solely on the testing of individuals fitting a strict clinical case definition for covid-19 will inevitably miss asymptomatic and pauci-symptomatic disease. this is of particular importance in the presence of falling numbers of community covid-19 cases, as hospitals will become potential epicentres of local outbreaks. therefore, we suggest that in the setting of limited testing capacity, a high priority should be given to a reactive asymptomatic screening programme that responds in real-time to hcw sickness trends, or (to add precision) incidence of positive tests by area. the value of this approach is illustrated by our detection of a cluster of cases in ward f, where the potential for uncontrolled staff-to-staff or staff-to-patient transmission could have led to substantial morbidity and mortality in a particularly vulnerable patient group. as sars-cov-2 testing capacity increases, rolling programmes of serial screening for asymptomatic staff in all box 1. clinical vignettes. self-isolation instructions were as described in table 2 . case 1: completely asymptomatic. hcw1 had recently worked on four wards (two 'green', two 'amber'). upon testing positive, she reported no symptoms over the preceding three weeks, and was requested to go home and self-isolate immediately. hcw1 lived with her partner who had no suggestive symptoms. upon follow-up telephone consultation 14 days after the test, hcw1 had not developed any significant symptoms, suggesting true asymptomatic infection. case 2: pre-symptomatic. hcw2 was swabbed whilst asymptomatic, testing positive. when telephoned with the result, she reported a cough, fever and headache starting within the last 24 hr and was advised to self-isolate from the time of onset of symptoms ( table 2) . her partner, also a hcw, was symptomatic and had been confirmed as sars-cov-2 positive 2 days previously, suggesting likely transmission of infection to hcw2. case 3: low clinical probability of covid hcw3 developed mild self-limiting pharyngitis three days prior to screening and continued to work in the absence of cough or fever. she had been working in' green' areas of the hospital, due to a background history of asthma. self-isolation commenced from the time of the positive test. hcw3's only contact outside the hospital, her housemate, was well. on follow-up telephone consultation, hcw3's mild symptoms had fully resolved, with no development of fever or persistent cough, suggesting pauci-symptomatic infection. case 4: medium clinical probability of covid hcw4 experienced anosmia, nausea and headache three days prior to screening, and continued to work in the absence of cough or fever. self-isolation commenced from the time of the positive test. one son had experienced a mild cough~3 weeks prior to hcw4's test, however her partner and other son were completely asymptomatic. upon follow-up telephone consultation 10 days after the test, hcw4's mild symptoms had not progressed, but had not yet resolved. case 5: high clinical probability of covid. hcw5 had previously self-isolated, and did not repeat this in the presence of new high-probability symptoms six days before screening. self-isolation commenced from the date of the new symptoms with the caveat that they should be completely well for 48 hr prior to return to work. all household contacts were well. however, another close colleague working on the same ward had also tested positive, suggesting potential transmission between hcws on that ward. areas of the hospital is recommended, with the frequency of screening being dictated by anticipated probability of infection. the utility of this approach in care-homes and other essential institutions should also be explored, as should serial screening of long-term inpatients. the early success of our programme relied upon substantial collaborative efforts between a diverse range of local stakeholders. similar collaborations will likely play a key role in the rapid, de novo development of comprehensive screening programmes elsewhere. the full benefits of enhanced hcw screening are critically dependent upon rapid availability of results. a key success of our programme has been bespoke optimisation of sampling and laboratory workflows enabling same-day resulting, whilst minimising disruption to hospital processes by avoiding travel to off-site testing facilities. rapid turnaround for testing and sequencing is vital in enabling timely response to localised infection clusters, as is the maintenance of reserve capacity to allow urgent, reactive investigations. there appeared to be a significantly higher incidence of hcw infections in 'red' compared to 'green' wards. many explanations for this observation exist, and this study cannot differentiate between them. possible explanations include transmission between patients and hcw, hcw-to-hcw transmission, variability of staff exposure outside the workplace and non-random selection of wards. it is also possible that, even over the three weeks of the study, 'red' wards were sampled earlier during the evolution of the epidemic when transmission was greater. further research into these findings is clearly needed on a larger scale. furthermore, given the clear potential for pre-symptomatic and asymptomatic transmission amongst hcws, and data suggesting that infectivity may peak prior to symptom onset (he et al., 2020) , there is a strong argument for basic ppe provision in all clinical areas. the identification of transmission within the hospital through routine data is problematic. hospitals are not closed systems and are subject to numerous external sources of infection. coronaviruses generally have very low mutation rates (~10 à6 per site per cycle) (sanjuán et al., 2010) , with the first reported sequence of the current pandemic only published on 12 th january 2020 (genbank, 2020). in addition, given sars cov-2 was only introduced into the human population in late 2019, there is at present a lack of diversity in circulating strains. however, as the pandemic unfolds and detailed epidemiological and genome sequence data from patient and hcw clusters are generated, realtime study of transmission dynamics will become an increasingly important means of informing disease control responses and rapidly confirming (or refuting) hospital acquired infection. importantly, implementation of such a programme would require active screening and rapid sequencing of positive cases in both the hcw and patient populations. prospective epidemiological data will also inform whether hospital staff are more likely to be infected in the community or at work, and may identify risk factors for the acquisition of infection, such as congregation in communal staff areas or inadequate access to ppe. our study is limited by the relatively short time-frame, a small number of positive tests and a lack of behavioural data. in particular, the absence of detailed workplace and community epidemiological data makes it difficult to draw firm conclusions with regards to hospital transmission dynamics. the low rate of observed positive tests may be partly explained by low rates of infection in the east of england in comparison with other areas of the uk (cumulative incidence 0.17%, thus far) (public health england, 2020). the long-term benefits of hcw screening on healthcare systems will be informed by sustained longitudinal sampling of staff in multiple locations. more comprehensive data will parametrise workforce depletion and covid-19 transmission models. the incorporation of additional information including staffing levels, absenteeism, and changes in proportions of staff self-isolating before and after the introduction of widespread testing will better inform the impact of screening at a national and international level. such models will be critical for optimising the impact on occupationally-acquired covid-19, and reducing the likelihood that hospitals become hubs for sustained covid-19 transmission. in the absence of an efficacious vaccine, additional waves of covid-19 are likely as social distancing rules are relaxed. understanding how to limit hospital transmission will be vital in determining (table 4) . hcws working across >1 ward were counted for each area. the left-hand y-axis shows the percentage of positive results from a given ward compared to the total positive results from the hcw asymptomatic screening group (blue bars). the right-hand y-axis shows the total number of sars-cov-2 tests (stars) and the number positive (pink circles). additional asymptomatic screening tests were subsequently performed in an intensified manner on ward f and ward q after identification of clusters of positive cases on these wards (figure 4) . asymptomatic screening tests were also performed for a number of individuals from other clinical areas on an opportunistic basis; none of these individuals tested positive. results of these additional tests are included in summary totals in table 1 , but not in this figure. infection control policy, and retain its relevance when reliable serological testing becomes widely available. our data suggest that the roll-out of screening programmes to include asymptomatic as well as symptomatic patient-facing staff should be a national and international priority. our approach may also be of benefit in reducing transmission in other institutions, for example carehomes. taken together, these measures will increase patient confidence and willingness to access healthcare services, benefiting both those with covid-19 and non-covid-19 disease. two parallel streams of entry into the testing programme were established and managed jointly by the occupational health and infectious diseases departments. the first (hcw symptomatic, and hcw symptomatic household contact screening groups) allowed any patient-facing or non-patientfacing hospital employee (hcw) to refer themselves or a household contact, including children, should they develop symptoms suggestive of covid-19. the second (hcw asymptomatic screening group) was a rolling programme of testing for all patient-facing and non-patient-facing staff working in defined clinical areas thought to be at risk of sars-cov-2 transmission. daily workforce sickness reports and trends in the results of hcw testing were monitored to enable areas of concern to be highlighted and targeted for screening and cluster analysis, in a reactive approach. high throughput clinical areas where staff might be exposed to large numbers of suspected covid-19 patients were also prioritised for staff screening. these included the emergency department, the covid-19 assessment unit, and a number of 'red' inpatient wards. staff caring for the highest priory 'shielding' patients (haematology/oncology, transplant medicine) were also screened, as were a representative sample of staff from 'amber' and 'green' areas. the personal protective equipment (ppe) worn by staff in these areas is summarised in table 5 . inclusion into the programme was voluntary, and offered to all individuals working in a given ward during the time of sampling. regardless of the table 6 continued on next page route of entry into the programme, the process for testing and follow-up was identical. wards were closed to external visitors. we devised a scoring system to determine the clinical probability of covid-19 based on symptoms from existing literature giacomelli et al., 2020; table 1 ). self-referring hcw and staff captured by daily workforce sickness reports were triaged by designated occupational health nurses using these criteria ( table 2) . self-isolating staff in the medium and low probability categories were prioritised for testing, since a change in the clinical management was most likely to derive from results. self-isolation and household quarantine advice was determined by estimating the pre-test probability of covid-19 (high, medium or low) in those with symptoms, based on the presence or absence of typical features (tables 1-2) . symptom history was obtained for all symptomatic hcws at the time of self-referral, and again for all positive cases via telephone interview when results became available. all individuals who had no symptoms at the time of testing were followed up by telephone within 14 days of their result. pauci-symptomatic individuals were defined as those with low-probability clinical covid-19 criteria ( table 2) . testing was primarily undertaken at temporary on-site facilities. two 'pods' (self-contained portable cabins with office, kitchen facilities, generator and toilet) were erected in close proximity both to the laboratory and main hospital. outside space was designed to enable car and pedestrian access, and ensure !2 m social distancing at all times. individuals attending on foot were given pre-prepared self-swabbing kits containing a swab, electronically labelled specimen tube, gloves and swabbing instructions contained in a zip-locked collection bag. pods were staffed by a team of re-deployed research nurses, who facilitated self-swabbing by providing instruction as required. scenario 1 ppe ( table 5 ) was worn by pod nurses at all times. individuals in cars were handed self-swabbing kits through the window, with samples dropped in collection bags into collection bins outside. any children (household contacts) were brought to the pods in cars and swabbed in situ by a parent or guardian. in addition to pod-based testing, an outreach hcw asymptomatic screening service was developed to enable self-swabbing kits to be delivered to hcws in their area of work, minimising disruption to the working routine of hospital staff, and maximising pod availability for symptomatic staff. lists of all staff working in target areas over a 24 hr period were assembled, and kits pre-prepared accordingly. self-swabbing kits were delivered to target areas by research nurses, who trained senior nurses in the area to instruct other colleagues on safe self-swabbing technique. kits were left in target areas for 24 hr to capture a full cycle of shift patterns, and all kits and delivery equipment were thoroughly decontaminated with 70% ethanol prior to collection. twice daily, specimens were delivered to the laboratory for processing. the swabbing, extraction and amplification methods for this study follow a recently validated procedure (sridhar et al., 2020) . individuals performed a self-swab at the back of the throat followed by the nasal cavity as previously described (our world in data, 2020). the single dry sterile swab was immediately placed into transport medium/lysis buffer containing 4m guanidine thiocyanate to table 7 . distribution of positive sars-cov-2 tests amongst symptomatic individuals with a positive test result, categorised according to test group and covid-19 symptom-based probability criteria (as defined in table 2 ). inactivate virus, and carrier rna. this facilitated bsl2-based manual extraction of viral rna in the presence of ms2 bacteriophage amplification control. use of these reagents and components avoided the need for nationally employed testing kits. real-time rt-pcr amplification was performed as previously described and results validated by confirmation of fam amplification of the appropriate controls with threshold cycle (ct) 36. lower ct values correspond to earlier detection of the viral rna in the rt-pcr process, corresponding with a higher copy number of the viral genome. in 2/1,270 cases, rt-pcr failed to amplify the internal control and results were discarded, with hcw offered a re-test. sequencing of positive samples was attempted on samples with a ct 30 using a multiplex pcr based approach (quick et al., 2017) using the modified artic v2 protocol (quick, 2020) and v3 primer set (artic network, 2020). genomes were assembled using reference based assembly and the bioinformatic pipeline as described (quick et al., 2017) using a 20x minimum coverage as a cut-off for any region of the genome and a 50.1% cut-off for calling of single nucleotide polymorphisms (snps). samples were sequenced as part of the covid-19 genomics uk consortium, cog-uk), a partnership of nhs organisations, academic institutions, uk public health agencies and the wellcome sanger institute. as soon as they were available, positive results were telephoned to patients by infectious diseases physicians, who took further details of symptomatology including timing of onset, and gave clinical advice ( table 2) . negative results were reported by occupational health nurses via telephone, or emailed through a secure internal email system. advice on returning to work was given as described in table 2 . individuals advised to self-isolate were instructed to do so in their usual place of residence. particularly vulnerable staff or those who had more severe illness but did not require hospitalisation were offered follow-up telephone consultations. individuals without symptoms at the time of testing were similarly followed up, to monitor for de novo symptoms. verbal consent was gained for all results to be reported to the hospital's infection control and health and safety teams, and to public health england, who received all positive and negative results as part of a daily reporting stream. swab result data were extracted directly from the hospital-laboratory interface software, epic (verona, wisconsin, usa). details of symptoms recorded at the time of telephone consultation were extracted manually from review of epic clinical records. data were collated using microsoft excel, and figures produced with graphpad prism (graphpad software, la jolla, california, usa). fisher's exact test was used for comparison of positive rates between groups defined in the main text. mann-whitney testing was used to compare ct values between different categories of tested individuals. hcw samples that gave sars cov-2 genomes were assigned global lineages defined by rambaut et al., 2020 using the pangolin utility (o'toole and mccrone, 2020). as a study of healthcare-associated infections, this investigation is exempt from requiring ethical approval under section 251 of the nhs act 2006 (see also the nhs health research authority algorithm, available at http://www.hra-decisiontools.org.uk/research/, which concludes that no formal ethical approval is required). written consent was obtained from each hcw described in the anonymised case vignettes. the citiid-nihr covid-19 bioresource collaboration ravi gupta harmeet gill; iain kean; mailis maes; nicola reynolds; michelle wantoch; sarah caddy anita furlong nathalie kingston; sofia papadia anne meadows naidine escoffery; heather jones; carla ribeiro nick brown; surendra parmar ; hongyi zhang; ailsa bowring; geraldine martell; natalie quinnell stefan grä f aloka de sa; maddie epping; andrew hinch conceptualization, data curation, formal analysis, investigation, methodology, project administration, writing -review and editing conceptualization, data curation, formal analysis, validation, methodology, project administration, writing -review and editing data curation, formal analysis, writing -original draft, project administration, writingreview and editing writing -original draft, project administration, writingreview and editing data curation, investigation, methodology, writing -original draft, project administration, writing -review and editing data curation, validation data curation, formal analysis, investigation data curation, writing -original draft conceptualization, writing -original draft, project administration, writing -review and editing data curation, supervision, writing -review and editing; the citiid-nihr covid-19 bioresource collaboration, conceptualization, data curation, formal analysis, funding acquisition, investigation, writing -original draft data curation, software; ashley shaw, supervision, project administration project administration, writing -review and editing data curation, formal analysis, supervision, project administration, writing -review and editing conceptualization, data curation, formal analysis, methodology, writing -original draft, project administration, writing -review and editing writing -original draft, project administration, writing -review and editing author orcids lucy rivett ethics human subjects: as a study of healthcare-associated infections, this investigation is exempt from requiring ethical approval under section 251 of the nhs act 2006 (see also the nhs health research authority algorithm presymptomatic sars-cov-2 infections and transmission in a skilled nursing facility artic network. 2020. artic-ncov2019 / primer_schemes covid-19: the case for health-care worker screening to prevent hospital transmission characteristics of health care personnel with covid-19 -united states exclusive: deaths of nhs staff from covid-19 analysed covid-19: identifying and isolating asymptomatic people helped eliminate virus in italian village asymptomatic transmission, the achilles' heel of current strategies to control covid-19 wuhan seafood market pneumonia virus isolate wuhan-hu-1 complete genome self-reported olfactory and taste disorders in sars-cov-2 patients: a crosssectional study temporal dynamics in viral shedding and transmissibility of covid-19 first experience of covid-19 screening of health-care workers in england report 16: role of testing in covid-19 control roll-out of sars-cov-2 testing for healthcare workers at a large nhs foundation trust in the united kingdom immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers epidemiology of covid-19 in a long-term care facility in king county software package for assigning sars-cov-2 genome sequences to global lineages to understand the global pandemic, we need global testing -the our world in data covid-19 testing dataset surveillance of influenza and other respiratory viruses in the uk to coronavirus (covid-19) in the uk 2020 multiplex pcr method for minion and illumina sequencing of zika and other virus genomes directly from clinical samples ncov-2019 sequencing protocol v2 a dynamic nomenclature proposal for sars-cov-2 to assist genomic epidemiology viral mutation rates a blueprint for the implementation of a validated approach for the detection of sars-cov2 in clinical samples in academic facilities stay at home advice covid-19: management of exposed healthcare workers and patients in hospital settings clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in report of the who-china joint mission on coronavirus disease who. 2020b. covid-19 strategy update virological assessment of hospitalized patients with covid-2019 clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study additional files . source data 1. asymptomatic sars-cov-2 screening programme source data.. transparent reporting form sequencing data have been deposited in gsaid under accession codes epi_isl_433989-epi_-isl_433992, epi_isl_434005, epi_isl_433489-epi_isl_433497. researchers will be prompted to register and log on to the website to access the datasets (https://www.epicov.org/epi3/ frontend#1f1442). key: cord-305146-iprzeigk authors: chughtai, abrar ahmad; khan, wasiq title: use of personal protective equipment to protect against respiratory infections in pakistan: a systematic review date: 2020-03-04 journal: j infect public health doi: 10.1016/j.jiph.2020.02.032 sha: doc_id: 305146 cord_uid: iprzeigk like other low-income countries, limited data are available on the use of personal protective equipment (ppe) in pakistan. we conducted a systematic review of studies on ppe use for respiratory infections in healthcare settings in pakistan. medline, embase and goggle scholar were searched for clinical, epidemiological and laboratory-based studies in english, and 13 studies were included; all were observational/cross-sectional studies. the studies examined ppe use in hospital (n = 7), dental (n = 4) or laboratory (n = 2) settings. policies and practices on ppe use were inconsistent. face masks and gloves were the most commonly used ppe to protect from respiratory and other infections. ppe was not available in many facilities and its use was limited to high-risk situations. compliance with ppe use was low among healthcare workers, and reuse of ppe was reported. clear policies on the use of ppe and available ppe are needed to avoid inappropriate practices that could result in the spread of infection. large, multimethod studies are recommended on ppe use to inform national infection-control guidelines. healthcare workers are at the frontline when treating infectious disease cases and at high risk of acquiring influenza and other respiratory infections [1] [2] [3] . several outbreaks of new infectious diseases have occurred in recent decades, such as the outbreak of severe acute respiratory syndrome coronavirus (sars-cov) in 2002-2003 [4] , influenza pandemic (h1n1) in 2009 [5] , middle east respiratory syndrome coronavirus (mers-cov) in 2012 [6] and ebola virus diseases in 2014-2016 [7] . many healthcare workers were infected and died during these outbreaks because of a lack of infection control [4, 8, 9, 10] various infection control strategies are used to protect healthcare workers from respiratory and other infections in healthcare settings [11, 12] . these strategies can be broadly classified as administrative control measures, environmental control measures and the use of personal protective equipment (ppe). administrative control measures include developing policies and procedures, implementing triage protocols and providing health education and trainings. environmental control measures includes ensuring proper ventilation, establishing airborne infection isolation and negative pressure rooms, developing systems for cleaning and waste disposal. [13, 14] . ppe is commonly used in healthcare settings as standard or transmission based precaution to protect healthcare workers from infections and to prevent further spread to patients around them [14, 15] . ppe is generally ranked lowest in the infection control hierarchy due to less effectiveness compared to other control measures and high expenditure in the long run. therefore, most infection control guidelines recommend using ppe together with other administrative and environmental control measures. however, ppe is important during the early stage of an outbreak or a pandemic when drugs, a vaccine and other control measures are not available, or access is limited. commonly used ppe to protect from respiratory infectionsare; face masks, respirators, gloves, and goggles or face shields [16] . face masks (or medical masks) and respirators are the most commonly used ppe to protect from influenza and other respiratory infection in healthcare settings. however, these two products are not the same. face masks are not designed for respiratory protection and are used to avoid respiratory droplet and spray of body fluids on the face. they are also used by sick patients to prevent spread of pathogens to others (referred to as "source control"), or by surgeons in the operating theatre to maintain a sterile operating field. face masks are not fit to the face and have [17] . respirators are designed for respiratory protection and are used to protect from respiratory aerosols [18] . a properly fitted respirator provides better protection again respiratory infections than a face mask. gloves are used to protect hands from blood and body fluids, including respiratory secretions. goggles and face shields are used to prevent transfer of respiratory pathogens into the eyes from contaminated hands and other sources. gowns, coveralls, surgical hoods and shoe covers can also be used where procedures on infectious patients generate aerosols or when a new respiratory virus has emerged [18] . there is an ongoing debate about the selection and use of various types of ppe in healthcare settings. this is mainly because of a lack of high quality studies on the use of ppe. most studies are observational and on the use of masks and/or respirators [18] . to date, only five randomized clinical trials have been conducted on use of ppe in hospital settings and all were on face masks/respirators [18] . moreover, most studies on ppe use were conducted in high/middle income countries and currently there are limited data from lowincome countries where the burden of infectious diseases is high. it is therefore important to examine the use of ppe in low resource countries to inform infection control policies. pakistan has a population of about 200 million. as a low-income country, its gross domestic product is low, as is its expenditure on health [19] . the country has one of highest rates of infant and maternal mortality in the south asia region. infectious diseases are still among the main causes of death, particularly in young children. health and surveillance systems are generally weak and limited data are available on infection prevention and control strategies. the aim of this study was to examine the use of ppe for respiratory infections in healthcare settings in pakistan. a systematic review was conducted using the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines. we searched for studies on the electronic databases medline and embase using selected key words. a combination of keywords were used including: 'face mask' or 'mask' or 'medical mask' or 'surgical mask' or 'cloth mask' or 'respirator' or 'gloves' or 'gowns' or 'coverall' or 'surgical cap/hood' or 'shoe/boot covers' or 'goggles' or 'face shield' or 'eye protection' and ' respiratory infection' or 'respiratory tract infection' or 'respiratory diseases', 'outbreaks' or 'infectious disease' or 'influenza' or 'pandemic influenza' or 'flu' or 'tuberculosis' or 'pneumonia' and 'pakistan' or 'punjab' or 'sindh' or 'balochistan' or 'khyber pakhtunkhwa'. we used an open date strategy up to december 2017. we anticipated that studies published in local journals might not be indexed on the medline or embase, therefore, an additional search was made on google scholar using the same keywords. we set a limit of 20 results per page on google scholar and first three pages were reviewed for each keyword search. after the initial search; we reviewed titles and abstracts and selected studies for full text review (fig. 1) . clinical, epidemiological and laboratory-based studies conducted in any part of pakistan and published in english were included in the review. the focus of this systematic review was on the use of ppe for prevention of respiratory infections. therefore, we only included those studies which examined the use of facemask and/or respirator in healthcare settings, with or without other ppe. we only included those studies where ppe was discussed for respiratory infections. studies where ppe was examined for general infection control were also included, given respiratory protective equipment (face masks and/or respirators) was mentioned. we excluded studies on the use of ppe only for bloodborne infections. conference abstracts and poster presentations were also excluded. a total of 137 studies were found in the initial search. after reviewing titles and abstracts, 46 studies were selected for full text review. finally, 13 articles were included in this review (table 1 ) [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] . we only found observational/cross-sectional studies on the use of ppe for infectious diseases in healthcare settings in pakistan. in all studies data were collected through questionnaires or interviews. no clinical trials or laboratory-based studies on the use of ppe in such settings were found. seven studies examined the use of ppe in hospital [20] [21] [22] [23] 25] and among those, two examined the ppe perceptions among medical students [24] or pharmacy students [32] . two studies were conducted in the laboratory settings [26, 27] while, four in dental settings [28] [29] [30] [31] two studies focused on the use of ppe for influenza [24, 32] , two were for tuberculosis [20, 25] and nine studies were on multiple respiratory diseases, including influenza [21, 22] or general infections [23, [26] [27] [28] [29] [30] [31] . only two studies examined the use of ppe alone [21, 22] , while other studies examined other infection control practices as well [20, [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] . guidelines and standard operating procedures on ppe do not exist in most of the hospitals [23] or laboratories [26, 27] in pakistan. two studies examined the guidelines and current practices on the use of face masks/respirators for influenza, tuberculosis and sars in pakistan [21, 22] . recommendations on the use of masks were reported to be inconsistent and different types of product were recommended and used in various healthcare settings [21, 22] . face masks were the most commonly used ppe to protect from respiratory infections in most hospitals in pakistan. medical masks were generally used to protect from influenza, tuberculosis and other respiratory infections, while the use of respirators was limited to high-risk situations [21, 22] . in a cross-sectional survey among final-year pharmacy students in seven universities of karachi, about 60% of 443 participants highlighted the need to cover the nose or mouth to protect from influenza and about 57% highlighted the use of face masks, gloves and other ppe [32] . laboratory coat and gloves were the most commonly used ppe in the laboratories in pakistan while face masks and eye covers were rarely used [26, 27] . a survey of dentists working in various settings (dental colleges, hospitals and private clinics) showed that face masks and gloves were also commonly used ppe [29] . the use of ppe was also reported to be low among health workers. according to a hospital-based survey, face masks are not provided to patients with tuberculosis and respirators are not provided to the healthcare workers [23] . another survey showed that 25% of participants used ppe for patients with suspected tuberculosis and 56% used ppe for patients with confirmed tuberculosis [25] . a study in a ward for patients with multidrug-resistant tuberculosis reported that 65% of the healthcare workers used n95 respirators and 58% were provided with a mask [20] . a study on 253 biosafety level (bsl) 2 laboratory workers showed that ppe was not used by about half of the staff (46.2%) [27] . a countrywide survey showed that almost one third (31.9%) of bsl-2 laboratory workers did not routinely use ppe [26] . both gloves and laboratory coats were used by only 26.7% of the personnel, while a laboratory coat or gloves alone were used by 30.4% and 8.1%, respectively. less than 1% of all the respondents across pakistan reported using eye covers [26] . in a survey of medical students during pandemic (h1n1) 2009, 75% said that they would use a face mask to protect from infection. students with less risk perception were more hesitant to use face masks [24] . the use of face masks was common in dental practice and according to various surveys, 68-100% of dentists wear masks during dental procedures [28] [29] [30] [31] . across all the studies in dental settings, more than 90% also used gloves. among the ppe, face masks were considered the most bothersome to use by wearers. reuse of ppe was also reported in many studies, mainly because of unavailability of ppe and lack of training. gowns are shared among the healthcare workers in hospital many times [23] . two surveys in dental clinics showed that more than half of the dentist reuse masks during routine work [28, 29] . the availability of ppe was generally low in all healthcare settings [21, 22, 28] and varied according to the type [23] ; gloves and masks were available while gowns and n95 respirators were not available in several wards [23] . a shortage of ppe was also reported during sars and pandemic (h1n1) 2009 [21, 22] . a lack of training was a common issue reported and most healthcare workers were not trained in the use of ppe. most of the studies (11/13) discussed other infection control practices as well, in addition to the use of ppe. other non-standard infection control practices included reuse of syringes, improper waste disposal, a lack of hand hygiene practices, non-isolation of infectious cases and low influenza vaccination among healthcare workers. we reviewed the use of ppe in various healthcare settings in pakistan. a lack of guidelines and standard operating procedures, inconsistent policies and practices, low compliance, and non-availability and reuse of ppe were the main issues highlighted in this study. evidence is lacking on the use of ppe in hospitals and other healthcare settings in pakistan and most studies are of low quality. clinical studies should be conducted to examine the effectiveness of ppe and improve the compliance. reuse of ppe may increase the risk of self-contamination to the wearer and this practice should be discontinued. there is a need to improve the availability of ppe and healthcare workers should be trained. ppe is generally considered lowest in the infection control hierarchy and is generally recommended in combination with other control measures. other infection control practices in such settings should also be examined. different types of ppe are used by healthcare workers in pakistan, which reflects a lack of standard policies and guidelines. the different policies and practices may be because of the different recommendations by the world health organization (who) and the united states (us) centers for disease control and prevention (cdc) [33, 34] . debate continues about the selection and use ppe for different infections, for example, face masks versus respirators, gowns versus coveralls, face shields versus goggles [7, 18, 34, 35] . selection of ppe mainly depends on mode of transmission, however, several individual and organizational factors also contribute the selection and use of ppe, such as risk perception, presence of adverse events, pre-existing medical illness, availability and cost [7] . respiratory infections are generally transmitted through contact, droplet and/or airborne routes. gloves should be used to protect from infections transmitted through contact (e.g. respiratory syncytial virus and adenovirus), face masks should be used for droplet infections (e.g. influenza and coronavirus) and a respirator should be used to protect form airborne infection (e.g. tuberculosis and measles). however, infection transmission is rarely by only one route and most infections are transmitted by more than one route [36] . for example, influenza and sars primarily transmit through droplet and contact routes, but airborne transmission has also been reported [37, 38] . similarly, ebola primarily transmits through direct contact with blood and body fluids [39] , but animal studies have shown that airborne transmission is also possible [7] . the risk of transmission further increases during aerosol-generating and other high-risk procedures [40, 41] . moreover, uncertainty exists about how pathogens transmit during outbreaks and pandemics [14, 34, 42, 43] . therefore, superior ppe should be used where the mode of transmission is uncertain, the case-fatality rate is high and pharmaceutical interventions are not available [7] . infection control guidelines in pakistan need to be updated urgently to reflect these recommendations. given that mers cov is circulating in the eastern mediterranean region (emr), policies and practices on the use of ppe in other countries of the region should also be examined. our study also reported low availability of ppe in hospital, dental and laboratory settings in pakistan. the availability of ppe is a challenge, not only in low-resource counties, but also in highincome countries, particularly during outbreaks and pandemics when the use of ppe greatly increases [46, 47] . this may result in non-standard practices such as reuse and extended use of ppe. shortages of ppe were even reported in many high-income countries during the 2009 influenza h1n1 pandemic and staff had to use various alternatives [46] [47] [48] . the availability of ppe is important to ensure proper use and compliance. low use of ppe among laboratory workers in pakistan may be due to non-availability and a lack of resources. for example, ppe use was relatively higher in laboratory workers in punjab, which is an affluent province, than other provinces [26] . moreover ppe use was reported more in the private sector in pakistan than the public sector which has fewer resources [27] . proper use of ppe depends on several factors such as availability, knowledge, training, risk perception and comfort [7, 44, 45] . this study showed the compliance with the use of ppe was generally low among healthcare workers and was mainly due to unavailability of ppe, discomfort and a lack of training. while the use ppe depends on many factors, a greater perception of risk was positively associated with compliance [24] . continuous use of face masks and respirators may have psychological and physiological effects on the wearer and result in more adverse events [49] [50] [51] . compliance with the use of face masks has been shown to be based on the nature of the disease, infectiousness of patients and the performance of high-risk procedures [52] . previous studies have tested the precede (predisposing, reinforcing and enabling) framework to examine healthcare workers' compliance with universal precautions [53] . the results showed that reinforcing factors, such as availability of ppe and less job hindrance, and enabling factors, such as safety climate and regular feedback, were significant predictors of compliance with ppe [53] . in addition, the health belief model [54] was also used to examine the compliance and use of face mask during the sars outbreak [55, 56] . perceived susceptibility (vulnerability to acquiring sars and close contact with case), perceived benefits (that face masks can prevent infection) and cues to action (someone asked them to use face masks) were significant predictors of protective behaviour and use of face masks [55] . our study showed that most healthcare workers were not trained on the use of ppe in pakistan. the risk of infection can be reduced with proper training and availability of policies and standard operating procedures [57] . however, regular monitoring is also required to make sure that healthcare workers are using ppe according to the protocols. a study in the us reported many deviations from the protocols even though all healthcare workers were trained [15] . this may result in self-contamination to the wearers and the spread of infection to others [58] . training programmes should be arranged for newly recruited staff and then annual refresher courses should be provided. our study had some limitations. the initial search was made on medline and embase but very few studies were retrieved because many papers are not indexed on these databases. therefore, we also searched google scholar but we only reviewed the first 3 pages after each search so some studies could have been missed. however, we checked the references lists of the relevant studies and could not find any other studies. our search was up to 2017 and studies in 2018 were not included. we only considered ppe in this study and did not examine other infection control practices. the use of ppe is generally recommended with other administrative and environmental control measures. the selection and use of ppe vary according to the type of healthcare worker and working environment. face masks and gloves were the most commonly used ppe to protect from respiratory and other infections. overall, compliance with the use of ppe was low, and non-availability and reuse of ppe were reported. most studies were observational and large-scale prospective studies are needed to collect more evidence about the use of ppe in healthcare settings in pakistan. no funding sources. aac tested the filtration of mask samples by 3 min in another study; 3m products were not used in this study. wk declares none. as this was a systematic review of published data, ethics approval was not required. aac devised the structure and topic areas for this review and made the initial search. wk and aac reviewed titles and abstracts and selected studies for full text review. aac prepared the first draft of manuscript and both authors contributed equally to the final manuscript. influenza and rhinovirus infections among health-care workers nosocomial transmission of measles among healthcare workers tuberculosis among health care workers emergencies preparedness, response. summary of probable sars cases with onset of illness from 1 world health organization. emergencies preparedness, response. pandemic (h1n1) 2009 -update 112 comparative epidemiology of middle east respiratory syndrome coronavirus (mers-cov) in saudi arabia and south korea respiratory protection for healthcare workers treating ebola virus disease (evd): are face masks sufficient to meet occupational health and safety obligations? epidemiology of h1n1 (2009) influenza among healthcare workers in a tertiary care center in saudi arabia: a 6-month surveillance study h1n1 influenza infection in korean healthcare personnel uncertainty, risk analysis and change for ebola personal protective equipment guidelines interim guidance on infection control measuresfor 2009 h1n1 influenza in healthcare settings, including protection of healthcare personnel infection prevention and control guidance for care of patients in health-care settings, with focus on ebola. interim guidance guideline for isolation precautions: preventing transmission of infectious agents in health care settings infection prevention and control of epidemic-and pandemic-prone acute respiratory infections in health care. who guidelines. geneva: world health organization assessment of healthcare worker protocol deviations and self-contamination during personal protective equipment donning and doffing guidance on personal protective equipment (ppe) to be used by healthcare workers during management of patients with confirmed ebola or persons under investigation (puis) for ebola who are clinically unstable or have bleeding, vomiting, or diarrhea in u.s. hospitals, including procedures for donning and doffing ppe protecting healthcare staff from severe acute respiratory syndrome: filtration capacity of multiple surgical masks face masks for the prevention of infection in healthcare and community settings infection control in hospitals managing drug-resistant tuberculosis in pakistan: how are we doing? infection control survey in the hospitals to examine the role of masks and respirators for the prevention of respiratory infections in hcws practices around the use of masks and respirators among hospital health care workers in 3 diverse populations infection control at a government hospital in pakistan medical students' knowledge, perceptions, and behavioral intentions towards the h1n1 influenza, swine flu, in pakistan: a brief report assessment of the protective measures taken in preventing nosocomial transmission of pulmonary tuberculosis among health-care workers biosafety perspective of clinical laboratory workers: a profile of pakistan practices and awareness regarding biosafety measures among laboratory technicians working in clinical laboratories in karachi cross infection control infection control practices across karachi: do dentists follow the recommendations? infection control practices among dental practitioners of lahore, pakistan knowledge attitude and practice of infection control measures among dental practitioners in public setup of karachi, pakistan: cross-sectional survey perspectives about pandemic influenza and its prophylactic measures among final year pharmacy students in karachi examining the policies and guidelines around the use of masks and respirators by healthcare workers in china, pakistan and vietnam availability, consistency and evidencebase of policies and guidelines on the use of mask and respirator to protect hospital health care workers: a global analysis a highly precautionary doffing sequence for health care workers after caring for wet ebola patients to further reduce occupational acquisition of ebola aerosol transmission of infectious disease aerosol transmission of influenza a virus: a review of new studies environmental transmission of sars at amoy gardens persistence of ebola virus in various body fluids during convalescence: evidence and implications for disease transmission and control health workers need optimal respiratory protection for ebola transmission of ebola viruses: what we know and what we do not know preventing transmission of pandemic influenza and other viral respiratory diseases: personal protective equipment for healthcare personnel interim recommendations for facemask and respirator use to reduce 2009 influenza a (h1n1) virus transmission the use of face masks to prevent respiratory infection: a literature review in the context of the health belief model compliance with the use of medical and cloth masks among healthcare workers in vietnam infection preventionists' experience during the first months of the 2009 novel h1n1 influenza a pandemic initial response of health care institutions to emergence of h1n1 influenza: experiences, obstacles, and perceived future needs insufficient preparedness of primary care practices for pandemic influenza and the effect of a preparedness plan in japan: a prefecture-wide cross-sectional study a cluster randomized clinical trial comparing fit-tested and non-fit-tested n95 respirators to medical masks to prevent respiratory virus infection in health care workers physiologic and other effects and compliance with long-term respirator use among medical intensive care unit nurses discomfort and exertion associated with prolonged wear of respiratory protection in a health care setting the cookie monster muffler: perceptions and behaviours of hospital healthcare workers around the use of masks and respirators in the hospital setting behavioral-diagnostic analysis of compliance with universal precautions among nurses social learning theory and the health belief model factors influencing the wearing of face masks to prevent the severe acute respiratory syndrome among adult chinese in hong kong practice of habitual and volitional health behaviors to prevent severe acute respiratory syndrome among chinese adolescents in hong kong personal protective equipment for the ebola virus disease: a comparison of 2 training programs risk of self-contamination during doffing of personal protective equipment key: cord-305419-l68ewxar authors: smart, hiske; opinion, francis byron; darwich, issam; elnawasany, manal aly; kodange, chaitanya title: preventing facial pressure injury for health care providers adhering to covid-19 personal protective equipment requirements date: 2020-06-11 journal: adv skin wound care doi: 10.1097/01.asw.0000669920.94084.c1 sha: doc_id: 305419 cord_uid: l68ewxar objective: to determine if a repurposed silicone-based dressing used underneath a n95 mask is a safe and beneficial option for facial skin injury prevention without compromising the mask’s seal. methods: since february 21, 2020, staff in high risk areas such as the ed and icu of king hamad university hospital have worn n95 masks when doing aerosol-generating procedures to protect against the novel coronavirus 2019. at that time, without education enablers or resources that could be directly translated into practice, the hospital’s pressure injury prevention committee explored and created a stepwise process to protect the skin under these masks. this procedure was developed over time and tested to make sure that it did not interfere with the effectiveness of the n95 mask seal. results: skin protection was achieved by repurposing a readily available silicone border dressing cut into strips. this was tested on 10 volunteer staff members of various skin types and both sexes who became part of this evidence generation project. oxygen saturation values taken before and after the 4-hour wear test confirmed that well-fitted facial protection did not compromise the mask seal, but rather improved it. an added advantage was increased comfort with less friction as self-reported by the staff. an educational enabler to prevent mdrpi from n95 mask wear was an important additional resource for the staff. conclusions: this creative and novel stepwise process of developing a safe skin protection method by which staff could apply a repurposed silicone border dressing beneath an n95 mask was largely effective and aided by the creation of the enabler. the global impact of the novel coronavirus 2019 (covid19) has had severe implications for frontline health care providers (hcps). the safety of hcps requires consistent and adequate use of personal protective equipment (ppe). in particular, the use of facial protective equipment against aerosolized transfer of covid-19 droplets is a key recommendation worldwide. 1 it requires the use of a protective filtering respirator such as a n95 mask, eye protection such as glasses, fitted facial shields, and/or specially designed protective suits. facilities have noted an attendant increase in medical device-related pressure injuries (mdrpi) among frontline hcp wearing facial ppe protection that requires risk mitigation. guidelines are being rapidly developed all over the world to ensure that the best solution for each setting can be implemented. the staff of the king hamad university hospital (khuh) includes many ethnicities and various skin types. as in many other facilities, these hcps have been wearing ppe with n95 masks in high risk areas since february 2020 as protection against covid-19 (first confirmed case, february 21, 2020). 2 early on, the pressure injury prevention and nursing quality committees of the khuh agreed that ppe-related pressure and skin injury protection of all staff fell under their purview. bundled pressure injury prevention interventions 3 such as the intact skin bundle are supported by the best evidence for patient pressure injury prevention; the use of these bundles is well documented in high-risk settings. accordingly, the nursing quality committee advised the pressure injury prevention committee to follow this approach in developing and testing a skin care bundle specifically applicable to the work environment of khuh for those hcps providing acute covid-19 care. a mnemonic-based approach 4 was used to enhance knowledge retention, with a one-word reminder of the importance of self-care: help. this mnemonic was designed to help hcps remember the new rules and procedures that had been implemented in a very short time. this led to the creation of the help enabler, which emphasizes 10 evidence-based points to improve hcp prevention of facial mask injuries ( figure 1 ). the key message is to help yourself first, before helping others. elements such as sufficient hydration 5 and nutrition 6 to support a 4-hour shift, emptying bladders before donning ppe, 7 keeping an eye on the amount of time spent in ppe, 1, 3, 8 good skin hygiene, 9 and the importance of mask leak tests 1 form the basis of this care bundle. additional recommendations include using an acrylate lotion 10 or a protective dressing 11 for facial protection under ppe. because adhesives increase the risk of skin stripping and subsequent skin tear injuries, 12 the use of an atraumatic silicone dressing on the face also was proposed. the pressure injury prevention committee repurposed a readily available dressing for facial pressure injury prevention in the absence of existing evidence. however, the team had to establish that this use would not compromise the n95 seal efficacy and facial skin would remain intact under the dressing. further, because this study had to address skin safety for all staff, skin type variation had to be taken into account; for this, researchers used the fitzpatrick skin type classification. the fitzpatrick skin type classification 13 was developed in the 1980s to measure the impact of sunburn injury on different skin types, and is deemed the criterion standard for skin type classification. the classification comprises six skin types ranging from light skin (type 1, which burns easily and never tans, and type 2, that usually burns and figure 1 . help enabler tans slightly) to olive/medium brown skin (type 3, that initially burns and tans well, and type 4, that usually tans) and finally to dark brown and black skin (types 5 and 6). 13 in this study no hcp with type 1 (extremely light caucasian skin) could be included because there are no nursing staff with that skin type at khuh. this prospective observational cohort study was divided into five steps to establish the appropriateness, efficacy, and safety of each phase. it involved wear-time tests culminating in a final 4-hour crossover experiment. developing the protocol and assembling key departments (nursing, infection control, quality assurance representatives, covid-19 hospital committee) to discuss and approve the proposed skin protection protocol took time; this practice innovation began in march 2020 and was tested in the first 2 weeks of april 2020. institutional review board approval was received because the study involved human participants (reference #20-334). because n95 mask wear is mandatory for covid-19 frontline care provider safety, any facial injuries sustained as a result were not deemed an ethical objection for this experiment. essentially, facial injury was the real-life risk this study tried to mitigate. participants signed an informed consent form to take part in the study and for all photos to be used in subsequent publication with no parts of faces obscured. phase 1. ascertain how to repurpose an atraumatic silicone border dressing (mepilex border sacrum, mölnlycke, norcross, georgia) to cover bony facial prominences without compromising the n95 particulate respirator and surgical mask fit (3m type 1860, minneapolis, minnesota) using only one small dressing per day for the duration of a shift (this allows for the most stringent interpretation of infection control practice). phase 2. fit eight participating staff members with various skin types who volunteered for this project with a protective dressing layer. have infection control staff conduct a n95 fit test according to international best practice. phase 3. continue the use of facial protection for 1 hour after the fit test and examine the condition of the facial skin thereafter. phase 4. determine the efficacy and stability of the dressing underneath a fitted n95 mask after 3 hours and examine facial quality thereafter. (only one participant was included in this phase.) phase 5. compare the difference in facial skin quality and metabolic oxygen saturation values (spo 2 ) as determined by a fingertip applied pulse oximeter with and without facial protection applied in a 4-hour shift period on a normal working day among five participants. this test took place over 2 days in a work environment not actively caring for patients who were covid-19 positive. facial skin evaluation and spo 2 values before and after removal of the mask were repeated. during the study development period (march 2020), relevant guidelines on this topic were scarce. a process of creative problem solving was therefore followed to determine how facial skin injuries in health care providers in the authors' setting could be addressed in the most efficient and cost-effective manner. because staff would have to remove the protective dressing at the end of each shift, it was clear that any product with aggressive adhesion would soon strip the outer layer of the skin 12 and that the additional pressure exerted by the n95 mask on the barrier would enhance adhesion. pain on removal and skin injury over time would be likely. 12 therefore, an atraumatic dressing was required. at the khuh, an atraumatic silicone sacrum dressing is routinely used for pressure injury prevention of high-risk hospitalized patients 11 as part of the standard pressure injury prevention skin care bundle. 3 it is the only type of atraumatic silicone dressing available in the authors' setting; each dressing is similar in cost to a take-away coffee. the aim was to repurpose a single 10 x 10 dressing for frontline hcps during each shift to provide facial protection and limit cost for the institution. earlier testing revealed that the dressing edge could catch on to the n95 mask sponge and create an interlocking mechanism to position two offloading areas next to each other rather than on top of each other. this enhances the distribution of pressure over a larger area and prevents additional pressure on any given area by stacking multiple layers. the rationale was that if pressure was equally distributed over the nose with the interlocking fit of the n95 mask sponge on the dressing edge, the cheekbones were only in need of friction control (maintaining mask integrity without adding bulk). further, this placement was successful even with some small facial hair stubble present on the cheeks and chins of male staff members; the dressing sat snugly despite being applied over chin hair, and removal was painless. there was a square piece left for the forehead that could be used as pressure relief underneath protective eye shields or goggles resting on the forehead. two additional small pieces remained to offset the pressure from the elastic band of the n95 mask touching the sides of the face close to the ears ( figure 3 ). to ensure each person uses the correct n95 mask size, a standardized initial fit test in accordance with international guidelines is required. the khuh infection control team conducted the leak tests in late january and early february using the hood method. 14, 15 the method involves placing a see-through polymer hood with an applicator window in front of the face and a tight-fitting seal around the hcp's neck. to determine a participant's individual sensitivity, a distinct smell (denatonium benzoate) is serially sprayed into the hood to determine at what point (after how many sprays) a smell is observed. next, the hood is removed, and the participant is instructed to rinse his/her mouth and wait 15 minutes. then a n95 mask is donned and the procedure repeated. the mask fit is deemed effective when no smell is observed if half of the sprays required during the sensitivity test are applied. the infection control team documents each time a person passes the fit test (smell only observed after more than the threshold number of sprays). a person who fails the fit test is fitted with a different sized mask and the spray test is repeated until passing; however, it only needs to be completed once per person. 14 leak testing is the responsibility of each staff member and involves positioning the n95 mask on the head and fitting it around the nose by applying two fingers on either side of the nose and pressing the mask tight while breathing in. next, hands are placed over the middle of the mask (without adjusting its position) and the staff member exhales sharply. if air escapes from the sides of the mask, the mask should be adjusted and all of the steps repeated until exhaled air exits only through the middle of the mask and no leaks occur on inhalation or exhalation. this process is repeated twice every single time an n95 mask is applied. 16 where limited reuse of n95 masks is practiced, it is done in accordance with the khuh infection control protocols governing mask functionality/ cross-contamination prevention and not to exceed five uses per person. 17 eight volunteer staff members (four males and four females) with various fitzpatrick skin types were included in this phase. two work in the ed, two in icu, one in a male surgical ward, and three in the wound care unit. all participants had previously passed the official n95 fit test. all staff previously wore n95 masks without skin protection. participants applied the repurposed, separated atraumatic dressing segments on their own faces after an initial demonstration. the application took less than 5 minutes, inclusive of the time required to cut up the dressing. they then donned n95 masks and conducted manual leak tests. 16 all eight participants achieved the same mask positioning with the applied dressing beneath their mask as without. infection control then conducted another fit test. staff all reported only a slight smell after 4 sprays, and this was consistent up to 6 sprays. therefore, 95% blockage was achieved with this mask configuration. this outcome was certified by infection control as conforming to international standards-that is, all eight participants passed the fit test while using the atraumatic dressing. staff were instructed to maintain that exact ppe configuration for the next hour without repositioning or removal. once the hour was over, they had to remove the mask and the facial dressing themselves, take a photograph of their face, and present it to the research team. all photos were time stamped to ensure masks were not removed before the period was completed. staff also had to report on this experience compared with their previous experience/original fit tests. there were no negative comments from the staff, despite application over hair in some men. in fact, some staff noticed that the nose dressing prevented mask movement they had previously experienced when looking up or down. this interlock also helped to minimize the perpendicular pressure of the n95 mask exerted on the nasal crest; all participants commented on improved nose comfort, as well as the absence of facial irritation caused by the direct contact of mask fibers to the cheeks. comfort underneath the chin was also noted; itching and moisture vapor build-up appeared to be absent in this configuration. when asked if the dressing was worth the application time, the answer was a unanimous yes. the immediate facial condition of all staff with protective dressings can be seen in figure 4 . those with fitzpatrick skin types 2 and 3 (lighter skin tone, n = 2) showed a bit of visible erythema over the bony cheek area. no marked erythema or pressure was visible on any of the other participants (n = 6). no erythema or pressure marks were visible on any staff member on the sides of their faces where the top applied elastic band of the n95 mask is placed. one staff member with fitzpatrick type 2 skin was willing to test the mask without facial protection for 2 hours on a different day, before the leak tests were conducted. researchers believed that this skin type would show visible injury most quickly. the next day, this participant wore the mask for 3 hours with facial protection applied. the results of this trial are depicted in figure 5 . mask wear without skin protection resulted in friction and chafing with erythema visible over and along the bony prominences of the cheekbones. a blanchable area was visible on the bridge of the nose after the 2-hour test. this finding is consistent with extant literature reporting that pressure injury can occur in as little as 2 hours. 8, 11 after testing with facial protection, slight erythema was again present over the bony prominences of the check bones with only a little redness on the left lateral side of the nose. however, these changes were much less noticeable than before, without additional friction or chafing areas present, signifying good mask fit with minimal movement during the 3-hour period. all erythema visibly diminished after 1 hour. this experimental test took place over 2 consecutive days with five volunteer staff members (one male, four female) with skin types from fair to dark brown on the fitzpatrick scale. researchers theorized that skin damage or injury would be easier to observe in females, who have thinner skin than males. 18 if female skin was protected by the selected method, it could reasonably be assumed that males would be protected as well. female nurses also outnumber male nurses in this setting and are therefore more likely to participate in direct care and require protection. on the first day of this phase, the n95 mask was worn for 4 hours (no eating, drinking, or bathroom breaks allowed) with protection prepared and applied by each participant. comfort was self-assessed by participants. at the end of the 4 hours, three participants felt that they could have continued for an hour or two more. slight sweating was present, with indentations visible on all of the participants' faces. only one (fitzpatrick type 2) presented with slight erythema; the least damage was visible on the darkest skin. pulse oximetry saturation levels of each participant were also taken before and after the test. all participants lost between 1% and 3% spo 2 in this test, with a mean loss of 2% metabolic spo 2 (table 1 ). this is in line with extant studies on n95 mask use that confirms overall oxygen intake is diminished during wear, even with a perfectly fitting mask. 19, 20 on the next day, the n95 mask was worn without any protection ( table 2) . each participant positioned their own mask and it was again worn for 4 hours without any eating, drinking, or bathroom breaks. all four female participants battled with discomfort; pruritus on the mask edges was noted after the first hour. all participants reported that they were relieved when the mask could be removed; none wished to continue wearing the mask for a longer time. less moisture build-up was visible compared with the day before, but skin indentations were present on all five faces. the lighter skin tones appeared to have more pressure-related impact than those with darker skin tones. all four females had various levels of skin erythema, with the fair skin most damaged of all. the participant with the darkest skin had the least visible damage; one small darkened area was visible that fully recovered in 1 hour. of the female participants, three continued to have signs of indentation and erythema an hour after the test, with the fair-skinned participant least recovered compared with results from the day before. with regards to metabolic spo 2 on the second day, three participants retained the exact same starting value, and one gained 1%. the remaining participant had a 2% spo 2 loss. the mean loss was 0.2% metabolic spo 2 . figure 6 depicts spo 2 readings taken from the same participant before and after both 4-hour tests. this article describes a holistic approach to facial skin injury prevention for hcps to "help" staff to embrace a longer periods of ppe use (with each participant serving as their own control) produced a distinct difference between mask wear with and without protection, including improved facial condition and comfort without compromising mask seal. three possible mechanisms of injury were identified in this experiment. the first was associated with direct high pressure causing skin indentations (ie, from mask edges, nose fitting device, and straps); the second a diffuse erythema in a linear pattern associated with lower pressure with or without friction (ie, mask edges moving). both were more pronounced when no facial protection was present. the third was related to sweating: slight localized sweating underneath the mask was more pronounced when skin protection was used, attributable to the better integrity of the acquired seal. associated moisture build-up from sweat is therefore a risk with this ppe configuration; accordingly, the use of a skin-protective acrylate 10 followed by meticulous facial care 9 is recommended for off-duty hcps. all participants cut up the dressing into segments with ease and could easily apply the dressing to their faces with the use of a mirror. after donning this protective layer, the integrity of the n95 mask was also easily established, with all staff passing both the leak and the fit tests. the most crucial safety consideration for frontline providers during the pandemic lies in the order of ppe removal; it must be doffed in the exact reverse order it was donned. 1 bathroom and eating breaks cannot be factored into shifts because the proper reverse removal of layers of ppe takes more time than application to prevent contamination and risk to others in the facility. 1, 7 all body ppe must be removed first, followed by a thorough handwashing, 21 after which the n95 masks are removed by touching only the elastic bands, 1 and the handwashing procedure is repeated before the facial protective dressings can be removed. essentially, staff can greatly increase the risk for covid-19 self-contamination if they touch their faces before all contaminated ppe is safely removed. 1 this stringent ppe process requires heightened staff awareness of this vital safety precaution, reinforcing the help enabler's focus on adequate nutrition and hydration in off duty times and recommendations to limit excessive amounts of fluids immediately before a shift. given these self-care strategies, a 4-hour fasting period is feasible. the key is to plan and shift nutrition and hydration activities to directly after and/or no less than an hour before a shift. staff with medical conditions who cannot adhere to a 4-hour fasting or bathroom break-free shift should be deemed at high risk for contagion not only to themselves, but also others using the same facilities. at least one facility has already trialed this approach with success. for each 4-hour shift of frontline staff in full ppe in wuhan, china, 7 touching masks, eating, drinking, and bathroom breaks were prohibited. this simple process ensured zero staff contracted covid-19. 7 their experience provided the rationale for the 4-hour wear test conducted in this study. a different cross-sectional study 22 (n = 4,306) from china on facial injuries sustained by hcps when using ppe also identified this 4-hour cut-off time. researchers found a statistically significant difference in the number of injuries sustained if hcps exceeded this time frame in ppe. 22 skin protection under masks is therefore a necessity because shift lengths can be unpredictable based on ppe supplies 23 but also because facial injuries have been noted in shorter shift periods 22 and within 2 hours in this study. it is of vital importance that hours of ppe wear (regardless of facial protection applied) be documented 3 to prevent prolonged exposure, excessive moisture build-up, and skin breakdown. based on the experience of aggressive frontline covid-19 care in wuhan, 7, 22 it is recommended that each 8-hour shift be divided between two teams where one team does the work requiring n95 mask wear (in the dirty/infected area) while the rest works in the clean area. after 4 hours inside without eating, drinking, or a bathroom break in full ppe, the two teams switch. this prevents exhaustion, mask hypoxia, 19 and protects the skin of hcps 7,22 with minimal impact on staffing. the most interesting finding of this study was the drop in participant spo 2 values by 2% on average when using the protective dressing underneath the n95 mask. this corresponds with tight-fitting mask wear studies conducted during flu outbreaks. 19, 20 it is possible that the protective dressing increases the mask's seal stability while mitigating pressure-related skin damage. critically, extended periods of n95 mask wear may be related to mask-induced hypoxia in hcps; 19, 20 hypoxia is an established major risk factor for pressure-related skin breakdown. 3 mitigation of this concern can be achieved by the split-shift approach previously described. 7,22 the reduced spo 2 finding was not the case with n95 mask use alone. this may indicate that despite passing the fit and leak tests, the discomfort from mask wear results in participants occasionally moving their faces to relieve pressure and facial irritation, which could result in small leaks. the participant with type 2 skin most likely had a leak present during the test where the protective layer was not applied that was sustained during the test by mouth, chin, and facial movements. this participant had a 1% increase in spo 2 and the most pronounced skin damage present after the test. mask discomfort may therefore add to the iatrogenic risk of contracting covid-19 infection. the same risk applies to staff with any facial injury resulting in a skin breach, because pain may compromise proper n95 mask seal. adding repeated pressure to an existing facial injury has the potential to exacerbate minor injuries and lead to deeper dermal injuries; this is why patients are carefully positioned to displace pressure to other body parts once a stage 1 pressure injury is present. 3 this small sample was recruited to serve in a pilot project to determine if the application of a facial protective layer could mitigate facial injury risk among n95 mask wearers. more research using different border dressings would be beneficial to expand the evidence base on this topic and give providers more options. the staff at khuh is also mainly of west and east asian descent, hence the lack of a nurse with a fitzpatrick skin type 1. this is a major limitation because this skin type is usually the most sensitive to injury and skin insults. further, although the fitzpatrick scale is the criterion standard for sun-related skin damage, it may not fully predict pressure and shear damage on skin because deeper injuries may not be immediately visible. further testing in institutions that have hcps with fitzpatrick type 1 skin is warranted. further work is also needed on n95 mask wear and the impact of reduced spo 2 on fatigue, headache, and concentration to determine the optimal safety balance between skin risk, metabolic stress, and personal protection. early on in the covid-19 health crisis, the need to protect the skin of hcps was prioritized at the khuh. at that time, there were no educational resources available to guide practice. (some enablers have since been released, beginning in april 2020. 24, 25 ) the creative stepwise process of skin protection described in this article was developed with readily available products and participants who volunteered to help develop a safe solution for skin injury prevention. at roughly the same cost as a daily take-away coffee, a repurposed atraumatic silicone border dressing can support skin health underneath a tight-fitting mask. by cutting it into segments and carefully applying it without creases over the nose, cheekbones, and sides of the face, hcps can achieve pressure redistribution and facial skin protection. this method does not appear to interfere with n95 mask integrity and in fact may provide additional leak protection by securing the mask more firmly in position, ultimately protecting against accidental viral transfer to the face. 1 accordingly, these authors recommend that hcps add an atraumatic silicone border dressing as a safe and beneficial option to protect facial skin under ppe. however, no dressing by itself (regardless of testing) can provide complete care of facial skin underneath n95 masks. it is critical that hcps implement a comprehensive skin care approach. frontline staff who "help" themselves by taking responsibility for their own skin care, who are well prepared, well rested, fed, and hydrated can more safely take care of others. it is the authors' hope that this creative evidence-based clinical facial protection solution and help enabler will be of assistance to their global colleagues in the fight against covid-19. • supplemental table. application of the protective dressing step 1: hand preparation handwashing according to correct technique, 40 to 60 seconds step 2: prepare dressing by cutting it in required segments 1-7 step 3: apply dressing segments in this order: 1) on the nose 2, 3) sides of face 4) under chin step 4: apply the rest of the dressing on areas in need of added relief: 5) forehead (thicker or thinner as needed) 6, 7) sides of ears step 5: apply n95 mask and other protective equipment over dressing step 6: removal handwashing for 40 to 60 seconds remove the mask using elastics only and discard properly wash hands again, 40 to 60 seconds remove all protective dressings in reverse order (7 through 1) wash hands and face and apply moisturizer on both follow the help enabler for total self-and skincare rational use of personal protective equipment (ppe) for coronavirus disease (covid-19). interim guidance public awareness campaign to combat coronavirus. coronavirus (covid 19) latest updates. 2020. www.moh.gov.bh/?lang=en. last accessed european pressure ulcer advisory panel, national pressure injury advisory panel, pan pacific pressure injury advisory panel. prevention and treatment of pressure ulcers/injuries: clinical practice guideline the impact of a mnemonic acronym on learning and performing a procedural task and its resilience toward interruptions facial skin mapping: from single point bio-instrumental evaluation to continuous visualization of skin hydration, barrier function, skin surface ph, and sebum in different ethnic skin types nutrition and skin ulcers protection of medical team in wuhan using multi-layer foam dressing to prevent pressure injury in a long-term care setting enhancing skin health: by oral administration of natural compounds and minerals with implications to the dermal microbiome impact of water exposure on skin barrier permeability and ultrastructure a randomized controlled trial of the clinical effectiveness of multi-layer silicone foam dressings for the prevention of pressure injuries in high-risk aged care residents: the border iii trial skin tears and risk factors assessment: a systematic review on evidence-based medicine the validity and practicality of sun-reactive skin types i through vi particle size-selective assessment of protection of european standard ffp respirators and surgical masks against particles-tested with human subjects kansas department of health and environment. fit testing procedures for n95 respirators (using 3m ft-30, bitter fit test equipment) singapore general hospital. n95 3m mask fit: how to wear and remove unmc heroes, n95 respirator limited reuse -health care professionals providing clinical care male versus female skin: what dermatologists and cosmeticians should know preliminary report on surgical mask induced deoxygenation during major surgery respiratory consequences of n95-type mask usage in pregnant healthcare workers-a controlled clinical study van den wymelenberg k. 2019 novel coronavirus (covid-19) pandemic: built environment considerations to reduce transmission the prevalence, characteristics, and prevention status of skin injury caused by personal protective equipment among medical staff in fighting covid-19: a multicenter, cross-sectional study rational use of personal protective equipment for coronavirus disease (covid-19) and considerations during severe shortage. interim guidance prevention and management of skin damage related to personal protective equipment (ppe) national pressure injury advisory panel. npiap position statements on preventing injury with n95 masks key: cord-293055-8scoocvx authors: deressa, w.; worku, a.; abebe, w.; gizaw, m.; amogne, w. title: availability of personal protective equipment and satisfaction of healthcare professionals during covid-19 pandemic in ethiopia date: 2020-11-03 journal: nan doi: 10.1101/2020.10.30.20223149 sha: doc_id: 293055 cord_uid: 8scoocvx healthcare professionals (hcps) are at the frontline in the fight against covid-19 and are at an increased risk of becoming infected with coronavirus. risk of infection can be minimized by use of proper personal protective equipment (ppe). this study assessed the availability of ppe and satisfaction of hcps in six public hospitals in addis ababa, ethiopia. a cross-sectional study was conducted from 9th to 26th june 2020. the study hospitals included: tikur anbessa specialized hospital, zewditu memorial hospital, ghandi memorial hospital, menelik ii hospital, yekatit 12 hospital medical college and st. paul hospital millennium medical college. data were collected using a self-administered questionnaire. descriptive statistics were used to describe the data and chi-square test was used to assess the association between the groups. bivariate and multivariable logistic regression models were used to assess factors associated with the satisfaction level of healthcare workers with regard to the availability and use of proper ppe during the current covid-19 pandemic. a total of 1,134 (92.3%) valid questionnaires from a possible 1,228 were included in the analysis. the mean (sd) age of the participants was 30.26 (6.43) year and 52.6% were females. nurses constituted about 40% of the overall sample, followed by physicians (22.2%), interns (10.8%), midwives (10.3%) and others (16.7%). an overall shortage of ppe was reported in all study hospitals. the majority (77%) of the healthcare professionals reported that their hospital did not have adequate ppe. a critical shortage of n95 respirator was particularly reported, the self-reported availability of n95 increased from 13% to 24% before and during covid-19, respectively. the self-reported use of n95 increased from 9% to 21% before and during covid-19, respectively. almost 72% of the respondents were dissatisfied with the availability of ppe in their hospital. the independent predictors of the respondents satisfaction level about ppe were male gender (adjusted or=1.39, 95% ci:1.05-1.85), healthcare workers who reported that ppe was adequately available in the hospital (adjusted or=7.53, 95% ci:5.08-11.16), and preparedness to provide care to covid-19 cases (adjusted or=1.65, 95% ci:1.22-2.12). a critical shortage of appropriate ppe both before and during covid-19 was identified. the high level of dissatisfaction with the availability of ppe might potentially lead to a lower level of preparedness and readiness to fight against covid-19. therefore, urgent efforts are needed to adequately supply the healthcare facilities with appropriate ppe to alleviate the challenges. the outbreak of coronavirus disease 2019 , caused by the severe acute respiratory syndrome coronavirus 2 (sars-cov-2), has been declared as a pandemic by the world health organization (who) on the 11 th of march 2020 [1] . worldwide, the pandemic has caused over 41 million confirmed cases and more than 1.1 million as of 22 nd oct 2020 2020 [2] . the african continent has the lowest number of globally confirmed cases, standing roughly at 1,685,589 and registering 40,690 deaths. as of 22 nd october 2020, ethiopia has confirmed 91,693 covid-19 cases, 1,396 deaths, and 45,260 recoveries from over 1,423,505 tests performed to date. at the moment, ethiopia stood at 4 th from africa in terms of the reported number of confirmed covid-19 cases next to south africa (1 st ), egypt (2 nd ) and morocco (3 rd ). thus far the case fatality rate of ethiopia, which represents 1.5% of the cumulative confirmed covid-19 cases, is less than the average for africa (2.4%) and the world (3.3%). nonetheless, recent reports from the country suggest a spiking rate of coronavirus transmission in the community [3] . healthcare professionals (hcps) are at the frontline of defense in combating covid-19 and they play a critical role, not only in the management of covid-19 patients, but also in ensuring adequate infection prevention and control (ipc) measures in healthcare settings. as a result, they are at a substantially increased risk of becoming infected with the virus and could potentially contribute to the transmission [4] [5] [6] . in ethiopia, over 1,311 health workers have contracted coronavirus as of 17 th september 2020. about 11% of hcps retrospectively studied in spain had tested for covid-19 [7] . early evidence from countries with the highest mortality rates indicates that healthcare workers are considerably at greater risk of being infected with covid-19 ranging from 15% to 20% of the infected population and are therefore at a disproportionate risk to the rest of the population [8, 9] . for instance, the italian regional reference laboratories reported that healthcare workers accounted for 10% of 162,000 cases of covid-19 in the country [10] . similarly, the us centers for disease control and prevention reported that accounted for about 11% of all confirmed covid-19 cases in the united states between [11] . infection prevention and control (ipc) measures such as the use of appropriate ppe, proper handwashing, and hand hygiene are critical in preventing the transmission and risk of infection of covid-19 in healthcare settings. the use of appropriate ppe by healthcare workers in particular during the current covid-19 pandemic is highly recommended and the national and international safety protocols for healthcare workers should be strictly followed [1, 12] . since the initial outbreak report of covid-19 in china in december 2019, there has been an increasing demand for ppe globally. in many healthcare settings particularly in africa hcps have limited access to appropriate ppe to protect their health in many healthcare settings [6] . as a result, many healthcare workers remain concerned about the risk of infection from the sars-cov-2 due to the shortage of appropriate ppe recommended by who, and they have become ill-equipped to care for patients with covid-19 or other causes, due to acute shortage of appropriate ppe [13] . a lack of ppe puts both hcps and patients at risk of contracting coronavirus infection. it also presents many hcps with challenging decisions about whether to care and provide treatment for covid-19 patients in the absence of effective ppe. in addition, compliance with guidance on the correct use of ppe in healthcare setting is another challenge. on the other hand, the number of covid-19 cases is rising and the shortages in ppe remains a major concern. the purpose of this study was to assess the self-reported availability and use of ppe as well as satisfaction level of hcps practicing in public hospitals in addis ababa during the current covid-19 pandemic. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10. 30.20223149 doi: medrxiv preprint a hospital-based cross-sectional study was conducted from 9 th to 26 th june 2020 at six public hospitals in addis ababa city administration, three months after the first confirmed covid-19 case in ethiopia in march 2020. addis ababa city is the most populated urban city in ethiopia, and is home to about 17% of the urban dwellers in the country. in 2019, the city had a projected population of about 3.6 million and accounted for 3.7% of the total population [14] . the city has the highest number of health infrastructure and medical personnel compared with any city or region in the country. there were 12 hospitals and close to 100 health centers belonging to the public center, and about 25 private hospitals in addis ababa city. there were also over 17,000 hcps in the city, including 2,441 (14%) physicians and 8,172 (47%) nurses by the end of july 2019. addis ababa city has the highest rate of covid-19 cases and deaths in ethiopia. as of 22 nd oct 2020, a total of 46,570 confirmed covid-19 confirmed cases and 122 deaths were reported in addis ababa [15] . the hospitals selected for the current study were the leading hospitals in the country and provided outpatient and inpatient services for the city residents and patients coming from different parts of the country. of the 12 government hospitals in addis ababa city administration, the following six were purposively selected based on the relatively higher number of health work forces: tikur anbessa of hcps practicing in the selected hospitals at the time of the survey. in this study, hcp is defined . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10.30.20223149 doi: medrxiv preprint as a healthcare provider in the selected hospital involved in the provision of healthcare services including intern doctors, resident doctors, general practitioners, medical specialists and subspecialists, health officers, anesthetists, nurses, midwives, laboratory technologists, radiologists, physiotherapists, x-ray and laboratory technicians. the study targeted the hcps since they are the majority involved in a number of healthcare activities which render them at risk of acquiring and transmitting infections. sample size was calculated using a single cross-sectional study design formula based on a 50% prevalence estimate of the availability of ppe in the hospital at 95% confidence level, 4% precision, a design effect of 1.5 and 25% non-response rate. accordingly, the minimum total sample size targeted for this survey was 1,200 respondents. a mix of purposive and random sampling was applied to select participants based on their availability and willingness to participate in the study. in each hospital, the types and number of wards were initially identified and the number of healthcare workers within each ward was obtained from the human resource department. the sample size allocated to the hospital was distributed to the wards proportional to the size of their healthcare workers. since it was difficult to obtain the complete list of healthcare workers in each ward at the time of the study, proper random sampling was not followed to select the study participants. some healthcare workers in particular physicians or nurses were on duty, some were working in different departments in the same hospital or another hospital, and others were reluctant to accept the invitation to participate in the study. the list of the available voluntary healthcare workers was obtained and a simple random sampling was applied to select potential respondents based on the sample size allocated to each ward. all eligible participants who consented to participate were recruited into the study. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10.30.20223149 doi: medrxiv preprint date were collected using structured paper-based self-administered questionnaires that composed of sections on demographic and occupational characteristics of the respondents (e.g., gender, age, education and years of work experience), working unit, availability and practices regarding compliance with usage of ppe (gloves, gowns, facemask, n95 respirator, goggles, face shields, and hair covers), as well as their main concerns and worries about the availability and use of proper the questionnaire was developed in english based on related literature and available national and international ppe guidelines. a total of 12 experienced data collectors with health backgrounds were involved in data collection. one data collector per hospital was independently recruited and trained for this purpose, while one assistant healthcare workers was recruited from each hospital to facilitate and assist the data collection process. a guideline was developed by the research team to guide the data collectors, assistant healthcare workers and supervisors for data collection, quality assurance of data and ethical conduct during implementation of the survey. the components of the . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10.30.20223149 doi: medrxiv preprint guidelines included sections on selection of respondents, data collection procedures using selfadministered questionnaire, and ethical issues including covid-19 infection prevention measures. training and orientation on the survey including how to administer the questionnaire were conducted for the data collectors using webinar. before handing out the questionnaires to the potential study participants in the selected hospitals, the data collectors introduced themselves to the respondents, build a rapport with them and explained the aims of the study and data collection procedures. after obtaining consent from the participants, the questionnaires were handed out to the respondents and appointed for return to recollect the completed questionnaires. the questionnaires were distributed with a cover letter (consent form), introducing the study and explaining the purpose of the survey, instructions on how to complete the questionnaire, and researchers contact information for any questions the respondent might have. participants completed the questionnaires by themselves in english language. data collection took place concurrently in all hospitals. upon return of the questionnaires, the data collectors checked for completeness and consistency, and incomplete questionnaires were taken back to the respondents for completion as much as possible. before data entry, each questionnaire was checked for completeness. data were entered into the census surveys professional (cspro) version 7.2 statistical software package and subsequently exported to spss version 23.0 (spss inc., ibm, usa) for cleaning and data analysis. continuous data were summarized using means and standard deviations, while categorical data were presented as frequency counts and percentages. descriptive statistics were used to describe the study variables. the chi-square test was used to assess the association between the groups. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10.30.20223149 doi: medrxiv preprint the overall satisfaction score regarding the availability and use of ppe for each respondent was calculated by taking the sum of the scores of the four questions. responses to these questions were summed to form a total satisfaction score ranging from 4 to 20, with higher scores indicating higher level of satisfaction. using the total satisfaction score, individuals were classified into two groups: dissatisfied (≤ median score) and satisfied (>median score). the reliability of the questionnaire was measured by cronbach's alpha coefficient, and the cronbach's alpha for the satisfaction level was 0.769. a bivariate and multivariable binary logistic regression were performed to identify the main factors associated with healthcare professional's satisfaction level regarding availability and use of ppe. individuals were classified into two based on their satisfaction level: satisfied group (1), and the rest were placed in the dissatisfied group (0). odds ratios (ors) and their 95% confidence intervals (cis) were used to quantify the associations between potential predictors and outcome variable, satisfaction level. a value of p<0.05 was used for all tests of statistical significance. ethical clearance for the study was obtained from the institutional review board of the college of health sciences at addis ababa university (aau). permission to undertake this study was obtained from every relevant authority at all levels. official letters from aau were written to each hospital to cooperate and participate in the survey. all participants gave their informed consent prior to data collection. anonymity and data confidentiality were ensured, and no identifiable data from individual participants were collected. all personnel involved in the survey received orientation on covid-19 infection prevention and control measures. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10.30.20223149 doi: medrxiv preprint from a total of 1,228 questionnaires distributed in six hospitals, 1,146 were completed and returned. of these, 12 questionnaires were discarded due to missing data, resulting in 1,134 (92%) valid questionnaires for analysis. about 53% were females. among the respondents reporting age, the mean (±sd) age was 30.3 ±6.4 years, about 58% aged between 20-29 years, and 32% aged 30-39 years ( table 1 ). the largest number of respondents were from tash (25%, n=283) and sphmmc (20.5%, n=233), followed by zmh (15.6%, n=177) and mh (15.3%, n=174). nurses constituted about 40% of the overall study participants, followed by physicians (22.2%), interns (10.8%) and midwives (10.3%). among 252 physicians (22.2%) participated in the study, gps and resident doctors accounted for 44.8% and 42.9%, respectively, while specialists and sub-specialists consisted the remaining 12.3%. with gyn&ob department constituting 17.2% of the respondents, surgical (13.9%), pediatrics (13.1%), medical (13.0%) and opd (10.5%) departments represented a fairly similar number of study participants. among the study participants reporting work experience, about 49% and 25% of the respondents reported that they served in the hospital less than 5 years and 5-9 years, respectively. however, the majority of the respondents (67%) at sphmmc only served less than five years as compared to 28.3% of their counterparts at tash. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10.30.20223149 doi: medrxiv preprint . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10.30.20223149 doi: medrxiv preprint the hcps were asked the types of ppe that were frequently available in the hospital before and after the covid-19 pandemic. table 2 shows the self-reported availability of different ppe by hcps before and during the covid-19. gloves and gowns were reported as the most frequently available ppe in the routine care of patients before and during the pandemic. during the covid-19 pandemic, the frequent availability of most ppe as reported by the study participants has improved, for example, the frequent availability of surgical facemask and n95 respirator has increased from 59.3% and 12.6% before the pandemic to 82.6% and 24.2% after the pandemic, respectively. the self-reported availability of gloves before and during covid-19 was >90%, and statistically not significant for any of the hospitals. the availability of gowns for all study hospitals was >60% before and during the covid-19, with no significant increase during the covid-19. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10.30.20223149 doi: medrxiv preprint is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10.30.20223149 doi: medrxiv preprint 36% of the participants from sphmmc and 30% from tash as compared with 9.2% at mh and 13% at gmh. even simple hand sanitizer was in short supply in some hospitals as reported by some respondents. the hcps were asked the types of ppe that were frequently used in the hospital before and after the covid-19 pandemic. table 3 presents the self-reported frequently used ppe by hcpss before and during covid-19. gloves and gowns were identified as the most frequently used ppe in the hospital before and during the covid-19 pandemic. the use of gloves by all hcps was above 90%, while the self-reported use by other healthcare workers before and after covid-19 was relatively lower than others, despite showing some improvement during covid-19. likewise, the self-reported use of gowns remained not statistically significant before and during covid-19, whereas its use rate remained less than 80% for the different categories of hcps. the use of surgical facemask has increased from 47.2% before the pandemic to 85.7% during the pandemic for all hcps (p<0.001). . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10.30.20223149 doi: medrxiv preprint table 3 . self-reported frequently used ppe by healthcare professionals before and during covid-19 (n=1134) *other: includes anesthetist, pharmacist, health officer, lab technologist and radiographer. the use of n95 respirator has also increased from 9.1% before the pandemic to 21.2% after the pandemic (p<0.001). similarly, the use of eye protection (goggles and face shield) has increased from 11.6% before the pandemic to 22.4% during the pandemic (p<0.001). a statistically significant increase in the percentage of respondents reporting the frequent use of hair covers during the pandemic as compared with the time before covid-19 was also reported (p=0.008). the self-reported use of n95 respirator was the highest for physicians than other even before (16%) and after (23%) covid-19, while the least use of n95 respirator was reported by interns. overall, the self-reported use of n95 respirator was lower than other ppe except the use of hair cover. although there was an increase in the self-reported use of hair cover during covid-19, its use is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10.30.20223149 doi: medrxiv preprint was generally very low and the difference was not statistically significant regarding its use by the different categories of hcps. with regard to the types of ppe used during their last interaction with a patient, the majority of the hcps reported the use of gloves (91.2%), gowns (72.4%), and facemasks (86.8%), with about 24%, 19% and 18% reporting n95 respirator, eye protection and hair dresses, respectively (table 4 ). . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10.30.20223149 doi: medrxiv preprint table 5 shows the satisfaction level of hcps with regard to the current availability and use of ppe in the study hospitals, and 54.7% (n=584) and 17.5% (n=187) of the respondents reported that they were unsatisfied or somewhat unsatisfied with the availability of ppe, respectively. similarly, 48.8% (n=521) and 20% (n=213) of the participants self-reported that they were unhappy or somewhat unhappy with the current use of ppe by health professionals in the hospital. overall, only 12% or less of the respondents expressed their opinion that they were satisfied or somewhat satisfied with the current availability or use of ppe at their hospitals. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10.30.20223149 doi: medrxiv preprint about 28% (n=294) and 27% (n=291) of all the respondents self-reported that they were dissatisfied or strongly dissatisfied, respectively, about the availability of the correct ppe in their hospital, as recommended by who, for managing suspected/confirmed covid-19 patients (table 5) . it is only about one-third of the respondents who agreed or strongly agreed about the availability of ppes in their hospital for managing covid-19 patients as recommended by who. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10. 30.20223149 doi: medrxiv preprint generally, more than half of the different healthcare professional categories reported that they disagreed or strongly disagreed about the statement on the availability of correct ppe in the hospital for managing covid-19 patients as per the who recommendation, ranging from about 51% by physicians and 66% by interns. about 54% and 17.5% of the respondents reported that they were unsatisfied or somewhat unsatisfied with the availability of ppe, respectively. the overwhelming majority of interns (76.8%), physicians (72.3%) and nurses (72.9%) were unsatisfied with the current availability of ppe in the study hospitals. only 10% of the respondents expressed their opinion that they were satisfied or somewhat satisfied with the current availability of ppe at their hospitals. this study also assessed the level of preparedness of hcps to provide direct clinical care to covid-19 patients. only 5.2% and 32.8% of the participants felt they were completely prepared or somewhat prepared to provide direct clinical care to covid-19 patients, respectively. overall, the majority (77%, n=872/1134) of the participants perceived that the ppe currently available to them at their hospital was inadequate to keep them safe from infection when managing suspected or confirmed covid-19 patients. the mean and the sd of the satisfaction scores of the four items regarding the availability and use of ppe were calculated. table 6 shows the degree of satisfaction scores of all respondents. the first two items had a score of <2 (1.85±1.13 and 1.97±1.13), indicating strong dissatisfaction of the hcps, while the remaining two items had a mean score of between 1.5 and 2.0 (2.65±1.40 and 2.70±1.39), showing the dissatisfaction of the study participants. the overall score was 2.29±0.97, showing that the majority of the respondents reported that they were dissatisfied with the availability and use of ppe in the study hospitals. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10.30.20223149 doi: medrxiv preprint *range from 1 "strongly dissatisfied" to 5 "strongly satisfied" the total satisfaction score regarding the availability and use of ppe for each respondent was used as dependent variable and dichotomized into two groups: dissatisfied (≤median score) and satisfied (>median score). this dependent variable was further subjected to bivariate and multivariable binary logistic regression analyses using eight potential independent variables (gender, medical profession, working unit, hospital, whether received training in ppe during the covid-19 pandemic, whether used any 'homemade' or 'creative' ppe during covid-19, whether they reported that adequate ppe was available to protect them from risk of infection while managing suspected/confirmed covid-19 patients, and preparedness to tackle covid-19). table 7 shows the relationship between the respondents ppe satisfaction level and independent factors for both bivariate and multivariable logistic regression analyses. in the bivariate logistic regression, the odds of satisfaction with the availability of ppe among males were 1.37 times higher than females (or=1.37, 95% ci:1.08-1.75, p=0.010). however, nurses were less likely to be satisfied with the availability and use of ppe than physicians (or=0.48, 95% ci:0.29-0.77, p=0.003). the hcps at mh were less likely to be satisfied with the availability and use of ppe in . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10.30.20223149 doi: medrxiv preprint their hospital than those in sphmmc (or=0.46, 95% ci:0.30-0.72, p=0.011). the odds of satisfaction among those respondents who reported that ppe was adequately available to protect themselves from the risk of infection when managing suspected or confirmed covid-19 cases were 8.31 times higher than among those who said 'no' (or=8.31, 95% ci:5.84-11.82, p<0.001). the odds of satisfaction among those health workers who used any 'homemade' or 'creative' ppe such as homemade fabric, face covering clothes or sewed cotton masks (or=2.01, 95% ci:1.53-2.66, p<0.001) and those who reported that they were prepared to provide direct care to suspected or confirmed covid-19 cases (or=1.45, 95% ci:1.12-1.87, p=0.004) were higher than among other healthcare workers. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10.30.20223149 doi: medrxiv preprint . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10. 30.20223149 doi: medrxiv preprint in the multivariable logistic regression analysis (table 7) , which was performed using eight independent variables in the model, the odds of satisfaction with availability of ppe among males were again 1.39 times higher than female healthcare workers (or=1.39, 95% ci:1.05-1.85, p=0.023). the odds of satisfaction among hcps from gmh were 1.69 times higher than among those working at sphmmc (or=1.69, 95% ci:1.05-2.71, p=0.031), while healthcare workers at mh were less likely to be satisfied with ppe than those at sphmmc (or=0.45, 95% ci:0.28-0.72, p=0.001). the odds of satisfaction among those healthcare workers who reported that ppe was adequately available to protect themselves from the risk of infection when managing suspected or confirmed covid-19 cases were 7.53 times higher than among those who reported inadequate ppe (or=7.53, 95% ci:5.08-11.16, p<0.001). the odds of satisfaction among hcps who reported that they were prepared to provide direct care to suspected or confirmed covid-19 cases were higher than other healthcare workers (or=1.65, 95% ci:1.22-2.12, p=0.001). the factors such as medical profession, medical unit, training in ppe after covid-19, and use of any 'homemade', or 'creative' ppe in the hospital did not have significant influence on the satisfaction level of hcps regarding the availability and use of ppe. the multivariable binary logistic regression model presented in table 7 had goodness-of-fit under the hosmer-lemeshow test ( 2 =5.35, p=0.720), and the full model containing all predictors was statistically significant  2 (21, n=1067) = 231.56, p<0.001. the model as a whole explained between 19.5% (cox-snell r 2 ) and 26% (nagelkerke r 2 ) of the variance in satisfaction level. this study aimed to investigate the availability and use of ppe among 1,134 hcps working in six public hospitals during the early stage of covid-19 in addis ababa, ethiopia. our findings showed limited access to appropriate and sufficient ppe to health workers in the care of covid-. cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10. 30.20223149 doi: medrxiv preprint hcps irrespective of the hospitals they were serving is observed. this raises a concern regarding the availability and use of proper ppe in the hospitals and the challenges of healthcare workers to combat covid-19 infection. despite these concerns, the hcps continue to work during covid19 . though there is a global shortage, hcps must be equipped with appropriate ppe that they need to practice their clinical role with confidence. shortage of healthcare workers is already significant amidst the national effort against covid-19. in the previous studies, inadequate personal protection during the management of suspected or confirmed covid-19 patients, proximity to patients infected by the virus and prolonged exposure to the infected environment were cited as reasons for the health care workers becoming infected with the virus [16, 17] . lack of appropriate ppe itself can put the hcps at risk of contracting the virus and infecting other healthcare workers and their family. although this problem did not only exist in ethiopia, it was also reported from china [18] and other countries. in one study in jordan, only 18.5% of frontline doctors reported that all ppe were available and most shortage was reported in protective facemasks [19] . several studies emphasized that adequate training, proper use and uninterrupted availability of adequate ppe give hcps a minimal risk of infection when treating suspected or confirmed cases of covid-19 [18, 20, 21] . a study in china found that of 420 doctors and nurses deployed to frontline work at wuhan hospitals between january and april 2020 none of them contracted covid-19 after receiving training in proper use of ppe and provided with appropriate ppe [22] . a study from hong kong demonstrated that correct use of ppe by healthcare workers was associated with no cases of infection over a 42-day observation period [23] . studies have also revealed that the risk of sars-cov-2 infection is significantly higher particularly among frontline hcps with inadequate ppe caring for suspected or confirmed covid-19 patients [24] . . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10. 30.20223149 doi: medrxiv preprint the shortage of ppe is particularly concerning for the commonly used n95 respirators. however, recommendations are currently available to use surgical or medical masks when n95 is in short supply. a recent systematic review and meta-analysis showed that medical masks are not inferior to n95 respirators for protecting healthcare workers against viral respiratory infections during routine care and non-aerosol-generating procedures, but the researchers strongly recommended preservation of n95 respirators for high-risk, aerosol-generating procedures during covid-19 when its supply is inadequate [25] . in response to the shortage of appropriate ppe, studies showed that the scarcity could be mitigated through proper re-use or extended use techniques [26, 27] . evidence indicates that n95 respirators maintain their protection when used for extended periods [28] although using them for longer than four hours is not recommended due to increased discomfort [28, 29] . the choice of ppe is also dependent on the level of protection provided by ppe and the risk of exposure, thus understanding them is the key in choosing appropriate ppe [30] . in this regard, the who ipc recommendations have proven to be an invaluable resource and were quickly adopted and implemented in many countries in preparing their response to the covid-19 pandemic [31]. as a result, the who guidance on the rational use of ppe for covid-19 has provided appropriate criteria on how to select and use appropriate ppe in different settings when ppe is in short supply [13] . the current study gives a first impression of the satisfaction level of hcps with regard to the availability and use of proper ppe during the covid-19 pandemic. the findings show that the hcps had an overall low level of satisfaction with the availability and use of appropriate ppe in their hospital. the healthcare system, which was already affected by the widespread shortage of . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10.30.20223149 doi: medrxiv preprint hcps, will be further affected by the dissatisfied health workforce. currently, there is limited evidence on the satisfaction of healthcare workers about the availability and use of ppe. a recent study conducted in ethiopia reported that 75% of the healthcare workers in hospitals felt unsafe about their work environment and only <30% reported that they had access to proper ppe in the hospitals [32] . the multivariable logistic regression analysis showed that the satisfaction of hcps regarding the availability and use of ppe were affected by different factors, such as gender, hospital, perception that ppe is adequately available, and preparedness to provide direct care to suspected or confirmed covid-19 cases. male healthcare workers reported statistically significant higher satisfaction level with ppe than female health workers. among the healthcare workers, those who reported that ppe was adequately available to protect themselves from the risk of infection when managing covid-19 patients rather than those who reported the inadequacy of ppe in their hospitals had statistically significant level of higher satisfaction about ppe. as there is limited published research on the relationship between healthcare workers satisfaction level with regard to the availability and use of appropriate ppe and associated factors, this study contributes additional knowledge in this area of research. finally, this study had some limitations. first, the study might be affected by selection bias. second, the study focused on more general populations of hcps similar to other studies [33, 34] rather than healthcare workers who might have direct contact with covid-19 patients [35] . relying solely on respondents to determine the availability and use of ppe can introduce recall bias. lastly, the results of this study are based on a self-reported questionnaire using a crosssectional design, and the self-reported response might not represent actual or genuine answers. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10. 30.20223149 doi: medrxiv preprint despite these limitations, the results obtained provide important information to guide the efforts to avail appropriate ppe and optimize its use for effectively reducing the risk of covid-19 infection among hcps through implementing appropriate ipc measures. in conclusion, this study has illuminated the level of the availability and use of ppe by hcps working at hospitals, and identified a critical shortage of appropriate ppe both before and during covid-19. the availability of n95 respirator was particularly insufficient, and the use of goggle and gown were unsatisfactory, which might increase the risk of covid-19 infection among hcps. the study shows that the hcps had an overall low level of satisfaction with the current availability and use of ppe in their hospital, which might potentially lead to a lower level of preparedness and readiness among health workers to fight against covid-19 infection. with the current critical shortages of ppe in hospitals, the ongoing widespread covid-19 pandemic in ethiopia could result in devastating consequences. the findings provide considerable insights into the importance of urgent need and concerted efforts to adequately supply the healthcare facilities with appropriate ppe to alleviate the current challenges during the covid-19 pandemic. preventing the risks of covid-19 infection among hcps through providing proper and adequate ppe should be strengthened and needs to be a top priority for ministry of health and the government of ethiopia. ethical clearance was obtained from the institutional review board of the college of health sciences at addis ababa university. all participants gave their informed consent. this study was funded by addis ababa university and partly supported by the school of public health. publication charge for this article was waived since all the authors are from a low-income country. the authors declare no competing interests. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted november 3, 2020. ; https://doi.org/10.1101/2020.10.30.20223149 doi: medrxiv preprint jhu. coronavirus covid-19 global cases by johns hopkins csse. 2020. available at national public health emergency operation center (npheoc) monitoring approaches for health-care workers during the covid-19 pandemic africa: care and protection for frontline healthcare workers covid-19 risk factors among health workers: a rapid review. saf health work international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity sars-cov-2 infection among healthcare workers in a hospital in madrid risk assessment of healthcare workers at the frontline against covid-19 protecting healthcare workers from covid-19: learning from variation in practice and policy identified through a global cross-sectional survey characteristics of healthcare personnel with covid-19-united states international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings rational use of personal protective equipment for coronavirus disease (covid-19) and considerations during severe shortages. interim guidance. who, geneva attitude and behavior of health care workers in the prevention of covid-19 novel coronavirus (2019-ncov) pneumonia in medical institutions: problems in prevention and control association of personal protective equipment use with successful protection against covid-19 infection among health care workers preparedness of frontline doctors in jordan healthcare facilities to covid-19 outbreak supporting the healthcare workforce during the covid-19 global epidemic complete protection from covid-19 is possible for health workers use of personal protective equipment against coronavirus disease 2019 by healthcare professionals in wuhan, china: cross sectional study escalating infection control response to the rapidly evolving epidemiology of the coronavirus disease 2019 (covid-19) due to sars-cov-2 in hong kong international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity risk of covid-19 among frontline healthcare workers and the general community: a prospective cohort study. lancet public health 2020 medical masks vs n95 respirators for preventing covid-19 in healthcare workers: a systematic review and meta-analysis of randomized trials covid-19 pandemic and personal protective equipment shortage: protective efficacy comparing masks and scientific methods for respirator reuse n95 mask reuse in a major urban hospital: covid-19 response process and procedure commentary considerations for recommending extended use and limited reuse of filtering facepiece respirators in health care settings respirator tolerance in health care workers personal protective equipment for healthcare workers during the covid-19 world health organization. infection prevention and control during health care when coronavirus disease (covid-19) is suspected or confirmed: interim guidance. who, geneva preparedness and responses of healthcare providers to combat the spread of covid-19 among north shewa zone hospitals knowledge and attitude toward covid-19 among healthcare workers at district 2 hospital, ho chi minh city knowledge, attitude and practice regarding covid-19 among healthcare workers in henan assessment of healthcare workers' levels of preparedness and awareness regarding covid-19 infection in low-resource settings the authors are grateful to the participating hospitals and their healthcare staff for committing their time and voluntarily filling in the questionnaire. they are also thankful to all data collectors and logistics facilitators for their time and commitment. key: cord-276265-gjqqfudb authors: chiang, james; hanna, andrew; lebowitz, david; ganti, latha title: elastomeric respirators are safer and more sustainable alternatives to disposable n95 masks during the coronavirus outbreak date: 2020-07-20 journal: int j emerg med doi: 10.1186/s12245-020-00296-8 sha: doc_id: 276265 cord_uid: gjqqfudb background: in this paper, the authors review the safety and practicality of elastomeric respirators for protecting themselves and others from the novel coronavirus or covid-19. they also describe the safe donning and doffing procedures for this protective gear. main text: due to the shortage of personal protective equipment (ppe), the cdc has recommended ways to conserve disposable n95 masks, including re-use and extended use, and reserving n95 masks for aerosol-generating procedures. however, these were never made to be re-used. although the modes of transmission of covid-19 are not fully understood, based on what we know about severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers), droplets and aerosolized droplets contribute to the spread of this virus. more evidence from wuhan, china, has demonstrated that covid-19 viral particles are aerosolized and found in higher concentrations in rooms where ppe is being removed. thus, it is best for all healthcare providers to have full aerosol protection. conclusion: given the shortage of ppe for aerosols, it is logical to utilize reusable elastomeric respirators with filter efficiency of 95% or higher. a single elastomeric respirator may replace hundreds to thousands of new disposable n95 masks. since the coronavirus (2019-ncov) or coronavirus disease (covid-19) outbreak, shortage of personal protective equipment (ppe) has become a significant issue in numerous countries worldwide [1] , with an estimate of 89 million masks required monthly due to increased demand within and outside healthcare settings [2] . to combat these shortages, the center of disease control (cdc) has put forth recommendations to conserve ppe in the usa. some of these recommendations include using n95 masks for extended durations, using one mask for several different patients, reserving disposable n95 masks for aerosol generating procedures, and using reusable elastomeric respirators with appropriate filters [3] . re-using ppe has placed significant strain on health care professionals as many have resorted to reusing the same n95 mask for several days and keeping it in a paper or resealable plastic bag [4, 5] . disposable n-95 masks were never made to be re-used. this practice raises significant safety concerns as lack of ppe and negative pressure isolation rooms have contributed to more than 5000 confirmed cases of covid-19 in health care professionals in italy, and almost forty health care workers have died from coronavirus infections as of march 26, 2020 [6] . in the usa, similar cases are occurring as health care professionals are increasingly diagnosed with covid-19 and are dying from coronavirus [7] . given the persistent shortage of disposable n95 masks, the authors review the safety and practicality of elastomeric respirators as an alternative for protection against the coronavirus covid-19. the mode of transmission of covid-19 is not fully understood, but based on extrapolating research on influenza and similar respiratory infections also caused by other coronaviruses such as sars (severe acute respiratory syndrome) and mers (middle east respiratory syndrome), the world health organization (who) and cdc postulate that covid-19 is more likely to be transmitted by close contact and respiratory droplets, but these respiratory droplets may be inhaled [8, 9] , resulting in airborne transmission. according to the chinese cdc, aerosolized respiratory droplets are very likely inhaled when in close contact with patients, and thus, virtually, the entire population is susceptible to covid-19 infections [10] . a study done in wuhan where covid-19 had its initial outbreak found that aerosolized viral particles were detectable in high concentrations in rooms where providers were doffing ppe, and the majority of these particles were 0.25 to 0.5 μm. another study has found that aerosolized viral particles of covid-19 are detectable in the air 3 h after aerosolization [11] . based on this evidence, proper protective equipment against aerosols and the safe removal of ppe are crucial for prevention of coronavirus infection in the healthcare setting. reusing disposable n95 masks potentially exposes patients and workers to considerable infection risk. elastomeric respirators have more commonly been used in industrial and mining settings, but can be considered for use in the health care setting during times of increased demand such as during infectious disease outbreaks [12] . these respirators' gas and vapor cartridges have a finite duration of use for protection against various toxic vapors, organic or inorganic gases, and chemical aerosols based on the chemical's exposure limit and concentration. once the sorbents are saturated, these toxic gases will break through, and thus, cartridges are regularly renewed [13] . for particulates such as dust, aerosols, mold, and bacteria, electrostatic particulate filters are used instead, and the more the filter is filled with contaminant, the more effective these electrostatic forces are. hence, particulate filters are more effective with use over time given proper conditions, although once they become too difficult to breathe through, they must be replaced [14] . in this regard, respirator masks with particulate filters can be used for an extremely long duration in a hospital setting, at least 1 year, so long as the filter is not damaged or soiled [15] . evidence shows that coronavirus remains detectable and viable on various surfaces up to 3 days [11] . it can then be extrapolated that once these viral particles are trapped in the electrostatic filters, they will slowly die over several days, negating the need to change viral filters frequently. given the current short supply of disposable n95 masks, this advantage can potentially allow one respirator mask to replace using hundreds to potentially thousands of new disposable n95 masks. elastomeric respirators also differ from disposable n95 masks in that they have a separate exhale vent, and exhaled air does not travel through the contaminated filter and re-aerosolize trapped viral particles. this is in contrast to disposable n95 masks, which when re-used may carry an increased risk of transferring viral particles from one patient to another. however, this same advantage of elastomeric respirators can be a disadvantage if the wearer has an active respiratory infection, as he or she could spread their own infection from patient to patient. thus, the health care provider must be vigilant for any signs or symptoms of covid-19 in themselves. national institute for occupational safety and health (niosh)-approved respirator masks have three nonpowered particulate filter efficiency classes: 95, 99, and 100, for 95%, 99%, and 99.97% filtration of particulates down to 0.3 μm, respectively. there are three levels of oil-particle resistance, n for no resistance, r for some oil resistance, and p for being completely oil proof [16] . for most aerosols in healthcare settings, filter efficiency of at least 95% with no oil resistance is generally accepted. each user needs to be fit-tested for these respirator masks to be effective [17] . however, several studies show that healthcare professionals that do not frequently use n95 masks or wear masks for an extended duration tend to have inadequate seal. nearly half of healthcare professionals who repeat a fit test 3 months after passing a fit test end up failing the second fit test [18] . another study finds that 4.0-μm particulates were detectable inside respirator masks using portable aerosol spectrometers after only 10 min of body movements during nursing procedures [19] . this is an indication that the seal is easily lost during extended use. compared to disposable respiratory masks of the same filter efficiency, elastomeric respirators have been found to have 60% higher filtration performance and better seal [20] [21] [22] . although not as effective as powered airpurifying respirators (paprs), elastomeric respirators are still superior and preferred options over disposable respirators, especially given the severe shortage and increasing cases of healthcare professional infected with coronavirus. currently, the cdc recommends that health care providers that will be within 3 ft of a suspected or confirmed covid-19 patient without a mask, or if providers are in the room for an aerosolizing procedure, the provider may voluntarily utilize higher level of protection than n95 masks, such as elastomeric respirators or papr. the american academy of emergency physicians and american association of nurse anesthetists have made official statements that support healthcare providers using self-supplied niosh-approved ppe to feel safe or if it is inadequately provided [23, 24] . similar to use of disposable n95 masks, caution must be taken regarding the use and reuse of elastomeric respirators so as to decrease contamination of the inside of the respirator and thus increasing the risk of infecting healthcare workers. use falls under two primary categories with regard to elastomeric respirators: reuse and extended use [25] . reuse refers to the donning and doffing of a respirator multiple times throughout the duration of a clinical period. this is frequently seen in settings where different patients represent different infection transmission risk, and thus, the respirator is donned for use during aerosolizing procedures and doffed after the encounter. the greatest pitfall with reuse, as with disposable n95 masks, is the risk of contamination during the doffing and redonning procedure as repeated multiple times throughout the duration of the clinical period. in addition, appropriate storage of the masks is necessary so as to prevent contamination of the inner portion of the respirator when it is exposed. when comparing reuse of single-use n95 masks versus elastomeric respirators, there is a clear benefit of the latter as the material and efficacy of the filter will not degrade from repeated donning and doffing. utilizing a standard operating procedure, safe reuse of the elastomeric respirators can be performed (fig. 1) . moreover, given the ability to better effectively adjust fit, reuse of an elastomeric respirator ensures better seal on repeat use compared to n95 masks which often require manipulation of the contaminated front of the mask to reobtain proper seal. extended use of a respirator refers to the donning of a mask or elastomeric respirator at the start of a clinical period and kept on the provider for all patient encounters, only to be doffed after patient interaction has ceased. this is a preferred method of use with both n95 and elastomeric respirators as it eliminates the risk of contamination with reuse. the disadvantage to extended use is provider discomfort as well as the risk of transmission of pathogens between patients from the respirator [26] . with regard to n95, extended use should include wearing a disposable surgical mask or face shield over the respirator that can be removed after each patient encounter to prevent soiling of n95. the benefit to use of elastomeric respirators is that, while difficult to definitively test, the cdc recommends no more than 8 h of continued or intermittent use of n95 masks, purporting an obvious disadvantage if one were to require more than 8 h of continuous use [25] . moreover, given the material of the elastomeric respirators the external surface of the mask can be wiped down while still on, the providers face between encounters or during encounters where there was droplet exposure. an often-noted disadvantage of frequent reuse or extended use of elastomeric respirators is skin break down over the bridge of the nose and side of the face. early skin break down anecdotally can be mitigated by use of adhesive strips or barrier protection such as a bandage or tape prior to donning of the respirator. in times of ppe shortage as with the h1n1 influenza outbreak, methods for disinfection of disposable n95 masks have been suggested including ultraviolet germicidal irradiation and prolonged heat exposure [27, 28] . effective sterilization often requires equipment not readily accessible to healthcare providers. elastomeric respirators, however, as recommended by the manufacturer, can be easily disinfected using a solution containing free chlorine at 5000 parts per million. standard operating procedure for disinfection of elastomeric respirators has previously been published, and cleaning solution can be made with materials easily found in most healthcare facilities [29, 30] , which makes this mask even more versatile in pandemic times. it is recommended that the cleaning and disinfection process of the respirator be centralized and performed by trained personnel [15] . elastomeric face masks have several advantages over reusing disposable n-95 masks. they provide safe reusable protection, can be easily cleaned, and have lower risk of transmitting infection between patients. while not originally designed for hospital use, they provide an excellent solution to the shortage of disposable n-95 masks during this covid-19 pandemic. american hospital association. concerns rise for ppe shortages with coronavirus shortage of personal protective equipment endangering health workers worldwide checklist for healthcare facilities for supply of n95 respirators for covid-19 healthcare workers are reusing the very few face masks they have left -and they're begging the government to give them the protective equipment they desperately need. business insider some doctors treating coronavirus patients in new york are already reusing face masks because they're running out of supplies. business insider as if a storm hit': more than 40 italian health workers have died since crisis began. the guardian nyc nurse who treated covid-19 patients dies as one hospital reports 13 deaths in 24 hours. nbc rational use of personal protective equipment for coronavirus disease (covid-19): interim guidance world health organization how coronavirus spreads protocol for prevention and control of covid-19 chinese center for disease control and prevention aerosol and surface stability of sars-cov-2 as compared with sars-cov-1. nejm board on health sciences policy; committee on the use of elastomeric respirators in health care board on health sciences policy; committee on the use of elastomeric respirators in health care why and when to replace your 3m filters! [internet]. 3m elastomeric respirators: strategies during conventional and surge demand situations niosh guide to the selection and use of particulate respirators 3m respirator selection guide respirator-fit testing: does it ensure the protection of healthcare workers against respirable particles carrying pathogens? reliability of n95 respirators for respiratory protection before, during, and after nursing procedures comparison of performance of three different types of respiratory protection devices simulated workplace protection factors for half-facepiece respiratory protective devices board on health sciences policy; committee on the use of elastomeric respirators in health care a position statement supporting healthcare workers being allowed to use self-supplied personal protective equipment american association of nurse anesthetists cdc -recommended guidance for extended use and limited reuse of n95 filtering facepiece respirators in healthcare settings -niosh workplace safety and health topic considerations for recommending extended use and limited reuse of filtering facepiece respirators in health care settings facial protective equipment, personnel, and pandemics: impact of the pandemic (h1n1) 2009 virus on personnel and use of facial protective equipment strategies for optimizing the supply of n95 respirators: covid-19 cleaning and disinfecting 3m reusable elastomeric half and full facepiece respirators following potential exposure to coronaviruses disinfection & sterilization guidelines springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations this research was supported (in whole or in part) by hca healthcare and/or an hca healthcare affiliated entity. the views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of hca healthcare or any of its affiliated entities.authors' contributions jc and ah conceived the study. jc, ah, lg, and dl drafted the manuscript, and all authors contributed substantially to its revision. the authors read and approved the final manuscript. authors' information jc, ah, lg, and dl are emergency medicine physicians currently working in the midst of the covid-19 crisis in florida, usa. none of the authors have any competing interests.received: 27 april 2020 accepted: 23 june 2020 key: cord-205941-npp6566r authors: armani, andrea m; hurt, darrell e; hwang, darryl; mccarthy, meghan c; scholtz, alexis title: low-tech solutions for the covid19 supply chain crisis date: 2020-04-27 journal: nan doi: nan sha: doc_id: 205941 cord_uid: npp6566r a global effort is ongoing in the scientific community and in the maker movement, which focuses on creating devices and tinkering with them, to reverse engineer commercial medical equipment and get it to healthcare workers. for these low-tech solutions to have a real impact, it is important for them to coalesce around approved designs. since the first cases were reported in december 2019, the novel coronavirus disease 2019 has swept across the globe, straining healthcare facilities through sheer case numbers. the world health organization declared it a global pandemic on march 11, 2020. among other symptoms, covid-19 causes fever, cough, and shortness of breath that can vary from mild to severe, requiring hospitalization and ventilation for the most critical cases. although many of the basic symptoms are similar to those of a common cold, covid-19 is notable for its highly infectious nature and its aggressiveness. for example, on march 17, 2020, the u.s. reached the mark of 100 deaths due to covid-19. less than one month later, 26,000 people have died, and over 9,000 healthcare workers have been infected. similar trends have been observed globally. as hospitals and healthcare clinics increasingly test and treat patients with covid-19, healthcare workers expose themselves to the virus at much higher rates than the average person, because they are unable to observe social distancing procedures and other potential methods of mitigating risk while carrying out their jobs. it is therefore of vital importance that healthcare workers have proper personal protection equipment (ppe) not only to prevent further transmission, but also to prevent further strain to the healthcare system that may occur if these clinicians are unable to work due to illness. however, due to the pandemic's effect on the global supply chain, the stockpiles of ppe are dwindling in many regions, and some hospitals and clinics have gotten so desperate that singleuse items are now reused repeatedly. this crisis is not a new problem: supply chain vulnerabilities were exposed during the 2009 h1n1 influenza and 2014 ebola virus epidemics (1) . these vulnerabilities create a critical need for alternative sources of ppe. this need was quickly recognized by the members of the growing maker movement, a global community focusing on 'learning through doing'. as the cost of manufacturing equipment such as 3d printers and electronic components has dropped in recent years, this movement has permeated both formal educational settings and at-home hobbyist circles. thus, in essence, this movement formed an extremely distributed and agile global network of manufacturers with widely varying capabilities. this network is a naturally occurring component of the maker culture. during the course of this pandemic, the members have focused on tackling three key areas: worker protection, disinfection, and healthcare devices. their success is due, in large part, to an existing ecosystem that was established prior to covid-19. [h1] the manufacturing ecosystem innovative makers and hobbyists are stepping in to fill the gaps in the ppe supply chain resulting from the covid-19 public health emergency, and the u.s. food and drug administration (fda) has issued emergency use authorizations (https://www.fda.gov/medicaldevices/emergency-situations-medical-devices/emergency-use-authorizations#covid19ppe) to waive requirements for labeling and good manufacturing practices. companies and organizations have provided collated collections of designs and challenges to encourage creative solutions and their sharing. notable examples include thingiverse (https://www.thingiverse.com/), matter hackers (https://www.matterhackers.com/covid-19), and open source medical supplies (https://opensourcemedicalsupplies.org/), which host a multitude of device designs that have been shared across the web. organized efforts have also formed through social media and collaboration platforms. the impact overall is positive, but designs are quickly evolving. in many cases, they lack sufficient instructions to inform proper fabrication and use. even if the supply chain system is not prepared as a whole, we can capitalize on production methods that allow us to rapidly shift manufacturing to ppe and related supplies. 3d printing technology is well-suited to do this, because it requires little to no modifications to switch from creating one product to the next. however, the agility inherent to 3d printing technologies means that the same input file can be the starting point for almost infinite variations in structural and material composition. this level of variability is detrimental and becomes a risk factor when the product is used as a barrier to an infectious pathogen. thus, our ability to rapidly respond to the current supply chain crisis -whether through commercial manufacturers or individual makers -is dependent on determining not just what we should be producing and for whom, but also how we should produce it. the national institutes of health 3d print exchange (nih 3dpx) is a free resource that serves as an open repository of web-based tools for finding, sharing, and creating 3d-printable models related to bioscience and medicine (2) . the project was initiated in 2013, during the early days of consumer 3d printing, when existing 3d model repositories lacked biological relevance and accuracy. the nih 3dpx covid-19 supply chain response (https://3dprint.nih.gov/collections/covid-19response) collection aims to establish standards for both industry and the community. the project is a collaboration among nih and the national institute of allergy and infectious diseases, the fda, the veterans health administration, and america makes, and emerges from a shared goal of enabling a rapid and safe response to the ppe supply chain through opensource solutions. the objective is to collate and review open-source ppe designs through a systematic and transparent process, resulting in a curated collection of designs that have been vetted and are recommended for community use or in a clinical setting, and designate if a device must have fda approval or adhere to other standards for manufacturing. the maker community has focused efforts on making two types of ppe: barrier ppe, such as face shields, and filtering ppe, such as face masks. the success in the fabrication of barrier ppe has been widespread. face shields are particularly amenable to fabrication using 3d printing due to their simple design, and several variants of face shield designs created in collaboration with medical professionals are available on the nih 3dpx. initial designs were launched by prusa (https://www.prusa3d.com/covid19/), with subsequent versions designed by budmen in collaboration with columbia university (https://studio.cul.columbia.edu/face-shield/), among others. in addition, to address the lack of widespread access to 3d printers, single-use face shields, such as the badger shield from the university of wisconsin (https://making.engr.wisc.edu/shield/), are made from foam and elastic. these types of opensource designs made from accessible materials have unified the global maker community. with this immediate success, makers turned their attention towards respirators. unfortunately, success in this domain has been limited. often labeled erroneously as n95 masks, although their quality is not high enough for them to be categorized as such, these home-made masks are 3d-printed models with an integrated filter medium. the quality of the masks can be assessed based on two factors: the fit to the user's face and the type of material used as the filter. in most of these masks, the role of the 3d component is creating an air-tight seal between the airway of the user and the filter material. as such, all of these models are judged based on their ability to conform to the user's face to create a seal, their ability to secure the filter material, and their impedance to air flow. makers have created numerous models to meet these challenges, including combining components from different models to address issues such as ease of printing, differing face geometries, and filter availability. the challenge of cushioning the rigid plastic to the relative softness of the human face has been addressed using various materials, such as foam or weather stripping, and even by multi-material printing. the majority of filters have been commercially available, offering modified versions for use with 3d mask models. some mask designs include mounting hardware to secure existing filter modules from name brand respirators. others have adopted the use of furnace or high-efficiency particulate air (hepa) filters with known ratings; however, there are risks, as many of these filters contain fiberglass. sourcing n95-grade filtering material is challenging, and it has been a limiting factor to the adoption of 3d-printed filtered masks. with these limitations, clinical use of current 3d-printed mask designs seems unlikely. disinfection plays a key role in the safety and well-being of healthcare workers and broader society. the conventional disinfection strategy includes a chemical treatment to remove any gross contaminants and then a secondary thermal, chemical vapor, or irradiation treatment to remove any remaining microscopic or nanoscopic materials. however, the conventional autoclave-style thermal treatment degrades some of the less robust plastic materials, and can degrade fiber-based structures. this limit forces medical facilities to rely on irradiation and chemical vapor methods, which are newer techniques and are not commonly found in smaller clinics. therefore, to increase the total amount of ppe available to healthcare workers, alternative ppe disinfection systems are needed. the primary limitation for the maker community in building a disinfection method is the acquisition of materials. for example, one approach demonstrated by a team from cleveland clinic and case western reserve university relied on re-purposing the disinfection capabilities based on ultraviolet-c (uv-c) light in biosafety cabinets scattered in dormant research labs (3). although successful and quick to implement, this approach relies on existing infrastructure. to overcome this limitation, an alternative strategy focused on distilling the conventional industrial uv-c system to its basic elements. in such a simplified system, the interior of a plastic bin is spray-painted with a reflective coating, and a conventional uv-c bulb is mounted on the side. thus, through judicious choice of source intensity and exposure duration, similar performance to that of commercial systems can be achieved (4) . the plastic tubs are lightweight and portable, but the throughput is moderate because only a few masks can be disinfected at once. additionally, although uv-c is ideal for the disinfection of plastic structures such as face shields, there are currently conflicting reports on its suitability for fiber-based materials. ventilators have captured the attention of makers worldwide since early waves of the pandemic flooded italy, and it became clear that hospitals lacked the needed quantities of not just ppe, but also equipment. although regulatory agencies such as the fda have been reluctant to approve any engineered designs due to the high risks of the life-or-death situations in which ventilators are required, maker efforts have continued in full force. given that the covid-19 outbreak extends across the globe, sharing designs online makes them available in countries not subject to the same restrictions, and where the need for life-saving equipment may be more desperate due to a lack of resources. teams of makers of varying background and experience, from students to veteran engineers, have coalesced at various institutions around the globe to innovate and create emergency ventilators. robert l. read, the founder of the nonprofit initiative public invention (https://github.com/pubinv/covid19-vent-list), has compiled an extensive repository of resources for open-source ventilators, including analysis and websites of over 80 projects. true to the principles of the maker community, many of the projects are providing frequent updates and open-source designs with documentation. the most established design currently is the e-vent from mit (https://e-vent.mit.edu/). this e-vent, first presented in 2010, automates manual resuscitators. other highly developed and tested designs include that of the ambovent initiative (https://1nn0v8ter.rocks/ambovent-1690-108), created by a team in israel, and of the open source ventilator project (https://simulation.health.ufl.edu/technology-development/open-source-ventilator-project/) from the university of florida. perhaps a sign of the inspiring forces generated by the maker movement, in a drastic step away from the traditional trade secrets of industry, medtronic released full design schematics for its ventilator. the design of ventilators requires close collaboration with clinicians and may not be an accessible undertaking for many makers. however, the community has found many other ways to contribute to the covid-19 pandemic. these contributions are reflected in the increased diversity of designs submitted to nih 3dpx meant to help relieve stress on the ears of healthcare workers due to wearing a mask all day, and the emergence of designs for hands-free door handles such as those released by materialise (https://www.materialise.com/en/handsfree-door-opener). many of these designs embrace the philosophy of the maker community that anyone can contribute, and has helped foster a sense of the community coming together in a time of public need. though not the original motivation for the maker movement, the benefit of these community-led efforts to the healthcare community and broader society during the covid-19 pandemic is undeniable. makers were able to quickly mobilize by leveraging existing tools for source-code dissemination, accelerating innovation and targeted problem-solving. notably, the covid-19 emergency has highlighted the power of the maker community to make a real and immediate impact. although the emergency use authorizations issued by the fda for face shields (https://www.fda.gov/media/136842/download) and for systems developed by industry, such as the battelle decontamination system (https://www.fda.gov/media/136529/download), which can disinfect thousands of masks at a time using a vapor-phase hydrogen peroxide, are only effective for the duration of the covid-19 crisis, this does not diminish the important role of the community as a stopgap in this time of need. in future times of crisis, we can learn from the present to harness the energy, creativity, and generosity of makers. figure 1| how the makers are helping. a) overview of the multi-faceted contributions of the maker community to the covid-19 pandemic. the dashed arrow indicates a supply line that is not fully established. b) a 3d-printed face shield. c) a 3d-printed face mask. d) a disinfection box using ultraviolet light. personal protective equipment supply chain: lessons learned from recent public health emergency responses the nih 3d print exchange: a public resource for bioscientific and biomedical 3d prints uv sterilization of personal protective equipment with idle laboratory biosafety cabinets during the covid-19 pandemic build-at-home uv-c disinfection system for healthcare settings webpage links (in order of appearance) • public invention the authors thank the army research office (w911nf1810033). current contributions from nih/niaid are funded in part through the bcbb support services contract hhsn316201300006w/hhsn27200002. the authors declare no conflict of interest. all authors contributed equally to the writing of the article.references: key: cord-002246-er9kqdjw authors: lim, seong mi; cha, won chul; chae, minjung kathy; jo, ik joon title: contamination during doffing of personal protective equipment by healthcare providers date: 2015-09-30 journal: clin exp emerg med doi: 10.15441/ceem.15.019 sha: doc_id: 2246 cord_uid: er9kqdjw objective: in this study, we aimed to describe the processes of both the donning and the doffing of personal protective equipment for ebola and evaluate contamination during the doffing process. methods: we recruited study participants among physicians and nurses of the emergency department of samsung medical center in seoul, korea. participants were asked to carry out doffing and donning procedures with a helper after a 50-minute brief training and demonstration based on the 2014 centers for disease control and prevention protocol. two separate cameras with high-density capability were set up, and the donning and doffing processes were video-taped. a trained examiner inspected all video recordings and coded for intervals, errors, and contaminations defined as the outside of the equipment touching the clinician’s body surface. results: overall, 29 participants were enrolled. twenty (68.9%) were female, and the mean age was 29.2 years. for the donning process, the average interval until the end was 234.2 seconds (standard deviation [sd], 65.7), and the most frequent errors occurred when putting on the outer gloves (27.5%), respirator (20.6%), and hood (20.6%). for the doffing process, the average interval until the end was 183.7 seconds (sd, 38.4), and the most frequent errors occurred during disinfecting the feet (37.9%), discarding the scrubs (17.2%), and putting on gloves (13.7%), respectively. during the doffing process, 65 incidences of contamination occurred (2.2 incidents/person). the most vulnerable processes were removing respirators (79.2%), removing the shoe covers (65.5%), and removal of the hood (41.3%). conclusion: a significant number of contaminations occur during the doffing process of personal protective equipment. ebola was first identified 40 years ago. 1, 2 however, little interest has given to this highly contagious pathogen until an outbreak was confirmed by the world health organization in 2014 in congo. 3, 4 disease spreads across nine countries and its death was toll of over 11,000 person in three west african nations, and people around the world began to concern about the ebola nowadays. ebola spreads through human-to-human transmission via direct contact (through broken skin or mucous membranes) or indirect contact with infected materials, such as clothing. [5] [6] [7] as other infectious diseases, healthcare workers are at risk of infection because they have to work at the frontline, often without protections. 8, 9 cases of contamination while treating ebola patients rose rapidly during the current outbreak, and the centers for disease control and prevention (cdc) announced the new personal protective equipment (ppe) guidelines for healthcare providers treating ebola patients. [10] [11] [12] however, even with protective clothing, a healthcare worker can be contaminated if removal is not done in a manner that prevents exposure. [13] [14] [15] a limited numbers of studies have been performed regarding contamination with ppe usage. in this study, our primary aim was to evaluate contamination during doffing. the secondary purpose was to describe errors and delays during donning and doffing. this study was performed in a single tertiary-level academic hospital (samsung medical center, seoul, korea). the hospital has a disaster plan and equipment such as ppe. however, no official training or education was provided before this study. we recruited 29 participants for the study from the emergency department physician and nursing staff. they were informed of the purpose of the study, and each gave written consent. participants received a 20-minute lecture. after the lecture, a 20-minute demonstration with ppes was given, along with an educational movie produced by the korea centers for disease control and prevention. the course content contains donning and doffing procedure for ppe (gowns, gloves, respirators, and goggles), according to a 2014 cdc protocol. a 10-minute question and answer session followed the demonstration. the lecturer was a certified advanced disaster life support instructor, experienced with several training sessions. after the training, each participant was paired with another, and completed the donning and doffing procedures with help from the partner. each team was blinded from the others; however, the second participants were more exposed to the process after watching the first. each person was allowed to watch the protocol and to consult their partners. though the 2014 cdc protocol was close to level d (level of ppe is divided a to d and level d is the lowest protection), we modified the airway protection by upgrading the n95 mask (particulate filtering face-piece respirators) to a gas mask. we also modified the 2014 cdc leg cover process. fig. 1 demonstrates the overall look of our study ppe. table 1 shows the difference between the cdc guideline and study protocol. a demographic survey was performed with all participants. the survey also included questions on job experience and previous training with ppe. during a simulation study, two separate cameras with high-density capability were set up at an approximate 120 degree angle to document the process. all processes were videotaped during ppe donning and doffing. afterward, a trained examiner reviewed all video recordings and coded timer intervals and errors. time stamps were determined according to a 2014 cdc protocol. each procedure was initiated when the participant picked up the equipment. the procedure ended when the next procedure was initiated. errors were determined when the participants violated the order of procedures even with the help of their partners. for example, if a participant skipped putting on a second glove and proceeded to the next procedure, this was counted as an error. errors during the process were explained by partners and instructors, so participants could resume the normal process. the primary outcome was a potential incident of self-contamination during the doffing procedure, defined as the touch of the outside of ppe to the participant's body or clothing. the determination of contamination was performed by a single examiner on the basis of two recordings. if one of the recordings did not have sufficient information, the determination was carried out with only one. if two recordings suggested opposite conclusions, the outcome was determined as negative. a single trained examiner was considered sufficient for the examination because the outcome measure was relatively simple. this choice was supported by pilot cases before the study began. statistical analysis was performed with stata ver. 13 (stata corp., college station, tx, usa). demographic data were reported in a descriptive manner. continuous variables were presented as means with standard deviations, medians and interquartile ranges, or a pilot study on the contamination of ppe frequencies. categorical variables were described as numbers and percentages. differences between the two groups were tested using the independent two-sample t-test or the mann-whitney utest for continuous variables and the chi-square test for categorical variables. p < 0.05 was considered significant. demographic characteristics of the study participants are shown in table 2 . overall, 29 participants enrolled in the study. twenty (69.0%) were female, and mean age was 29.2 years (standard deviation [sd], 2.39). the mean work experience was 3.33 years (sd, 2.67). among participants, 20.7% had previously received ppe training (table 2 ). values are presented as median (interquartile range) or number (%). one to twelve number of the table 3 shows step by step process. ppe, personal protective equipment. values are presented as median (interquartile range) or number (%). one to seventeen number of the table 4 shows step by step process the average donning process interval was 234.2 seconds (sd, 65.7) from start to finish. the most time-consuming process was putting on the gown, putting on shoe covers, and putting on the respirator. the most frequent errors occurred while putting on outer gloves (27.6%), respirator (20.7%), and hood (20.7%). the entire donning procedures refer to table 3 . the average interval during doffing was 183.7 seconds (sd, 38.4) from start to finish. the most time-consuming processes were removing the shoe covers, putting on gloves, and removing outer gloves. the most frequent errors occurred during disinfecting feet (38.0%), discarding scrubs (17.2%), and putting on gloves (13.8%). the entire doffing procedures refer to table 4 . fig. 2 illustrates contamination locations. during the overall doffing process, 65 contamination incidents occurred. the most vulnerable process was removing respirators, which caused 23 contaminations (79.3%). two of these were on the head (6.9%), and 21 were on the neck (72.4%). removal of shoe covers was also associated with a high probability of contamination; 19 incidents (65.5%) were reported. all locations of contamination were consistent with the doffing step related to that part of the body. even after standardized education, 65 numbers of contamination were reported, or 2.2 per participant. further studies are required to minimize this number. this study provides a valuable first step in the evaluation of ppe used by healthcare workers. this study suggests healthcare worka pilot study on the contamination of ppe ers should be cautious about decontamination and that they need training. donning, doffing, and decontamination procedures should be optimized for specific clinical situations. the strengths and limitations of each protective system need to be considered when recommendations are made about ppe implementation. this study shows that a significant number of contamination incidents occurred during the process of removing ppe. this is consistent with previous reports, which have pushed the cdc into announcing recommendations for ppe handling. 16, 17 although the study could not conclude which factors resulted in contamination, it is important to comment that more training with technical support is required for the safety of workers. potential measures include interactive audiovisual devices to guide the procedures, or trained personnel specialized in assisting others with the procedures. intensive and repetitive training is also required. recommendations for decontamination mainly emphasize hand washing. however, despite hand washing, healthcare workers could touch other parts of their bodies or clothing that has not been properly decontaminated and consequently infect themselves. 18 more intensive education and training is required for safe doffing. evaluation of the effectiveness of training is also required. previous studies have focused on the importance of ppe, potential risks of doffing procedures, and doffing procedure experiments comparing different systems with a few subjects. 18 one study demonstrated contamination rates of 26% and 96% with two distinct methods; this study included only one subject for each arm, which makes it difficult to compare the outcome with the current study. 18 this study gives additional information because of the larger numbers of subjects, and because the scenario has more generalizability than previous studies. this study does have some limitations. first, the study setting is a single center without an existing ppe training program. inhospital staff people were inexperienced, which may have been a factor increasing errors and contamination rates. however, a majority of hospitals are inexperienced with hazmat and ppe incidents, so these study results have general applicability. second, the study number was very small, including only emergency department staff people. this makes it difficult to generalize to a broader population of hospital staff. third, contamination sometimes appeared obscure on video and was subject to examiner's decision. though the examiner reviewed recordings several times from different angles, there could be blind spots and unobservable touches. this could have made the rates underestimated, in other words the false negative rate of the outcome measure could have increased. also, the video review could have missed subtle contacts. depending on a single examiner also could have influenced the accuracy of the outcome. however, even if contaminations were underestimated, the number of reported incidents is still alarming. finally, the study protocol was not identical to 2014 cdc guidelines. it excluded aprons, leg covers, and tape seals between parts of the gear. the donning and doffing procedures refer to tables 3 and 4 . this could be the reason that donning and doffing procedures were finished in very short intervals. the advantage of this study is as a pilot study, exploring the need of further, more accurate investigations. ebola virus ebola: the virus and the disease ebola and great apes in central africa: current status and future needs guinea interministerial committee for response against the ebola virus; world health organization ebola virus: identification of virion structural proteins treatment of ebola virus disease ebola virus disease, transmission risk to laboratory personnel, and pretransfusion testing increased interleukin-6 and high-sensitivity c-reactive protein levels in pediatric epilepsy patients with frequent, refractory generalized motor seizures ebola virus disease in health care workers: sierra leone cdc demonstrates new ebola protocols safe handling of ebola samples: guidance from the cdc new improved cdc ebola guidance health care worker quarantine for ebola: to eradicate the virus or alleviate fear? ebola virus disease cases among health care workers not working in ebola treatment units: liberia clinical documentation and data transfer from ebola and marburg virus disease wards in outbreak settings: health care workers' experiences and preferences cluster of severe acute respiratory syndrome cases among protected health-care workers: toronto, canada possible sars coronavirus transmission during cardiopulmonary resuscitation contamination: a comparison of 2 personal protective systems no potential conflict of interest relevant to this article was reported. authors thank to nurses of samsung medical centers for volunteering as participants for the study. key: cord-271603-zy4l9vtf authors: skali, hicham; murthy, venkatesh l.; paez, diana; choi, elisa m.; keng, felix y. j.; iain, mcghie a.; al-mallah, mouaz; campisi, roxana; bateman, timothy m.; carrio, ignasi; beanlands, rob; calnon, dennis a.; dilsizian, vasken; dondi, maurizio; gimelli, alessia; pagnanelli, robert; polk, donna m.; soman, prem; einstein, andrew j.; dorbala, sharmila; thompson, randall c. title: guidance and best practices for reestablishment of non-emergent care in nuclear cardiology laboratories during the coronavirus disease 2019 (covid-19) pandemic: an information statement from asnc, iaea, and snmmi date: 2020-10-17 journal: j nucl med doi: 10.2967/jnumed.120.251355 sha: doc_id: 271603 cord_uid: zy4l9vtf nan the coronavirus disease 2019 (covid-19) pandemic is affecting healthcare systems and resources around the world in an unprecedented manner. based on recommendations from the numerous medical specialty societies and governmental agencies such as the united states centers for disease control and prevention 1 and centers for medicare & medicaid services 2 , non-urgent procedures and tests were either canceled or postponed during the buildup to and decline from the pandemic's peak. the american society of nuclear cardiology (asnc) and the society of nuclear medicine and molecular imaging (snmmi) issued an information statement 3 with guidance for nuclear cardiology laboratories during the covid-19 pandemic in late march 2020 that also recommended delaying all non-urgent studies. reestablishment of non-emergent care 4 in nuclear cardiology laboratories will require a careful approach to continue to mitigate the risk of viral transmission while also providing crucial cardiovascular assessments for our patients. the current document prepared by asnc, snmmi, the international atomic energy agency (iaea) and the infectious disease society of america (isda) describes potential practices for this reestablishment, reflecting diverse settings from the united states and worldwide. it is important to note that these recommendations are primarily based on expert opinion, not systematically tested, and may provide guidance to supplement guidelines, regulations and legislation as well as institutional infection control policies. 2 a survey of the authors' opinions regarding several issues outlined in this document is available in the online supplement (supplemental materials are available at http://jnm.snmjournals.org). 1. timing should follow national, state and local regulations and recommendations. 4-6 2. healthcare facilities should have adequate equipment and personnel and not be in crisis management mode or diversion mode. for inpatient laboratories, there should be available hospital beds and intensive care unit beds. 3 . in general, we recommend that utilization of nuclear cardiology services parallel opening of upstream and downstream resources such as clinics, catheterization laboratories, operating rooms and other services, so as to facilitate uniform care delivery. b. covid-19 testing: the diagnosis of covid-19 is based on the detection and identification of the virus by means of the reverse transcription polymerase chain reaction (rt-pcr), a molecular diagnostic technique based on the detection of specific genetic sequences of the virus. antibody tests detect immunoglobulin antibodies from an immune response to sars-cov-2 and are not appropriate for diagnosing current covid-19 infection. laboratories should rely on molecular tests to diagnose the presence of sars-cov-2 infections. however, a negative molecular test result does not rule out covid-19 for several reasons. some patients may have negative initial tests due to low viral load during the early days of infection or inadequate sampling of the posterior nasopharynx. thus, social distancing and ppe are critical to prevention of laboratory transmission of covid-19. when testing capacity allows, using a molecular test to test for covid-19 infection prior to appointments in the nuclear cardiology laboratory is recommended combined with screening patients for a fever and symptoms consistent with covid-19 infection upon arrival for testing appointments. patients who are known to have an active infection with the covid-19 virus should in the vast majority of cases have their nuclear cardiology test deferred. the implementation of preventive and mitigation measures is essential. the most effective preventive measures include performance of proper hand hygiene; avoidance of touching eyes, nose and mouth; practice respiratory hygiene when coughing or sneezing; wearing a medical mask and maintenance of physical distancing (ideally 2 meters or more). 8, 9 d. personal protective equipment (ppe): the goal of ppe use is to protect healthcare providers and patients and predominantly to minimize spread from asymptomatic individuals and surface exposure. 10 healthcare workers require additional precautions to protect themselves and prevent transmission in the healthcare environment. precautions include wearing proper ppe and donning and doffing items properly. recommendations for ppe use vary by institution, region and country and the type of ppe recommended will usually be based on institutional or regional policies. currently most healthcare centers in the united states require universal use of a surgical mask by staff and visitors with selective use of more advanced ppes. as nuclear cardiology and other laboratories re-expand their operations, a sufficient and increasing quantity of ppe will be required for protection for healthcare personnel and patients. ppe use is currently recommended throughout the nuclear laboratory when indicated; this use should follow national, state/regional, and local public health policies and recommendations. a. before the test: 1. prioritization of a study request: as we move into the next phase of the covid-19 pandemic, in which newly diagnosed cases have declined in many regions, regulations are permitting flexibility and allow facilities to reinstate services for patients needing non-emergent non-covid-19 care. urgent patients should continue to be tested first and as quickly as prudently possible while ensuring patient and healthcare provider safety. it is important to remember that many of the patients with higher priorities are typically symptomatic whose risk of a cardiac event is not insignificant. • for patients of equal urgency, those who have been waiting the longest for their procedure should be the first to undergo testing. • many patients have had testing delayed for several weeks during the period of sheltering in place; it is important for the provider team to maintain contact with patients and to encourage them to report changes in symptoms. • due to the delay in testing, extra caution needs to be exercised by clinical staff, including supervising physicians, as the patient's clinical status may have deteriorated to the point where stress testing may no longer be safe or appropriate. • for some patients requiring prior approval from the insurance carrier, the approval may have expired and need to be reinstated. however, some radiology benefit management companies in the united states have recently extended the time period before expiration during the pandemic. • case prioritization can be performed primarily by laboratory professionals but is most commonly decided collectively and in collaboration with other colleagues from cardiology, surgery, and other disciplines. • early during the covid-19 pandemic, many facilities prioritized patients being scheduled and those already scheduled according to the perceived clinical urgency of the study. please see an example of a prioritization scheme using four categories in table 1 . some laboratories use a 3-category scheme instead. 3 2. scheduling a patient: scheduling of patients should take into account a number of parameters including institutional and laboratory resources for safe performance of testing during the covid-19 pandemic. • institutional policies: when increasing patient volume through the nuclear cardiology laboratory, it is also important that this be coordinated with the affiliated institution to ensure that service delivery is consistent with their overarching plan during the pandemic. • staff: availability of laboratory staff is an equally important consideration, especially if many have been redeployed, furloughed or become ill as a result of the pandemic. • operating hours: as utilization increases, laboratories should consider extending to early/late hours and/or weekend testing to allow the backlog of patient tests to be completed and to allow more effective social distancing. this approach should be balanced with availability of staff and key equipment, especially ppe. • phased opening: a phased opening with a ramp up period is generally recommended by health agencies 2 . for example, 25% of a standard case load might be planned for the first 1-2 weeks, 50% case load in weeks 3 and 4, and then greater caseloads if conditions permit. concomitant overlapping cases should be avoided to provide for appropriate social distancing. • adequacy of supplies: to reestablish operations it is necessary to ensure the availability of radioisotopes which are produced in a limited number of facilities worldwide. one of the effects of the pandemic has been the disruption of distribution channels, including international cargo flights. in addition, many radiopharmacies have either furloughed or laid off staff because of reduced demand over the period of sheltering in place during the pandemic. • resources: in addition, the laboratory needs to ensure that they have adequate resources to safely perform testing, keeping in mind that the demand for certain equipment will grow as other healthcare providers ramp up deferred services. • communication/patient concerns: a significant proportion of patients may decline testing because of concerns about the risk of contracting covid-19 by visiting the testing facility. institutions must provide referring physicians detailed information about steps taken by the laboratory to minimize the risk of covid-19 infection. referring providers must remind patients about the real and significant risk of not undergoing testing. staff scheduling patients should have scripting available to screen patients for symptoms consistent with covid-19 to reassure patients, including a description of the additional precautions that are being undertaken by the laboratory to minimize covid-19 infection risk. if a patient refuses to undergo testing it is of the utmost importance for the nuclear cardiology laboratory to inform the referring physician to let them know of the patient's decision so that they can contact the patient to discuss this further and make alternate arrangements. • tracking: establishment of proper systems to track canceled or postponed studies is very important. providers should establish a priority score that can include indication for testing and overall cv risk, and covid-19 risk. b. day of testing: specific precautions are recommended on the day of the test at the time of arrival, during the imaging test and during the stress test to minimize covid-19 exposure risk as outlined below. an important principle is to minimize the amount of time spent by patients in the nuclear cardiology laboratory or at the associated institution to reduce risk both for patients and staff. 1. arrival/registration: a key goal is to avoid overcrowding of the elevators, waiting rooms, corridors, and scanners while not delaying patient care. the test procedures need to allow for adequate social distancing between patients before and during the whole testing process. • appropriate physical distancing should be maintained at all stages of patient engagement, including registration, waiting areas, and consent. waiting areas and processes should be arranged to allow appropriate physical distancing. in addition, accompanying visitors and family members should not be allowed or should be limited to one person and only if their presence is essential. if the facility has significant space constraints, consideration should be to having patients wait in their vehicles until contacted by cellphone by a member of the nuclear cardiology laboratory staff. the patient would then be met at the entrance of the facility by the staff member and escorted to the laboratory. • the use of telehealth to assess patients for new symptoms, to register the patient, to provide them with details about the test to be performed, and to obtain verbal consent is generally recommended. processes should also be automated as much as possible to reduce face to face interaction. some onsite administrative steps can be performed through the patient's smartphone. the healthcare screening questionnaire should be thorough. • temperature measurements and a screening questionnaire for all patients are generally recommended at arrival to healthcare facility and to nuclear laboratory. • face covering or masks are currently mandated at most medical centers (surgical/cloth/specific mask type as determined by local rules and infection control) for all patients, visitors, and healthcare personnel. • review indication for testing at registration or immediately upon a patient's arrival in clinical areas to ensure that the test is still indicated and urgent. changes in symptoms and/or health status may either render the test not indicated or demand a different test. the overarching goals are to perform rapid and hygienic imaging to minimize covid-19 exposure to healthcare professionals and patients. a. protocol selection • for spect myocardial perfusion imaging studies, elect stress first/stress only imaging when possible to potentially decrease duration of the study, and consider rapid acquisition protocols when feasible. • for spect myocardial perfusion imaging studies in inpatients who are not eligible for stress only testing, consider performing the rest injection in the patient's inpatient room, to avoid completely or minimize waiting time in the laboratory. a typical protocol would begin with a technologist bringing a dose of technetium-99m sestamibi or tetrofosmin to the patient's inpatient room, checking the intravenous line, and injecting the dose. after a suitable delay, the patient is transported to the laboratory, directly to a waiting open camera, where rest imaging is performed. after an appropriate delay, when the patient waits in their hospital room, he or she is brought to an open stress room where stress testing is performed. after stress testing, the patient is transported back to their room, and returns to a waiting open camera approximately 1-1.5 hours after stress injection. • for technetium-99m pyrophosphate (pyp) scans in inpatients, consider injecting the patient and allowing him/her to leave the laboratory, returning for imaging after the laboratory protocol delay. • for n-13 ammonia pet myocardial perfusion imaging studies, consider performing a protocol facilitating a single rest/ stress session on the camera with enhanced social distancing, and avoid the patient leaving the camera room between rest and stress sessions and the camera needing cleaning multiple times. a low-dose rest, high-dose stress protocol may enable a more rapid single-session imaging. b. imaging time slots may need to be expanded and extra time should be allowed for cleaning rooms, cameras, chairs, and other surfaces between patients. c. appropriate cleaning of equipment between cases is essential. d. for outpatients requiring rest imaging, consideration could also be given to performing this on a separate day to give greater control of workflow and minimize time within the department, although this approach may be less appropriate in some settings and needs to be balanced by the downside of using more ppe for 2-day imaging. e. for laboratories with access to myocardial perfusion pet using rb82, this modality is preferred because of its time efficiency. a complete rest-stress pet mpi study can be acquired within 30 to 45 minutes, not only minimizing exposure for patients and staff, but also potentially reducing number of rooms and spaces which could experience surface contamination and possibly reducing staffing needs. f. for patients tested with spect-ct or pet-ct instrumentation in regions with higher prevalence of covid-19 infections, some laboratories recommend a policy of reviewing the chest ct images before the patient leaves the laboratory. for patients who have lung infiltrates seen on chest ct images, they may require further evaluation for possible covid-19 infection. 12 3. stress laboratory considerations: the goals are to perform a safe test for the patient and minimize droplet exposure to healthcare professionals and patients. • if possible, consider pharmacologic testing preferably using vasodilator stress agents to decrease droplet exposure risk, 9 especially in patients who are not known to be covid-19 negative. patients breathing heavily during exercise may generate droplets and traditionally stress test personnel are in close proximity to patients. pharmacologic testing is not inferior to exercise testing in terms of diagnostic performance. regadenoson may be the preferred stress agent (if available and not contraindicated), since it requires a single 10 second infusion, after which providers can maintain a safe distance from the patient. for adenosine and dipyridamole stress testing, extralong tubing can be used to keep distance between staff and patients. • if after careful consideration, exercise testing is determined to be necessary, it is recommended to use a higher-level ppe for staff (for example n95/ffp2/p2/ds/kn95/korea 1 st class respirator or equivalent, face shield, gloves and gown) and surgical mask or face covering for patients, assuming these supplies are available, 11 and extra time should be allowed in order to clean the room. • appropriate cleaning between patients is required. an important goal of an ongoing monitoring process is to refine policies and procedures as needed in response to the evolution of the covid-19 pandemic as the laboratory operations resume to include more elective procedures. a. additional data collection and monitoring may be warranted. the nuclear cardiology laboratory's protocols and patient scheduling templates will need to be closely monitored and refined multiple times over the coming months as the covid-19 pandemic slowly recedes, with potential for local or widespread waves of new covid-19 infections. data collection and monitoring will be necessary to inform the need to modify existing laboratory policies. some suggested parameters for collecting and monitoring and potential responsive changes to laboratory workflow are listed in table 2 . b. availability of laboratory personnel might be impacted by redeployment to other work responsibilities in the healthcare system during the covid-19 pandemic, staff quarantine to home due to covid-19 infection of the staff or their close contacts, and other non-covid-19 related issues. c. laboratory testing hours should be adjusted as needed. • expansion of testing might need to be suspended completely if essential laboratory personnel are unavailable. similarly, if the supply of ppe or covid-19 testing is interrupted, test scheduling would need to be reduced to allow for adequate supply of ppe and covid-19 testing for other patient care areas of higher priority. • if, however, there is a large backlog of orders for nuclear cardiology procedures as a result of deferred testing during the height of the covid-19 pandemic, laboratories might need to consider temporarily extending weekday hours of operation or weekend testing to accommodate a surge in patient volume. the feasibility of extending hours of operation will depend of the availability of laboratory personnel, ppe, and covid-19 testing. d. tracking of total time required for nuclear cardiology procedures is desirable. this includes time required to fully clean and disinfect the stress testing equipment and the imaging equipment. this information will inform patient scheduling templates. while one cannot predict the potential for a second or subsequent waves of covid-19 pandemic, numerous public health authorities are warning that it is possible, and procedures need to be in place to mitigate the adverse effects of a second wave. hence, it is important to follow the steps below: • providers and institutions should monitor local data and follow national, state, and department of public health recommendations for possible second covid-19 waves that may require decreasing nuclear cardiology laboratory activities and enhanced protective measures. • physical distancing and masking should be maintained for the foreseeable future. • limitations on visitors and accompanying persons should be continued for the foreseeable future as well. trainees are an important part of nuclear cardiology programs and laboratories. during the covid-19 pandemic, many trainees have been redeployed from their imaging rotations to clinical care of covid-19 patients in the hospital and intensive care units. if the pandemic continues, trainee education needs to be revised to use novel training methods including web and video-based approaches to learning. new educational procedures need to be consistent with policies from stakeholders such as the accreditation council for graduate medical education, american board of internal medicine, american board of nuclear medicine, american board of radiology, and nuclear regulatory commission. this is particularly pertinent for hands-on education in the stress laboratory, hot laboratory, and radiopharmacy, which may need to be adapted to video methods. the number of cases required for graduation may need to include a larger percentage of virtual educational sessions, in compliance/collaboration with certifying agencies including the certification board of nuclear cardiology, american board of internal medicine, the american board of nuclear medicine, and the american board or radiology. • staff should be monitored for wellbeing during these sometimes-stressful times, especially if required to work long hours and if they are redeployed to unfamiliar areas. • in the united states, nuclear cardiology services are often impacted by the details of the patient's health insurance policy and enforcement by radiology benefits managers. more advocacy effort will be required to convince these oversight agencies to allow relaxation of previous policies on prior authorization and flexibility for longer approval windows and to resist one-size-fits-all prescribed approaches. • laboratory leadership should consider redeployment of physician and nursing staff away from routine (elective) office activities until backlog has been reduced, especially for higher priority patients. this approach will help get the higher risk patients whose tests have been deferred completed, while not adding more and more higher priority patients to the schedule. • nuclear cardiology laboratory operations, of course, are part of the local healthcare systems and work in conjunction with other departments in the hospital and areas of the medical practice. most of the suggestions outlined above must be instituted in concert and collaboration with other key departments. the unprecedented covid-19 pandemic has disrupted healthcare systems, including nuclear cardiology laboratories around the world, severely reducing their services. as the health crisis recedes, nuclear cardiology laboratories are able to gradually expand operations while maintaining appropriate safe practices. this document lays out guidance about best practices, but it is important to recognize that conditions are quite different in various locations and will change in the coming months. an individualized, adaptable, and thoughtful approach that coordinates with other providers and public health authorities will be needed for the foreseeable future. center for disease control and prevention. healthcare facilities: preparing for community transmission non-emergent, elective medical services and treatment recommendations guidance and best practices for nuclear cardiology laboratories during the coronavirus disease 2019 (covid-19) pandemic: an information statement from asnc and snmmi. j nucl cardiol national coronavirus response: a road map to reopening guidelines: opening up america again. proposed state or regional gating criteria opening up america again. centers for medicare & medicaid services (cms) recommendations: re-opening facilities to provide non-emergent non-covid-19 healthcare: phase i covid-19 testing by laboratories: q and a who -coronavirus disease (covid-19) pandemic towards aerodynamic equivalent covid-19 1.5 m social distancing for walking and running covid-19 pandemic: guidance for nuclear medicine departments rational use of personal protective equipment (ppe) for coronavirus disease (covid-19 adapting to a novel disruptive threat: nuclear cardiology service in the time of the coronavirus (covid-19) outbreak 2020 (sars reboot) key: cord-007571-xzm36og6 authors: valdez, anna maria title: are you covered? safe practices for the use of personal protective equipment date: 2015-01-19 journal: j emerg nurs doi: 10.1016/j.jen.2014.11.011 sha: doc_id: 7571 cord_uid: xzm36og6 nan e mergency nurses frequently encounter patients with a known or suspected infectious illness. to prevent the spread of infection and injury, emergency nurses must be well prepared to appropriately select and use personal protective equipment (ppe). furthermore, emergency nurses must have readily available access to ppe, as well as effective and timely training, including routine fit testing for respiratory protection. 1, 2 according to the occupational safety & health administration (osha), when ppe is required, training for health care personnel must include the identification of the correct ppe; how to properly put on (don), wear, and remove (doff) equipment; limitations of ppe; and how to appropriately maintain and dispose of ppe. 3 personal protective equipment ppe is defined by osha as "specialized clothing or equipment worn by an employee for protection against infectious materials." 1 in health care, ppe includes a range of items including but not limited to gloves, gowns/aprons, masks and respirators, goggles, face shields, and foot/leg covers. when selecting ppe, emergency nurses must consider the type of anticipated exposure and be knowledgeable about current standards set forth by the centers for disease control and prevention (cdc) and organizational policy. 1,2 the cdc sets the standard for ppe selection and use in health care settings within the united states. 1 these standards are based on the type of precautions required to prevent the spread of infection and include standard precautions (formerly termed universal precautions), as well as 3 categories of expanded precautions: contact, droplet, and airborne infection isolation. 2 standard precautions are required any time an infectious agent may be present in a patient's blood or body fluids. this type of precaution is used for contact with all patients, hence the term "standard precautions." 2 the amount and type of ppe used for standard precautions depends on the expected exposure that the health care provider will have with the patient. for example, gloves must be worn when contact with blood or bodily fluids is anticipated. during procedures when bodily fluids may splash or spray, health care providers should also be wearing fluid-resistant gowns, a mask and goggles or face shield, and shoe covers. 1 contact precautions contact precautions are required as an expanded transmissionbased precaution when infectious agents may be spread through touch either directly with the patient or indirectly with objects in the environment of care. 1 examples of illnesses that require contact precautions are norovirus, rotavirus, and clostridium difficile. 4 patients who are suspected or known to have an illness that can be spread through touch contact need to be placed in a private room or in a room with other persons who have been colonized with the same organism. 1 they also need to be treated with dedicated equipment that can be left in the room. anyone entering the room who may come in contact with the patient or objects in the room must wear a gown and gloves. ppe, including gowns and gloves, should be removed before leaving the room or in an anteroom if available. 2 as with all patient contact, thorough hand hygiene is critical to prevent the spread of infection. droplet precautions are necessary when infectious pathogens can travel from the respiratory tract of the patient over short distances (usually less than 3 ft, but the distance can extend up to 10 ft). 2 transmission of infection through droplet exposure generally occurs when a patient sneezes, coughs, talks, or undergoes invasive procedures such as endotracheal intubation or suctioning. 2 examples of infections that can be spread through droplet exposure include influenza, bordetella pertussis, respiratory syncytial virus, and severe acute respiratory syndrome-associated coronavirus. 1, 2 in addition to taking other appropriate standard precautions, emergency nurses should be wearing a face mask when in close proximity to patients requiring droplet precautions. 2 according to the cdc, "airborne transmission occurs by dissemination of either airborne droplet nuclei or small particles in the respirable size range containing infectious agents that remain infective over time and distance." 2 in addition to proper use of ppe, controlling the spread of infectious agents that can be transmitted via an airborne route requires special air handling and ventilation systems. examples of infections spread through airborne transmission include mycobacterium tuberculosis, rubeola virus (measles), and varicella-zoster virus (chickenpox). patients with suspected or known infection that can be transmitted via the airborne route should be placed in an airborne isolation infection room, and health care providers must wear respiratory protection certified by the national institute for safety and health at n95 or higher when they enter the patient's room. 2 complex transmission precautions infectious agents may fall into several transmission categories and require a combination of precautions to prevent the spread of infection. one example of an infectious illness that requires health care providers to adhere to multiple levels of precautions is the ebola virus disease (evd). health care providers who are caring for a patient with known or suspected evd must adhere to standard, contact, and droplet precautions. 5 recently the cdc issued revised standards for evd precautions, which include detailed guidance on the types of ppe required during patient care and strategies for ensuring safe practice. 6 because of the complex and detailed nature of the guidance on caring for a patient with known or suspected evd, emergency nurses should seek information about precautions and ppe standards directly from the cdc web page at http://www.cdc.gov/vhf/ebola/hcp/index.html. emergency nurses can also gain current and accurate information about how to safely triage and screen patients for evd, manage their care, and select and utilize ppe by accessing the ena ebola resource page located at http://www.ena.org/about/media/ebola/pages/default.aspx. the intent of ppe is to prevent harm to the health care provider; however, the use of ppe is not without risk, especially when wearing ppe that limits movement or when wearing respirators. risk of injury from the use or misuse of ppe can be addressed by implementing safety strategies in the emergency setting. examples of strategies that can be used to prevent injury include strict adherence to infection control precautions, hands-on and in situ training, and staffing that supports safe care. to prevent the spread of infection, emergency nurses must follow appropriate infection control precautions and use ppe as recommended by the cdc and organizational policy. in a study by nichol et al, 7 it was found that fewer than half of the nurses involved in the study met adherence standards for the recommended use of ppe. this finding is also supported by a literature review conducted by gammon et al, 8 who found that compliance with infection control precautions is unacceptably low among health care providers. in addition, nichols et al 7 found that emergency nurses were 60% less likely to report adherence with infection control procedures than were critical care nurses. 7 this finding is supported by an observational study by creedon et al, 9 who found that compliance with hand washing was lower in the emergency setting than in other areas of the hospital. known barriers to achieving optimal compliance include lack of training, time constraints, and lack of readily available ppe. 7, 8 emergency nurses and organizational leadership should explore ways to improve adherence to infection control procedures in the emergency setting. considering that the total number of infectious illness outbreaks have been increasing since 1980, 10 and with the recent emergence of infectious illnesses in the united states, including evd and enterovirus d68, the need for strict adherence to infection control protocols cannot be overstated. comprehensive training on infection control protocols and the proper use of ppe is a critical component of safe care delivery in the emergency setting. nichol et al 7 found that fewer than half of the nurses observed in their study demonstrated competence when using an n95 respirator. another finding in this study was that only half of the participants reported having received recent training or fit testing. participants that had been trained and fit tested in the prior 2 years were 1.66 times more likely to report adherence with recommended use of ppe. 7 the cdc recommends that health care providers receive repeated training and demonstrate competency in performing all ebola-related infection control practices and procedures, including donning and doffing proper ppe before engaging in patient care activities. 11 this guidance can be applied for all types of infection control precautions and is particularly important when n95 or powered air-purifying respirators (paprs) are used. 12 the use of respirators, particularly paprs, requires comprehensive training to ensure competency, 12 and failure to properly use this equipment could place the emergency nurse at risk for acquiring an airborne infection. according to the cdc, another area of ppe training that should receive special focus is the doffing procedure. historically, this part of the ppe sequence may not have been emphasized in the training process, but recent cases of the acquisition of evd by nurses have demonstrated that doffing ppe is a high-risk period that requires careful attention to detail, monitoring by a trained observer, and a designated space for equipment removal. 11 in addition to understanding how to properly select and use ppe, emergency nurses need to have practice in using ppe in realistic patient care situations. the use of ppe can affect clinical performance by limiting manual dexterity, impairing hearing and communication, and causing discomfort for the user. [12] [13] [14] [15] hands-on practice allows the user to be better prepared to provide safe patient care while wearing ppe. a strategy that can be used to prepare health care providers to provide safe care in the emergency setting is the use of in situ simulation training sessions. 16, 17 in situ simulation is a team-based training process that involves the use of a standardized scenario in the practice environment using actual unit staff, equipment, and resources. 15 regular practice using ppe in realistic simulation scenarios will aid members of the emergency care team in developing and maintaining competency. safe staffing patterns should be considered when planning care for patients with infectious illness. the cdc recommends that health care providers have adequate time to properly don and doff equipment before engaging in patient care. when engaged in the care of a patient with evd, this donning and doffing procedure should be monitored by a trained observer. 10 radanovich et al 13 conducted a study on respirator tolerance in health care providers and found that a significant portion of the study participants were unable to tolerate wearing a respirator for an 8-hour shift, even with break periods. shenal et al 15 also found that health care workers experienced increasing discomfort when wearing respiratory protection over a prolonged period. when health care providers are wearing paprs and fullbody coverage, especially when they are engaged in complex patient care activities, the period in ppe that is tolerable may be even shorter. planning should be in place to ensure that health care providers have adequate periods of rest without wearing ppe. in complex care situations, such as the care of a patient with evd, providers may require extended rest periods to prevent heat stress, fatigue, and dehydration. the united states department of health and human services 18 lists psychological stress, heat stress, and dehydration as risks associated with the use of ppe during chemical emergencies. to minimize the risk of injury, first responders are advised to obtain baseline vital signs and weight prior to donning equipment and after doffing equipment, hydrate before and after using ppe, monitor total time in ppe, and minimize time in ppe when possible (especially when wearing the highest levels of protection). 18 given the similarities in ppe that are recommended for the care of patients with evd and the types of ppe used during chemical and biological hazards, it may be prudent to integrate these safety measures into organizational policies and procedures for the use of paprs in the care of patients with evd. this step would require additional staff to assess providers before and after use of ppe; however, the "trained observer" recommended by the cdc could be used in this capacity. emergency nurses work in a hazardous environment. to minimize the risk of injury, emergency nurses must maintain competency in infection control measures and the use of ppe. the cdc and john hopkins medicine have created a web-based training program for the safe donning and doffing of ppe that can be accessed online at http://www.cdc.gov/vhf/ebola/hcp/ppe-training/index. html. although this type of training is important, emergency nurses should also advocate for regular handson training with ppe to ensure competency with equipment and supplies available in their work setting. emergency nurses should ensure that they have been fit tested for an n95 respirator and know the appropriate size to use when providing patient care. finally, emergency nurses can minimize risk of injury by committing to strict adherence to infection control standards. guidance for the use and selection of personal protective equipment (ppe) in healthcare settings guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings occupational safety & health administration. personal protective equipment basic infection control and prevention plan for outpatient oncology settings: transmission-based precautions ebola (ebola virus disease): when caring for suspect or confirmed patients with ebola ebola (ebola virus disease): information for healthcare workers and settings behind the mask: determinants of nurse's adherence to facial protective equipment a review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions hand hygiene compliance: exploring variations in practice between hospitals global rise in human infectious disease outbreaks guidance on personal protective equipment to be used by healthcare workers during management of patients with ebola virus disease in u.s. hospitals, including procedures for putting on (donning) and removing (doffing) personal protective equipment for care of pandemic influenza patients: a training workshop for the powered air purifying respirator respiratory tolerance in health care workers respiratory and facial protection: a critical review of recent literature discomfort and exertion associated with prolonged wear of respiratory protection in a health care setting highreliability emergency response teams in the hospital: improving quality and safety using in situ simulation training in situ simulation: detection of safety threats and teamwork training in a high risk emergency department united states department of health and human services key: cord-281627-8cq18gja authors: hon, chun-yip; gamage, bruce; bryce, elizabeth ann; lochang, justin; yassi, annalee; maultsaid, deirdre; yu, shicheng title: personal protective equipment in health care: can online infection control courses transfer knowledge and improve proper selection and use? date: 2008-12-31 journal: american journal of infection control doi: 10.1016/j.ajic.2008.07.007 sha: doc_id: 281627 cord_uid: 8cq18gja we used observational evaluation to assess the ability of an online learning course to effectively transfer knowledge on personal protective equipment (ppe) selection and removal. during orientations for new hospital staff, 117 participants applied either airborne, droplet, or contact precautions in mock scenarios. postcourse, all 3 scenarios demonstrated improvement in ppe sequence scores (p = .001); moreover, hand hygiene also was more frequent during both donning and doffing of ppe (p < .001). the use of personal protective equipment (ppe) is required in health care settings to protect health care workers (hcws). the choice of ppe is dictated by the route of transmission of the putative agent as well as by the clinical situation and may consist of a combination of gloves, gown, eye and/or facial protection (efp), and mask or n95 respirator. the appropriate ppe items must be selected, and the items must be put on and removed in the correct sequence to minimize the risk of exposure. this principle was illustrated during the severe acute respiratory syndrome (sars) epidemic in 2003 when some hcw infections possibly resulted from the improper use of ppe. 1, 2 through the use of consistent messages, images, and videos, online training has the potential to instruct hcws about ppe in a standardized and accessible manner. [3] [4] [5] [6] studies show that online training courses are as effective as traditional teaching methods. [3] [4] [5] [6] although ppe use has been researched, 7-12 how well online training imparts this knowledge to hcws has not been widely evaluated. the present study evaluated ppe selection and use by hcws through observational analysis, both before and after the hcws took an online infection control course. all new staff members at vancouver general hospital and its affiliated long-term care and rehabilitation facilities are required to take a 30-minute online infection control course as part of a 4-day orientation program. the course uses graphics, videos, and text to teach the principles of infection control, hand hygiene (hh), and ppe use. 13 to assess whether or not the course actually improves ppe selection and use by hcws, observational analysis was used to assess the transfer of learning from the course to the hcwsõ behavior. 14-17 from march to june 2007, nurses, care aides, and allied health staff attending the orientation program were invited to participate in a structured observation of ppe use before and after taking the infection control course. a total of 145 hcws were recruited (100% of all orientation program attendees), but only 117 complete observations precourse and postcourse were collected. all of the hcws provided informed consent before participation. in the hospital setting, patients are placed under airborne, droplet, or contact isolation precautions, depending on the mode of transmission of the putative agent. three scenarios were created, each requiring the application of 1 of these 3 precautions and based on the course-embedded videos demonstrating ppe use (based on health care guidelines). [18] [19] [20] [21] the scenarios reflected typical events in health care and were designed to initiate the minimally required steps in using ppe. the ratio of observers to participants was 1:1. the observer randomly selected a clinical scenario. then the participant was oriented to a mock patient room; the scenario was read aloud; the specific precaution was stipulated; and the participant was instructed to select, put on (don), and take off (doff) the appropriate ppe. immediately after completing the infection control course, the participant was provided with the same scenario and given the same instructions. the observer team was composed of professionals in occupational health, infection control, patient safety, and education. interobserver variability was minimized with prepared scripts and a standardized form outlining the accepted ppe use for each scenario. to ensure consistency, the observers were trained in groups in all scenarios. observers were supervised onsite, and all observations were recorded on the standard form. thirty participants per scenario were required to achieve a predetermined significance level of , .05; therefore, a target number of 40 participants per scenario was set. the observation forms were scored twice, once for ppe selection and once for the donning and doffing sequence. for ppe selection, a participant scored ''0'' if no errors were made; points were allotted for each error. errors were classified as high or low risk (to hcws and patients alike), with weighting based on established infection control principles. [18] [19] [20] 22 for the ppe sequence evaluation, the participant was given a ''1 point, 1 task'' score based on the observed structured clinical examination method, with a total maximum score based on the number of donning and doffing and hand hygiene tasks performed. 23, 24 the participant's precourse and postcourse scores were compared using paired t-tests, with comparative analyses computed collectively and for each of the 3 scenarios. analyses were done using spss for windows version 14.0 (spss inc, chicago, il). hh guidelines recommend a certain frequency of hand cleaning, depending on the type of isolation precaution. 18, 19, 25, 26 in these observations, the participant's use of the prescribed hh opportunities for each scenario was recorded. the hh score was calculated by multiplying the number of hh opportunities by the number of subjects in each scenario. the total hh score was compared with the maximum possible score. percentages of the total score were compared using the x 2 test. precourse and postcourse paired observations were fully completed by 117 participants (airborne precautions, n 5 37; droplet precautions, n 5 39; contact (2) or no mask whatsoever (2) . three points against for low-risk selection: using eye/face protection (1), gown (1), or gloves (1) (overprotection). y droplet precautions selection: four points against for high-risk selection: no eye and face protection (2) or no mask (either surgical mask or n95 respirator) (2) . two points against for low-risk selection: either no gown (1) or no gloves (1). z contact precautions selection: four points against for high-risk selection: no gloves (2) or no gown (2) . two points against for low-risk selection: using eye and face protection (1) or mask (surgical mask or n95 respirator) (1). precautions, n 5 41). most of the participants (81.2%) were nurses; the others were care aides and licensed practical nurses (12%) and allied health personnel (6.8%). nearly 55% of the participants had less than 1 year of experience in their current profession. a statistically significant improvement in scores postcourse (p 5 .043) was observed overall when proper selection of ppe was reviewed. this improvement was attributed largely to improved selection of ppe for the droplet precautions clinical scenario (table 1) . interestingly, as a group, the participants with less than 1 year of experience demonstrated more improvement postcourse (n 5 64; p 5 .016) than the more seasoned hcw group (n 5 53; p 5 .751) ( table 1) . thirty-two participants achieved a perfect precourse and postcourse selection score (droplet precautions, n 515; contact precautions, n 5 17; airborne precautions, n 5 0). when the perfect scores were removed, the analysis still revealed a statistically significant improvement in scores postcourse (n 5 85; p 5 .043). no differences in scores were found based on occupation or type of medical service. analysis of the proper sequence of ppe use revealed a statistically significant improvement (p , .001) for the overall score, postcourse score, and each of the 3 clinical scenarios (table 2) . no participant had a perfect sequence score either precourse or postcourse. both the separate donning and doffing sequence scores exhibited a statistically significant improvement (p , .002) postcourse. in addition, a statistically significant improvement (p , .001) in scores was seen for both the hcws with less than 1 year of experience and the more experienced hcws. scores for proper frequency of hh increased significantly from precourse to postcourse for all scenarios (airborne precautions, p 5 .001; droplet precautions, p 5 .018; contact precautions, p 5 .004) ( table 3) . the greatest improvement in ppe selection was seen in the droplet precautions scenario, arguably the most complex clinical scenario for hcws. scores for ppe selection in the airborne precautions scenario were not dramatically improved postcourse. as a result, the course has since been revised to include itemized lists of ppe for the different types of precautions and ''drag-and-drop'' exercises for ppe selection and donning/doffing sequences to immediately reinforce lessons learned. overall improvement in ppe selection for all clinical scenarios was found in hcws with less than 1 year of experience. this suggests that the novice workers may be especially amenable to targeted training in ppe selection and use, particularly given their requirements for immediate workplace training. as part of a larger infection control education program, accessible, standardized online learning appears to be suitable in meeting this need. experience during the sars outbreak and subsequent studies have highlighted the need for careful sequential removal of ppe. 1,2,7-12 thus, it was reassuring to find a statistically significant improvement in both donning and doffing of ppe for all clinical scenarios regardless of hcw experience level. it is likely that although correct selection of ppe was emphasized in hcw training previously, less attention was given to the sequence of removal, thus accounting for the general improvement regardless of experience level. the improvement seen in hh compliance was greater than that reported by other researchers. harbarth et al 25 reported an average hh compliance of only 34%, and golan et al 26 reported compliance of only 10% before care and 36% after care. we found average postcourse hh compliance scores of 87% when donning ppe and 68% when doffing ppe. a possible hawthorne effect cannot be ruled out; however, the initial low scores (despite being observed), followed by the improvement postcourse suggest that the course increased the partic-ipantsõ awareness of the need for hh. this is noteworthy given the critical role of proper and frequent hh in minimizing hospital-acquired infections. here we took a novel approach to studying ppe knowledge transfer by (1) embedding a study into an educational program already in session, (2) creating a realistic validation system for observing and scoring tasks, and (3) measuring the two elements of ppe practice-selection and sequence-separately. our findings indicate that online infection control courses are able to adequately transfer knowledge regarding appropriate ppe selection and use. this method of delivery could improve an organization's capacity to provide standardized and accessible infection control training. further studies are needed to verify that knowledge transfer is retained over time and that proper infection control practices are maintained in actual clinical settings. the canadian institutes of health research funded this research in partnership with the vancouver coastal health authority and the provincial health services authority of british columbia. the university of british columbia's behavioural research ethics board approved this research. protecting health care workers from sars and other respiratory pathogens: a review of the infection control literature an evaluative case study of online learning for healthcare professionals comparison of the instructional efficacy of internet-based cme with live interactive cme workshops: a randomized controlled trial infection control training: evaluation of a computer-assisted learning package designing tailored web-based instruction to improve practicing physi-ciansõ preventive practices contamination: a comparison of two personal protective systems the 2003 sars outbreak and its impact on infection control practices cluster of severe acute respiratory syndrome cases among protected healthcare workers-toronto, canada sars and the removal of personal protective equipment effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (sars) personal protective equipment for preventing respiratory infections: what have we really learned? vancouver coastal health authority, occupational health and safety agency for healthcare in british columbia performance-based evaluation: tools and techniques to measure the impact of training educational evaluation: alternative approaches and practical guidelines evaluating training programs: the four levels public health agency of canada: prevention and control of occupational infections in health care public health agency of canada: routine practices and additional precautions for preventing transmission of infection in health care occupational health and safety agency for healthcare in bc and vancouver general hospital infection control program bc: occupational health and safety agency for healthcare in bc and vancouver general hospital the infection control audit: the standardized audit as a tool for change evaluation of undergraduate students using objective structured clinical evaluation techniques for measuring clinical competence: objective structured clinical examinations compliance with hand hygiene practice in pediatric intensive care the impact of gown-use requirement on hand hygiene compliance key: cord-285804-lyj9tua8 authors: chen, yu-ju; chiang, po-jung; cheng, yu-hsin; huang, chun-wei; kao, hui-yun; chang, chih-kai; huang, hsun-miao; liu, pei-yin; wang, jen-hsin; chih, yi-chien; chou, shu-mei; yang, chin-hui; chen, chang-hsun title: stockpile model of personal protective equipment in taiwan date: 2017-04-01 journal: health secur doi: 10.1089/hs.2016.0103 sha: doc_id: 285804 cord_uid: lyj9tua8 the taiwan centers for disease control (taiwan cdc) has established a 3-tier personal protective equipment (ppe) stockpiling framework that could maintain a minimum stockpile for the surge demand of ppe in the early stage of a pandemic. however, ppe stockpiling efforts must contend with increasing storage fees and expiration problems. in 2011, the taiwan cdc initiated a stockpile replacement model in order to optimize the ppe stockpiling efficiency, ensure a minimum stockpile, use the government's limited funds more effectively, and achieve the goal of sustainable management. this stockpile replacement model employs a first-in-first-out principle in which the oldest stock in the central government stockpile is regularly replaced and replenished with the same amount of new and qualified products, ensuring the availability and maintenance of the minimum stockpiles. in addition, a joint electronic procurement platform has been established for merchandising the replaced ppe to local health authorities and medical and other institutions for their routine or epidemic use. in this article, we describe the ppe stockpile model in taiwan, including the 3-tier stockpiling framework, the operational model, the components of the replacement system, implementation outcomes, epidemic supports, and the challenges and prospects of this model. t he severe acute respiratory syndrome (sars) outbreak in 2003 had a severe impact on taiwan's health security systems. at the time, medical masks (including surgical masks and n95 respirators) and coveralls were in short supply, resulting in fear, decreased confi-dence, and decreased willingness to work among frontline healthcare workers. 1, 2 in addition, the insufficient supply of medical masks in the retail markets triggered panic buying by the public. consequently, the communicable disease control act in taiwan was amended, and a 3-tier stockpiling framework of personal protective equipment (ppe) was established in 2003. based on the act, the central government, local health authorities, and medical institutions are required to maintain a minimum stockpile of ppe (including surgical masks, n95 respirators, and coveralls) to ensure a sufficient supply for epidemic prevention and frontline healthcare personnel during the early phase of an epidemic. however, during nonepidemic periods, the use of ppe from the central government inventory was relatively limited; thus, most of the ppe remained unused and expired and needed to be destroyed. to solve this issue, the taiwan cdc, which is responsible for the management of the national stockpile system, developed a concept of stockpile replacement incorporated with a public-private partnership, including public sectors and private contractors, and employing the principles of logistics, supply chain management, commercial marketing, and relevant laws and regulations. [3] [4] [5] [6] [7] in this article, the national stockpile systems in the us, canada, australia, and singapore are briefly introduced, and the stockpile model with a replacement mechanism in taiwan is described and evaluated. the experience described may serve as a reference for improving the national stockpile system of other countries. to counter potential biological and chemical threats, some countries formulate and provide funds for medical countermeasure (mcm) stockpiles, such as the strategic national stockpile (sns) in the united states, 8 the national emergency stockpile system (ness) in canada, 9 the national medicine stockpile (nms) in australia, 10 and the rotation system in singapore. 11 these systems are prepared to provide medicine (antiviral drugs, chemical antidotes, and antibiotics), vaccines, medical materials, ppe, and lifemaintaining equipment. multiple stockpiles and releasing models were adopted in the sns system, including self-managed inventory, vendormanaged inventory, and just-in-time procurement and supply. 12 the stockpile includes vaccines, antiviral drugs, and ppe. the sns serves as a national repository for state and local public health authorities to support and resupply materials. it also supports multi-state and national emergencies, such as large-scale pandemics and natural disasters. the sns has developed the chempack (chemical hazards emergency medical pack) plan 13 to assist local governments in stockpiling antitoxin drugs in advance for an immediate response to terrorist attacks. in addition, state and local governments must develop plans for rapidly receiving and allocating mcms from the sns to the areas in need. there are numerous and various products in the sns, but only some medicines can be rotated before expiration. in addition, some drugs are candidates for the food and drug administration's shelf life extension program to extend their validity period. 14 however, the financial problems of refreshing the rest of the large amount of the stockpile continues to be a significant issue for the sns. since 1952 the canadian government has developed a national emergency strategic stockpile (ness) for providing health and social service supplies during an emergency. 9 there are 11 federal warehouses for stockpiling mcms with a 24-hour response capability. in addition, the ness contains a variety of mcms, including medical equipment and ppe, pharmaceuticals (antiviral agents, antibiotics, chemical and biological antidotes), social service supplies (generators, cots, blankets, flashlights), and units or kits (mini-clinics, reception center kits, etc). these supplies have been distributed domestically and internationally in response to a variety of public health events and emergencies. after the sars outbreak, the canadian government established a surge supply system of antiviral agents, antibiotics, and ppe (masks, face shields, gloves, gowns). however, at present, a significant proportion of the supplies and equipment in the stockpile is nearly out-of-date and not in accordance with current medical standards or practices. therefore, the canadian government is working on new strategies to solve the issue of the high maintenance cost. for instance, the ''mini-clinics'' program was designed as a concept of portable, modular, and flexible medical emergency response delivery. this pre-positioning of ''mini-clinics'' aims to supplement existing medical care facilities that might be overwhelmed in a disaster. the national medical stockpile (nms) system was established in 2002, providing a strategic stockpile of medicines, vaccines, antidotes, and ppe available for the national response to public health emergencies. 10 in 2011, the australian government had developed a range of strategies to improve the efficiency of stockpile management. two key strategies are: (1) the development of a fully costed model for shelf-life extension, and (2) the examination of options for stock cycling or rotation. the advantages of stock cycling or rotation are to minimize waste and storage and disposal costs and to reduce the need for regular replenishment. currently, the australian department of health is implementing the policy of stock rotation through suppliers for some antibiotics and p2 respirators, and a 10% to 15% rotation rate of p2 respirators was made possible. however, it is estimated that the savings for p2 respirators and antibiotic rotation over 10 years would be less than 1%. 15 the ministry of health (moh) in singapore has procured sufficient ppe to maintain a 3-to 6-month minimum stock chen et al for their national hospitals and clinics. the ppe includes surgical masks, gloves, gowns, and n95 respirators. the moh has made contracts with third-party logistics providers (3pl) for ppe management, storage, and delivery. the stockpile is rotated by national hospitals and clinics with the contractors' assistance. once they receive a request, the contractors inform 3pl to deliver ppe. when the ppe stockpiles are lower than 90% of the baseline stock, the contractors resupply directly to the warehouse. 11 during the early phase of an epidemic, the demand for ppe increases dramatically. however, manufacturers and suppliers often cannot meet the surge demand because of difficulties in material preparation, insufficient production capacity, and global panic buying. the discrepancy between the supply and demand directly affects protection measures for the frontline healthcare and epidemic prevention workers, causing fear and reduced workplace efficiency. after the sars epidemic, the taiwan cdc proposed ''a strategy plan for ppe minimum stockpile'' and established the 3-tier stockpiling framework-a central health authority (managed by the taiwan cdc), local health authorities, and medical institutions-to effectively respond to emergent demands and spread the risk of stockpiling. we have also formulated a minimum stockpile for each tier, taking into consideration: (1) the protective properties of ppe; (2) the consumption of ppe during nonepidemic and epidemic periods; (3) the production capacity of the manufacturers; (4) potential alternatives; and (5) the lead time. in addition, the amount of ppe required for nationwide medical care, border quarantine, and epidemic prevention during the early phase of an outbreak was estimated. in 2003, the nationwide minimum stockpile of ppe included 3 million n95 respirators, 1.5 million coveralls, and 25 million surgical masks. in 2006, the nationwide minimum stockpile was adjusted to 2 million n95 respirators, 800,000 coveralls, and 7 million surgical masks, with half of them stockpiled in medical institutions and a quarter of them in the central and local health authorities, respectively. after the h1n1 influenza epidemic in 2009, the authority and the amount among 3 tiers were reviewed and formalized. the stockpile in the central health authority is for nationwide epidemic control and emergency dispatch; the stockpile in local health authorities fulfills local public health and epidemic control needs; and the medical institutions have to assess and store their own minimum stockpile for 30-day epidemic use. 16 at the same time, the nationwide minimum stockpile was adjusted to 1.5 million n95 respirators, 320,000 coveralls, and 10 million surgical masks, and the minimum stockpile of the central health authority (taiwan cdc) is 900,000 n95 respirators, 140,000 coveralls, and 3 million surgical masks (table 1 ). in addition, 24 million surgical masks were stockpiled by taiwan cdc for public needs and price stabilization. 17 previously, the taiwan cdc adopted a traditional way to stockpile ppe in central inventory, with large purchases and then storage until use. usage during nonepidemic periods was quite low compared to the inventory level. to solve the issue of low consumption and having a mostly out-of-date ppe stockpile in the central health authority during nonepidemic periods, while maintaining the minimum stockpile, the taiwan cdc reviewed and evaluated different stockpile models in other countries and developed a replacement model for ppe stockpile management. the operational principles and outcomes of the ppe stock replacement model in taiwan are described below. since 2011 the taiwan cdc has initiated the procurement of surgical masks, n95 respirators, and coveralls, using a replacement model. in this model, the central health authority is regarded as a large reservoir of stocks, and the local health authority and medical institutions are regarded as small reservoirs. the concept is to combine the replacement of the large reservoir with the consumption of small reservoirs. the oldest stockpile of the large reservoir is regularly replaced and immediately replenished with the same amount of ppe by private contractors. meanwhile, the removed stock is circulated into small reservoirs for routine and emergency demand through the joint electronic procurement platform run by the contractors. through this replacement model, the stockpile continuously flows through the large reservoir to small reservoirs, and we ensure the ppe stockpile in the central health authority is available in appropriate quantities and within the expiry date. this replacement system involves cooperation between private contractors and the public sector. the private contractors play an important role in maintaining inventory, replacing the oldest stock, acquiring new and qualified products for replenishment in the central health authority, establishing the joint electronic procurement platform, and responding to the procurement requests of other institutions. the validity period of the released items from the central stockpile is about 2½ years on average, and that of the replenished new products is 5 years. during nonepidemic periods, rotating ppe stock to the market through the 3 main components of the ppe stockpiling system in the central health authority are warehouse management, stockpile replacement, and joint procurement, which are all carried out by private contractors. first, for warehouse management, the private contractor must provide exclusive storage space, adequate temperature and humidity control, and security management. to ensure the quality of storage, regular inventory checks are conducted by the taiwan cdc. second, according to the warehouse management principle of first-in-first-out, the contractor replaces a certain amount of the oldest ppe stock every year and subsequently replenishes with the same amount of new and qualified products into the central stockpile. the quantities of annual replacement and replenishment of surgical masks, n95 respirators, and coveralls in the central stockpile are 10 million, 300,000, and 45,000, respectively, which accounts for about one-third of the central stockpile. in addition, to ensure the surge capacity during epidemic periods, the contractors must guarantee to provide 5 million surgical masks, 100,000 n95 respirators, and 15,000 coveralls within 14 days in response to an emergency request from the taiwan cdc. third, for joint procurement, contractors built an electronic platform for receiving and processing orders from local health authorities and medical or other institutions. the platform also provides order statistics, information about warehouse environment monitoring, historical replacement records, and other information for the taiwan cdc. in addition, the n95 respirator contractor provides a variety of brands and sizes as well as fitting-test services for users to achieve the optimum protection of n95 respirators. in this replacement model, the taiwan cdc adopted a more economical and efficient way to refresh the stockpile, in which we pay the private contractors only a ''service fee'' instead of new products purchasing cost. the service fee includes the manual and computational process the contractors need to refresh the stockpile, which is less than the original purchasing cost because the contractors could further sell the replaced stockpile to domestic institutions through the joint e-purchasing platform or to other countries through their own channels of distribution. for example, the service fee for surgical mask replacement is only 27% of the original purchasing cost, and the total savings for surgical masks amounts to nt$53.7 million during the 5-year contract. the service fee for n95 respirators is only 46% of the original price; therefore, it is estimated that a total of nt$3.55 million is saved over a 4-year contract. for coveralls, the service fee is about 34% of the original price, and a total of nt$13.46 million is saved over a 4-year contract. the total savings from the 3 procurement projects with the replacement model is nt$70.71 million ( table 2) . during the h7n9 epidemic in 2013, the replaced surgical masks were all sold to domestic institutions via the joint epurchasing platform (compared to around 60% domestic requests and 40% overseas sales in a nonepidemic period), demonstrating that this model could indeed play a modulating role in material supply and successfully ease the surge demand in an emergency. in addition, the taiwan cdc actively participated in international cooperation and humanitarian aid by donating 100,000 coveralls and 100,000 surgical masks from the stockpiling system to west african countries during the ebola epidemic in 2014. in response to the avian flu epidemic in 2015 in taiwan, the taiwan cdc also immediately provided 128,500 coveralls, 147,040 n95 respirators, and 152,000 surgical masks to support the taiwan bureau of animal and plant health inspection and quarantine (baphiq) as emergency supplies. through these epidemic events, we have demonstrated our stockpile system to be a reliable and useful tool for domestic emergency response and international cooperation. in this replacement model, the replaced stockpile is designed for market sales, and therefore the success of these procurement projects depends on the market acceptability, market circulation, and contractors' sales channels. at present, the replaced surgical masks are distributed to domestic or overseas institutions, while n95 respirators and coveralls are sold for medical protection and mostly industrial safety in taiwan. in addition, although the contractors make sure of the annual ppe replacement and replenishment and guarantee the surge capacity in an emergency situation, the factories manufacturing surgical masks, n95 respirators, and coveralls in these contracts are mainly located on mainland china, in southeast asia, and in other countries. it may prove difficult to quickly obtain the ppe from these manufacturers overseas if a global large-scale epidemic occurs in which every country attempts to make a large purchase. recently, the ministry of economic affairs in taiwan has supported domestic production of surgical masks and n95 respirators for emergency demand. support for domestic production of coveralls might depend on further cost-effectiveness evaluation and discussion among various government departments. the taiwan cdc established a 3-tier framework for the national stockpile in 2003 and implemented a replacement model for ppe in 2011. this replacement model has been proven to be more economical and efficient over traditional purchasing practices as a way to renew the central stockpile, and it could also serve as emergency support in an epidemic situation and the basis of international cooperation. in the future, we will continuously improve our system by reviewing the operational outcomes of these contracts and evaluating the potential needs for different categories of ppe in response to various infectious diseases. severe acute respiratory syndrome-taiwan sars in healthcare facilities study on rational inventory level and supply chain model of national material stocks for the infectious disease with focus on personal protection equipment ?treeid= 9068 acd483c71fc1&nowtreeid=3b791eacc1b5c579&tid=274 070334d5bae18. accessed personal protective equipment management integrated research plan ?treeid=9068acd483c71fc1&nowtreeid=3b791ea cc1b5c579&tid= af7de2e0674261cf. accessed november 7 the establishment of the best resource allocation model of national personal protective equipment challenges and capacity building of public administrators in the view of cooperation governance new model of public-private cooperation in epidemic prevention materials ninth cross-strait conference on public administration (cscpa 2013) pandemic readiness and response plan for influenza and other acute respiratory diseases management of the national medical stockpile ?treeid=3847719104be0678&nowtreeid=73ce2 4f5d5c1fda4&tid= b0b038f9f893517e. accessed influenza pandemic strategic plan key: cord-253933-29tedkf8 authors: david, abel p.; russell, marika d.; el‐sayed, ivan h.; russell, matthew s. title: tracheostomy guidelines developed at a large academic medical center during the covid‐19 pandemic date: 2020-04-27 journal: head neck doi: 10.1002/hed.26191 sha: doc_id: 253933 cord_uid: 29tedkf8 background: during the sars‐cov‐2 pandemic, tracheostomy may be required for covid‐19 patients requiring long‐term ventilation in addition to other conditions such as airway compromise from head and neck cancer. as an aerosol‐generating procedure, tracheostomy increases the exposure of health care workers to covid‐19 infection. performing surgical tracheostomy and tracheostomy care requires a strategy that mitigates these risks and maintains the quality of patient care. methods: this study is a multidisciplinary review of institutional tracheostomy guidelines and clinical pathways. modifications to support clinical decision making in the context of covid‐19 were derived by consensus and available evidence. results: modified guidelines for all phases of tracheostomy care at an academic tertiary care center in the setting of covid‐19 are presented. discussion: during the various phases of the covid‐19 pandemic, clinicians must carefully consider the indications, procedural precautions, and postoperative care for tracheostomies. we present guidelines to mitigate risk to health care workers while preserving the quality of care. the novel coronavirus disease 2019 (covid-19) caused by the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is impacting hospital care globally at multiple levels. otolaryngologists and other surgeons will be called to assess and manage airways during this time period. because the primary morbidity associated with covid-19 is acute respiratory distress syndrome (ards), tracheostomy for patients requiring prolonged ventilation has emerged as an important element of care. the impact of covid-19 on hospital resources includes heightened need for intensive care unit (icu) capacity and the ability to provide ventilatory support. performance of tracheostomy has traditionally played an important role in ventilatory weaning, and its role in covid-19 is now a primary focus. transmission of the sars-cov-2 virus is primarily thought to occur through aerosolization or contact with contaminated surfaces. 1 as an aerosol-generating procedure (agp), tracheostomy is associated with high droplet and particle generation, placing health care providers at increased risk for transmission of respiratory viral infections. 2 the predominant response during this pandemic has been to increase the level of personal protective equipment (ppe) to airborne-level precaution during tracheostomy. while effective ppe is of critical importance, additional consideration and modification of routine tracheostomy guidelines is prudent. clinical decision making regarding indications and timing should be considered in the context of resource utilization, risk to health care providers, and patient benefit. at the university of california, san francisco (ucsf) medical center, an ad hoc work group consisting of stakeholders in the departments of otolaryngology-head and neck surgery (ohns), infectious diseases, critical care medicine and anesthesiology, was developed to analyze the impact of covid-19 at various levels of clinical care and administration. several covid-19 related factors were considered, including availability of viral testing, critical care capacity, availability of ppe, and risk to health care providers. all phases of routine tracheostomy care were considered in the review and modification of existing tracheostomy guidelines and clinical pathways. the concurrent goals of these modifications were to (a) mitigate risk to the health care providers while (b) preserving the riskbenefit profile for patients. published reports from countries with previous covid-19 pandemic experience and the published literature from the 2003 severe acute respiratory syndrome (sars) pandemic were reviewed and augmented by individual expertise in order to develop working guidelines for management of tracheostomy at ucsf. the following are covid-19 related tracheostomy guidelines developed at the ucsf medical center. ppe is regarded as the primary means to reduce transmission of the sars-cov-2 virus to health care workers. barrier protection with gowns, gloves, face shields, and surgical masks may be augmented with respiratory filtration systems, including n95 masks and powered air-purifying respirator (papr) systems. at the ucsf medical center, we created a paradigm to delineate ppe for agps, which carry a higher risk for health care providers. because of the potential for asymptomatic sars-cov-2 infection, we recommend the same level of precautions and ppe in covid-19 positive and asymptomatic patients undergoing aerosolgenerating procedures. the perioperative ppe guidelines developed at ucsf are outlined in table 2 . all team members involved in tracheostomy (anesthesia, surgery, nursing) don contact and airborne precaution-level ppe, including gown, double gloves, and either n95 respirator and face shield or papr hood. to conserve ppe, n95 masks may be reused in the setting of asymptomatic or covid-negative patients. for known covid-19 positive patients or person under investigation (pui), n95 masks should be single-use. donning and doffing of ppe must be appropriately carried out. fit testing protocols for respirators and education for providers on proper ppe use are necessary. proper doffing of ppe is particularly critical, as this is the most likely time for inadvertent self-contamination. a ppe "champion" observer may be utilized to monitor providers during doffing of ppe to ensure adherence to proper protocol. viral reduction is managed with a time-based strategy until effective antiviral treatment becomes available. maintaining endotracheal intubation for an average of 21 days prior to tracheostomy is undertaken to limit viral shedding. at the time of this writing, preoperative testing in asymptomatic patients is not routinely performed due to lack of testing availability, though remains an active area of protocol development. the decision to proceed with tracheostomy should involve a multidisciplinary discussion and should be supported by multiple ohns team members. notably, survival is reported to be extremely poor (<20%) in patients with covid-19 requiring mechanical ventilation, which argues against early tracheostomy. 3-5 when the determination is made to perform tracheostomy, a delay in timing from 14 days postintubation to 21 days postintubation should be considered to allow for sufficient decline in viral load. in the event of a surge with the need for ventilator rationing, reconsideration of timing may need to occur. ventilator parameters to qualify for safe tracheostomy placement include positive endexpiratory pressure (peep) < 12 and fraction of inspired oxygen (fio 2 ) < 0.60. technical considerations for performance of tracheostomy are summarized in table 1 . for covid-19 positive or pui patients, tracheostomy procedures will preferentially be performed in the icu to allow for a negative pressure environment and to minimize potential contamination of additional patient care areas. the number of providers in the procedure should be kept to a minimum. tracheostomy may be performed either as an open or as a percutaneous procedure, depending on patient factors and surgeon preference. coughing during the procedure can aerosolize droplets and special modifications are employed to reduce the risk. during the time of tracheal incision and endotracheal tube exchange, a systemic paralytic agent should be administered to minimize coughing, and aerosolized topical anesthetic should be avoided. meticulous hemostatic technique should be employed prior to tracheal incision to limit the need for additional tissue manipulation after the tracheal window is created. close communication between surgical and anesthesia teams is necessary. ventilation should be held prior to creation of the tracheal window and while the endotracheal tube (ett) cuff is deflated. application of suction to the surgical wound may be used to create a local negative pressure environment during exchange of the ett for the tracheostomy tube. importantly, the suction circuit should include a high-efficiency particulate arrestance (hepa) filter to capture aerosolized viral particles and avoid aerosolizing them into the operating theater. after placement of the tracheostomy tube, closed-circuit ventilation with inline hepa filtration should be maintained and only inline suction should be performed. tracheostomy care should be performed with droplet-level precautions (gloves, gown, mask/eye protection) at a minimum. tracheostomy in covid-19 positive patients should utilize closed-circuit suction, heat and moisture exchanger (hme) if not ventilated, and inline hepa filtration if ventilated. cuff inflation is preferred in patients with known covid-19 disease until viral shedding has subsided. the frequency of tracheostomy changes should be reduced to every 1 to 3 months for all patients, except for downsizing and cuff related issues that are determined to be clinically urgent. tracheostomy changes should be avoided in covid-19 positive patients until viral clearance has been achieved to minimize unnecessary health care worker exposure. the covid-19 pandemic has presented health care systems with the unprecedented task of managing large volumes of patients with critical respiratory illness. tracheostomy has emerged as a downstream component of care with heightened risk of viral transmission to health care providers and requires careful consideration in this context. our multispecialty work group was created during the early spread of covid-19 cases in the united states and we evaluated and modified our current institutional tracheostomy guidelines in preparation for a surge of covid-19 positive patients with the potential to overwhelm our health care system. these guidelines were created with the intent of preserving quality of patient care and reducing clinician exposure in order to maintain a capable health care workforce. factors relevant to our review included optimal timing of tracheostomy, duration of viral shedding in patients with covid-19, risk to procedural teams from aerosol generation during tracheostomy, icu capacity, and availability of ppe. a summary of risk mitigation strategies is presented in table 2 . there is limited evidence available during this evolving stage of the covid-19 pandemic. as such, modifications to our existing protocols were made by consensus and were based upon published reports from countries with earlier covid-19 experience and data available from the 2003 sars epidemic. the policies that were developed at ucsf are aligned with the position statement on tracheostomy recently published by the airway and swallowing committee of the american academy of otolaryngology-head and neck surgery (aao-hns). 6 experience with tracheostomy during the 2003 sars epidemic offers a framework for management strategy during the covid-19 pandemic. in the context of the current pandemic, tay et al conducted a literature review of tracheostomies performed during the sars epidemic and concluded the following: (a) proper ppe (n95 mask, surgical cap, gown, goggles, and gloves) is of utmost importance; (b) surgical tracheostomy is preferably performed in a negative pressure icu room by experienced providers with meticulous planning and seamless communication; (c) aerosol generation should be minimized through patient paralysis, ventilation hold during creation of tracheal window, and utilization of hepa-filtered suction systems. this group identified no cases of sars transmission to the surgical team in 23 tracheostomies. 7 others have reported on ppe for tracheostomy during the sars epidemic, drawing similar conclusions that use of n95 masks, face shields, fluid-resistant gowns, and gloves (contact and airborne precautions) provides effective protection against transmission to providers during tracheostomy. 8, 9 n95 masks filter 99.5% of particles larger than 0.75 μm, providing excellent protection against airborne particles with a mask that is appropriately fitted. 10 covid-19 testing is accomplished via detection of sars-cov-2 in a nasopharyngeal specimen or bronchoalveolar lavage (bal) using reverse transcriptase-polymerase chain reaction (rt-pcr). 11 the role of preoperative testing in ascertaining the covid-19 status of asymptomatic individuals has emerged as a point of discussion, as the prevalence of asymptomatic sars-cov-2 infection is unknown but assumed to be meaningful given high rates of community transmission. 12, 13 at the time of this writing, due in large part to the relative lack of available testing supplies, there is not a standard protocol for preoperative testing of asymptomatic patients planned for tracheostomy or other agps. patients who do not have respiratory symptoms suggestive of covid-19 have an unknown risk of being asymptomatic carriers of disease. if resource availability permits, preoperative testing prior to surgical intervention is preferred, as a positive test would alert the health care team to the increased risk, and surgery may be deferred to maximize safety if clinically appropriate. importantly, for patient with some conditions, including head and neck cancer, airway compromise may be imminent and necessitate urgent treatment with tracheostomy. 14 acute airway compromise, or inability to intubate, as can occur in patients with head and neck cancer, could necessitate an awake tracheostomy. in this scenario, the patient is breathing orally and potentially seeding the room with aerosolized viral particles. all precautions with appropriate ppe should be taken by the surgical team in cases where potential airway manipulation is anticipated. currently, specialized hoods to cover the patient and prevent aerosolization have been proposed but are not widely available. 15 preoperative testing is significant in determining the appropriate timing of tracheostomy for patients with covid-19 infection. for patients with known disease, testing is a reasonable surrogate for viral clearance. bal is the most sensitive means of testing and is recommended in intubated patients. 11 these tests will be important in enacting deisolation protocols, whereby hospitalized patients with recent infection may be removed from an isolation environment. one such proposed deisolation protocol calls for two consecutive negative pcr tests 24 hours apart. 16 due to constraints on the availability of testing and the turnaround time for results, preoperative testing may not be universally feasible. in the absence of a standard preoperative testing protocol, we have proposed not pursuing early tracheostomy, but rather delaying for covid-19 positive patients in order to reduce exposure to higher viral loads, which are expected to peak in the first few days of symptom onset. 16 the duration of viral shedding is estimated to be between 20 and 24 days from symptom onset, based on laboratory testing of nasopharyngeal swabs. the longest observed duration of shedding reported in one study was 37 days. 5, 16 importantly, viral loads in asymptomatic and symptomatic patients are believed to be similar, 13 highlighting the need for proper ppe and surgical protocols in all cases of tracheostomy. the optimal timing of tracheostomy for asymptomatic patients without ards is not clear. at ucsf, we have elected to maintain standard timing of 10 to 14 days postintubation for this group. the clinical course of the covid-19 infected patient is well described by zhou et al, who found the median time from illness onset to dyspnea was 13 days and dyspnea to invasive mechanical ventilation was 10 days. 5 in pre-pandemic conditions, we typically aim to perform tracheostomy for patients requiring prolonged mechanical ventilation by 10 to 14 days postintubation. in the current pandemic, we propose when resources are available, that an additional week of mechanical ventilation be permitted to reduce viral load and thereby limit risk to health care personnel. the benefits of tracheostomy are well established. these include facilitated ability to wean sedation and mitigation of sedation-associated delirium, improved patient comfort, and facilitation of weaning to spontaneous ventilation. the optimal timing of tracheostomy varies by clinical context; outside of the current pandemic, it is generally recommended to be performed within 2 weeks postintubation. prolonged intubation is associated with postintubation laryngotracheal stenosis, but in systematic reviews, early tracheostomy (typically <10 days) has not been shown to reduce risk of this complication. 17, 18 the role of tracheostomy during the covid-19 pandemic remains to be determined. poor patient outcomes and resource scarcity may well have a dramatic influence on the total number of tracheostomies performed. in published studies from the chinese experience, survival of covid-19 after mechanical ventilation is low (<20%) and zhou et al determined that the time from illness onset to death in nonsurvivors of covid-19 was just 18.5 days. [3] [4] [5] if this trend holds as the pandemic progresses, the obvious implication is that early tracheostomy may be a futile endeavor for most patients, and late tracheostomy is not likely to assist in ventilatory weaning. the covid-19 pandemic presents a rapidly shifting landscape of clinical care. of primary concern within the united states at the time of this writing is the relative scarcity of mechanical ventilators to support critically ill patients. this resource scarcity could lead to a push to perform tracheostomies, though whether this would allow for a more expeditious ventilator weaning process is unclear. continued close collaboration with our critical care and ethics colleagues will be imperative to navigate this scenario should it arise. it is important to acknowledge that conditions other than covid-19 will still need to be addressed during this time period and may require tracheostomy. the need for mechanical ventilation in patients with other conditions should be considered when developing and applying covid-19 guidelines. during the covid-19 pandemic, standard pathways and guidelines for tracheostomy and tracheostomy care should be carefully reconsidered. additional measures should be taken to protect health care providers who are at increased risk of infection. special care must be taken in the selection of patients for tracheostomy with consideration of delayed timing for patients with covid-19. while the landscape of care is rapidly shifting, the above guidelines are intended to support safe and effective clinical decision making during this challenging time. abel p. david https://orcid.org/0000-0003-1687-8240 ivan h. el-sayed https://orcid.org/0000-0001-8121-3726 aerosol and surface stability of sars-cov-2 as compared with sars-cov aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in wuhan, china clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective, observational study clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study tracheotomy recommendations during the covid-19 pandemic surgical considerations for tracheostomy during the covid-19 pandemic: lessons learned from the severe acute respiratory syndrome outbreak tracheostomy in a patient with severe acute respiratory syndrome safe tracheostomy for patients with severe acute respiratory syndrome performance of n95 respirators: filtration efficiency for airborne microbial and inert particles detection of sars-cov-2 in different types of clinical specimens transmission of 2019-ncov infection from an asymptomatic contact in germany sars-cov-2 viral load in upper respiratory specimens of infected patients emergent awake tracheostomy-the five-year experience at an urban tertiary care center taiwanese doctor creates cheap protective device amid virus crisis epidemiologic features and clinical course of patients infected with sars-cov-2 in singapore early versus late tracheostomy for critically ill patients laryngotracheal stenosis in early vs late tracheostomy: a systematic review tracheostomy guidelines developed at a large academic medical center during the covid-19 pandemic key: cord-277167-qdi6hu82 authors: fuzaylov, gennadiy; dabek, robert j. title: adjustment for international surgical outreach missions due to covid-19 date: 2020-07-30 journal: burns doi: 10.1016/j.burns.2020.07.016 sha: doc_id: 277167 cord_uid: qdi6hu82 nan dear editor, today we are in midst of an extraordinary time when our lives have become disrupted and we are forced to adjust to a new reality. on march 11, 2019 the world health organization (who) declared a viral global pandemic [1] . the covid-19 pandemic is burdening medical systems across the globe, with the number of confirmed cases reaching over 14.5 million with over 600,000 deaths, as of july 20, 2020 [2] . this worldwide spread of the novel coronavirus poses incredible public health challenges domestically, as well as abroad. often, lmic (low and middle-income countries) are more vulnerable due to a number of factors, including socio-economic and geographic factors [3] . with a paucity of resources and personnel available to provide treatment, many health systems, at the local, state, and national level, were forced to take drastic measures to minimize spread of the virus, as well as optimize resource and personnel distribution. with patient and provider safety in mind, the majority of elective surgical procedures were temporarily halted globally. in addition, strict limitations to regional and international travel have been implemented, effectively disabling international surgical outreach missions. doctors collaborating to help children is one such non-profit organization which started a global health campaign to improve burn care in ukraine [4] . as many other organizations dedicated to providing medical care abroad in underserved areas, we are now faced with the difficult decision to cancel scheduled outreach programs. the incidence of burn injury, and other surgically treated diseases is unlikely to acutely change in the setting of the covid-19 pandemic, undoubtably creating an increase in patients seeking care [5] . however, discontinuing international surgical missions is critical in preventing regional viral spread, preserving ppe, and protecting ourselves and our patients. protection of medical personnel from risk of covid-19 infection is paramount given the high mortality rate and high disease duration. the protective strategy is two-fold; reduction of exposure, and proper use of personal protective equipment (ppe) and sterilization techniques. during induction of anesthesia or any airway manipulation there is potential for aerosolization of droplets, significantly increasing risk to providers and or staff. with this elevated risk there is a greater need for the use of ppe. for these reasons the cdc has recommended discontinuing elective surgical procedures in many places based on perceived risk of population exposure as well as to preserve ppe as necessary [6] . internationally this risk may be difficult to assess given the implicit limitations of current testing techniques, and limited availability of tests. due to the global shortage of ppe, care must be taken to preserve supplies [7] . in line with cdc recommendations to increase telemedicine care, we encourage providers involved in surgical outreach to do the same. however, telemedicine as an outreach tool presents certain challenges, namely; poor or absent infrastructure, language and social barriers, legal issues, and inability to perform a physical exams or procedures [8] . if possible, continuing or increasing telemedicine efforts at this time may help to offset the inevitable increase in patients requiring surgical care within our outreach target populations. assisting with triage, telemedicine rounds, case discussion and formal education can be conducted remotely provided that barriers can be overcome. unfortunately, no one can predict the duration and full impact of the covid-19 pandemic on global health and economy. due to the novelty of the virus, there are still many unknows surrounding transmission, treatment, and long-term sequalae of infection. limitations in testing and ventilators, ppe requirements, and a call for reducing global spread necessitate a stop in international travel for providers involved in surgical outreach missions. we continuing to work with doctors and health care ministers abroad remotely through increasing telemedicine efforts. as testing becomes more available with increasingly rapid results, and the development of a vaccine inches forward, we may begin to plan for resuming outreach activity [9] . ultimately, resuming our missions must wait until it is safe and international travel is permitted, and should be in line with local regulations. who director-general's opening remarks at the media briefing on covid-19 -11 covid-19 map -johns hopkins coronavirus resource center n the burden of communicable and non-communicable diseases in developing countries a plan to improve pediatric burn care in ukraine paediatric burns epidemiology during covid-19 pandemic and 'stay home' era healthcare facilities: managing operations during the covid-19 pandemic | cdc n global shortage of personal protective equipment barriers to development of telemedicine in developing countries. telehealth, intechopen an mrna vaccine against sars-cov-2 -preliminary report this work was not funded by any outside entities. j o u r n a l p r e -p r o o f key: cord-279396-qmixem8i authors: carter, chris; notter, joy title: covid-19 disease: a critical care perspective date: 2020-06-01 journal: nan doi: 10.1016/j.intcar.2020.100003 sha: doc_id: 279396 cord_uid: qmixem8i abstract covid-19 is a new highly infectious disease with an incompletely described clinical course, which has caused a pandemic, with europe being identified as the third epicentre. covid-19 has placed unprecedented pressure on critical care services which is likely to stretch resources beyond capacity. the situation is exacerbated by increased staff absence from self-isolation and illness, increased referral of patients with suspected or confirmed covid-19 who develop respiratory failure, and limited availability of extra corporeal membrane oxygenation (ecmo) services. in addition, there is the ongoing challenge of patients being transferred between departments and hospitals for ongoing care. in consequence, as current needs continue to rise, innovative approaches are needed to redress shortages and support the continuance of services. this article provides an overview of severe covid-19 infection, outlining treatment strategies and nursing processes that will need to develop and extend in response to this evolving situation. the world health organization (who) has now declared covid-19 as a pandemic, with europe being identified as being another epicentre (after china, italy and iran). 1 for many countries, this is the worst public health emergency of a generation and has led to the implementation of widespread enforcement measures to help to reduce the spread of the virus. in response, healthcare systems have rapidly adapted services to focus efforts on dealing with the consequences of the covid19 pandemic, but it has to be recognised that as current needs continue to rise, existing resources are being stretched well beyond normal usage. as a result innovative approaches are needed to redress shortages and support the continuance of services. all hospitals have critically ill patients and critical care services, but these have been developed to reflect usual service need, and not the covid-19 needs. evidence from other countries estimates that 5% of patients who develop severe covid-19 will require intensive care. 2 in consequence, critical care units will be subjected to extraordinary pressure, where patient demand may exceed the available critical care bed capacity. the origins of critical care have been traced to the crimean war in 1850 when florence nightingale separated seriously injured patients and nursed them in one area of the hospital, allowing for intensive observation and nursing care to be provided. 3 the practice of grouping the sickest patients nearest to the nurses' station and providing increased observation and intensive nursing care continued for many decades. but it was only during the polio outbreak in copenhagen in 1952 when hundreds of patients developed respiratory failure that critical care emerged as a specialty. in response to this epidemic, dr bjorn ibsen, a copenhagen anaesthetist, successfully treated a 12year-old girl with severe respiratory failure by inserting a tracheostomy and using positive pressure ventilation. other polio patients were treated similarly, with medical students providing one-to-one care and resulted in the mortality decreasing from over 80% to approximately 40%. 4 following the epidemic, ibsen argued that a dedicated unit within a hospital with one nurse per patient should be developed. 4 this was deemed the start of the modern-day critical care speciality. advances in critical care over the past 20 years have led to greater recognition that the care of a critically ill patient often has to start before admission to intensive care, in emergency departments, wards and recovery areas. this has led to ward nurses and doctors becoming increasingly skilled in the recognition, prevention and escalation of care of a critically ill patient. in consequence, critical care units now admit patients who are no longer at the end stage of a disease process, who will have received time-critical interventions before transferring to critical care. critical care advances include better understanding of disease processes and evidence to support practices, lung protection mechanical ventilation strategies, and better technology including ventilators and monitoring. 4 intensive care tends to refer to a place within a hospital that provides highly specialised care to critically ill patients, whereas critical care refers to any area where acutely unwell or critically ill patients may be managed, for example, theatre recovery, emergency departments and acute wards. today, intensive care provision and capacity varies drastically across the globe. in the united states, an estimated 4 million patients are admitted to critical care, compared to england, wales and northern ireland where an estimated 184,000 patients are admitted annually. 5 the uk has one of the lowest numbers of critical care beds in europe 6 , with critical care provision classified by levels of care (table 1) . 7 in consequence, critical care services vary between hospitals and may be purely intensive care (level 3) or incorporate coronary care and high dependency units (level 2), as part of the provision. intensive care unit (icu) use either operates an open or closed approach to admission. open icus mean the admitting physician remains responsible for them during the patients' care on icu, whereas a closed icu means the patients' care transfers to the intensivist. covid-19 has placed unprecedented pressure on critical care services which is likely to continue for the near future. there will be ongoing increased staff absence from self-isolation and illness, and the need to refer patients with suspected or confirmed covid-19 who develop respiratory failure. this will impact on the availability of extra corporeal membrane oxygenation (ecmo) services and extend the challenge of preparing and accompanying patients transferring between departments and hospitals for ongoing care. in addition to the relatively high numbers of covid-19 patients developing severe respiratory failure resulting in acute respiratory distress syndrome (ards) and requiring intubation and ventilatory support, the current data suggests an average length of stay for covid patients in intensive care of eight days. 8 critical care nursing is not simply a list of skills or tasks provided to critically ill patients; it requires the nurse to understand the complex needs of each critically ill patient. the world federation of critical care nurse (wfccn) 9 defines a critical care nurse as: 'a registered practitioner who enhances the delivery of comprehensive patient centred care, for acutely ill patients who require complex interventions in a highly technical environment, bringing the patient care team a unique combination of knowledge and skills. the role of critical care nurses is essential to the multi-disciplinary team who are needed to provide their expertise when caring for patients and their relatives'. using this definition, the nurse is there to provide effective patient centred care, observing and being proactive in the patient's management, so that any deterioration or changes can be immediately identified and acted upon. this includes being able to cope with unpredictable and unexpected events, explaining all nursing procedures, providing emotional support to patients and their relatives and acting as advocate for the patient. s/he also has a key role in providing detailed information to other members of the healthcare team, raising concerns, while maintaining and respecting patient dignity and confidentiality. 9 as a result of the covid-19 pandemic, staff from across the hospital may be re-deployed to work in critical care units. to increase the nursing workforce, a pragmatic approach has to be taken, with the first tranche being volunteers, those with previous critical care experience or those with transferrable skills such as anaesthetic and recovery nurses. staff should be identified early and orientated to critical care before capacity is exceeded and time for orientation becomes impossible. the aim must be to 'best match' the available skill mix to the acuity of patients, with supervision by a critical care nurse, to maintain safe care, even if traditional critical care staffing ratio recommendations cannot be followed for a period. 10 staff redeployed to critical care should not be expected to work outside their professional scope of practice, independently nursing level 3 patients unless they are deemed and have been assessed as competent. 10 coronaviruses (cov) are large, enveloped, positive-strand rna viruses, that can cause illnesses ranging from the common cold to more severe diseases. 11 they are zoonotic, meaning the virus is transmitted between animals and people. severe cov diseases include middle east respiratory syndrome (mers-cov) and severe acute respiratory syndrome (sars-cov). the novel coronavirus (ncov) is a new strain that has not been previously identified in humans 12 and was first identified in wuhan, china in late 2019. the virus severe acute respiratory syndrome coronavirus 2 (sars-cov-2) causes coronavirus disease. the term covid-19 was introduced by the who on 11 february 2020 and replaced previous terms such as '2019 novel coronavirus'. 13 the incubation period remains unclear, with most estimates ranging from 1-14 days, with an average five days before symptoms. 12 covid-19 is a highly contagious respiratory illness, currently thought to be spread through close contact and respiratory droplets. severe covid-19 disease causes an aggressive pulmonary impact resulting in respiratory failure, similar to that of other viral pneumonias that cause respiratory failure. 14 however, due to its highly contagious nature, the risk of transmission is significant. it has to be accepted that in spontaneous self-ventilating patients, all oxygen administration strategies are at risk of aeroslisation, which increases risk of transmission. 15 aerosol generating procedures (agp), are medical and patient care activities that can result in the release of airborne particles (aerosols), increasing the risk of airborne transmission of infections that are usually only spread by droplet transmission. 16 examples of agp include humidification, open suctioning, non-invasive ventilation and intubation. the highest risk of transmission of respiratory viruses is during agps of the respiratory tract. 15, 16 following identification by li et al., 17 that there was a lower risk of transmission when using hudson, venturi masks and nasal cannulae, as compared with high-flow nasal oxygen (hfno) and non-invasive ventilation (niv) with facemasks or hoods, these are now being used. the critical care nurse needs to recognise that patients who develop severe covid-19 can rapidly develop type 1 respiratory failure, ards and therefore require ventilatory support. in the uk, an estimated two-thirds of patients who required admission to critical care were intubated and mechanical ventilated within 24 hours of admission. 18 in non covid-19 patients with increasing respiratory failure the use of high flow nasal oxygen (hfno) or non-invasive ventilation (niv) such as continuous positive airway pressure (cpap) may be used as a treatment strategy. however, evidence from the outbreak in italy has shown niv may be insufficient to manage covid-19-induced respiratory failure. [19] [20] [21] in addition, niv is not recommended for patients with viral infections complicated by pneumonia, as it may temporarily improve oxygenation, initially reducing the effort of breathing but does not change the natural disease progress. 22, 23 thus, the use of niv and hfno in covid-19 patients remains controversial, but it has been suggested if used early in the disease progression, it may avoid the need for intubation and mechanical ventilation. the who 24 support the use of hfno in some patients but recommend close monitoring for clinical deterioration that could result in emergency intubations, which in turn increases the risk of infection to healthcare workers. with limited availability of ventilators, cpap may be considered to improve oxygen, as anecdotal reports have suggested this may reduce the need for ventilation, but that there has to be increased monitoring, as the patient may be developing multi-organ failure. in addition, regular assessment should be undertaken to determine whether intubation is required. emergency tracheal intubation maybe required, but is a high-risk procedure increasing the risk of transmission to healthcare workers and other patients. although, increasingly, as a result of the rising demand for intubation, it has to be performed outside of the critical care unit, it is usually carried out by specially formed intubation teams, termed mobile emergency rapid intubation teams (merit). 25 these teams have the requisite expertise to intubate patients in emergency departments and ward areas, then transfer them to the critical care units. a common feature of severe covid-19 disease is the development of ards: a syndrome characterized by an acute onset of hypoxemic respiratory failure with non-cardiogenic pulmonary oedema resulting in bilateral infiltrates. 15 internationally recognized ards treatment guidelines include conservative fluid strategies for patients without shock following initial resuscitation, empirical early antibiotics for suspected bacterial co-infection until a specific diagnosis is made, lung-protective ventilation, prone positioning, and consideration of ecmo for refractory hypoxemia. 26 it is essential that fluid strategies must take account of the duration of the illness and the accompanying insensible fluid loss. access to specialised services such as ecmo may become increasingly difficult due to the to the relatively small number of units offering this services and increased pressure on beds. in consequence, the prone position may be used to improve oxygenation. pan et al's 27 cohort study of 12 patients in wuhan city, china, with covid-19-related ards suggests the prone position may have improved lung recruitability and oxygenation if used early. anecdotal experiences from centres suggest using the prone position while the patient is on cpap on the ward, as this may improve oxygenation and prevent the need for intubation. due to the high numbers of patients requiring prone position, 'proning teams' may be set up to improve efficiency. 25 traditionally, in ards, partial pressure of oxygen (pao₂)/fraction of inspired oxygen (fio₂) is used as an indicator of lung function. 28 however, it is suggested in covid-19, clinical performance using oxygen saturations, rather that the pa02/fi02 ratio should be used. 29 at the time of writing, there is currently no vaccine or specific antiviral to prevent or treat covid-19 and treatment focuses on supportive care. several clinical trials are in progress for possible vaccines and specific drug treatments. for example, the randomised evaluation of covid-19 therapy (recovery) trial is testing the use of lopinavir-ritpnavir (hiv anti-retroviral treatment), low-dose dexamethasone (steroid anti-inflammatory), hydroxychloroquine (anti-malarial drug) and azithromycin (an antibiotic). 30 however, currently the use of high dose corticosteroids in covid-19 have been found to be ineffective and are not recommended. 31, 32 covid-19 is caused by a virus; therefore, antibiotics should not be used as a means of prevention or treatment. however, it is worth noting that empirical early antibiotics may be appropriate if bacterial co-infection is suspected. de-escalation of antibiotics should be based on microbiology results and clinical judgement. 12, 25 there have been concerns raised following advice by the french health minister regarding the use of non-steroidal anti-inflammatory drugs (nsaids). 33, 34 from the current data available, there is no evidence that nsaid increase the chance of acquiring covid-19. however, the use of nsaids in sars 1 showed that there may be an adverse impact on pneumonia. in consequence, it is recommended that until more information is available, patients who have confirmed or suspected covid-19, should use paracetamol instead of nsaids, unless they are currently on a nsaid for other medical reasons. 35 personal protective equipment covid-19 is a highly infectious respiratory illness, currently thought to be transmitted through close contact, respiratory droplets and through contact with contaminated surfaces. 17 with high rates of covid-19 circulating in the community and patients requiring hospitalisation, healthcare workers are at repeated risk of contact and droplet transmission during their daily work. in addition, swab results may take 3-4 days, resulting in challenges in establishing whether patients meet the case definition for covid-19 prior to a face-to-face assessment or care episode. 17 therefore, the use of personal protective equipment (ppe) cannot be overstated, but it may not be 100% effective. specialist filtering face piece (ffp) face masks are recommended when dealing with high-risk covid-19 patients (table 2) . ffp provides respiratory protection that is worn over the nose and mouth designed to protect the wearer from inhaling hazardous substances, including airborne particles (aerosols). there are three categories of mask: ffp1, ffp2, ffp3 (table 3) , with ffp3 respirator providing the highest level of protection, and is the only category of respirator legislated for use in uk healthcare settings. 16 international, national and regional variations in ppe guidance and provision have been identified, providing conflicting information and confusion among healthcare professionals. in addition, potential supply issues with ppe and changes in ffp3 respirators due to the increasing demands, require staff to be 'fit tested' prior to using the new equipment. this may lead to further delays and concerns for staff who have not been trained or measured appropriately for masks and a sufficient variety of appropriately sized masks is not readily available. 36, 37 this concern has already been raised by the who, 38 who have highlighted ppe may run out in some countries. regardless of the type of ppe worn, one of the greatest risks is prolonged wearing of ppe, as this has shown to increase fatigue over time, reduce visibility due to visor and mask and reduced dexterity due to wearing double or triple gloves. 39 procedures such as breaking glass ampoules, drawing up medication, performing intravenous cannulation, and intubation whilst wearing several layers of gloves and ppe, have been shown to be slower which in turn impacts on practice. 40 there is also a suggestion that an increased number of healthcare professionals is needed when providing care, particularly in critical care for procedures requiring two nurses to one patient (2:1) when ppe is worn. in addition, staff may need to be rotated to enable them to have time out of ppe and regular breaks, and additional staff may need to act as runners in the clean zone to prepare drugs and equipment and assist with the donning and doffing of ppe. 39, 40 the most significant risk of self-viral contamination is potential during the 'doffing stage' (removal of ppe) if this is done incorrectly. doffing is a complex, high-risk skill which is often undertaken during periods of stress. 41 during the ebola outbreak in 2015, studies undertaken during training with a fluorescent marker, showed complex ppe doffing procedures left contamination on hands after ppe removal. [42] [43] [44] [45] in consequence, doffing procedures must be clear and simple to follow. simulation training may provide additional confidence for practitioners to prepare and confirm their skills, as well as increasing expertise in wearing and removing ppe. to provide an effective critical care service, a specialist workforce, appropriate infrastructure and adequate resources are needed, with critical care units using a multi-disciplinary team approach to care. during the height of the covid-19 pandemic countries coping with an unprecedented number of patients requiring critical care have to recognize that, as identified in italy, a major challenge is the risk of collapse in the healthcare system due to difficulty in triaging, allocation, and too few critical care beds. 16 should this occur, the current models of critical care will be unsustainable and a radical adaptation to the delivery of nursing care will be required. then too, healthcare staff, including physicians and nurses, becomes infected or exposed, quarantined and unable to work causing additional workforce pressures. 16 to support the requirement for expanded critical care services, staff from across the hospital may need to be re-deployed to work in the intensive care unit. during the increased pressures on staffing and increased demand for critical care beds, traditional staffing models may not be able to be followed. however, safe care must always be delivered, even if staffing ratio recommendations need to be temporarily set aside. many hospitals have followed a 'pod system' whereby a group of critically ill patients are supervised by one critical care nurse, with direct care delivered by registered nurses. additional, support from physiotherapists, pharmacists, dieticians and support workers (including medical or nursing students) is used. this maintains a staff to patient ratio of 1:1, but the critical care nurse, may in reality be supervising 1:3, 1:4 and in extremis 1:6. with limited numbers of critical care nurses and doctors, the focus on care needs to be not 'who' does each aspect of patient care, but rather 'what' needs to be done. this teamwork approach and sharing of workloads improves effectiveness without placing the burden on one professional group. an overall nurse-in-charge will manage the unit, with support from the critical care medical team. due to increased pressure on hospital services, it may not be possible to maintain an open or closed unit. however, specialist medical input is likely to be required from respiratory, cardiology, surgical and medical teams as appropriate. strategic leadership will be provided by the matron (also termed head nurse, lead nurse) and the clinical director (lead doctor), who have overall responsibility for critical care services. with the rapid expansion of critical care services, current policies and guidelines may be unrealistic due to the differing levels of staffing, the large influx of new staff not familiar with critical care and the dynamic and rapidly evolving covid-19 situation. in consequence, maintaining standardized practice and supporting staff in practice, means guidelines need to be developed, which can include the of flashcards and care bundles. flashcards can be used to provide an aide-memoire of key guidelines and core standards relating to care and reflect changes in practice. they may also be displayed to remind all staff of core standards for example, shift safety checks, guidance for handover, admission process, syringe management and drawing up of infusions. care bundles are a series of proven evidence-based interventions relating to a condition or disease that when implemented together can significantly improve outcomes. 46 each intervention must have a well-established scientific basis and direct the way care is provided. they are presented in practical and easy to use formats, which can be followed by all healthcare professionals. examples of commonly used care bundles in critical care relate to ventilator care, central venous catheters and tracheostomy. care bundles provide consistency in care and can be used as an audit tool to ascertain if they are being followed and the impact on care. care planning is an important part of nursing care and follows the nursing process ( figure 1 ). for covid-19 patients, the care plan should involve a systematic assessment of the patient and undertaken on admission and at the start of each shift. goals and the nursing diagnosis are identified, but appropriate plans of care may need rapid revision due to the rate of progression of the disease. evaluation at the end of the shift needs to review not only if goals have been met, but whether these need changing or adapting, and the best way to utilize the diluted skill-mix of healthcare professionals. due to increased work pressure, such formalized care planning may be difficult, but the critical care nursing process documentation on the 24-hour chart must accurately reflect the patient's changing status. at the start of each shift, a general handover takes place, whereby all patients are handed over, as part of the process nurses are allocated to a specific group (pod) of patients and then a more detailed individual handover is taken. in covid-19, as a minimum, the bed-side handover should include the patients name, age, past medical history, if the patient has any allergies, reason for admission, length of stay in critical care (number of days), key events that have taken place during the patient's critical care admission, system handover (respiratory, cardiovascular, neurological, renal, liver), next of kin details, a review of the patient's observation chart, drug chart and medical and nursing notes. in addition, a physical check of the patient's name band, infusions and ventilator settings by both the outgoing and oncoming nurse should be conducted to confirm all are correct. hospital infrastructures need to be adapted to respond to the increasing demands, which include oxygen, air and power supply and critical care equipment. oxygen supplies are now under huge pressure, with increased use of ventilators and oxygen therapy being delivered across the hospital. staff must be made aware of the need to conserve oxygen supplies, reduce hyperoxia and prevent unnecessary waste, for example switching off an oxygen supply when not in use. 27 emergency portable oxygen cylinders need to be available. while it is accepted that they are unlikely to be able to sustain a critical failure in walled oxygen supply, they should be readily available to facilitate transfers and for emergency use. then too, the increased use of ventilators means there is currently a likelihood of an 'enriched oxygen' atmosphere in clinical areas, increasing the risk of combustion and fire. 47 fire preventive checks must be carried out at regular intervals, and any necessary remedial action taken. in many clinical areas, as a patient safety measure, air supply outlets have been restricted to reduce the risk of connecting oxygen tubing to air flowmeters. 48 most ventilators require piped air supply, with the exception of ventilators used in transport, sufficient outlets and supply will need to be available in locations not traditionally used to provide invasive ventilation. as the pandemic continues, healthcare services are likely to have to be re-configured and transformed to respond to the need for a greater focus on the covid-19 to sustain care utilizing staff available for re-deployment. however, while this response is seen as crucial, the problem for care providers is that it is essential for healthcare services to be able to respond to non-covid-19 patients such as those with cerebrovascular accidents (cva), cardiac emergencies, maternity services, major trauma and cancer care. 49 for hospital managers, the differing needs and approach to services between covid-19 and non-covid-19 critical care availability and input will be an on-going challenge when planning services and identifying how these patients will be managed. critical care is still a relatively new specialty, which has developed dramatically in the last two decades, and continues to be at the cutting edge of response to the current pandemic. covid-19, as a new highly infectious disease with an incompletely described clinical course, results in perhaps the greatest challenge for intensive care since services were first initiated. however, it was developed in response to what was then an unprecedented need. it has become a highly skilled and expert workforce designed to advance care and cope with new and unknown situations. yet it still retains the ability to transform itself as our understanding of disease processes increase. treatment strategies will evolve and nursing processes will develop and extend, building on currently used treatments, to meet the unexpected and unprecedented number of patients needing their help, care and support. level 0 care can be met though acute ward-based care. level 1 patients at risk of deterioration or recently re-located from a higher level of care. additional input, advice and support from critical care may be required. level 2 patients requiring more detailed observation and intervention including single organ support or post-operative care or patients 'stepping down' from level 3 care. patients requiring advanced respiratory support and/or basic respiratory support with support of at least two organ systems. table 1 . source: ref 7 guidance on wearing a mask • before touching the mask, clean hands with an alcohol-based hand rub or soap and water • take the mask and inspect it for tears or holes. • orient which side is the top side (where the metal strip is). • ensure the proper side of the mask faces outwards (the coloured side). • place the mask to your face. pinch the metal strip or stiff edge of the mask so it moulds to the shape of your nose. • pull down the mask's bottom so it covers your mouth and your chin. • after use, take off the mask; remove the elastic loops from behind the ears while keeping the mask away from your face and clothes, to avoid touching potentially contaminated surfaces of the mask. • discard the mask in a closed bin immediately after use. • perform hand hygiene after touching or discarding the mask -use alcohol-based hand rub or, if visibly soiled, wash your hands with soap and water. who director-general's opening remarks at the media briefing on covid-19 -11 characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china the ''lady with the lamp'' illuminates critical care today intensive care medicine is 60 years old: the history and future of the intensive care unit intensive care national audit & research centre welcomes a new chair intensive care a global problem guidelines for the provision of intensive care services clinical course and risk factors for mortality of adult inpatients with covid19 in wuhan, china: a retrospective cohort study world federation of critical care nursing best practice guidelines for non-critical care staff working in critical care to enable the escalation process only in times of surge coronavirus infections-more than just the common cold question and answers on covid-19 naming the coronavirus disease (covid-19) and the virus that causes it care for critically ill patients with covid-19 the italian corona virus disease 2019 outbreak: recommendations from clinical practice guidance: transmission characteristics and principles of infection prevention and control role of air distribution in sars transmission during the largest nosocomial outbreak in hong kong covid-19: most patients require mechanical ventilation in first 24 hours of critical care outbreak of a new coronavirus: what anaesthetists should know practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-ncov) patients comparison of high-flow nasal cannula versus oxygen face mask for environmental bacterial contamination in critically ill pneumonia patients: a randomized controlled crossover trial respiratory support for patients with covid-19 infection non-invasive ventilation for critically ill patients with pandemic h1n1 2009 influenza a virus infection clinical management of severe acute respiratory infection (sari) when covid-19 disease is suspected the experience of high-flow nasal cannula in hospitalized patients with 2019 novel coronavirus-infected pneumonia in two hospitals of chongqing, china. ann intensive care features, evaluation and treatment coronavirus (covid-19) clinical guide for the management of critical care patients during the coronavirus pandemic an official american thoracic society/european society of intensive care medicine/society of critical care medicine clinical practice guideline: mechanical ventilation in adult patients with acute respiratory distress syndrome lung recruitability in sars-cov-2 associated acute respiratory distress syndrome: a single-center, observational study clinical features of patients infected with 2019 novel coronavirus in wuhan clinical evidence does not support corticosteroid treatment for 2019-ncov lung injury fda advises patients on use of non-steroidal antiinflammatory drugs (nsaids) for covid-19 ibuprofen use and coronavirus (covid-19) clinical management of persons admitted to hospital with suspected covid-19 infection godzilla in the corridor: the ontario sars crisis in historical perspective. intensive and critical care nursing early experience with influenza a h1n1/09 in an australian intensive care unit. intensive and critical care nursing rational use of personal protective equipment for coronavirus disease 2019 (covid-19) limiting factors for wearing personal protective equipment (ppe) in a health care environment evaluated in a randomised study does wearing cbrn-ppe adversely affect the ability for clinicians to accurately, safely, and speedily draw up drugs? contamination: a comparison of 2 personal protective systems healthcare worker self-contamination during standard and ebola virus disease personal protective equipment doffing variation in health care worker removal of personal protective equipment ebola virus disease: the use of fluorescents as markers of contamination for personal protective equipment. idcases. 2. 27-30 46. institute for health improvement hospitals warned of increased fire risk on covid-19 wards supporting information for patient safety alert: reducing the risk of connecting oxygen tubing to air flowmeters london begins major covid-19 reconfiguration does wearing cbrn-ppe adversely affect the ability for clinicians to accurately, safely, and speedily draw up drugs? the italian corona virus disease 2019 outbreak: recommendations from clinical practice care for critically ill patients with covid-19 key: cord-255264-2kj961en authors: hasan, syed shahzad; kow, chia siang; zaidi, syed tabish razi title: social distancing and the use of ppe by community pharmacy personnel: does evidence support these measures? date: 2020-05-01 journal: res social adm pharm doi: 10.1016/j.sapharm.2020.04.033 sha: doc_id: 255264 cord_uid: 2kj961en community pharmacists are one of the most accessible healthcare professionals and are often served as the first point of contact when it comes to minor ailments and health advice. as such, community pharmacists can play a vital role in a country's response to various preventative and public health measures amid the covid-19 pandemic. given the essential nature of community pharmacy as a health service, community pharmacies are unlikely to shut down in any foreseeable lockdown scenario. it is therefore important to assess the preventative measure directives for community pharmacies that are in place to safeguard community pharmacy personnel from sars-cov-2 in the various parts of the world. upon reviewing the recommendations of 15 selected countries across five continents (asia, europe, oceania, north america, and africa) on social distancing and the use of personal protective equipment (ppe) in community pharmacies, we found inconsistencies in the recommended social distance to be practiced within the community pharmacies. there were also varying recommendations on the use of ppe by the pharmacy personnel. despite the differences in the recommendations, maintaining recommended social distance and the wearing of appropriate ppe is of utmost importance for healthcare workers, including community pharmacy personnel dealing with day-to-day patient care activities, though full ppe should be worn when dealing with suspected covid-19 patients. the novel coronavirus disease 2019 (covid-19) is the biggest immediate public health challenge facing our world currently. at the time of writing, nearly 3 million people have a documented positive test for the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) and over 150,000 have lost their lives. community pharmacists are one of the most accessible healthcare professionals and are often served as the first point of contact when it comes to minor ailments and health advice. as such, community pharmacists can play a vital role in a country's response to various preventative and public health measures. at the same time, community pharmacy personnel should practice general precautions and put in place the necessary preventative measures to ensure their wellbeing and safety. given the essential nature of community pharmacy as a health service, community pharmacies are unlikely to shut down in any foreseeable lockdown scenario. as community pharmacies are considered as the first point of call for cold and flu symptoms, community pharmacy personnel are likely to encounter symptomatic or asymptomatic (including carer of a symptomatic patient) carrier of sars-cov-2 and thus at high risk to get infected. since infected individuals may not show symptoms at least during the incubation period, there is an increasing probability of further transmission of sars-cov2 to the general public visiting pharmacies. therefore, social distancing and the proper use of personal protective equipment (ppe) are essential in community pharmacy practices. the front-line role of community pharmacies/pharmacists is likely to expand further in the coming days as the covid-19 situation worsens. for example, the new york state government is planning to allow independent pharmacists (more than 5000 pharmacies) to conduct diagnostic covid-19 tests. it is therefore important to assess the preventative measure directives for community pharmacies in terms of social distancing rule and use of ppe that are in place to safeguard community pharmacy personnel from covid-19 in the various parts of the world. these measures will not only provide reassurance to community pharmacy personnel to carry out their professional duties https://doi.org/10.1016/j.sapharm.2020.04.033 received 29 april 2020; accepted 30 april 2020 optimally to serve the local communities but will also provide useful information for countries that are yet to issue preventative measure directives for the operation of community pharmacies amid covid-19 pandemic. we reviewed the recommendations of 15 selected countries across five continents (asia, europe, oceania, north america, and africa) on social distancing and the use of ppe in community pharmacies. the recommendations are tabulated in table 1 . there were inconsistencies in the recommended social distance to be practiced within the community pharmacies, a range from at least 1 m to at least 2 m. more than half (n = 9) of the countries adopted a social distance of 1 m in their community pharmacies. united kingdom, new zealand, and canada recommended a social distance of 2 m, while australia and the united states advised social distances of 1.5 m and 1.8 m, respectively. there were also varying recommendations on the use of ppe by the pharmacy personnel (table 1) . while the united states adopted a universal mask approach and turkey recommended the use of masks and protective goggles for their pharmacy personnel, almost all of the countries recommended against routine use of face mask and other ppe (gloves or aprons/gowns), except when dealing with suspected covid-19 patients or performing activities requiring close contact (unable to maintain recommended social distance) with the patients. canada left the decision on the use of ppe during close contact activities to the professional judgment of pharmacy personnel. since who's recommendation is to keep a distance of 1 m from others, it is not surprising that most countries adopted the same social distance in the community pharmacy setting. the purpose of social distancing is to avoid contact with respiratory droplets. the one-meter recommendation probably originates with work done in the 1930s by william wells, who found that respiratory droplets tend to land within three feet when expelled. 1 nevertheless, a distance of 1 m may not be enough, since a 2003 study on the transmission of severe acute respiratory syndrome reported that 90% of the individuals who became infected were seated more than 1 m away from the index patient. 2 such finding suggested that viruses may spread as an airborne aerosol and challenges the traditional belief where the virus is transmitted only through droplets that are coughed or sneezed out. the evidence from preliminary studies and field reports have indicated the possibility for sars-cov-2 to spread in aerosols. to exemplify, during the peak of the covid-19 outbreak in wuhan, china in february and march 2020, researchers at wuhan university set up aerosol traps in and around two government-designated covid-19 hospitals which were exclusively used for the treatment of covid-19 patients during the outbreak and public areas in wuhan including busy department stores. the existence of sars-cov-2 in aerosol samples was determined through the quantification of ribonucleic acid (rna) genetic material. 3 they reported the finding of viral rna from sars-cov-2 in various places of the hospitals as well as the entrance of a department store with customers frequently passing through. recently, a new study in china observed that the sars-cov-2 coronavirus-laden aerosols could be found in air samples as far as 4 m away from infected patients. 4 these findings are consistent with a recent experimental work that demonstrated the existence of a multiphase turbulent gas cloud and its payload of pathogen-bearing droplets from sneezes and coughs, which could travel up to 8 m. 5 whilst questions remain regarding the infectivity of these airborne virus-laden aerosols, a preprint illustrated the possibility of sars-cov-2 coronavirus-laden aerosols to be infectious where the authors investigated an outbreak of covid-19 involving three non-associated families sitting at three neighbouring tables in a restaurant in guangzhou, china. 6 ten individuals from these families were found to be infected although no significant close contact or fomite contact was observed. though the observation from such case study cannot be regarded as conclusive, the assumption, for now, should be that airborne transmission of sars-cov-2 is possible unless being discredited in the future, and therefore we opine that the wearing of appropriate ppe is of utmost importance for healthcare workers, including community pharmacy personnel dealing with individuals may or may not be infected on a day-to-day basis, regardless if they manage to observe social distancing in their workplace or if they perform close contact activities. people can spread the virus before they develop symptoms, which limits the detection of suspected individuals through symptoms screening. the need for appropriate ppe cannot be overstated in community pharmacies which are frequently visited by individuals with ailments and are unable to observe social distancing at all times due to constraint in the floor space of pharmacies. indeed, a snapshot survey among pharmacists in the united kingdom indicated that 94% of respondents were unable to maintain social distancing from other pharmacy personnel, while another 40% of respondents were unable to maintain social distancing from patients. 7 another rather worrying finding, 34% of respondents said they are unable to source continuous supplies of ppe. there are concerns from some countries (e.g. ireland) if routine use of ppe may compromise other appropriate hygienic measures, but we would optimistically assume that such concern should be least expected among community pharmacy personnel with their healthcare knowledge and professional peer pressure. a case study from singapore underlines the importance of appropriate ppe where it was reported that healthcare workers (85% wearing a surgical mask and 15% wearing an n95 mask) identified to have had exposure for ≥10 min at a distance of < 2 m from patients with sars-cov-2 undergoing aerosol-generating procedures, none became sars-cov-2 positive by nasopharyngeal swab within 14 days of exposure. 8 therefore, a universal ppe approach adopted by the united states and turkey should be complimented and strongly considered by other countries. relevant health authorities when issuing the preventative measure directives for community pharmacies may consider the availability of local resources due to a worldwide shortage of ppe, but we feel that recommendations should be made based on current science and not based solely on the supply of ppe. a similar analogy would be the issuance of evidence-based recommendations in clinical practice guidelines regardless of the supply of medications. however, in cases where a continuous supply of ppe to community pharmacies cannot be confidently maintained, consideration should be given to recommending a further social distance specific to community pharmacy settings to avoid the transmission of sars-cov-2 viruses in infectious amount. else, innovations such as the installation of the perspex or plexiglass barrier at the customer contact area to provide barrier protection could also be promoted if feasible. community pharmacy could unwittingly become a hub for covid-19 transmission without strict preventative measures in place because is often being the first point of contact for people who are sick and being the place for patients with non-communicable diseases including hypertension and diabetes who are at high risk of being infected with covid-19 to get their routine medicine supply. though a difference among countries with regards to recommended social distance in community pharmacy, it must be stressed that the recommended distance is the minimum distance that should be followed, and measures should be taken to increase the social distance as far as possible to avoid transmission of sars-cov-2. however, the currently recommended social distance might need to be updated in accordance with current findings with sars-cov-2. also, considering the potential for sars-cov-2 to aerosolize, pharmacy personnel should be protected at least with medical-grade face mask, along with other ppe if necessary, to deal with day-to-day patient care activities, though full ppe should be worn when dealing with suspected covid-19 patients. therefore, the distribution of local ppe resources should take into consideration the need for community pharmacy personnel, who may be neglected due to false assumptions for low risk of transmission. the last thing we may want to see is for community pharmacies to become a source of transmission of sars-cov-2. on air-borne infection: study ii. droplets and droplet nuclei transmission of the severe acute respiratory syndrome on aircraft aerodynamic analysis of sars-cov-2 in two wuhan hospitals aerosol and surface distribution of severe acute respiratory syndrome coronavirus 2 in hospital wards, wuhan, china, 2020 [published online ahead of print turbulent gas clouds and respiratory pathogen emissions: potential implications for reducing transmission of covid-19 evidence for probable aerosol transmission of sars-cov-2 in a poorly ventilated restaurant pharmaceutical society royal. pharmacists 'unable to maintain social distancing' at work and risk infection covid-19 and the risk to health care workers: a case report covid-19 pandemic planning and guidelines: information and guidance for community pharmacies in australia pharmaceutical association belgian. [sop (standard operating procedure) coronavirus: recommendations for the pharmacy/pharmacist pharmacists association canadian. personal protective equipment (ppe): suggested best practices for pharmacies during the covid-19 pandemic union syndicale des pharmaciens d'officine guidance to minimise the risk of transmission of covid-19 infection in pharmacies covid-19 pandemic guidance document for malaysian pharmacists folder?action=view%20file&folder_id=96& file=pharmacy%20practice%20during%20covid-19%20pandemic%20% 20-%202020%2004%2007.pdf, accessed date ministry of national health services. regulation and coordination. covid-19: 10-step guidance for pharmacy teams philippines pharmacists association. community pharmacy guide: covid-19 preparedness how to reduce infection risk of coronavirus? guidelines for pharmacies south african pharmacy council. sapc covid-19 infection prevention guidelines for the pharmacy general pharmaceutical council of spain association turkish guidance for pharmacies: guidance for pharmacists and pharmacy technicians in community pharmacies during the covid-19 response national community pharmacists association. ppe use, re-use and sanitation recommendations for community pharmacies supplementary data to this article can be found online at https:// doi.org/10.1016/j.sapharm.2020.04.033. key: cord-029722-85h5060v authors: proffitt, edmund title: decoding the english standard operating procedures for dentists and the dental industry date: 2020-07-24 journal: br dent j doi: 10.1038/s41415-020-1853-7 sha: doc_id: 29722 cord_uid: 85h5060v the recently published standard operating procedure: transition to recovery for the resumption of dental treatment in england may prove to be not only the blueprint for the resumption of face-to-face treatments, but also a possible catalyst for change. seemingly, the raison d'être of the new standard operating procedures is not just to outline the detailed procedures for kick-starting dentistry, but also to support practices through transition and the shift towards a preventative and minimally invasive clinical approach that meets the current clinical challenges, and possibly then goes beyond. detailed guidance is also provided throughout the document, including the provision and type of required personal protective equipment and clinical guidelines. it may, however, prove to be not only the blueprint for the resumption of face-to-face treatments, but also a catalyst for change as cdo england, sara hurley, outlined in her introduction to the document: 'the limitations in agps present an opportunity to re-think our approach to care pathways. the patient-focused, team-delivered minimum intervention oral healthcare philosophy helps in taking on the current challenges in delivering dental care. the philosophy with its four interlinking domains of identifying the problem, prevention & control, minimally invasive treatments and suitable recall strategies dependent upon longitudinal disease susceptibility, underpins all disciplines of dentistry. whilst dental teams may use a variety of acceptable techniques to risk manage care, the guidelines for remote consultations, non-agp periodontal treatment, restorative and paediatric dental care contained in this sop provide an aide memoire to best practice, minimising agps and delivering quality health outcomes' . 2 seemingly, the raison d'être of the new sops is not just to outline the principles and procedures for kick-starting dentistry, but also to support practices through transition and the shift towards a preventative and minimally invasive clinical approach that meets the current clinical challenges, and then goes beyond. it could be seen as a vehicle to herald what the cdo england has described as a 'covid-19 legacy hallmarked by a determined revision of the current activitydriven clinical approach, optimising time with patients and delivered as an integrated oral health team.' 3 beyond the scope of the sop document, there also appears to be an appetite for contract reform to support this 'revision' going forwards. the document anticipates and paints a picture of a phased approach to full resumption based on risk management and outlines the steps in some detail, with those steps thoroughly dependent upon risk assessment and the availability of ppe at all stages. from an industry perspective, the british dental industry association (bdia), supported by its members, has worked hand in hand with the office of the cdo (ocdo) england, the bda and many other professional organisations, government agencies and representative parties every step of the way towards resumption, and standard operating procedures for dental practices to undertake a phased transition towards the resumption of a full range of dental provision in england have now been published by the nhs/office of chief dental officer england. the document essentially fulfils the role of a 'resumption blueprint' for dentistry in england and could also be seen as a catalyst for change in how dentistry is delivered going forwards through the covid-19 pandemic and beyond. resumption of treatment will be risk-assessed throughout and will bring a number of very significant changes in the way in which dentistry will be delivered, with a heavy emphasis on personal protective equipment and strict infection prevention and control. the recently published standard operating procedure: transition to recovery for the resumption of dental treatment in england may prove to be not only the blueprint for the resumption of face-to-face treatments, but also a possible catalyst for change. seemingly, the raison d'être of the new standard operating procedures is not just to outline the detailed procedures for kick-starting dentistry, but also to support practices through transition and the shift towards a preventative and minimally invasive clinical approach that meets the current clinical challenges, and possibly then goes beyond. detailed guidance is also provided throughout the document, including the provision and type of required personal protective equipment and clinical guidelines. has advised on ppe and product availability regularly. in the short term, ppe provision remains a challenge for the dental (and broader medical) devices supply chain, both in terms of availability and cost. however, things do seem to be easing gently as time moves on, but we cannot completely eliminate the possibility of some further future supply chain 'wobbles' , and should anticipate and prepare for contingencies as the profession and industry move forwards together along the road to resumption. we must not, of course, disregard the possible impact of the end of the brexit 'transition period' as the uk currently remains set to leave the eu on 31 december 2020. however, perhaps we can take heart in some words from the cdo england, who wrote: 'i strongly argue that dental care has not run out of road and that covid-19 presents the opportunity to shift gear and change lanes' . 3 moving forwards, with an initial helping hand of ppe from the department of health and social care, the industry is confident that dentistry's highly professional supply chain can fully support the accelerating pace of resumption. however, at this point in time, both the profession and industry cannot predict what the rate of recovery and treatment volumes will be, or whether there may be additional lockdowns or cessations of treatment based on future disease patterns. with the need for additional ppe and aerosol generating procedure (agp) mitigation activities, patient throughput remains a challenge. this will inevitably have implications for income generation and the sustainability of both dental practices and the dental industry. anecdotal estimates of around 30-40% of historic patient activity resuming over the coming months will mean that practices and the industry will face some significant economic challenges along the 'road to resumption' . moving back to ppe, the sops do contain much technical detail of interest and relevance to all of us. its protocols remain fully in line with government advice and public health england (phe) remains the final word on ppe. the sops contain no real surprises in this area but are helpful in terms of detailing requirements. incidentally, the document lists what constitutes both agp and non-agp activities in its 'section 3' . for non-agp care, standard infection control precaution ppe consisting of eye protection, disposable fluid-resistant (type iir) surgical masks, disposable aprons and gloves are cited. for all agps, to prevent aerosol transmission, disposable fluid-repellent gowns (or approved equivalent), gloves, eye/face protection and an ffp3 respirator should be worn by those undertaking or assisting in the procedure. however, it is important to note that the sops do allow for a fit-tested ffp2 respirator to be used where ffp3s are not available. in the real world of current global ppe supply, this means that the much more readily available ffp2 respirators will be the backbone of the resumption of any agp-based activity going forwards. subsequent to the publication of standard operating procedure: transition to recovery, on 9 june 2020, nhs england issued updated guidance for healthcare providers, including dental practices, aimed at minimising nosocomial infections in the nhs. 4 the guidance states that, from 15 june 2020, all staff in dental practices will be required to wear a surgical face mask when not in ppe or in a part of the facility that is covid-secure. phe has also responded to requests from the industry and has provided the bdia with a detailed interpretation of covid-19 guidance for dental industry maintenance, and service engineers and technical staff attending dental practices, so that surgeries can rest safe in the knowledge that the industry has its own bespoke phe guidance on appropriate ppe to wear when visiting practices. the sop document also clarifies sessional use of ppe, stating that fluid-resistant (type iir) surgical masks and eye protection can be used for a session of work rather than a single patient or resident contact. it also confirms that ffp2/n95 respirators are suitable for sessional use in dental practice, adding that a full-face visor changed between patients will protect the respirator from droplet/ splatter contamination. the procedures also state that, although good practice, there is no evidence to show that discarding disposable respirators, face masks or eye protection inbetween each patient reduces the risk of infection transmission to the health worker or the patient. among the procedures, guidance, illustrations, tables and appendices featured, there are, of course, some central and fundamental tenants and core guidance which are becoming part of the covid-19 era's dental mantra. where dental treatment is planned, care planning should focus on achieving stabilisation, intervention should be kept to a minimum to reduce exposure risk, and agps should be avoided where possible and only undertaken if the dental service has the appropriate ppe. treatment should be completed in the minimum number of visits possible, and when an agp has been undertaken, it is recommended that the room is left vacant for one hour for a neutral pressure room before cleaning is carried out. this period did raise a number of eyebrows and there are differing times cited in guidance from other countries. 5 it is understood that additional mitigation means and technologies could play a part in reducing this time, subject to suitable risk assessment. of course, patient flow and practice layout should be considered in order to comply with social distancing measures throughout the practice, with reception use minimised, digital appointment booking (online, e-mail) used, the consideration of fitting physical barriers at reception (for example, perspex shields) and arrangements for contactless card payment where possible. the dental industry will endeavour to render all possible help and support to practices through all of these steps. additional training of staff may be necessary and should be provided before recommencing any dental provision. areas highlighted include rubber dam placement, four-handed techniques, decontamination and ipc, remote consultation and triaging, training in new it software tools (for example, online medical history software), and scenario-based team training of new policies and procedures. again, the dental industry will endeavour to render all possible help and support to practices through all of these steps and processes. as services resume and practice capacity to provide care hopefully accelerates and increases, there will be a demand for a broader range of clinical activities and thus support from the industry. areas of support to the profession will include tools to assist in preventative and self-care measures, delivered in line with delivering better oral health, 6 and in agp mitigation. the sop document highlights and addresses areas of agp mitigation, including the use of hand instrumentation/ scaling and non-agp periodontal treatment, simple dental extractions, caries excavation with hand instruments, caries removal with slow-speed and high-volume suction, the placement of restorative material, orthodontic treatments and paediatric oral health, including stainless steel crowns and diamine fluoride applications. detailed appendices provide guidance in these areas. by working through the sops, the dental industry can identify just how and where it can support the resumption of more widespread dental treatment in the community and, importantly, explore new opportunities and areas of support for practices and the profession going forwards, as dentistry takes this opportunity to re-think and re-evaluate its approach to care pathways. resumption is a partnership between many groups: the patient, the dental team, the dental industry, the nhs, the bda and other professional bodies and organisations, regulators and the government (apologies to any others that i have missed out). while there are a plethora of ideas and views across these groups, the most important thing is that they share common goals. why re-invent the wheel you've out of road? minimising nosocomial infections in the nhs recommendations for the re-opening of dental services: a rapid review of international sources -version 1.1. 2020. available online at https:// oralhealth.cochrane.org/news/recommendations-reopening-dental-services-rapid-review-internationalsources delivering better oral health: an evidence-based toolkit for prevention key: cord-317884-zni0aj1n authors: shirodkar, amy-lee; de silva, ian; verma, seema; anderson, sarah; dickerson, polly; walsh, francine; siriwardena, dilani; dhawahir-scala, felipe title: personal protective equipment (ppe) use among emergency eye care professionals in the uk during the covid19 pandemic date: 2020-05-21 journal: eye (lond) doi: 10.1038/s41433-020-0970-5 sha: doc_id: 317884 cord_uid: zni0aj1n eec staff were provided with rapidly changing personal ppe guidance by public health england (phe) with specific subspecialty advice from the british emergency eye care society (beecs) and the royal college of ophthalmologists (rcophth) uk during the covid19 pandemic. beecs undertook a baseline survey of its members after the initial response from the rcophth 16/3/20 mirroring public health england (phe) advice and a followup survey after the guidance was updated on 9/4/20. a combined total of 84 responses were received. improvements after rcophth changes between the two surveys from hospital respondents showed increases in temperature screening (13%), scrub use (34%), use of aprons (31%), masks (4%), eye protection (35%), gloves (25%) and slit lamp guard (1%). our findings demonstrate a positive and significant adaptation of ppe in response to change in guidance published by phe, rcophth and beecs between 16/3/20 and 11/4/20. the covid19 pandemic has rapidly taken over the normal activity of ophthalmic departments creating unprecedented challenges. following initial confusion and vulnerability expressed by eec professionals to ppe guidance, most trusts appear to have adapted and are doing similar things. the response has been swift and effective as a result of good team work and early advice from beecs and the rcophth. on the whole, management teams are listening. the novel coronavirus disease 2019 (covid19) caused by severe acute respiratory syndrome coronavirus-2 (sars-cov-2) was declared a global pandemic by the world health organisation on the 11th of march 2020 [1] . the royal college of ophthalmologists response for uk ophthalmic departments was to reduce activity and provide hospital services for sight-threatening emergencies due to the threat of fatal covid19 complications among the uk population [2] . the college of optometry, similarly, provided guidance for practices to stop routine gos services and only provide emergency eye services by accredited mecs/mecs type practices [3] . emerging publications from china, where the disease was first reported, highlighted the increased risk of transmission of sars-cov-2 for health care workers working in close contact with infected patients [4] . reports found sars-cov-2 present on ocular surfaces and a cause of conjunctivitis of varying incidence [5] [6] [7] . emergency eye care (eec) professionals come into close contact with patient's ocular surfaces while managing ocular emergencies in both community and hospital settings, increasing their risk of acquiring covid19 [5] [6] [7] . personal protective equipment (ppe) are (is) used to reduce the risk of health care workers exposure to potentially infectious droplets while managing a patient infected with sars-cov-2 [8] . eec staff were provided with rapidly changing personal ppe guidance by public health england (phe) with specific subspecialty advice from the british emergency eye care society (beecs) and the royal college of ophthalmologists (rcophth) uk. the aim of this study was to survey eec professionals in primary and secondary care about (and evaluate) the provision and response of departments to information given with regard to ppe during the covid19 pandemic period. beecs undertook a baseline survey of its members after the initial response from the rcophth 16/3/20 mirroring public health england (phe) advice and a follow-up survey after the guidance was updated on 9/4/20. see table 1 for time line of events and rcophth ppe guidance and table 2 for survey questions. each survey was completed by beecs members delivering eec services in both primary and secondary care during the covid19 pandemic. a total of 50 responses were received for the baseline survey and 34 for the followup survey. a combined total of 84 responses were received for the surveys sent. hospital respondents totalled 29 for survey 1 (20% stand alone eye unit, 52% university hospital/acute trust and 27% district general hospital) and 32 for survey 2 (19% stand alone eye unit, 44% university hospital/acute trust and 34% district general hospital). figures 1, 2 demonstrate a change between the surveys for temperature screening with an increase of 13% noted and an increase of 34% in the use of scrubs to examine lowand high-risk covid19 patients. other changes noted was an increase in the use of aprons (31%), masks (4%), eye protection (35%), gloves (25%) and slit lamp guard (1%) ( table 3) . hospital management were seen to be more receptive to the demands of eec professionals after the 9/4/20 rcophth guidelines were updated, an increase of 21% and 40% more were providing ppe advice. an improvement in the supply of ppe and relaxation on eec table 4 . twenty-one optometrists replied to survey 1-76% of which are affiliated to mecs/mecs type services. see table 3 for their ppe use. our findings demonstrate a positive and significant adaptation of ppe in response to change in guidance published by phe, rcophth and beecs between 16/3/ 20 and 11/4/20. initial responses for health care workers during the covid19 pandemic from phe meant ophthalmology was not on trust radars as a high-risk specialty leading to ophthalmologists and ahp feeling vulnerable to exposure and objection to self provided protection. early response by the rcophth and beecs included advice to install substantial guards to slit lamps, thereby creating a physical barrier to the transfer of aerosol droplets during close ocular examination [2] . ninetythree percent of hospital eec professions initially surveyed had slit lamp guards; however, not all units were compliant. with the initial guidance, many were forced to use temporary diy homemade guards while awaiting robust options. prior to the change in ppe advice on 9/4/20, 17% of individuals experienced objection or threat of disciplinary action if they were seen to wear their own personally acquired ppe items. this reduced to 6% in the second survey, which may reflect the change in phe recommendations and provision of additional ppe by the government to the employers. there was an increase from 47% to 78% in respondents that were satisfied with the information they were given about ppe and from 50% to 60% in those that felt management listened to them about their views on ppe provision. importantly after the 9/4/20 update, there was an increase in satisfaction with information about ppe and more felt a reduction in the number of responses to our followup survey from the primary care ophthalmic practitioners (mecs and non-mecs practices) might reflect that many had to close their doors due to the lack of ppe, which was not prioritized in this sector. those currently operating are providing telephone consultations and face to face emergency consultations where ppe has been provided. the covid19 pandemic has rapidly taken over the normal activity of ophthalmic departments creating unprecedented challenges. following initial confusion and vulnerability expressed by eec professionals to ppe guidance, most trusts appear to have adapted and are doing similar things. the response has been swift and effective as a result of good team work and early advice from beecs and the rcophth. learning from other affected countries has been paramount when planning and adjusting to this new challenging situation. on the whole, management teams are listening and hopefully in the very near future our primary care optometry colleagues will be provided with similar levels of ppe for continued collaboration in the management of ocular emergencies during this covid19 global pandemic. what was known before • very little was known before as this is a novel infection. no health planning for this type of pandemic. what this study adds • a positive and significant adaptation of ppe in response to change in guidance. most trusts appear to have adapted and are doing similar things. who. www.who.int. accessed royal college of ophthalmologists. www.rcophth.ac.uk characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention ophthalmologic evidence against the interpersonal transmission of 2019 novel coronavirus through conjunctiva. medrixiv characteristics of ocular findings of patients with coronavirus disease 2019 (covid-19 2019-ncov transmission through the ocular surface must not be ignored novel coronavirus disease 2019 (covid-19): the importance of recognising possible early ocular manifestation and using protective eyewear acknowledgements we acknowledge beecs committee members for this work. conflict of interest the authors declare that they have no conflict of interest.publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-295322-9kye4w9g authors: kumar, parmeshwar; killedar, makhdoom; singh, gagandeep title: adaptation of the ‘assembly line’ and ‘brick system’ techniques for hospital resource management of personal protective equipment, as preparedness for mitigating the impact of the covid-19 pandemic in a large public hospital in india date: 2020-05-22 journal: j hosp infect doi: 10.1016/j.jhin.2020.05.029 sha: doc_id: 295322 cord_uid: 9kye4w9g nan the covid-19 pandemic had a slow start in india due to strict restrictions and screening imposed on foreign travel, but by the first week of march 2020, it was clear that the surgical store of our hospital needed to rapidly ramp up its inventory of personal protective equipment (ppe), well ahead of an anticipated increased transmission. ppe items provided by our regular vendors were not available as complete kits. in addition, some important items such as coveralls were not being routinely procured. logistical delays from the nationwide lockdown, financial constraints like fluctuating pricing and demands for advance payment as well as regulatory pressure due to caps imposed on purchase quantity and pricing, made it difficult to procure ppe. the supply chain disruption consequent upon limited supply of raw material with manufacturers and export bans imposed by other countries added to the complexity of the issue. managing the supply chain of ppe in this scenario was difficult and made it necessary to evolve new systems and guidelines to mitigate these conditions. our hospital responded by bringing together a team consisting of hospital administrators, microbiologists, and clinicians. an equitable model for appropriate use of ppe in various healthcare settings was created, which also reassured and boosted the morale of healthcare workers. it was decided to assemble ppe kits in-house from piecemeal purchases of individual items of appropriate quality. an assembly line was put in place where components of the ppe kit were added in sequence until the final completed product was packed and ready for distribution. the processes adopted involved the following principles. the reputation of our institute, large size of advance orders and extensive reach available from previous history of purchases allowed us to attract a choice of vendors. a few components not routinely available in adequate numbers, like hood caps and long shoe covers, were custom-made by reliable manufacturers. the patient waiting hall was reconfigured to become the staging area for incoming vendor inventory (figure 1 ). data entry operators and patient care coordinators were enlisted as assembly line workers. faculty members volunteered to be assembly line supervisors. in the indian armed forces, a 'brick system' has been in vogue since the colonial era. a brick is an operationally self contained box for a manpower based unit. it is typically used inventory management of the personal kit issued to each fighting unit and also used by the united nations peace keeping forces (the un brick) [1] . the system also envisages different types of kits required at different levels. this method was modified by a hospital administrator having previous experience in the indian army medical corps. the number of beds in a given medical unit and the human resources needed to operationalise it were considered a functional unit. the number of ppe kits required per day was ascertained. for laboratories, the monthly requirement was considered. the requisite number of in-house ppe kits for the various wards were then assembled into one brick(a carton) and supplied to that unit on a daily basis. the brick system aids in inventory management by rationalising the indents, keeping track of future requirements and projecting the purchasing of components far ahead of time. bricks of varying sizes and levels help in rationing of ppe between different wards based on differentiating essential and elective patients. availability of smaller bricks helps in downsizing of certain wards in terms of patient admissions or rostering of health care workers based on ppe availability. computerised records of each brick helps in storage, retrieval, issue and consumption patterns. keeping the system ready for all eventualities, based on reports from other countries [2] , disinfection and reuse scenarios were envisaged. modifications to a number of hospital rooms were carried out for disinfection of different kit components, if found necessary in future. hydrogen peroxide vapour based disinfection rooms [3, 4] revenue procurement practices in the indian army. institute for defence studies and pursuit of ppe dupont personal protection covid-19 supply update (rev 3/25) and fact sheet downloads at evaluation of five decontamination methods for filtering facepiece respirators key: cord-314517-n1yj2zdy authors: huang, dayong; shu, wen; li, menglong; ma, juntao; li, ziang; gong, jiajian; khattab, nourhan m; vermund, sten h; hu, yifei title: social media survey and web posting assessment of the covid-19 response in china: health worker attitudes towards preparedness and personal protective equipment shortages date: 2020-08-31 journal: open forum infect dis doi: 10.1093/ofid/ofaa400 sha: doc_id: 314517 cord_uid: n1yj2zdy background: understanding health worker awareness, attitudes, and self-confidence in the workplace can inform local and global responses towards emerging infectious threats, like covid-19 pandemic response. availability of accessible personal protective equipment (ppe) is vital to effective care and prevention. methods: we conducted a cross-sectional survey from february 24-28, 2020 to assess covid-19 preparedness among health workers. in addition, we assessed trends from search engine web crawling and text-mining data trending over the sina weibo platform from january 1 to march 3, 2020. data were abstracted on chinese outbreak preparedness. results: in the survey, we engaged 6,350 persons, of whom 1,065 agreed to participate and after an eligibility logic check, 1,052 participated (16.6%). we accessed 412 internet posts as to ppe availability. health workers satisfied with current preparedness to address covid-19 were more likely to be female, to obtain knowledge about the sars-cov-2 outbreak from government organizations, and to consider their hospital prepared for the outbreak management. health workers with more confidence in their abilities to respond were those with more faith in their institution’s response capacities. elements of readiness included having airborne infection isolation room, visitor control procedures, training in precautions and ppe use. both survey and web post assessments suggested that health workers in need were unable to reliably obtain ppe. conclusion: health workers’ self-confidence depends on perceived institutional readiness. failure to maintain available ppe inventory for emerging infectious diseases preparedness suggests a failure to learn key lessons from the 2003-2004 sars outbreak in china. according to the coronavirus disease (covid-2019) situation reports of the world health organization (who), sars-cov-2 infections had been reported from 213 countries, territories, or international conveyances (ships) by august 8, 2020 1 . china has been classified from a level 5 country for community viral transmission, the highest level of concern 2 based on clusters of cases. who had urged nations to prepare for the threat of autochthonous transmission, noting that emerging cases from secondary transmission now typically lacked a direct link to the original china epicenter. the u.s. centers for disease control and preparedness (cdc) define a pandemic as a global disease outbreak (i.e., multicontinent) in its all-hazards preparedness guide 3 and pandemic infectious threats is health professional preparedness. in the who influenza pandemic plan in 1999, who urged the global community for plans to address "infectious diseases: global alert, global response" 4 . this plan was eerily prescient as to the sars pandemic just four years later. the roles and responsibilities of the who and national authorities in preparing for and responding to an influenza pandemic are identical to what would be needed for other respiratory pandemic threats. health workers are critical for building societal confidence during epidemic outbreaks. they cannot function effectively if they lack personal protective equipment (ppe), essential to ensure continuity of healthcare services during a public health emergency and to avoiding nosocomial acquisitions 5 a c c e p t e d m a n u s c r i p t 6 as of april 4, 2020, 60 chinese health workers have died, of whom 22 (36.7%) were confirmed dead of covid-19, according to reports by china central television. at least 3,387 medical staff from 476 medical institutions across the country were infected with sars-cov-2, including 2,055 confirmed cases, 1,070 clinically diagnosed cases, and 157 suspected cases. in hubei province alone, 3,062 infected cases (>90% of the national total) in health workers were reported by february 24, 2020 7 (no further update was released officially since hospital burdens were eased after a large national-wide medical taskforce was dispatched to hubei province for assistance). we sought to study health worker self-perception of preparedness and ppe availability in 2020, over two decades after the who call for pandemic influenza readiness. our mixed methods study was a two-part effort consisting of: (1) an online cross-sectional survey using an online electronic questionnaire and (2) a mining of web text via data crawling of ppe-related postings (fig 1) . data crawling is a technique for data extraction from the internet using a crawling agent (automated script) that helps gather publicly available data in very large quantities. our survey was based on the who and cdc preparedness checklists and we targeted licenced health workers, evaluating awareness of, and confidence in covid-19 preparedness and response at their institutions. we also reviewed policy changes on provision of ppe in china related to the 2019-2020 sars-cov-2 outbreak. a c c e p t e d m a n u s c r i p t 7 our survey targeted health workers based in hospitals, including physicians, nurses, and others. eligible participants were licensed health workers in practice; given our hubei province focus, this including workers at the front-line of care provision in the midst of the covid-19 crisis. while we did not indicated exclusion criteria in the recruitment poster (supplemental fig 1) , we specified our research aims regarding self-perception of health worker preparedness. online consent was obtained for participation. participants were recruited using two methods. the first was an online advertisement on a the second means of recruitment was engagement via wechat "moments sharing". wechat is a comprehensive package of online services, equivalent to combining apps such as facebook  , whatsapp  , and paypal  . eligible recruited persons providing consent were given a self-administered structured questionnaire online using https://www.wjx.cn/. this "wjx" is similar to surveymonkey  and is more popular and accessible in china. we developed a poster with a qr code to link people to the questionnaire (suppl. fig 1) . both the physician service app and the wechat moments sharing methods promoted the poster a c c e p t e d m a n u s c r i p t 8 and encouraged interested health workers to identify the qr code and enter the online survey system. the first page of the questionnaire assessed eligibility and obtained informed consent for those who were eligible. no incentive was provided for survey participation. we studied three main outcome indicators using 5 or 3 text mining of the weibo announcement searched (in chinese) for "(help or support or donate) and ppe" . weibo is a twitter  -like social media platform in china. people share social, cultural, and historical insights or comments on trending topics via the platform. we crawled text data or scripts of the video of needed ppe including "求助" (help) or "防护服" (gown)or "口罩" (facemask) from https://weibo.com/ from jan 1, 2020 through march 3rd, 2020 using python tm 3.8.2. after manually verifying and cleaning the raw data, we the survey data were exported into microsoft excel ® and then manually labelled with the level of the capability of the hospital according to the 3-tier category in china. through dynamic ip address and the name of the local hospital, we identified the geo-location of the participants and generated two variables of the location as "city" and "province" for each participant. in the case of a conflict between ip address and hospital, we chose the affiliated hospital for location classification. completed databases were analysed after data cleaning using statistical analysis system  (v.9.4; sas institute inc, cary, nc, usa). we used univariate and multivariable logistic regression analysis to identify the association between a respondent's current confidence in coping with covid-19 suspected/confirmed cases and his/her sociodemographic characteristics. crude and adjusted odds ratios (cor and aor) with 95% confidence interval (95%ci) were calculated for the association of the covariates with the outcome (self-confidence). the variables with p value of <0.05 in univariate analysis were entered into the multivariable backward regression models and only variables with twosided p value of <0.05 or less were considered statistically significant in the final model. a c c e p t e d m a n u s c r i p t 10 the study was approved by capital medical university ethics review board (2020sy004). the study protocol, contents, and procedure were explained before survey inception. online consent was obtained for participation. non-identifiable data from the app was collected or analysed per the study protocol. the web-based questionnaire was uploaded february 24, 2020 and taken offline on fig 2b) . doctors accounted for 75.8% of the respondents, nurses representing 17.3%, and others 6.9%. fewer than half (48%) of participants were satisfied with the protective equipment in the hospital to cope with the covid-19 epidemic, and 6.4% of respondents were very dissatisfied. nearly three-quarters (73%) of health workers expressed selfconfidence in coping with persons under investigation (pui) or known patients. about half (53%) of the participants expressed confidence in institutional preparedness and its ability to respond to eids in the future (table 1) . a c c e p t e d m a n u s c r i p t 11 there were 412 posts of ppe request announcements from our weibo crawl during january 1 to march 3, 2020. for 386 posts, we were able to do manual city-labelling, narrowing the focus of the request for ppe and mapping respondents' locations (fig 2) . weibo posts calling for help or donations of ppe, including gowns, facemasks, and goggles, increased sharply from january 23 to january 25, 2020 and the number of cities that posted requests for urgent help for medical supplies online increased drastically, and then levelled after the lockdown of the city of wuhan, policy guidance was gradually put into place. health workers who were infected were seen in the early stages of the epidemic, correlating with the time of acute shortage of ppe. after centralized management and emergency response protocols and the action of ppe manufacturers to accelerate production and supply mobilization to the hubei province epicenter, the number of health workers being infected decreased significantly (fig 3) . a c c e p t e d m a n u s c r i p t 12 suppl. table 1 presents predictors of health workers' satisfaction with current readiness of ppe in their hospitals during the outbreak. multivariable analysis suggested that health workers who were more satisfied with the readiness of the affiliated hospitals were more likely to be female (aor=1.30, 95% ci: 1.03-1.63), obtain knowledge /information of the sars-cov-2 outbreak from government sources (aor= 1.36, 95% ci: 1.03-1.81), have airborne infection isolation rooms in their hospital (aor= 2.15, 95% ci: 1.69-2.74), and to think their hospital is prepared for the outbreak (aor= 4.28, 95% ci: 3.14-5.83). suppl. table 2 presents predictors with a sense of confidence in treating patients and confidence in current institutional readiness during the outbreak. those who tended to have higher current confidence to deal with suspected patients were more likely to be male health self-discipline to exercise in order to increase immunity (5%), and rotating the shift times since wearing ppe accelerated a sense of exhaustion in the medical workplace (3%). over half of them recommended compulsory training on self-protection standards. some respondents suggested the need for attention to gender-related vulnerability in crises. one example was for female health workers to be allowed to take breaks during their menstruation due to inconvenience with gowning and consequent potential of increasing infection risks. over 10% of the respondents complained about an amateurish style of hospital leadership, for instance, exhibiting managerial incompetent to achieve effective responses as well as exhibiting a lack of health care knowledge and professionalism (suppl. preparedness of their hospitals than in their personal readiness. since hospital level preparedness requirements are intensive and complex to battle outbreaks, our finding echoed an ebola virus preparedness report from the u.s. 11 compulsory training on precautions and the application of universal standard guidelines, including ppe use, can reduce occupational infection and increase confidence during a crisis 9, 12 . health emergency responders should consider integrating grass-root level simulation training for staff (primary and undetermined hospitals, clinics) to increase the capacity and readiness for patient management 13 . we also found that health workers had more trust in the source of information when it was from the government than from other channels. this may be true in china, but could plausibly be the opposite in other nations. chinese health authorities' timely disclosure of epidemic information likely increased a sense of security through viable up-to-date information in late january 10, 14, 15 . better hospital infrastructure, worker satisfaction with ppe, and a worker's current sense of confidence in the hospital's current readiness seem to increase self-confidence of health professional staff in addressing eids 16 . outbreaks and epidemics mean that hospitals and frontline care facilities need products in unprecedented quantities 17 . alongside the significant spike in product demand, health care workers can experience fear and panic, devastating the confidence of the public and health workers alike. this occurred when ppe distributors and manufacturers were unable to fill early orders for the sars-cov-19 programs 5 . hospitals and governments must address the needs for surging supply and stock via tiered advanced planning to cope with different epidemic scenarios 18, 19 . this phenomenon can also be seen in a c c e p t e d m a n u s c r i p t 17 study strengths were the ability to draw conclusions from mixed methods results. that we could do the study in such proximity to the epidemic's geometric rise ensures the freshness of opinions of our respondents, minimizing recall bias. our study has some limitations. data crawling text information was gathered retrospectively. it may underestimate the actual quantity of postings asking for ppe help since some information that was shared by the institutions may have been taken down when their needs were met. some information over the internet (such as criticisms of local responses) are more likely to be removed than other responses, making the current data an under-estimate of gaps in preparedness. changes in the trend of numbers may reflect either true product shortages or difficulties in supply chains over time. our survey was a convenience web-based sample with a comparatively low response rate, limiting generalizability. however, this method was the only feasible way to avoid intra-person contact in data gathering during the pandemic crisis in china. since our survey was conducted after the ppe supply need was almost met after extreme scarcity, the satisfaction rate of the ppe supply may have been an overestimate. ensuring ppe supply for health workers is an essential inventory component for effective health emergency response, and ppe should be an integrated element in all-hazards emergency preparedness procedures. ppe availability increases a sense of confidence among health workers and reduces nosocomial infection. tiered management, reasonable rotation, specified inventory of ppe for stockpile, and inventories that are ready-for-use for health workers are all vivid lessons from china for consideration by other global infection control fighters. who. coronavirus disease (covid-19) situation report -201 covid-19). who. rolling updates on coronavirus disease (covid-19) web site all-hazards preparedness guide infectious diseases : global alert, global response approach to prioritizing respiratory protection when demand exceeds supplies during an influenza pandemic: a call to action potential demand for respirators and surgical masks during a hypothetical influenza pandemic in the united states rolling update of those died for combatting covid-19 evolving epidemiology and impact of non-pharmaceutical interventions on the outbreak of coronavirus disease lessons learned from hospital ebola preparation health care provider knowledge and attitudes regarding reporting diseases and events to public health authorities in tennessee ebola in the netherlands, 2014-2015: costs of preparedness and response ebola outbreak preparedness and preventive measures among healthcare providers in saudi arabia developing a simulation-based training program for the prehospital professionals and students on the management of middle east respiratory syndrome attitudes towards zika virus infection among medical doctors in aceh province the sars, mers and novel coronavirus (covid-19) epidemics, the newest and biggest global health threats: what lessons have we learned? straining the system: novel coronavirus (covid-19) and preparedness for concomitant disasters personal protective equipment supply chain: lessons learned from recent public health emergency responses what us hospitals should do now to prepare for a covid-19 pandemic. website: clinicians' biosecurity news implementation of mitigation strategies for communities with local covid-19 transmission monitoring pharmacy and test kit stocks in rural mozambique: u.s. president's emergency plan for aids relief surveillance to help prevent ministry of health shortages cdc's evolving approach to emergency response the asia pacific strategy for emerging diseases -a strategy for regional health security strategy for emerging infectious disease control and prevention[卫生 部关于印发《突发急性传染病预防控制战略》的通知 national health commission; 2016. 26. national health and family planning commission c. guidance on strengthening the standardized construction of health emergency work《关于加强卫生应急工作规范化建设 的指导意见》 addressing maternal health during cdc's ebola response in the united states considerations for u.s healthcare facilities to ensure adequate supplies of personal protective equipment (ppe) for ebola preparedness accessed. 31. ministry of finance c. hospital financial measures a c c e p t e d m a n u s c r i p t 18 a c c e p t e d m a n u s c r i p t 19 a c c e p t e d m a n u s c r i p t 20 key: cord-287303-b7vg439c authors: piché-renaud, pierre-philippe; groves, helen e.; kitano, taito; arnold, callum; thomas, angela; streitenberger, laurie; alexander, laura; morris, shaun k.; science, michelle title: healthcare worker perception of a global outbreak of novel coronavirus (covid-19) and personal protective equipment: survey of a pediatric tertiary-care hospital date: 2020-08-12 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.415 sha: doc_id: 287303 cord_uid: b7vg439c objective: in this study, we aimed to capture perspectives of healthcare workers (hcws) on coronavirus disease 2019 (covid-19) and infection prevention and control (ipac) measures implemented during the early phase of the covid-19 pandemic. design: a cross-sectional survey of hcws. participants: hcws from the hospital for sick children, toronto, canada. intervention: a self-administered survey was distributed to hcws. we analyzed factors influencing hcw knowledge and self-reported use of personal protective equipment (ppe), concerns about contracting covid-19 and acceptance of the recommended ipac precautions for covid-19. results: in total, 175 hcws completed the survey between march 6 and march 10: 35 staff physicians (20%), 24 residents or fellows (14%), 72 nurses (41%), 14 respiratory therapists (8%), 14 administration staff (8%), and 14 other employees (8%). most of the respondents were from the emergency department (n = 58, 33%) and the intensive care unit (n = 58, 33%). only 86 respondents (50%) identified the correct donning order; only 60 (35%) identified the correct doffing order; but the majority (n = 113, 70%) indicated the need to wash their hands immediately prior to removal of their mask and eye protection. also, 91 (54%) respondents felt comfortable with recommendations for droplet and/or contact precautions for routine care of patients with covid-19. hcw occupation and concerns about contracting covid-19 outside work were associated with nonacceptance of the recommendations (p = .016 and p = .036 respectively). conclusion: as part of their pandemic response plans, healthcare institutions should have ongoing training for hcws that focus on appropriate ppe doffing and discussions around modes of transmission of covid-19. the novel coronavirus disease (covid-19) pandemic presents a significant infection control challenge within healthcare settings. 1, 2 published studies from various countries have highlighted a significant proportion of healthcare-related infections as well as infections among healthcare workers (hcws), especially in the early phase of the pandemic. [3] [4] [5] these findings are consistent with healthcare-associated infections previously documented early within the middle east respiratory syndrome coronavirus (mers-cov) outbreak and the severe acute respiratory syndrome (sars) outbreak. [6] [7] [8] a number of published studies from prior sars and mers-cov outbreaks have highlighted the significant impact of such outbreaks on hcw morale and levels of concern that may impact perceptions and confidence in infection prevention and control (ipac) measures as well as adherence to these approaches. [9] [10] [11] [12] [13] indeed, lack of confidence in institutional control measures can result in absenteeism, which in turn can have significant impacts on delivery of care within an outbreak setting. 13, 14 during the 2003 sars outbreak in canada, inconsistent use of ppe and lack of adequate infection control training were among the factors contributing to the infection of hcws. 15 in this study, we aimed to capture attitudes and knowledge of hcws regarding covid-19 and ipac measures in the early phase of the covid-19 pandemic, especially related to ppe. we also sought to identify factors influencing hcw knowledge and self-reported use of personal protective equipment (ppe), concerns about contracting covid-19, and acceptance of the recommended ipac precautions for covid19 . this evaluation of the perspectives of hcws on ipac measures from the early phase of the pandemic provides invaluable information regarding the potential causes of initial nosocomial transmission of covid-19 and ways to mitigate them moving forward. this is a cross-sectional study consisting of a self-administered survey for hcws working at the hospital for sick children, in toronto, canada. as the only pediatric tertiary-care hospital in toronto, our center is uniquely positioned in regard to the current outbreak, given our previous experience with the sars outbreak in 2003. 10 the survey was distributed to clinicians and nonclinicians in emergency, intensive care, and pediatric wards as well as ambulatory clinics. responses were recorded over a 5-day period from march 6 to march 10, 2020, using convenience sampling. an ethics review was completed through the quality improvement process at the hospital. the survey instrument consisted of a series of questions developed by the infectious diseases, occupational health and safety and ipac unit at our hospital. the survey was distributed by email to an electronic mailing list of 951 clinical and nonclinical hcws of the hospital for sick children from the emergency department, intensive care unit, pediatric wards, and ambulatory clinics. an initial email was sent on march 6 with a reminder on march 9. responses were collected anonymously using research electronic data capture (redcap). 16 the survey instrument was developed using previously published surveys delivered during similar viral outbreaks of global significance (sars and mers-cov). [10] [11] [12] [17] [18] [19] following initial validation by internal testing with ipac and infectious diseases teams, the survey was subsequently pilot tested with a selected sample of hcws to ensure comprehension and to resolve ambiguities. the finalized survey consisted of 19 questions divided in 3 sections: (1) baseline demographic characteristics and previous relevant training including ppe training, hand hygiene training, and covid-19-specific ppe training; (2) knowledge, attitudes, and practices regarding ppe use; and (3) accessed sources of information and concerns regarding covid-19. covid-19 ppe training was done in person with a hands-on demonstration of donning and doffing by the nurse educators as well as by the occupational health and safety team (ie, occupational hygienists). a video of the proper donning and doffing sequence was shown in addition to printed instructional materials and the public health ontario donning and doffing posters. information on the recommended equipment for care of patients with covid-19 and other covid-19 ipac measures was also given. this training was made mandatory for all hcws working at our institution, including new hires and current staff, starting in early january 2020. our aim was to retrain as many hcws as possible, but not all of them could be trained in-person for a number of reasons, including vacations and conflicting schedules. to evaluate ppe knowledge, hcws were asked the order in which they would don (put on) and doff (remove) ppe equipment. for both donning and doffing questions, a score of 1 was attributed if the correct order was identified, and a score of 0 was given for an incorrect order. the correct order for donning was defined in accordance with public health ontario guidelines: (1) perform hand hygiene, (2) put on gown, (3) put on mask or n95 respirator, (4) put on eye protection, (5) put on gloves. 20 the correct doffing order was defined as follows: (1) remove gloves, (2) remove gown, (3) perform hand hygiene, (4) remove eye protection, (5) remove mask or n95 respiratory, (6) perform hand hygiene. 20 respondents were also asked to report their usual use of ppe for droplet and/or contact precautions using a likert scale: never (1), rarely (2), occasionally (3), frequently (4) and every time (5) . because the current evidence suggests that the mode of transmission of sars-cov-2 is through direct contact and respiratory droplets, the ontario ministry of health updated its recommendation on march 12 to the use of droplet and/or contact precautions for routine care of patients with covid-19 and airborne precautions only for patients requiring aerosol-generating medical procedures (agmps). 21, 22 this was a change from the previous recommendation of n95 for all patients and based on experience from healthcare settings in which hcws have not acquired covid-19 while using droplet and contact precautions for routine care, including in other canadian provinces. 23 in anticipation of this change to be aligned with the provincial recommendations, the survey included questions around the acceptance of this recommendation, and what information would help hcws feel comfortable making the change. hcw concern regarding being exposed or contracting covid-19 at work and outside work was assessed using the following 5-point likert scale: not at all concerned (1), neutral (2), somewhat concerned (3), very concerned (4) and extremely concerned (5) . lastly, participants were prompted to provide comments on their use of ppe, ipac precautions for covid-19, and their satisfaction with the information provided to hcws by the institution. the detailed survey can be found in appendix 1 (online). responses were analyzed using statistical package for social sciences version 25.0 (spss, chicago, il). baseline demographic characteristics were reported for each category using absolute numbers and percentages. the χ 2 test and the fisher exact test were performed to estimate the significance among categorical study variables where appropriate. analysis of variance (anova) was performed to assess to estimate the significance between ordinal variables. nonclinical hcws (administration) were not included in the analysis of occupation on donning and doffing scores. differences were considered statistically significant at p < .05. missing answers were excluded from the analysis after confirmation that the underlying demographics were not substantially different from those analyzed, therefore minimizing selection bias. thematic analysis was performed in respect to respondents' free text comments to identify common themes. in total, 175 hcws completed the survey, which corresponds to a response rate of 18.4%. among them were 35 staff physicians (20%), 24 residents or fellows (14%), 72 nurses (41%), 14 respiratory therapists (8%), 14 administration staff (nonclinical, 8%), 14 other employees (8%), and 1 unknown. also, 34 respondents (19%) reported having worked in the healthcare system during the 2003 sars outbreak in toronto. one-third of the respondents were from the emergency department (n = 58, 33%), one-third were from the intensive care unit (n = 58, 33%), and the other third were from the ward, the ambulatory clinic or other settings, such as specialty consulting services and patient support services. detailed characteristics of the respondents are reported in table 1 . survey responses were recorded in the 5 days immediately before the covid-19 outbreak was declared a pandemic by the world health organization (who). the study timing and number of responses in relation to the covid-19 outbreak in canada and pandemic declaration are detailed in figure 1 . at the time of the survey, cases of covid-19 in canada were mainly reported among returning travelers or their contacts. in total, 86 respondents (50%) identified the correct order for donning ppe, and 60 (35%) identified the exact correct doffing a score of 1.00 was given as the value obtained was above 1. c a score of 0 was given as the value obtained was below 0. order. also, 113 (70%) identified the need to perform hand hygiene prior to removal of their face mask and/or eye protection. those who reported receiving previous training related to ipac in the past 2 years (either general ppe training, hand washing training or covid-19 specific ppe training) had significantly higher doffing ppe scores than those without reported training. comparison of other baseline demographics and their impact on ppe knowledge are also presented in table 1 . no other factors had a statistically significant impact on ppe knowledge. with respect to usual ppe use for patients requiring droplet and/or contact precautions, respondents who received ppe training in the past 2 years reported using the most elements of ppe and more frequently than those who did not report ppe training. there was no statistical difference for the use of eye protection. these results are reported in appendix 2 (online). in general, respondents were more concerned about being exposed or contracting covid-19 at work than about contracting it outside work. baseline demographics and other factors influencing concerns about contracting covid-19 at work and outside work are detailed in table 2 . notably, hcws from the emergency department were the most concerned about contracting covid-19 at work. administration staff were the group most concerned about contracting covid-19 outside work. use of social media as a primary source of information was associated with increased concern of contracting covid-19 both at work and outside work, whereas satisfaction with institution-provided information on covid-19 was associated with lower concern. every age group had similar concerns about contracting covid-19 both at work and outside work. with respect to the use of droplet and/or contact precautions for the routine care of suspect or confirmed covid-19 patients, 91 of 167 respondents (54%) felt comfortable with this recommendation. we detected a statistically significant association between hcw occupation and acceptance of the recommendations (p = .016). nurses and respiratory therapists indicated that they would need more information compared with physicians, residents, and other staff. thematic analysis of the respondents' comments allowed us to identify facilitators for ppe implementation, acceptance of covid-19 ipac measures, and information transmission regarding covid-19. hcws indicated that they would be more likely to accept the recommendation for droplet and/or contact precautions for the routine care of patients with covid-19 if they were more confident in their knowledge of ppe donning and doffing. they also had concerns about ppe availability in their workplace and feared that an impending shortage could influence guidance around ipac measures. respondents reported that thorough information on transmission modes of covid-19 would facilitate their acceptance of the recommendation. respondents preferred information that was tailored to their occupation and provided by the fewest sources possible. our findings provide insight into hcw attitudes and knowledge of covid-19 and the related ipac measures during the early phase of the pandemic. covid-19-specific ppe training had the most significant impact on hcws knowledge of ppe donning and doffing. the early implementation of ipac and ppe trainings may therefore have mitigated the nosocomial spread of covid-19. hcws were most concerned about being exposed or contracting covid-19 at work, and half of the respondents from our study reported being comfortable with recommendations for droplet and/or contact precautions for routine care of patients with covid-19. approximately one-third of the respondents were able to correctly identify the appropriate order to remove ppe equipment. this finding was of concern because incorrect doffing order has been shown to lead to increased contamination of hcw clothing and the surrounding environment, potentially leading to hcw infections. 24,25 ppe training with a focus on ppe doffing was identified as a priority for all hcws caring for patients with suspected or confirmed covid-19, regardless of their previous work experience. given that 30% of hcws did not report the need to perform hand hygiene immediately before removal of face mask and/or eye protection in our survey, we identified this as an important focus of ppe training at our institution because it was a source of hcw contamination during the sars outbreak. 26 with the feedback from this survey, we also created an online learning module for all hcws at our institution that incorporated lessons learned, including modes of transmission of covid-19, proper protection needed for specific clinical tasks, and a focus on the importance of the correct sequence of doffing ppe. the online module made it easier to reach all hcws and to provide further reinforcement and learning opportunities, compared to in-person trainings. notably, our study captured hcw concerns about contracting covid-19 early in the outbreak, just days before it was declared a pandemic by the who, at which time not all hcws had received ppe refresher training. having a thorough insight into hcw attitudes and knowledge of ipac measures from the early phase of the pandemic is important to understanding the causes of covid-19 infection among hcws. most hcw infections occurred early in the covid-19 outbreak. 5, 27 in ontario, 4,230 hcws have been infected, which represents 17.5% of the 24,202 confirmed covid-19 cases as of may 14, 2020. as few as 3.1% of the infected hcws were documented to have acquired covid-19 nosocomially. 27 unfortunately, no data on the adequacy of ppe used by hcws infected nosocomially are available. based on the results of our study, initial gaps in hcw ppe knowledge, especially related to doffing order, may have contributed to nosocomial infections among hcws in the early phase of the pandemic. in our study, hcws from the emergency department had the highest level of concern regarding contracting covid-19 at work, which is not surprising given the volume and acuity of patients they see. this finding is in keeping with previous experience of the 2003 sars outbreak in toronto, during which hospital emergency departments were important sites for sars transmission in the early part of the epidemic. 28 recently, tan et al 29 assessed the psychological impacts of covid-19 on hcws in singapore, and 68 of the 470 surveyed participants (14.5%) screened positive for anxiety. in our study, using social media as a source of information was strongly associated with hcw concerns regarding contracting covid-19, both at work and outside work. this finding affirms previous assumptions that the use of social media may induce anxiety regarding covid-19 in users and therefore should not be promoted as the main source of information. 30 however, it is important to acknowledge the possibility that direction of causality in our study may be the reverse, and hcws that have greater concerns about contracting covid-19 are more likely to consume more information surrounding the pandemic, including a greater diversity of information sources. this hypothesis is reinforced by the fact that using public health website and moh communications as sources of information was also associated with increased concerns about contracting covid-19 at work. our study has some limitations. first, respondents were recruited using convenience sampling, which could therefore limit the external validity of our study. the studied population was relatively young: 42% were aged 30-39 years. although most of our results reflect those of previous studies on viral outbreaks of global significance, a lack of standardized methodologies between studies limits such comparison. moreover, in view of the cross-sectional nature of the study, we were only able to capture hcw knowledge and perceptions within a limited period. this study has provided important insight into hcw knowledge and attitudes toward covid-19 and ipac measures during the early phase of the pandemic. to ensure that ipac responses accurately reflect gaps in knowledge and to identify specific facilitators to continuous improvement, follow-up assessments are also required. a consistent framework through which ipac knowledge can be assessed should also be developed, allowing for comparisons at national and international levels as well as rapid dissemination of hospital epidemic response plans. with this survey, we aimed to contribute to this important topic and to provide an adaptable framework with which to generate context-specific ipac plans. covid-19) technical guidance: infection prevention and control/wash. world health organization website occupational risks for covid-19 infection risk factors of healthcare workers with corona virus disease 2019: a retrospective cohort study in a designated hospital of wuhan in china covid-19 and italy: what next? coronavirus disease 2019 (covid-2019) infection among health care workers and implications for prevention measures in a tertiary hospital in wuhan, china an outbreak of sars among healthcare workers comparative analysis of eleven healthcare-associated outbreaks of middle east respiratory syndrome coronavirus (mers-cov) from comparative epidemiology of human infections with middle east respiratory syndrome and severe acute respiratory syndrome coronaviruses among healthcare personnel psychosocial effects of sars on hospital staff: survey of a large tertiary-care institution paediatric emergency department staff perceptions of infection control measures against severe acute respiratory syndrome middle east respiratory syndrome (mers): comparing the knowledge, attitude and practices of different health care workers knowledge and attitude towards the middle east respiratory syndrome coronavirus among healthcare personnel in the southern region of saudi arabia surge capacity and casualization: human resource issues in the post-sars health system diverse implications of a national health crisis: a qualitative exploration of community nurses' sars experiences cluster of cases of severe acute respiratory syndrome among toronto healthcare workers after implementation of infection control precautions: a case series the redcap consortium: building an international community of software platform partners middle east respiratory syndrome risk perception among students at a university in south korea questionnaire-based analysis of infection prevention and control in healthcare facilities in saudi arabia in regards to middle east respiratory syndrome design and validation of a questionnaire to measure the attitudes of hospital staff concerning pandemic influenza removing and putting on personal protective equipment. public health ontario website air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) from a symptomatic patient covid-19 and the risk to healthcare workers: a case report covid-19-what we know so far about routes of transmission. public health ontario website self-contamination during doffing of personal protective equipment by healthcare workers to prevent ebola transmission impact of doffing errors on healthcare worker self-contamination when caring for patients on contact precautions sars and the removal of personal protective equipment covid-19 infections among healthcare workers and transmission within households investigation of a nosocomial outbreak of severe acute respiratory syndrome (sars) in toronto, canada psychological impact of the covid-19 pandemic on health care workers in singapore the pandemic of social media panic travels faster than the covid-19 outbreak acknowledgments. we thank the infection prevention and control team at the hospital for sick children (richard wray, krista cardamone, megan clarke, and renee friedman) and occupational health and safety for their guidance in the creation of the survey, their help in the redaction of this manuscript, and their essential work in the implementation of infection prevention and control measures at our hospital in the context of the current covid-19 pandemic.financial support. no financial support was provided relevant to this article.conflicts of interest. all authors report no conflicts of interest relevant to this article. key: cord-276945-gly0stxm authors: coxon, kirstie; turienzo, cristina fernandez; kweekel, liselotte; goodarzi, bahareh; brigante, lia; simon, agnes; lanau, miriam morlans title: the impact of the coronavirus (covid-19) pandemic on maternity care in europe date: 2020-06-10 journal: midwifery doi: 10.1016/j.midw.2020.102779 sha: doc_id: 276945 cord_uid: gly0stxm nan this month, europe remembers the end of the second world war and reflects on 75 years of peace, and also celebrates the bicentenary of florence nightingale's birth on 12 th may 1820. the world health organisation designated 2020 the international year of the nurse and midwife to mark florence nightingale's birth; florence nightingale's legacy is extensive, but she is perhaps most often associated with improvements in sanitation and infection control during her work in the crimean war, and in gathering and using evidence, and those insights remain with us as we work to provide safe, high quality maternity care in the era of covid-19. amist these anniversaries, 2020 has also seen the rapid and unpredictable spread of across europe. although the evidence to date would suggest that pregnancy does not increase the likelihood of developing covid-19 complications compared to non-pregnant population (docherty et al 2020) , and that vertical transmission appears to be unusual (knight et al 2020) , the clinical picture remains uncertain, and much more evidence is needed before we can be confident about these early indications. however, what is clear that the burden of morbidity and death does not fall equitably. there is mounting evidence that covid-19 disproportionately affects those from black, asian and minority ethnic backgrounds; a recent uk obstetric surveillance system (ukoss) study (knight et al., 2020) of pregnant women hospitalised with covid-19 found a clear association between hospitalisation and black and other minority ethnicity (aor 4.49, 95%ci 3.37-6.00), and also that older women or those with raised bmi or other comorbidities were more likely to be hospitalised and require critical care. this observation, also seen in other countries which gather and report case ethnicity (khunti et al., 2020) , has shocked many; the reasons are not fully understood, but it is clear that people with bame ethnicity, whether they are pregnant women, members of the public, essential workers or health care providers, need to be pro-actively protected from contracting covid-19. a recent ukoss report (knight et al 2020) also revealed that five pregnant women in uk have died with or from covid-19, although it is not yet known whether covid-19 was the direct cause of death in these cases, and that 4.9 women per 1000 maternities were admitted to hospital with covid-19, of whom 9% required respiratory support. italy has also reported a maternal death with covid-19; to date, other eu countries have not, but as many women remain hospitalised, this situation may change. in this editorial, we consider the impact that covid-19 has had on maternity care in europe, and examine how those countries most affected have had similar or different responses. the purpose of this is to share these experiences, show commonalities and differences where these exist, and to reflect on the impact of covid-19 on maternity care in europe, now and in the coming months. we acknowledge of course that the greatest burden of covid-19 care provision, morbidity and death has fallen on those working in medicine, social care and nursing, in community care provision, in care homes, in mental health settings and in prisons; by comparison, midwives often care for healthy women at home or in low-acuity settings, and most pregnant women who contract covid-19 have only mild disease (knight et al 2020) . yet women and midwives remain very much affected; care during pregnancy, birth and the postnatal weeks has changed radically and fast, and basic elements of the midwife-woman relationship such as meeting in person and providing a comforting touch have been upended in an attempt to maintain distance and reduce cross-infection. women who have complex medical and obstetric conditions have had access to 'face to face' care reduced, whilst being encouraged to keep attending hospitals even as these are being recognised coronavirus 'hot spots'. at the moment, we have no idea of the impact these necessary adjustments will have on women and babies' wellbeing, or on women's experiences of birth. outside usa, european countries have had the highest number of covid-19 cases and deaths; uk, italy, spain, france, belgium and netherlands are all amongst the top ten affected countries in the world (john hopkins university 2020). in this context, concern about what constitutes safe care of pregnant women and newborns has increased, and in many settings, risk averse decisions have been taken in maternity care provision which, it is argued, may increase unnecessary medical interventions, put women at risk of being infected with covid-19 by reducing provision of community or home based care, and reduce or reverse progression towards high quality maternity care (renfrew et al 2020, forthcoming). whilst it is very difficult to make comparisons between countries at this early stage, information about maternity care, and about the way that the pandemic has progressed in different regions, seems to show some common themes. we discuss these below, drawing on first-hand accounts from colleagues and clinicians in some of the affected countries. commonalities include concerns around supply of ppe, high numbers of healthcare staff affected by the virus, and steps taken to reduce pregnant women's exposure to health settings by switching to online and telephone consultations where possible. differences emerge in how labour care and choice of place of birth has been planned, the reductions in antenatal and postnatal 'face to face' care provision and in promotion of skin to skin contact and breastfeeding for covid-19 positive women following birth. most eu countries moved to expand their healthcare workforces as the covid-19 pandemic developed. common responses were to invite recently retired staff back into general medical practice (reported in uk, italy netherlands, france and spain) or to arrange for near-qualified students to start working in the health service as has happened in uk. in spain, recently qualified medics have been deployed early into public healthcare before specialising, but have mainly undertaken administrative and non-patient facing work to release the wider workforce. in spanish hospitals with open maternity units, midwives have stayed in maternity care, but staff in smaller hospitals which may have discharged lots of patients were redeployed elsewhere. concerns about midwives being moved to medical wards in uk were addressed by the royal college of midwives, which made a strong case for maintaining maternity services in a context of staff shortage where many staff were self-isolating, sick or could not access child care cover for shifts. in the netherlands, midwives' training does not equip them to work in general medicine, and although retired midwives have been invited to return to practice, they have not been required to do so to date. affected eu countries report similar changes to the care provided to pregnant women and their families since the covid pandemic. it is worth reflecting that these changes have often been wholesale and widespread, occurring very suddenly and impacting on women already pregnant who had no advance warning that the care would change almost overnight. in the netherlands, an initial online or phone consultation was followed by an initial visit to the midwife at 10-12 weeks for blood tests and early ultrasound. subsequent appointments were by phone or online but with regular growth assessment and bp checks. partners are not allowed to attend these face to face meetings. france and uk have also stopped most face to face consultations and replaced these with online and telephone consultations. in some areas of the uk, women have been provided with blood pressure machines and urinalysis sticks to undertake their own antenatal checks, and those with known or pre-existing hypertension were often already self-monitoring and using online apps to inform healthcare providers of their readings. in italy, the ministry of health produced guidance for pregnancy but care still varied; some hospitals reduced antenatal clinics and used phone consultations, whilst face to face clinic appointments and home visits continued in others. in spain, this has again varied, with some clinics continuing, and other hospitals moving to phone consultations. the changes to care are all designed to reduce the covid-19 infection risk for pregnant women and staff, and whilst phone and online consultations can be acceptable and valued by women as an interim measure, these may also reduce the sense of genuine communication between women and midwives. they may create problems with care access for women with language problems or who lack it resources and skills and could provide fewer opportunities to identify issues such as domestic violence. there are fewer opportunities to hear the fetal heartbeat, which can increase anxiety for women, especially those with complex pregnancies; other women may be disproportionately affected by additional anxiety due to language issues, mental health problems or learning disabilities. whilst many women will be well throughout pregnancy, these changes are experimental and the effect on outcomes is unknown; cases of pre-eclampsia and other antenatal complications could be missed, and anxiety about entering acute hospital settings might deter women from seeking additional care during pregnancy. in uk, where women have choice of place of birth, difficult decisions have had to be made about support for home births in areas severely affected by covid-19. these have included re-allocation of midwifery-led birth centres to triage centres for pregnant women who present with symptoms of covid-19. some areas initially reduced and restricted home birth services or midwife-led care in birth centres, due to reduced staffing, or limited access to ambulance transfer. others sought to maintain these in an effort to reduce unnecessary hospitalisation, and developed new protocols for transfer using, for example, private cars where the transfer is not clinically urgent. in april, nhs england (2020) released guidance that supported continued choice of place of birth and reiterated that home birth or midwife-led settings are safest for women at low risk of complications, noting that more women were requesting home birth as an alternative to hospital admission. the uk's move to providing continuity of midwifery care appears to have been affected by covid-19 however. the dutch midwifery association (knov 2020) published guidance which continued to emphasise that home birth was safe and that birth in outpatient settings should be considered where feasible, to reduce infection risk, enhance continuity models of midwifery to reduce number of caregivers in contact with women and babies, and report that women were choosing home births. unused hotels were identified as potential birth settings as midwives may not be able to access community outpatient settings, but these have not been needed yet. in italy, france and spain, home birth and midwife led units are less common, and often provided privately, so most women have continued to give birth in hospitals. maternity providers have often severely limited visiting, and as in other eu countries, some uk hospitals have stopped allowing birth partners to be present, except during 'active' labour, although others have continued to support partner presence during labour and on the postnatal wards. there are also reports of even more stringent restrictions (such as partner visits limited to the birth itself and an hour following birth).this has also affected bereavement care as women are sent home more quickly after a miscarriage or stillbirth, and accounts of bereavement rooms being re-allocated to the care of women who have covid-19. these changes have led to concerns about women's rights to partner support during labour and after birth, access to pain relief and access to water birth, and the uk birthrights organisation responded with guidance for women in relation to their rights during coronavirus (birthrights, 2020) . in the netherlands, only one person can be present during labour, and partners could attend even if they have symptoms of covid-19, as long as ppe was available and symptomatic partners maintained their distance. in france, partners can be present but are asked to wear a face mask, and in spain, government guidance supports one supporter being present with women during labour, but practice varies between hospitals. in italy, epidural services were withdrawn at times in the most affected regions, as anaesthetists were redeployed to urgent care for coronavirus patients and other eu countries have certainly prepared guidance for this scenario. this is clearly something which would only occur in extremis, but the anxiety this may cause to women, partners and midwives caring for them is clear. another area of variation is postnatal care. world health organisation (who, 2020) covid-19 guidance has consistently promoted continued skin to skin contact and breastfeeding, and most eu countries appear to have followed this approach, only separating women and babies if the baby requires nicu care. as the current evidence suggests that women who are hospitalised with covid-19 are more likely to have preterm births (knight et al 2020) , this will be a more common outcome that usual. breastfeeding and skin to skin contact have continued in most eu countries but women are being advised to wear face masks and take hygiene precautions to reduce the risk of transmission to babies, which is consistent with current who guidance. in spain, some hospitals have isolated covid-19 positive women from their babies, with no skin to skin contact or breastfeeding until the mother tests negative, whilst others have kept covid-19 positive and symptomatic women with their babies, encouraging usual skin to skin and breastfeeding care; in cases where symptomatic women have been separated because the woman's condition requires it, they have been supported to express breast milk or to breastfeed. these measures are undertaken in the context of uncertainty about risks to the neonate, and it appears that separation occurred more often in the early days of the pandemic, but recent research is reassuring; it appears that few babies acquire covid-19 either by vertical transmission or by infection following birth, and that those babies who have acquired covid-19 are likely to have mild disease (knight et al 2020) . on the other hand, the observed higher proportion of preterm births amongst women hospitalised with covid-19 suggests that these babies may be at risk from the many complications of prematurity and that skin to skin contact and promotion of breastfeeding remain essential elements of care, although it remains unclear whether covid-19 itself or other conditions are leading to the observed increase in prematurity in these cohorts. the changes detailed above were instigated to reduce risk to pregnant women and to health care workers, by expanding online consultations and limiting face to face contact, and visits to health care settings, as far as possible. in uk, italy and spain, health systems struggled to provide sufficient ppe to staff, especially in the earlier days of the covid-19 pandemic. some european countries, including france and netherlands, seem to have had better supply of ppe in hospitals, but in france, uk, italy and spain there are reports of community staff being left unprotected for longer, leading to midwives and general practitioners seeing pregnant women without ppe. the provision of ppe for community midwives in the netherlands started slowly; midwives had to compile their own ppe packages and received supplies from the community, such as from nail salons and veterinarians. in severely affected countries, including uk, spain and italy, midwives and other health clinicians describe feeling pressured to continue caring for hospitalised covid-19 patients without basic ppe. a common experience has been frequent, fast changes to guidance and rapid cultural shifts; in early april, midwives in different uk trusts anecdotally reported being criticised for 'scaremongering' by electing to wear surgical masks, and yet were called 'irresponsible' a few days later if they were not wearing masks for all contacts. the evidence informing effective use of ppe and the capacity of ppe to prevent transmission of respiratory disease is acknowledged to be incomplete, and to contain uncertainties (verbeek et al 2020) . there have been reports that health workers have been more likely to be infected than the general public, but it is not yet clear whether this is the case, or whether they are more likely to be tested. in europe, testing of staff and public has been notoriously variable and slow in places. where staff have been tested, results appear variable -in the netherlands, cable news network (cnn) reported that 26% of reported covid-19 cases were amongst healthcare staff, whilst a prevalence study conducted amongst staff based in a hospital in barcelona, spain found that around 11% of staff had been infected by covid-19 (garcia-basteiro et al., 2020) . a similar uk study found 24.4% seroconversion amongst staff in a birmingham hospital (shields et al 2020) , and both studies reported that some staff seroconverted without experiencing symptoms of covid-19. although these reported rates reflect that health workers have access to testing when the public does not, the situation remains uncertain and this picture is certainly complicated by the lack of ppe protection provided in the early weeks of the pandemic. it raises the question of whether ppe can effectively prevent transmission of covid-19, given human factors, supply issues and problems maintaining protocols in emergencies. not surprisingly, some health care workers feel they may be unsafe even with ppe and infection control measures, and remain concerned that they may transmit the virus to women, and to their own families and colleagues. elsewhere in the world, the apparent ability of south korea, japan and china to reduce spread and limit mortality has been attributed to both proactive testing and tracing, access to ppe and widespread use and acceptance of facemasks amongst the public, although it is difficult to draw conclusions from cross-country comparisons at this point. the uk has reported deaths of three working midwives from covid-19, two midwives have died in italy. over a hundred healthcare staff have died from covid-19 in both uk and in italy, and in uk there is clear evidence that, as in the general population, staff from bame backgrounds are disproportionately affected, with deaths amongst bame staff 2-3 times higher than would be expected based on the ethnicity profile of the workforce (cook et al., 2020) . none of the other eu countries have reported deaths amongst working midwives. it is unclear why other countries severely affected by covid-19 including france, spain (and us), have not experienced similar levels of death amongst healthcare workers, but it appears that rates of staff deaths vary widely, with uk and italy reporting the highest rates at present. inevitably, this leads to questions about the extent to which staff were effectively protected, by ppe provision and training or by proactive withdrawal from frontline or 'face to face' work for those at increased risk, and these questions need to be raised within nations and at the global health level, and addressed though rapid and transparent enquiry. looking to the future covid-19 will affect maternity care for the foreseeable future, and as covid-19 rates are increasing in the americas, most eu countries are now attempting to adjust to a 'new normal'; shops and schools are opening, and cafes, restaurants and hotels will follow, bringing concerns about second or third waves of infection. health service providers across europe struggle with the same set of related problems; staff shortages as children's schools and nurseries have closed, healthcare workers who have needed to self-isolate, or self-shield during the third trimester of pregnancy, problems accessing ppe or effective testing, sickness and even death in the workforce and huge organisational restructures to their services affecting midwives, doctors, gps, and the student workforce. what do future maternity services look like in europe, for midwives and for women and their families, as they seek to accommodate and anticipate the possibility of further waves of covid-19? we have seen moves to return to face to face healthcare services, although with 'social distancing' and expectations that women wear masks, and midwives wear ppe, but this has implications for communication and relationship formation. in the netherlands, midwives have mainly returned to providing normal care, with more 'face to face' appointments and partners welcome to attend uss scans. nevertheless, midwives across europe may find it difficult to work as they may have family members who need to be shielded from covid-19, and they may themselves be at increased risk. some uk hospital services have moved staff from black and minority ethnic groups and those with chronic health conditions away from 'frontline' services, and redeployed them to provide telephone or online care, but it is unclear what will happen as services revert to face to face provision. women, midwives and employers across europe will need to consider how best to keep each other safe. the immediate concerns are perhaps also clinical in nature; we need research and information sharing to understand the impact of the covid-19 era on pregnant women. how do we support and reassure the majority of pregnant women who are healthy and well? how should we prevent perinatal mental health problems whilst we advise women to self-isolate in the third trimester, and ensure that women at risk of domestic violence are protected? how much online and telephone support is enough, and how many women are missing out? how are women who experience perinatal loss being supported? how are women managing after giving birth with reduced visits and online breastfeeding support? how do we ensure we remain alert for new and developing problems or trends? at a time of great concern about rising interventions during birth, how do we continue to support women to have a positive pregnancy and birth in the context of sustained covid-19 anxiety? whilst current evidence suggests that pregnant women are not at increased risk of covid-19 complications, they remain, as buerkens et al (2020) argue, vulnerable to social risks and risks related to socio-economic and gender inequalities. we have a thriving research community in europe and beyond, and midwives across the world are rising to the challenge of finding new ways of working, based on useful, applicable evidence. midwifery journal is planning a special issue to bring together research on covid-19 in pregnancy, and we know that rapid dissemination of good evidence will help; we also know that we should not be complacent, and that we need to maintain vigilance and speak up for staff safety and for the safe, high quality care for women and families during the covid-19 era. 2020) a call for action for covid-19 surveillance and research during pregnancy coronavirus -how will it affect my rights to maternity care? 2020) netherlands sees surge of covid-19 cases among medical workers, as testing ramps up exclusive: deaths of nhs staff from covid-19 analysed 12 features of 16,749 hospitalised uk patients with covid-19 using the isaric who clinical characterisation protocol pre-print) seroprevalence of antibodies against sars-cov-2 among health care workers in a large spanish reference hospital coronavirus resource center maps and trends cumative cases characteristics and outcomes of pregnant women hospitalised with confirmed sars-cov-2 infection in the uk: a national cohort study using the uk obstetric surveillance system (ukoss is ethnicity linked to incidence or outcomes of covid-19? clinical guide for the temporary reorganisation of intrapartum maternity care during the coronavirus pandemic what are the risks of covid-19 infection in pregnant women? lancet royal college of midwives. coronavirus (covid information for healthcare professionals knov (the royal dutch organisation of midwives pre-print) sars-cov-2 seroconversion in health care workers doi personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff world health organisation (2020) (who) pregnancy, childbirth, breastfeeding and covid-19 not applicable; this is an editorial, and does not present new or unpublished research data. not applicable. key: cord-268874-ldja6aa4 authors: park, sun hee title: personal protective equipment for healthcare workers during the covid-19 pandemic date: 2020-06-24 journal: infect chemother doi: 10.3947/ic.2020.52.2.165 sha: doc_id: 268874 cord_uid: ldja6aa4 the coronavirus disease (covid-19) pandemic has posed a challenge for healthcare systems, and healthcare workers (hcws) are at high risk of exposure. protecting hcws is of paramount importance to maintain continuous patient care and keep healthcare systems functioning. used alongside administrative and engineering control measures, personal protective equipment (ppe) is the last line of defense and the core component of protection. current data suggest that severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is mainly transmitted through respiratory droplets and close contact. airborne transmission may occur during aerosol-generating procedures. however, the modes of transmission still remain uncertain, especially regarding the possibility of airborne transmission when aerosol-generating procedures are not performed. thus, there are some inconsistencies in the respiratory protective equipment recommended by international and national organizations. in korea, there have been several modifications to ppe recommendations offering options in choosing ppe for respiratory and body protection, which confuses hcws; they are often unsure what to wear and when to wear it. the choice of ppe is based on the risk of exposure and possible modes of transmission. the level of protection provided by ppe differs based on standards and test methods. thus, understanding them is the key in selecting the proper ppe. this article reviews evidence on the mode of sars-cov-2 transmission, compares the current ppe recommendations of the world health organization with those in korea, and discusses standard requirements and the proper selection of ppe. coronavirus disease , which is caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2), has spread to 216 countries in just a few months. the numbers of cases and deaths have been on the rise since the first case was identified in wuhan, china in early december 2019 [1] . the covid-19 pandemic has posed a great challenge for healthcare systems, as the disease has spread explosively, exceeding hospital capacities and placing healthcare workers (hcws) at high risk of exposure. the proportion of infected mode of transmission 1 in general, respiratory viruses can spread through multiple modes of transmission: contact, respiratory droplets, or aerosols [13] . contact transmission can occur through direct physical contact with virus-laden respiratory secretions from infected individuals or indirectly through contact with inanimate objects or environments contaminated with the virus [13] . conventionally, respiratory transmission is classified as either droplet or airborne transmission [4, 7] . it is generally accepted that droplet transmission occurs through deposition of large droplets (>5 µm in diameter) on the mucous membranes (eyes, nose, or mouth) of susceptible people. it occurs when a person is in close proximity to an infected person, as large droplets travel only short distances (<1 m). airborne transmission occurs through inhalation of aerosols (≤5 µm in diameter) generated from the respiratory tract of an infected person. aerosols remain suspended in the air for a prolonged period, allowing them to be transmitted over a long distance [4] . however, mode of transmission cannot be simply dichotomized. there is no clear cut-off to differentiate small and large droplets. different cutoffs have been suggested based on the area of the respiratory tract where particles deposit (respirable particles <10 µm in diameter penetrating the lower respiratory tract or inspirable particles 10 -100 µm in diameter depositing in the upper respiratory tract) [14] or based on how they behave (particles <10 µm in diameter suspended in the air or particles >20 µm in diameter that settle fast by gravity) [15] . particle size is dynamic; it depends on the initial size and composition, the force and pressure at emission, environmental conditions (e.g. temperature, relative humidity and airflow), and the time spent airborne [4] . the distance traveled and the length of time particles remain suspended in the air is also determined by particle size, settling velocity, relative humidity, and airflow [16] . large droplets settle faster due to gravity, contaminating the near vicinity; some of them can rapidly evaporate to form aerosol particles termed "droplet nuclei," which behave as other aerosols. settled droplets may facilitate fomite transmission and can be re-suspended in the air by diverse human activities. large droplets can also move horizontally for more than 2 meters from the source during coughing or up to 8 meters during sneezing [17] . they can remain suspended for prolonged periods in certain environments, especially where turbulent airflow is abundant, such as in hospital settings where doors open constantly [15] . particles of varying sizes (0.01 -500 µm) are produced not only by medical procedures but also by respiratory activities such breathing, speaking, singing, coughing, or sneezing [18] [19] [20] [21] . the proportion of aerosol-size particles differs according to the respiratory activities and individuals [21] . as such, it is important to understand that the size of the particles and the resulting behavior follows a continuum; it may overlap either side of this cut-off [21] . however, being airborne does not in itself guarantee effective transmission through aerosols. the virus in aerosols must remain viable in a sufficient quantity to be inhaled by a susceptible host. the virus contained in droplets is subject to biological decay over time, which is affected by the initial metabolic state of the virus, genetic characteristics, and the environment [22, 23] . in this context, the relative contribution of different modes of transmission should be considered, albeit the possibility of airborne transmission does exist. airborne transmission can be classified as obligate, preferential, or opportunistic. in obligate airborne transmission, transmission occurs only via inhalation of aerosols (e.g., in tuberculosis). though transmission occurs through multiple routes in preferential airborne transmission, it predominately occurs through aerosols (e.g., in measles, varicella). in opportunistic airborne transmission, the virus is transmitted predominantly through other routes; however, the virus may be transmitted through aerosols under favorable circumstances where aerosols are generated by performing agps (e.g., in influenza, sars-cov-1 infection) [7, 22, 24] . the current consensus regarding the transmission of sars-cov-2 is that it is transmitted mainly through respiratory droplets and contact and that airborne transmission is possible during agps [9] [10] [11] 25] . although no study has conclusively linked sars-cov-2 transmission to contaminated environmental surfaces, indirect contact with fomites is considered a possible route based on the evidence of heavy environmental contamination in healthcare settings, objects used by covid-19 patients [26, 27] , and the finding that the virus remains viable on plastic surfaces for as long as 3 days [28] . however, there has been controversy whether sars-cov-2 can become airborne when agps are not performed. some studies have suggested the potential of airborne sars-cov-2 transmission. in one experimental study, viable sars-cov-2 was detected in the air for 3 hours when an aerosolized environment was created using a three-jet collison nebulizer and a goldberg drum [28] . however, though this experimental condition may simulate circumstances when agps are performed, it does not reflect real-life clinical settings. a study in nebraska detected viral rna in air samples collected in covid-19 patient rooms more than 6 feet way from the source patient and in the hallway outside patient rooms, but failed to detect viable virus in air samples [29] . guo et al. detected sars-cov-2 rna in air samples collected in intensive care units and general wards at a hospital in wuhan, but the viral rna was not detected on face shields, in buffer rooms, or in doffing rooms [30] . liu et al. also found a high concentration of viral rna in air samples from patients' toilet areas and staff ppe removal areas in two hospitals in wuhan, suggesting re-suspension of the virus from contaminated surfaces [31] . however, both studies in wuhan did not investigate the infectivity of the virus in those air samples. the presence of viral rna in the air does not necessarily indicate viable virus in sufficient amounts to cause infection, nor does it mean that the virus can effectively be transmitted through this route [11, 32] . further studies are needed to determine whether it is possible to detect viable sars-cov-2 in air samples from patient rooms in which no agps are performed and what role it may play in transmission. more importantly, in the study by liu et al., viral rna was reduced to undetectable levels in staff ppe removal areas after implementation of rigorous disinfection procedures, which emphasizes the importance of environmental disinfection to prevent the spread of the virus in the perspectives of infection prevention and control. in contrast, other studies have shown that viral rna was not detected in air samples collected from covid-19 patient rooms [26] , 10 cm away from the patient's chin [27] , or 2-5 meters away from the patient [33] . transmission did not occur among hcws wearing surgical masks when they were exposed to a covid-19 patient, even during endotracheal intubation [34, 35] . no instances of transmission were observed among hcws caring for covid-19 patients when they used surgical masks as part of ppe routine care [36] . based on these findings, it is believed that sars-cov-2 is mainly transmitted through droplets and contact, and that airborne transmission is possible under certain circumstances when aerosols are generated during agps or support treatment [9, 11] . at the same time, the possibility of airborne transmission should carefully be considered as new evidence emerges. in this context, the who currently recommends droplet and contact precautions for hcws caring for covid-19 patients and airborne precautions for settings where agps or support treatment are performed [25] . for droplet precaution, use of medical masks (also referred to as surgical masks) and eye protection (goggles or face shields) is recommended. for contact precaution, long-sleeved water-resistant gowns and gloves are recommended; when agps are performed, use of n95, filtering facepiece (ffp)2, ffp3, or equivalent respirators is recommended instead of surgical masks, and additional use of aprons is suggested if gowns are not fluid-resistant [37] (table 1) . however, there are inconsistences in the recommendations of organizations and countries. ppe recommendations in canada [38] , australia [39] , and the united kingdom [40] are consistent with those put forth by the who. the us centers for disease control and prevention (cdc) and the european center for disease control and prevention (ecdc) initially recommended airborne precautions for any situations involving contact with covid-19 patients; however, they have modified their recommendations to specify that surgical masks are acceptable alternatives if respirators are not available [9, 10] . despite this difference, airborne precautions are commonly recommended when agps are performed ( table 1) . although the transmission risk for hcws may differ based on procedure being performed [41] , agps listed in the guidelines generally include endotracheal intubation, bronchoscopy, tracheostomy, cardiopulmonary resuscitation, sputum induction, non-invasive ventilation, manual ventilation, airway suctioning, and nebulizer therapy. in the ecdc guidelines, prone positioning of the patient and disconnecting the patient from a ventilator are also considered agps [10, 42] . surgery or procedures in which high-speed devices are used can also generate aerosols [43] . although it remains uncertain whether sars-cov-2 is transmitted through this route, such procedures may impose substantial transmission risk in dental-clinic settings [44] . collecting nasopharyngeal/oropharyngeal swabs for sars-cov-2 tests can provoke coughing and sneezing, possibly leading to the production of aerosols [9, 10] . however, this procedure requires less time and may pose a less significant risk than other agps. for this reason, the recommended respiratory protective equipment for collecting swabs differs among guidelines ( table 1) . the australian and canadian guidelines emphasize the need for a point-of-care risk assessment to determine the likelihood of exposure based on a patient's symptoms, tasks, and specific environments [38, 45] . in korea, airborne and contact precautions continue to be recommended in any situations involving any contact with suspected or confirmed patients, with some modifications. initially, the korea center for disease control and prevention (kcdc) guidelines recommended coveralls with shoe covers for contact precautions, goggles/face shields for eye protection, n95 or equivalent respirators for respiratory protection, and powered airpurifying respirators (paprs) when agps are performed [46] . in the march 2020 revision of these guidelines, long-sleeved water-resistant gowns and kf94 masks were recommended [47] . these modifications may have caused confusion and misunderstanding among hcws [48] . to select appropriate ppe, it is important to know the differences among respiratory protective equipment (respirators, surgical masks, paprs) and protective clothing (coveralls, gowns) and their benefits and drawbacks. the main difference between medical masks and respirators is their purpose. medical masks, also known as surgical masks, are designed to reduce spread of infections from the wearer to others and to protect the wearer's mucous membranes in the nose and mouth from exposure to large respiratory droplets and splashes or sprays of blood or bodily fluids. they are loose-fitting devices not designed to filter small airborne particles [49] . in contrast, respirators are designed to protect the wearers from inhaling hazardous airborne particles by filtering airborne particles (an air-purifying respirator) or supplying clean air to the wearer (an atmosphere-supplying respirator). air-purifying respirators are further divided into three categories: filtering facepiece respirators (ffrs), elastomeric facepiece respirators, and paprs [49] . ffrs, generally known as respirators, are disposable particulate respirators classified in accordance with their filtering efficiency. in healthcare settings, ffrs with at least 95% filtering efficacy, also known as n95 respirators, are commonly used for airborne precautions and need to tightly fit the face to provide proper protection. other types of airpurifying respirators can be used as alternatives to n95 respirators [49] [50] [51] . the who has released the disease commodity package (dcp) for covid-19, a datasheet that lists critical commodities and technical specifications [52] . according to this dcp, surgical masks worn by hcws should meet the standards of en 14683 type ii, ir, iir or american society for testing and materials (astm) f2100 minimum level 1, or the equivalent, while surgical masks won by patients (for source control) should meet type i, level 1, or equivalent standards. the following are recommended for ffrs: 1) the minimum n95 respirator according to the food and drug administration (fda) class ii under 21 cfr 878.4040 and the cdc national institute for occupational safety and health (niosh), 2) the minimum ffp2 respirator according to the en149, eu ppe regulation 2016/425 category iii, or 3) the equivalent [52] . to choose the proper equipment, it is necessary to understand the standards and requirements to which surgical masks or respirators must conform. most surgical masks are composed of three-layers: an outer fluid-repelling layer, a middle layer serving as a high filter, and an inner moisture-absorbing layer. surgical masks without this three-layer feature cannot provide adequate protection [53] . in the us and europe, surgical masks are classified as medical devices and regulated accordingly. in the us, five elements are tested to standardize their quality: fluid resistance to synthetic blood, particulate and bacterial filtration efficiency, breathing resistance (pressure drop), flammability, and biocompatibility [54, 55] . in europe, similar standard requirements have been adopted [56] . surgical masks are categorized into levels 1, 2, or 3 in the us and i, ii, or iir in europe ( table 2 ). in korea, however, there are no minimum standards or standardized testing methods to determine the filtering efficiency of surgical masks, and the efficiency of the filters in available surgical masks may vary widely. fluid resistance to water is the only performance test required for surgical masks in korea [57] . fluid resistance reflects only one of the surgical mask's purposes: to minimize the amount of fluid that could transfer from the outer layers through to the inner layer in cases of splash or spray. however, the surface tension of water is greater than that of blood, and blood can penetrate through fabrics more readily than water [58, 59] . the lack of equivalent korean standards makes it difficult for hcws to choose appropriate surgical masks as recommended by the who. also, it is difficult to uniformly recommend the use of any surgical mask during care for patients with covid-19 in korea unless reliable korean standards for surgical masks are established. healthcare facilities should cautiously check whether products meet the standard requirements when procuring surgical masks for hcws. ffrs are labeled according to their filtering efficiency and the national regulations defining the standard conditions. in the us, there are nine classes of ffrs according to filtration efficacy (95%, 99%, and 99.97%) and the filter's oil resistance (n, r, and p). n95 respirators filter 95% of airborne particles 0.3 microns in size and are not resistant to oil. they are regulated under niosh cfr part 84 [60] . the european standard (en149:2001) places ffrs into three classes: ffp1, ffp2, and ffp3 according to their filtering efficiency (80%, 94%, and 99%, respectively) [61, 62] . as the korean standards follow the european standards, ffrs manufactured in korea are classified similarly: kf80, kf94, and kf99 ( require ≤343 pa at 85 l/min. since pressure drop increases with the flow rate, standard pressure drop requirements are similar, even though they appear different [64, 65] . in korea and europe, total inward leakage (til) is also tested on human subjects ( table 3 ) [62] . in the us, the til test is not performed. instead, fit testing must be performed prior to working in the environment where wearing a respirator is required and be repeated annually under the occupational safety and health administration (osha) regulation 1910.134 [66] . despite differences in test methods, it is generally considered that us n95, eu ffp2, and kf94 respirators are equivalent for filtering non-oil based airborne particles [64, 65, 67] . however, concerns have been raised because the fit test is not regularly performed in many korean hospitals, despite the korea osha recommending a fit test for wearers every year [68, 69] . respirators must fit the face tightly for effective filtering of airborne particles. noti et al. demonstrated that a poorly-fitting n95 respirator was not as effective as a tightly fitting respirator at blocking infectious viruses (66.5% vs. 99.6% blocked, respectively) and performed no better than unsealed surgical masks (66.5% vs. 56.6% blocked, respectively) in a simulation experiment [70] . in korea, the til test is performed on ten human subjects doing five types of exercise [63] . this til test can eliminate respirators that are inherently poorly-fitting and that do not comply with this requirement or identify that the tested respirator is generally well-fitting. however, fitting is affected by a wearer's face shape and size, age, and gender, as well as the respirator design [71, 72] . fit testing helps to select a respirator model that fits an individual's face well enough to provide at least the assigned protection factor of 10 [73] . fit performance was also found to vary by respirator model, ranging from fitting less than 5% to those fitting 95% of the test subjects [71] . in addition to the model type, ear-loop designs appear to be less effective in achieving a proper fit than head-band designs [67] . this is worrisome, since most kf94 masks have ear loops. as agps may put hcws at an increased risk for virus exposure and infection, the design of kf94 masks limits their use during agps. kf94 masks of various shapes and sizes and with elastic head-band designs should be offered to hcws to improve the fitting of the masks. a recent study on the current status of fit testing in korea showed that 82% of 52 hcws failed to meet the criteria of fit factor 100, even when using n95 respirators [68] . considering these findings, hcws should be fit-tested for ffrs, regardless of their labels (kf94, n95, or ffp2) to ensure respiratory protection. though it is challenging and laborious for hospitals to implement fit testing practices for all hcws in the midst of the covid-19 pandemic, protecting hcws is of paramount importance. even so, fit testing alone does not guarantee respiratory protection [74] . inappropriate donning and skipping the self-seal-check after donning an ffr were found to be frequent https://icjournal.org https://doi.org/10.3947/ic.2020.52.2.165 for european standards, at least 8 out of 10 individual wearers' arithmetic means for total inward leakage shall not be greater than the requirements as well. causes of improper fit [68, 74] . since training on the proper use of ffrs can improve fitting of the respirators among hcws [74, 75] , training programs should be implemented along with fit testing. the risk of exposure to blood or bodily fluids should also be considered when selecting the proper ffrs, because most ffrs are not water-resistant. to protect hcws against the splash/ spray of blood or bodily fluids as well as airborne particles (i.e., during an operation on a patient with covid-19), surgical respirators with fluid resistance properties should be used [49] . a surgical n95 respirator, which is approved by the niosh as an ffr and the fda as a surgical mask, is one example. paprs are increasingly used as an alternative to n95 respirators. paprs use a batterypowered fan to force air through a filter, cartridge, or canister to a tight-fitting facepiece or loose-fitting hood [49] . loose-fitting paprs are commonly used in healthcare settings, as they have several advantages: higher respiratory protection with an assigned protection factor of 25 (as compared to 10 for n95 respirators), a barrier against splash, and less difficulty in breathing. they are also reusable, and do not require fit testing [50, 76] . however, there are disadvantages to paprs use: they are heavy, may impede hcws' ability to care for patients, limit communication due to noise, require batteries to be recharged or replaced, and take up significant storage space [76] . although a fit test is not required, they do need to be properly sized, as protection can decrease with oversized or stretchedout paprs [77] . another disadvantage is that the wearer's exhaled air is unfiltered, which limits the use of paprs in close proximity to sterile fields [50, 76] . more importantly, risk of contamination during doffing procedures is high, requiring hcws to receive special training and assistance in the doffing process. cleaning and disinfection must be performed between uses. this process must be thorough and performed by trained individuals. loose-fitting paprs are suitable when agps are frequently performed (such as in intensive care unit settings), when hcws are not able to wear tight-fitting ffrs, or when the fitting of a ffr may be compromised. for safe use, healthcare facilities should be aware of the advantages and disadvantages associated with paprs. they must also establish a robust maintenance program, including hcw training for proper papr use and the cleaning and disinfection process prior to the use of paprs [76, 78] . infectious aerosol particles are produced by diverse respiratory activities, including speaking and breathing [79, 80] . hcws in close proximity to patients with covid-19 are at risk of short-range airborne transmission as well as large-droplet transmission [81] . as such, there have been debates regarding the effectiveness of surgical masks against the virus in routine patient care, and use of n95 respirators or the equivalent is often advocated [82] . however, no clinical trial has compared the effectiveness of surgical masks and n95 respirators in preventing covid-19 among hcws. based on the systematic review of five observational studies on hcws, wearing any mask (surgical mask or n95 respirator) reduced the risk of developing respiratory infection (odds ratio [or] for surgical masks, 0.13; 95% confidence interval [ci], 0.03 -0.62 vs. or for n95 respirators, 0.12; 95% ci, 0.05 -0.26) [83] . a recent randomized clinical trial in the us demonstrated no significant difference in the incidence of laboratory confirmed influenza between outpatient hcws wearing surgical masks and those wearing n95 respirators [84] . two meta-analyses, which were separately performed by different research groups, reached the same conclusion: surgical masks and n95 respirators offer similar protection against respiratory viral infection among hcws during non-aerosolgenerating care [85, 86] . based on these findings, the infectious disease society of america recommends that hcws caring for patients with suspected or confirmed covid-19 use either a surgical mask or n95 (or n99 or prpr) respirator and that hcws involved in agps use n95 or higher-level respirators [83] . chu , and both n95 and surgical masks had a strong association with protection when compared to single-layer masks [87] . the review, however, included only four studies comparing n95 or similar respirators with no mask, and two of them involved situations in which agps were performed. based on this review alone, it is difficult to generalize that the use of n95 or similar respirators provides more protection during routine care for patients with covid-19. therefore, the use of n95, ffp2, or higher-level respirators such as paprs should be prioritized when agps are performed. it is also necessary to vigilantly monitor situations or procedures that may increase the possibility of aerosol transmission, because many of the characteristics of sars-cov-2 remain unknown. the choice of protective clothing should be based on a thorough risk assessment of potential exposure to blood and body fluids and transmission modes. the risk of exposure may depend on the stage of the disease, the severity of symptoms, and the types of procedures conducted. once the risks are assessed, selection can be guided by the type of barrier, design, critical properties such as seams/closures, and donning and doffing features of the clothing. the who, cdc, and ecdc recommend the use of long-sleeved water-resistant gowns and gloves when caring for covid-19 patients. in its recent publication on the rational use of ppe, the who also specifies situations in which gowns should be donned. according to the who dcp for covid-19, en 13975, any performance level gowns or association for the advancement of medical instrumentation (aami) pb70, all level or equivalent gowns are acceptable [52] . regarding coveralls as ppe against covid-19, the who stated they are neither required nor generally recommended, and the cdc recommends them as an alternative in contingency situations. on the other hand, in korea, initial recommendations recommended only coveralls for body protection; the guidelines were subsequently changed to specify that either gowns or coveralls can be used. this may cause confusion among frontline hcws regarding what kind of protective clothing should be chosen. moreover, there is no national standard for hcw protective clothing in korea. therefore, it is necessary to understand the relevant international standards and test methods to select and procure the proper protective clothing. in the us, surgical and isolation gowns are medical devices subjected to regulation. ansi/ aami pb70 classifies surgical gowns and isolation gowns into 4 levels (level 1 being the lowest, level 4 being the highest) based on their liquid barrier performance [88] . tests for level 1 -3 gowns use water, but level 4 gowns are required to pass blood and viral penetration resistance tests at a pressure of 13.8 pa, which is considered water-impermeable (table 4) [59]. the designs of surgical and isolation gowns are based on the anticipated location (critical zones) and degree of liquid contact. for isolation gowns, the whole garment is anticipated to have direct contact with blood, bodily fluids, or pathogens, and the entire gown, including the seams, needs to achieve barrier performance. for surgical gowns, the front panel and lower sleeves of the gown are required to achieve barrier performance [88] . the european standard en13759 classifies gowns as either high performance or standard performance based on their resistance to liquid and microbial penetration ( table 4 ) [59, 89] . for gowns to protect hcws from infectious agents, the garments must meet the standard en 14126 performance requirements, which include tests for penetration resistance to blood/bodily fluids (iso 16603) or to blood-borne pathogens (iso 16604) under different hydrostatic pressures ranging from class 1 (0 kpa) to class 6 (20 kpa) [59, 89] . this standard is usually also used to evaluate and classify coveralls for hcws in europe. in the us, the nfpa 1999 standard is used to classify clothing items, including coveralls for hcws; the materials and seams are tested for viral penetration resistance using astm f1671, and the overall liquid integrity, strength, and physical hazard resistance are also tested [59] . as there are various performance levels of gowns and coveralls, it cannot be simply concluded that one is more protective than the other. the specific barrier properties should be thoroughly reviewed, and protective clothing appropriate for specific diseases should be selected accordingly. for example, for ebola virus disease, which is mainly transmitted through contact with blood or bodily fluids, gowns and coveralls should be resistant to penetration by blood and any bodily fluids or by blood-borne pathogens and compliant with the corresponding standards. using astm 1670 (13.8 kpa), iso 16603 class 3, or higher pressure (≥3.5 kpa). protective clothing resistant to blood-borne pathogen penetration includes ansi/aami level 4 gowns or coveralls made of fabric passing tests using astm f1671 (13.8 kpa), iso 16604 class 2, or higher pressure (≥1.75 kpa) [90] . for covid-19, any water-resistant level gowns are acceptable [52] . thus, the proper level of gown protection should be chosen based on the risk assessment of exposure, the pressure and type of contact, as well as the duration and type of procedure [91] . no study has compared the effectiveness of gowns and coveralls in reducing transmission of the virus to hcws, and gowns and coveralls are generally considered acceptable and effective [59, 92] . one of the major differences is the design. coveralls are designed to cover the whole body, including the back and lower legs, while gowns do not provide continuous whole body protection. when wearing gowns, protection of the back area can be compromised depending on the activities of hcws, such as squatting or sitting down, so sufficient overlap of fabric is necessary to cover the back. on the other hand, barrier protection can be compromised when using coveralls with a front zipper closure not covered with a flap of barrier material because seam barrier properties are essential for protection [59] . gowns are easier to don and doff, and they are more likely to be used correctly as hcws are relatively more familiar with gowns than with coveralls. in contrast, coveralls are difficult to doff, and the risk of self-contamination can be higher during the doffing process [59, [93] [94] [95] [96] [97] . hcws should be trained properly and should practice the use of coveralls before using them during patient care. moreover, coveralls generate more heat stress than do gowns, which leads to discomfort, fatigue, and dehydration. considering these differences, the decision of which of the two to use should be based on availability, hcw activities, and the physical characteristics of the work environment [59] . in summary, current data suggest that sars-cov-2 is primarily transmitted through respiratory droplets and close contact. airborne transmission may occur during agps in healthcare settings. ppe for droplet and contact precautions, such as surgical masks with eye protection, gowns, and gloves, are recommended for hcws in contact with suspected or confirmed covid-19 patients, and n95 or equivalent respirators should to be worn by hcws whenever agps are performed. although droplets and close contact are the main modes of sars-cov-2 transmission, selection of the proper ppe should be based on a through risk assessment of the extent and duration of exposure and the properties of the ppe required for protection. degrees of respiratory protection and barrier properties differ according to various standards and test methods. therefore, it is important to understand the national or international standards for respiratory protective equipment and protective clothing, and ppe certified to provide effective protection against sars-cov-2 should be chosen. healthcare facilities must check the specifications of products thoroughly before procuring them. it is also important to ensure that hcws are well trained for the proper use of ppe, because appropriate donning and doffing is essential for proper protection. the overuse of ppe can lead to supply shortages when high levels of protection must be used, potentially exposing hcws to greater risk of infection. therefore, ppe should be appropriately selected and rationally used. it should bear in mind that ppe is the last line of protection and its use alone does not effectively reduce transmission risk. effective administrative and engineering controls, including early identification of suspected patients and source control, must be implemented simultaneously. furthermore, basic infection prevention measures, such as frequent hand washing and rigorous environmental cleaning and disinfection, must be who coronavirus disease (covid-19) dashboard (2020/6/6) coronavirus disease 2019 (covid-19) in the eu/eea and the uk -ninth update characteristics of health care personnel with covid-19 -united states the who guidelines infection prevention and control of epidemicand pandemic-prone acute respiratory infections in health care coronavirus disease 2019 (covid-19): n95 respirators glove-wall system for respiratory specimen collection and covid-19 mass screening guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings infection prevention and control during health care when covid-19 is suspected: interim guidance interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings infection prevention and control for covid-19 in healthcare settings -3rd update modes of transmission of virus causing covid-19: implications for ipc precaution recommendationsscientific brief controversies in respiratory protective equipment selection and use during covid-19 transmission of sars and mers coronaviruses and influenza virus in healthcare settings: the possible role of dry surface contamination preventing transmission of pandemic influenza and other viral respiratory diseases: personal protective equipment for healthcare personnel recognition of aerosol transmission of infectious agents: a commentary how far droplets can move in indoor environments--revisiting the wells evaporation-falling curve airborne or droplet precautions for health workers treating covid-19? distribution of airborne influenza virus and respiratory syncytial virus in an urgent care medical clinic measurements of airborne influenza virus in aerosol particles from human coughs visualizing speech-generated oral fluid droplets with laser light scattering the role of particle size in aerosolised pathogen transmission: a review airborne transmission of communicable infection--the elusive pathway factors involved in the aerosol transmission of infection and control of ventilation in healthcare premises airborne transmission and precautions: facts and myths infection prevention and control during health care when novel coronavirus (ncov) infection is suspected: interim guidance air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) from asymptomatic patient escalating infection control response to the rapidly evolving epidemiology of the coronavirus disease 2019 (covid-19) due to sars-cov-2 in hong kong stability of sars-cov-2 in different environmental conditions. the lancet microbe 2020 transmission potential of sars-cov-2 in viral shedding observed at the university of nebraska medical center aerosol and surface distribution of severe acute respiratory syndrome coronavirus 2 in hospital wards aerodynamic analysis of sars-cov-2 in two wuhan hospitals national academies of sciences, engineering, and medicine. rapid expert consultations on the covid-19 pandemic a field indoor air measurement of sars-cov-2 in the patient rooms of the largest hospital in iran risk of nosocomial transmission of coronavirus disease 2019: an experience in a general ward setting in hong kong world health organization (who). who "save lives: clean your hands" campaign and who covid-19 response: who webiar series rational use of personal protective equipment for coronavirus disease (covid-19) and considerations during severe shortages: interim guidance infection prevention and control for covid-19: second interim guidance for acute healthcare settings australian government department of health. guidance on the use of personal protective equipment (ppe) in hospitals during the covid-19 outbreak (last update covid-19: guidance for infection prevention and control in healthcare settings aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (covid-19) nosocomial transmission of emerging viruses via aerosol-generating medical procedures interim infection prevention and control guidance for dental settings during the covid-19 response interim advice on non-inpatient care of persons with suspected or confirmed coronavirus disease (covid19), including use of personal protective equipment (ppe) ministry of health and welfare. infection prevention and control for novel coronavirus infection infection prevention and control for covid-19 in healthcare facilities press release on full body protective clothing hospital respiratory protection program toolkit: resources for respirator program administrators powered air purifying respirators: for healthcare practitioners (hcp) elastomeric respirators: conventional, contingency, and crisis strategies covid-19 v4: operational support and logistics: disease commodity packages use mask properly surgical masks -premarket notification [510(k)] submissions: guidance for industry and fda staff standard specification for performance of materials used in medical face masks disposable masks: disinfection and sterilization for reuse, and non-certified manufacturing, in the face of shortages during the covid-19 pandemic guideline on establishment of test item in preparation of standards and analytical methods of quasi-drugs considerations for selecting protective clothing used in healthcare for protection against microorganisms in blood and body fluids the national institute for occupational safety and health (niosh). 42 cfr part 84 respiratory protective devices healthcare infection society working group on respiratory and facial protection. guidance on the use of respiratory and facial protection equipment usage of filtering-facepiece masks for healthcare workers and importance of fit testing do?seq=12791&srchfr=&srchto=&srchword=&srchtp=&itm_seq_1=0&itm_ seq_2=0&multi_itm_seq=0&company_cd=&company_nm=&page=6 comparison of filtration efficiency and pressure drop in anti-yellow sand masks, quarantine masks, medical masks, general masks, and handkerchiefs. aerosol air 3m. technical bulletin: comparison of ffp2, kn95, and n95 and other filtering facepiece respirator classes occupational safety and health act. 29cfr 1910.134. respiratory protection the national personal protective technology laboratory (npptl) a study on the current status and system improvement of the respiratory protection test. ulsan: korea occupational safety and health agency korea occupational safety and health admisnitration (kosha) detection of infectious influenza virus in cough aerosols generated in a simulated patient examination room a must for niosh: certify fit performance of the half mask particulate respirator implementing fit testing for n95 filtering facepiece respirators: practical information from a large cohort of hospital workers assigned protection factors: for the revised respirtory protection standard respirator-fit testing: does it ensure the protection of healthcare workers against respirable particles carrying pathogens? comparison of fit factors among healthcare providers working in the emergency department center before and after training with three types of n95 and higher filter respirators the use and effectiveness of powered air purifying respirators in health care: workshop summary performance of an improperly sized and stretched-out loose-fitting powered air-purifying respirator: manikin-based study to papr or not to papr? infectious virus in exhaled breath of symptomatic seasonal influenza cases from a college community viable influenza a virus in airborne particles from human coughs short-range airborne transmission of expiratory droplets between two people how well do n95 respirators protect healthcare providers against aerosolized influenza virus? infectious diseases society of america guidelines on infection prevention for health care personnel caring for patients with suspected or known covid-19 respect investigators. n95 respirators vs medical masks for preventing influenza among health care personnel: a randomized clinical trial effectiveness of n95 respirators versus surgical masks against influenza: a systematic review and meta-analysis medical masks vs n95 respirators for preventing covid-19 in healthcare workers: a systematic review and meta-analysis of randomized trials covid-19 systematic urgent review group effort (surge) study authors. physical distancing, face masks, and eye protection to prevent person-toperson transmission of sars-cov-2 and covid-19: a systematic review and meta-analysis liquid barrier performance and classification of protective apparel and drapes intended for use in healthcare facilities public works and government services canada (pwgsc). specifications for covid-19 products ebola virus disease: operational support and logistics: disease commodity packages aami tir11:2005/(r)2015: selection and use of protective apparel and surgical drapes in health care facilities personal protective equipment for use in a filovirus disease outbreak: rapid advice guideline safe use of personal protective equipment in the treatment of infectious diseases of high consequence self-contamination during doffing of personal protective equipment by healthcare workers to prevent ebola transmission cdc prevention epicenters program. personal protective equipment doffing practices of healthcare workers use of ultraviolet-fluorescence-based simulation in evaluation of personal protective equipment worn for first assessment and care of a patient with suspected high-consequence infectious disease effective personal protective clothing for health care workers attending patients with severe acute respiratory syndrome emphasized. as the occurrence of airborne transmission when agps are not performed remains uncertain, ppe recommendations are subject to change in accordance with future study results. healthcare facilities and hcws should be vigilantly aware of such changes in recommended ppe and prepare for the future. key: cord-274477-jkjyh4cs authors: zhang, zhiruo; liu, shelan; xiang, mi; li, shijian; zhao, dahai; huang, chaolin; chen, saijuan title: protecting healthcare personnel from 2019-ncov infection risks: lessons and suggestions date: 2020-03-23 journal: front med doi: 10.1007/s11684-020-0765-x sha: doc_id: 274477 cord_uid: jkjyh4cs the outbreak of a novel coronavirus disease (covid-19, caused by the 2019-ncov infection) in december 2019 is one of the most severe public health emergencies since the founding of people’s republic of china in 1949. healthcare personnel (hcp) nationwide are facing heavy workloads and high risk of infection, especially those who care for patients at the epicenter of the outbreak, hubei province. sadly, as of february 20, 2020, over two thousand covid-19 cases are confirmed among hcp from 476 hospitals nationwide, with nearly 90% of them from hubei province. based on literature search and interviews with some hcp working at wuhan, capital city of hubei, we have summarized some of the effective measures taken to reduce infection among hcp, and also made suggestions for improving occupational safety during an infectious disease outbreak. the experience and lessons learned should be a valuable asset for international health community to contain the ongoing covid-19 epidemic around the world. the local outbreak of novel coronavirus epidemic (covid-19, caused by the 2019-ncov infection) in wuhan, hubei province of china, last december has rapidly spread nationwide with a cumulative number of 80 026 laboratory-confirmed cases and 2912 deaths as of march 1, 2020 [1] . as the epicenter of the outbreak, hubei province has been hit hardest, accounting for over 83% of all the confirmed cases in china [1] . more than 40 000 healthcare personnel (hcp) from around the country rushed to hubei, working around the clock with local hcp in the public health intervention, diagnosis and treatment, patient care, field investigation, samples testing and sterilization [2] . sadly, as of february 20, 2020, 2055 laboratory-confirmed cases were reported among hcp from 476 hospitals across china. the majority of hcp cases (88%) were reported from hubei [2] (table 1) . so far, no super spreader has been identified among the hcp infections. such a high number of infections among hcp in this ongoing epidemic is very alarming, testifying the magnitude of the epidemic, the lack of understanding of the novel virus, and the need for improvement in the medical system. little knowledge about the novel virus led to a surge of hcp infection in the first month after the outbreak. in addition, the sudden tide of patients in january 2020 added unprecedented stress on the municipal healthcare system of wuhan. healthcare staff from different medical departments in the city had to hastily take actions in a short period of time. many did not have the required experience, knowledge, and preparedness for dealing with infectious diseases, such as proper sequence of use, replacement, and disposal of personal protective equipment (ppe). some healthcare workers had to work ten or more hours daily with no break time due to a high volume of patients and severe staff shortage. stress and extreme fatigue could further challenge the immune system and increase the susceptibility to 2019-ncov among hcp (fig. 1) . the rapid expansion of the epidemic also caused a severe shortage of critical ppe. as many mass production of medical supplies was halted when workers left for family reunification at the chinese new year (january 25 , 2020), the healthcare system was completely caught off guard, and quickly exhausted the emergency ppe reserves. some hospitals in hubei had to reduce the replacement of critical ppe. the grim shortage of protective equipment greatly increased the risk of hcp infections at the onset of the outbreak, exacerbating the spread of diseases among visitors, staff, and patients. a healthy and effective team of hcp is crucial to successfully preventing the on-going epidemic from further expansion. the high infection toll underscores the necessity and urgency of protecting hcp from covid-19. it is laudable that the central government has attached great importance to protecting the health of hcp and has taken a number of immediate actions [3] , such as improved guidance on the proper use of ppe, strengthened logistics and medical supplies, and enhanced disinfection at the hotels where hcp stay. in addition, an emergency surveillance system is now in place to monitor all exposed hcp, contributing to prompt detection, effective triage, and isolation of infected hcp. a special medical expert group is making every effort to diagnose and treat medical staff of suspected and confirmed infection. in addition, a special health and life insurance fund is set up for all hcp working in the frontline at both national and provincial levels [4] . all of these are conducive to ensuring the confidence and efficiency of the hcp, but more needs to be done for further protection of their occupational health in the long run. the covid-19 outbreak calls for the establishment of exposure risk assessment and management system in healthcare settings. public health schools should be given more support within medical education system and all medical students should receive regular theoretical courses and practical training of public health, including the knowledge and skills to deal with large scale health emergencies, such as covid-19. standard guidelines and procedures should be in place to detect infectious diseases at an early stage, to timely announce the pathogens, transmission paths, diagnosis, and treatment among hcp. furthermore, improvement in professional development as essential part of continuous medical education at all public health and medical institutions is another critical step toward reducing infection rate among healthcare workers. hcp, regardless of the disciplines they are in, should have routine emergency drills for infectious diseases, receive professional development periodically in the protection from occupational hazards. especially, medical staff related to the handling of infectious diseases should be well trained to properly use ppes, and continuing education certificate can be mandatory for key hcp or staff members in all medical institutions. in addition, easy access to mental health service for hcp should be available throughout their career journey, especially during the time of crisis when they need for anxiety and stress relief. with the stabilizing of epidemics and measures taken by the decision-makers, the shortage of ppe in china was significantly attenuated by mid-february [5] . yet, the covid-19 outbreak alerts us that a carefully planned stockpile of ppe and other essentials is key to effective infectious disease preparedness and to the optimal function of hcp [6] . an epidemic can affect a broad population, hence the availability and appropriate use of ppe, such as n95 respirators, face masks, gowns, and gloves, are crucial to protecting the health of hcp [7] . while it is very difficult to predict an outbreak of widespread epidemic, all the healthcare facilities should stockpile a certain amount of critical ppe to ensure an adequate supply at the onset. in addition, it is also important to set up a centralized and coordinated network of emergent ppe supply among central and local governments, healthcare facilities, and medical equipment, so as to meet the demand for consumable and durable supplies when a wide spread epidemic lasts long. the ratio of confirmed hcp infection to patients is on the decrease, from 5.72% (january 11-20, 2020) to 2.68% (february 1-11, 2020), thanks to the increased supply of critical ppe, enhanced vigilance, and accumulated experienced among hcp [8] . it is hard to predict when and where an epidemic, like the covid-19, will occur in the world as disease knows no national boundaries. therefore, the compelling lessons learned in the fight against coronavirus in china must be remembered so that better public health emergency response preparedness mechanisms can be established not only in china but all over the world. national health commission of the people's republic of china. the latest situation of novel coronavirus pneumonia who. report of the who-china joint mission on coronavirus disease national health commission of the people's republic of china. notification for further strengthening the protection of health personnel during 2019-ncov outbreak the state council. press conference of the joint prevention and control mechanism of the state council information office of hubei provincial people's government. press conference on prevention and control of new coronavirus infected pneumonia protecting health-care workers from subclinical coronavirus infection association between 2019-ncov transmission and n95 respirator use novel coronavirus pneumonia emergency response epidemiology team. the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19) in china we would like to extend sincere gratitude to mengyun luo, yue fang, kun qian, xueyuan li, jiawei xu, and jiahui li who collected data. zhiruo zhang, shelan liu, mi xiang, shijian li, dahai zhao, chaolin huang, and saijuan chen declare no conflicts of interest. this manuscript is a commentary and does not involve a research protocol requiring approval by the relevant institutional review board or ethics committee. key: cord-002885-dhdyxnr3 authors: den boon, saskia; vallenas, constanza; ferri, mauricio; norris, susan l. title: incorporating health workers’ perspectives into a who guideline on personal protective equipment developed during an ebola virus disease outbreak date: 2018-03-09 journal: f1000res doi: 10.12688/f1000research.12922.2 sha: doc_id: 2885 cord_uid: dhdyxnr3 background: ebola virus disease (evd) health facility transmission can result in infection and death of health workers. the world health organization (who) supports countries in preparing for and responding to public health emergencies, which often require developing new guidance in short timelines with scarce evidence. the objective of this study was to understand frontline physicians’ and nurses’ perspectives about personal protective equipment (ppe) use during the 2014-2016 evd outbreak in west africa and to incorporate these findings into the development process of a who rapid advice guideline. methods : we surveyed frontline physicians and nurses deployed to west africa between march and september of 2014. results: we developed the protocol, obtained ethics approval, delivered the survey, analysed the data and presented the findings as part of the evidence-to-decision tables at the expert panel meeting where the recommendations were formulated within eight weeks. forty-four physicians and nurses responded to the survey. they generally felt at low or extremely low risk of virus transmission with all types of ppe used. eye protection reduced the ability to provide care, mainly due to impaired visibility because of fogging. heat and dehydration were a major issue for 76% of the participants using goggles and for 64% using a hood. both gowns and coveralls were associated with significant heat stress and dehydration. most participants (59%) were very confident that they were using ppe correctly. conclusion : our study demonstrated that it was possible to incorporate primary data on end-users’ preferences into a rapid advice guideline for a public health emergency in difficult field conditions. health workers perceived a balance between transmission protection and ability to care for patients effectively while wearing ppe. these findings were used by the guideline development expert panel to formulate who recommendations on ppe for frontline providers caring for evd patients in outbreak conditions. health facility transmission is a hallmark of early ebola virus disease (evd) outbreaks and usually results in infection and death of health workers particularly before the identification of ebola virus as responsible for the clinical presentation of one or a cluster of patients [1] [2] [3] . contributing factors include nonspecific clinical presentation, lack of local advanced diagnostic capabilities and suboptimal infection prevention and control (ipc) practices, amplified by poor surveillance in struggling health systems. the epidemiological pattern of the 2014-2016 evd outbreak in west africa revealed a similar story, but this time with an unprecedented scale and geographic spread, resulting in a record number of affected health workers, with 881 cases and 513 deaths by late 2015 4 . health workers are more likely than non-health workers to be infected: depending on the profession, the risk can be 21 to 32 times higher 5 . the correct use of personal protective equipment (ppe) as part of comprehensive ipc measures contributes to the prevention of evd transmission in healthcare settings by providing a protective barrier from contaminated fluids. however, the characteristics of the material and the configuration of the equipment may lead to health worker discomfort, overheating, and concerns about dexterity and safety to perform clinical tasks when ppe is used in the typical conditions of high heat and humidity present in west african evd treatment centers 6,7 . as the united nations' international health agency, the world health organization (who) has the mandate to support member states in preparing for and responding to a wide range of public health emergencies that often require that new technical guidance is developed in short timelines with scarce evidence base. following an urgent request from affected member states, who started the production of a ppe guideline for evd outbreaks in july 2014, shortly before declaring the evd outbreak in west africa a public health emergency of international concern. a rapid review of the efficacy and comparative effectiveness of various components of ppe was commissioned in preparation for an expert panel meeting to develop recommendations on optimal ppe for health workers in ebola treatment units (etus) in outbreak settings. it became clear very early in the process that high quality efficacy and comparative effectiveness studies addressing the use of specific ppe items for evd in outbreak settings were lacking 8 . in addition to the paucity of data, it was critically important to gather and include the perspectives of health workers who had "real-life" experience in etus in west africa. early reports of the local conditions indicated that broader clinical questions than ppe performance as a transmission barrier were as important: usability, comfort, dexterity and impact on communication with patients, for example. the underlying principle was that evidence from efficacy and comparative effectiveness studies was necessary but insufficient for contextualization and adequate decision-making. this approach highlights the importance of understanding the way individuals exercise judgement (values and preferences) when selecting options with potential benefits, harms, and inconveniences in real life and is current best-practice in who standard guidelines 9 . values and preferences are often informed mainly by the opinion of guideline expert panel members, however such proxies for persons affected by the recommendations in a guideline are often inadequate or even inaccurate. thus, in the early stages of the 2014-2016 evd outbreak in west africa, in the context of time constraints and the absence of published data, it was crucial to incorporate the values and preferences of health workers into the guideline development process. the purpose of this study was to support the development process of a who rapid advice guideline on ppe for evd care in outbreaks. the specific objectives were to understand and describe frontline physician and nurses' perspectives about ppe use, while providing direct care for evd patients in the unprecedented conditions of the 2014-2016 evd outbreak in west africa and to incorporate these findings into the rapid advice guideline development process. in september 2014, we electronically surveyed international frontline physicians and nurses who participated in foreign medical teams deployed to the affected countries in early stages of the evd outbreak. the pragmatic approach was necessary given that this survey was developed and delivered at the height of outbreak and that who had very limited time available in which to produce guidance. the online, 23-item survey was developed specifically for this study (supplementary file 1). the first section consisted of multiple-choice questions examining participant demographic characteristics, role, and experience with ppe in west africa. the next section addressed health worker exposure to the following specific components of ppe: eye protection (goggles/face shields), nose and mouth protection (medical mask/particulate respirator), gloves (single/double gloves), body covering (gowns/ coveralls), foot wear (boots/closed shoes), and head covering (hair cover/hoods). in subsequent sections, we used a four or five-point likert-scale to examine participants' perceptions about the impact of each ppe item on the following domains: safety, communication, ability to provide patient care, personal wellbeing (heat and we have made changes to the text based on the referees' comments, in particular emphasizing the connection to oxidative stress in the abstract and expanding the discussion. in response to the suggestions and comments from the reviewers we have made several edits to our research paper. first of all, we have revised table 2 by adding categories that were previously omitted from the table. for example, in version 1 we only presented in the table the number health workers that indicated they felt at extremely low or low risk, but in version 2 we have added a column indicating the number of health workers feeling at high or extremely high risk. we have also added a foot note explaining how the denominator in each cell reflects missing values for that particular question. we hope that this has improved the readability of the table. second, we have added some additional references to the literature on ppe in the discussion. finally, we have added a few small clarifications and moved some text to other sections in the paper. revised dehydration), and comfort. in addition, for each of the items, participants could provide free-text comments on open-ended questions to describe any difficulties or to provide suggestions on how ppe could be improved. the final section explored specific training needs and confidence in ppe. the last question asked participants to compare two sets of ppe available in west africa shown side-by-side in a picture: one was composed of lighter items and the other had more robust components. five experts reviewed the study protocol and questionnaire during the development phase. subsequently, three clinicians with experience in the evd outbreak in west africa similar to that of the sampling frame field-tested the survey for consistency, readability, completeness, and question sequencing. the final version of the online survey incorporated all relevant feedback and comments. we obtained expedited approval of the study protocol and survey from the who ethics review committee (rpc690). we contacted potential participants via email. the first email explained the objectives, expected time commitment, and provided a link to the informed consent form and online survey on survey monkey ® . participation was voluntary and implied informed consent. a follow-up email in 5 days reminded potential participants of the deadline (10 days after launching). participants could withdraw from the study at any time without providing any justification. the study population consisted of international frontline physicians and nurses with direct field experience caring for evd patients in west africa. our sampling frame targeted international physicians and nurses deployed by who and médecins sans frontières (msf) to west africa between march and september 2014. we used maximum variation purposeful sampling, a non-probability sampling strategy, to capture a wide range of health worker perspectives and experiences in two organizations and four different countries affected by the evd outbreak. health workers were reached through a contact individual in each organization (msf and who) who directly emailed potential participants. physicians and nurses from the affected countries and from other international organizations were not included for pragmatic reasons given the extreme time constraints and infeasibility of obtaining additional organizational approvals in the available timeline. an initial communication error led to the participation of other groups of health workers that did not have frontline clinical experience. the perspectives of these workers were considered for who quality improvement efforts, but were excluded from this analysis as these groups were not part of the approved sampling frame for this study. participants could indicate their experience with more than one item for each ppe component (e.g., both goggles and face shields for eye protection). for the purpose of statistical analysis, we considered each participant's experience with a ppe item unique and independent (i.e. we did not account for the fact that the experience came from one and the same health worker). we analysed closed-ended questions with stata 10 (statacorp. 2007. college station, tx) using counts, proportions, and the chi-square test when comparisons were appropriate. two independent researchers analysed the answers to the openended questions using an iterative and reflexive process. this encompassed close reading and re-reading of the answers using constant comparison within and across different participants to identify key topics. the researchers then grouped the interpretations and understanding of the participants' ideas and selected quotes to represent these findings, discussing discrepancies to achieve agreement. immediately after data collection with the survey monkey ® instrument, all information was downloaded to an anonymized spreadsheet and removed from the online database. all analyses were performed on de-identified data. informing rapid advice guideline recommendations the rapid advice guideline was developed using the grading of recommendations assessment, development and evaluation (grade) approach 9,10 . with this approach, clinical and public health recommendations are based on a systematic review and critical appraisal of the evidence on benefits and harms of an intervention, and an assessment of the balance between the two. other considerations are also taken into account when an expert panel formulates recommendations, including feasibility, acceptability and resource implications of the intervention options, and the effects on equity across subpopulations. the relative value of the potential outcomes of the intervention options and the values and preferences of persons affected by the intervention are also important considerations. the findings of the survey were presented at the guideline development meeting and incorporated into evidence-to-decision tables (supplementary file 2) to inform the formulation of recommendations for ppe components in the context of an evd outbreak. evidence-to-decision tables followed the grade-decide 11 approach and were populated by the who guideline development team in preparation for the expert panel meeting. these tables were key instruments used to present multiple sources of information to the guideline expert panel, helping to structure the discussion and to document the final judgements and decisions that underpin each recommendation. we developed the study protocol, obtained who ethics approval, contacted the participants, delivered the survey, analysed the data, and presented the findings as part of the evidence-to-decision tables at the expert panel meeting where the recommendations were formulated in a period of 8 weeks. we invited 192 health workers (166 from msf and 26 from who) to participate in the survey and 74 (39%) responded. respondents from msf included 30 logisticians and water, sanitation and hygiene experts who were excluded because they were not part of the sampling frame. thus 44 participants (33 physicians and 11 nurses) were included in the final analysis and their characteristics are described in table 1 . for each of the different components of ppe, one item was used by the majority of survey participants (table 2) . for example, 42 (95%) of participants had experience using goggles, while only seven (16%) had used a face shield (some participants had experience with both types of eye protection). generally, health workers felt at low or extremely low risk regardless of the type of ppe used. ppe, particularly goggles, particulate respirators, and medical masks or hoods, impaired communication (table 2) . a reduction in the ability to provide care was predominantly related to eye protection equipment -both face shields and goggles. heat and dehydration were a significant or major issue for 31 participants using goggles (76%) compared to two (29%) using a face shield (p=0.02), and for 27 (64%) using a hood compared to none using a hair cover (p=0.02). heat and dehydration also were a significant or major issue for the majority of individuals using a gown (n=11, 73%) or coverall (n=26, 87%); however, there was no significant difference between the two groups (p=0.41). goggles were considered more uncomfortable (n=29, 71%) than face shields (n=2, 29%, p=0.08) ( table 2) . participants indicated that fogging of goggles or face shields was a major issue, affecting visibility and potentially creating a hazard for health workers as well as patients. there was some indication that fogging was a bigger issue with goggles and a few participants indicated that they would have preferred a face shield. two participants indicated that the goggles caused pain after using them for extended periods. a number of participants noted that goggles did not cover sufficient skin of the face and there were requests for larger goggles, which would have the added advantage of greater visibility. other issues were the poor quality of face shield and goggles, poor fit of goggles, and the logistical challenges of waiting to clean and dry re-usable goggles. one respondent summarized it as follows: "the goggles (are) not so comfortable and (they) felt like the "unsafe" part of the ppe. they move easily, hurt on the head, and affect vision in a negative way due to sweat, etc.". medical mask and the particulate respirator were reported to cause difficulty breathing when wet (due to sweat or condensation). one participant doubted the mask's effectiveness when wet. two participants were of the opinion that respirators were excessive since evd is not airborne. the main problem regarding gloves was the risk of having them slip down, allowing fluids to contact the skin as illustrated by the following respondent: "some people found using tape over gloves (the second pair) useful as sometimes they did roll down during arduous patient care activity and in the end i also did this". other participants also attempted to solve this problem by taping gloves to the coverall, however this occasionally resulted in the tearing of gloves or the coverall. it was also mentioned that gloves were not long enough and that they tore easily. difficulties included finding the right size coverall -in several instances the available coveralls were too small, leaving the health worker to opt for a coverall of lesser quality or have difficulties removing the coverall. a number of health workers indicated that they had difficulty taking off the coverall. specific issues included having to remove the face shield first, leaving the eyes and face unprotected while undressing from the coverall, and problems taking off the coverall over large rubber boots. one respondent mentioned that coveralls with attached shoe covers could increase the risk of tripping. one respondent commented that boots were too big causing difficulty walking on irregular ground. as for reusable items (goggles and boots), it was mentioned that the time required to fully decontaminate and dry them sometimes brought challenges and put pressure on the team. training on ppe use a third of survey participants had received formal training over 2 to 3 days (n=15, 34%) and four (9%) reported training duration of more than 3 days. on the other hand, 20% (n=9) had received no formal or on-the-job training and another 20% (n=9) reported training for 2 hours or less. the remaining 15% of study participants (n=7) had training of one day or less. a number of participants commented that they would have liked to have had training, more formal training, or longer training. others indicated that they would have liked to receive training before their departure, or before arriving at the treatment centre. the training topics that the survey participants would have liked included were the removal of ppe, and, how to manage eye glasses. one health worker recommended weekly refresher training, especially in the light of frequent equipment changes, which may impact the order items are put on and taken off. another health worker commented: "i believe that only experienced people can teach about ebola. teaching on the use of ppe is not about dressing and undressing. it is about using a set of behaviours with it and the understanding of all the underlying water and sanitation principles and applying them". regarding hand hygiene, alcohol-based hand-rub was not always available and there was conflicting information in different settings about which product to use. the majority of participants (n=26, 59%) were very confident that they were using ppe correctly, 17 (39%) were reasonably confident and 1 (2%) was not very confident. generally, participants were least confident about goggles (fogging, moving/displacing), medical masks and particulate respirators (difficulty breathing, becoming uncomfortable), and gloves (rolling down, tearing). removing ppe was also an area that people felt less confident about (e.g., taking arms and feet out of a coverall, lack of face protection during undressing if the face shield was worn outside the hood). as one health worker illustrated: "taking off the (tyvek suit) coverall was difficult due to my height; it required me to wiggle out of it more than the average person". a respondent also mentioned feeling less confident working in the screening area where much lighter ppe was worn, while possibly also being exposed to infectious patients. when asked to indicate their preference regarding two sets of ppe depicted in a picture, 8 (18%) participants preferred the ppe that was composed of lighter items, 33 (77%) participants preferred the more robust components, 2 (5%) did not have a preference and one participant did not respond to the question. the 2014-2016 evd outbreak in west africa required extensive local and international response and for the first time since evd was described in 1976, a large number of organizations were directly involved in clinical and laboratory activities in the field. these interactions highlighted differences in the selection and use of ppe across the organizations. early on in the outbreak, when the cases of health worker transmission were numerous and confusion about the best available equipment was wide-spread, who was asked to provide technical guidance in a short period of time. when a public health emergency involves a new disease, or a known disease with a different presentation, there may be scarce or no evidence on the benefits and harms of potential interventions. indirect evidence (e.g., from related diseases such as other blood-borne pathogens and simulation), expert opinion, and data acquired and analysed in real-time may become the best available evidence for the guideline panel. in addition, factors other than the effectiveness of interventions may have a significant influence on the direction and strength of the recommendations. such was the situation in 2014 during the height of the evd outbreak in west africa; a rapid review of the effectiveness of different types of ppe for protecting health workers revealed insufficient evidence upon which to draw conclusions about optimal ppe 8 . in this context and within a period of 8 weeks, we developed and executed a survey, the results of which formed a critical part of the evidence upon which the recommendations developed by the expert panel were based 12 . to the best of our knowledge, this approach of collecting primary data regarding the values and preferences of persons affected by clinical or public health recommendations in a guideline is novel in the extremely challenging setting of a public health emergency. overall, our findings showed that health workers perceive a balance between transmission protection and the ability to effectively care for complex patients while using ppe. health workers accept a certain degree of discomfort in return for the protection provided by ppe. the survey highlighted a slight preference of health workers for face shields compared to goggles because of less fogging, easier communication and better fit. there was no strong preference for one item of ppe over the other for all other ppe components. given the variation in preferences for different components of ppe and the absence of data on comparative effectiveness, it may be important to provide a choice for health workers. this was, in fact, a guiding principle during the development of the ppe guidelines. several issues raised by survey participants should be relatively straightforward to address, making a major contribution to health worker safety and comfort, such as providing a sufficient range of sizes, choice of equipment, and adequate training on how to put on and take off ppe in the conditions that will be faced in the field. active training, in which health workers receive face-to-face training has been shown to improve doffing procedures 13 . we experienced a number of challenges planning and executing this study. we had to develop a survey questionnaire de novo with limited time for field testing. although this likely had a minimal impact on the results, we noted two questions that participants appeared to have difficulty comprehending (questions 11 and 23; see supplementary file 1); if we had had more time for field testing we could have revised the questionnaire before formal data collection began. while our aim was to include only health workers who had provided direct patient care, such as nurses and physicians, given a communication error early in the study, we invited to participate and consequently received responses from workers without direct clinical experience who had been deployed to the evd outbreak. because these workers were not part of our pre-defined sampling frame, we excluded their responses from the analysis. similarly, our survey failed to take into account the fact that ppe consists of different components such as eye protection, nose and mouth protection, gloves and body coverings that work together to protect the health worker from the risk of infection. in the first part of our questionnaire we asked how the survey participant experienced individual components of ppe (e.g., goggles or face mask). however, it is difficult to review these components as isolated items, separate from the rest of the ppe. as one survey participant noted: "it is the combination of the respirator and the face shield which is difficult. one or the other would be manageable but both together meant major impairment". another survey participant commented: "the coverall would probably be better tolerated if we could breathe easier and see without problems". in addition, although we compared gowns and coveralls, we did not specify or ask about the materials the body coverings were made of, its level of fluid resistance, or whether the head cover was attached or not. such issues can have a significant impact on health workers' experiences. for example, a simulation study carried out in hong kong in response to the outbreak of severe acute respiratory syndrome (sars) found that ppe made of more breathable material did not lead to a significant difference in contamination but did have greater user satisfaction 13,14 . it also became clear that solutions to an issue with one component of ppe could compromise the safety of another element of ppe. for example, participants mentioned that they would improvise and tape gloves to the coverall in order to prevent them from slipping down, but then the coverall would tear when removing the tape. finally, the combination of different components of ppe may change the order in which ppe items are put on and taken off, thus end-users may perform donning and doffing procedures that are different than the training they received. this is particularly relevant if there are frequent changes in the availability of specific types of ppe, as was the case early in the outbreak response. most of the limitations of this study were caused by pragmatic decisions the research team had to make in order to complete the study in the available time. this was in and of itself an invaluable learning experience for undertaking similar projects in the future. specifically, we had to include only international health workers deployed by who and msf in our study; therefore, we did not collect information on the values and preferences of local health workers and health workers deployed by other organizations. there were two important reasons as to why we selected our sampling frame. first, we carried out the survey at the height of the evd epidemic when local doctors and nurses were fully engaged in the response efforts and we refrained from removing them from their primary work. internationally recruited health workers on the other hand, were usually deployed for shorter periods and could thus participate when they returned home. second, we had little time in which to execute the survey before the guideline meeting and we anticipated that it would be a lengthier and more complex process to identify and recruit local health workers. thus, the findings of this survey may not be applicable to local health workers. in addition, generalizability of our findings to other international health workers involved in the ebola response may be limited due to the small size of our purposive sample. in the context of the most challenging of research settings, our study proceeded very efficiently and effectively in several regards. peer reviewers for both the study protocol and draft survey made very helpful comments within 1 to 2 days. the who ethics review committee approved the survey in less than two weeks. by reaching out to several key managers and opinion leaders from the two organizations, we were quickly able to identify frontline clinicians that were part of the sampling frame. the online format of the survey allowed us to quickly reach a larger number of health workers in different countries who had recent personal experience with different types of ppe in the evd outbreak. the combination of different types of questions in our survey also worked well. closed and likert-scale questions made analysis of trade-offs and comparisons of health workers' preferences possible while open-ended questions allowed the survey participants to share additional thoughts and perspectives in more depth. our study highlights some of the challenges and potential limitations and demonstrates the feasibility of generating and incorporating primary data on end-users' values and preferences into a rapid advice guideline developed during the height of a public health emergency with extreme field conditions. our survey showed that health workers perceive a balance between transmission protection and their ability to effectively care for patients while wearing ppe. these findings were a critical part of the information used by the guideline development expert panel when formulating recommendations on ppe for frontline health workers caring for evd patients in outbreak conditions. we obtained expedited approval of the study protocol and survey from the world health organization ethics review committee (rpc690). as approved by the ethics committee, we provided a link to the informed consent form with the survey. participation was voluntary and implied informed consent. supplementary file 1: study questionnaire. click here to access the data. supplementary file 2: evidence-to-decision tables used in the formulation of recommendations for the who rapid advice guideline: personal protective equipment in the context of filovirus disease outbreak response. click here to access the data. author response 05 mar 2018 , world health organization, switzerland saskia den boon i had difficulty reading the tables in the article. i thought maybe it was the way they were displaying on my computer, but nothing seemed to change when i clicked on them. please make these charts simple to read and clear. i need to see the tables to make sure your findings are adequately described. thank you for reviewing and approving our paper. we assume that you are author's response: referring to table 2. we have revised the table by adding the categories that were previously omitted from the table. for example, in version 1 we only presented in the table the number health workers that indicated they felt at extremely low or low risk, but in version 2 we have added a column indicating the number of health workers feeling at high or extremely high risk. we have also added a foot note explaining how the denominator in each cell reflects missing values for that particular question. we hope that this has improved the readability of the tables. the article is really well written. i was very pleased with the quality of the writing and the honesty of the authors about their challenges. this is important work in the area of ppe use. thanks for these kind words about our study. author's response: while i know that this was quick work in a difficulty setting, i still feel like the article needs to do justice to personal protective equipment research of the past 20 years (at least since sars). the major section that needs more referencing is the discussion section. how do your findings compare to what we have found in epidemiological studies, simulation studies, and others on ppe. even if these studies were not done in the context of an outbreak of evd in africa, they should still be discussed. there is literature on some of these areas that would bring worthwhile context to your findings. thanks for this suggestion. we have added a number of references to the author's response: literature to our discussion section. well written paper on an important and largely ignored subject: 'health workers perspectives for guidelines'; also on top global health issue 'ebola virus disease'. study process was speedy and appropriate for the urgency needed for guidelines to be developed making this a good learning experience. however, there are a few points of attention listed below. i have also highlighted the sections relevant to my comments . here 'the 2014-2016 evd outbreak in west africa was initially declared a public health emergency of international concern in early august 2014, coinciding with the decision to develop a who rapid advice guideline on the selection and use of ppe for evd care in outbreaks.' this statement will fit more within the background section, consider moving into background. 'we electronically surveyed international frontline physicians and nurses who participated in foreign medical teams deployed to the affected countries in early stages of the evd outbreak.' clearly stating time frame in the methods section within which survey was done will also be helpful for readers, although a time frame is given later under participants, it is not clear if this was for survey or the sampling. this time frame is also very early in the outbreak aq3: settings is not well described, consider discussing setting in more detail under a separate title. clinicians express discomfort and safety, it may be interesting to know if at some point in the interviews they weighed in on safety versus comfort e.g. will the feeling of safety make them cope with discomfort? or does discomfort make safety inconsequential? i have answered 'partly' to the question "is the work clearly and accurately presented and does it cite the current literature?" as a small part of the methods may benefit clarity if texts are moved around. i have answered 'partly' to the question "are the conclusions drawn adequately supported by the results?" as it will be important to discuss discomfort versus safety of risk or clearly state if this was not evaluated by the study. this is an interesting piece and important in the context of infectious diseases. i will like to appreciate the authors for taking the initiative during such an emergency to collect such data. i will recommend the paper to be considered for indexing especially as it contributes towards developing guidelines for ppe which was more of a challenge to health workers during the outbreak. understanding their challenges and experiences especially in very humid temperatures is important. most importantly, the 2014 outbreak was a remarkable and most catastrophic outbreak. thus, using the outbreak as a point of focus adds value to the work considering that it pulled health workers from various countries. 2 the work considering that it pulled health workers from various countries. why only physicians and nurses perspectives regarding ppe? i understand the relative risk for physicians and nurses as frontline workers is high, but other health workers are involved, and have recorded fatality rates, their experiences with ppe may also add value especially in the context of developing guidelines. maybe the authors should consider adding this to limitations. four or five likert is not explicit; it does not tell which questions were measured using scales of four and which used five and how they way categorize for-example., 1 indicating low or high? agree or somewhat agree? understand the sample size was small and is actually mentioned as a limitation, however, any data on number of nurses and physicians that were deployed by who and msf during the period of data collection for background purposes and to justify the limitation? the sentence under data analysis is not clear to me, maybe rephrasing to better explain to the audience "for the purpose of statistical analysis, we considered each participant's experience with a ppe item unique and independent." the survey assumes that all the participants speak and write english? language characteristic not mentioned considering that these affected countries some are french countries. if all participants were not english speaking how was it translated? especially as the authors mentioned that respondents could not comprehend some questions due to time constraint. the literature highlights some gender differences for ppe amongst physicians and nurses especially in african context-assuming nurses are mostly women and physicians men--it would have been good to explore differences between nurses and physicians with regards to the specific ppe used. were physicians exposed to more sophisticated ppe than nurses? other comments that may be of interest to the authors: i understand the limitation of the paper is focused on participants in ebola treatment centers and only foreign deployed. however, guidelines should take into consideration local reality in terms of culture? based on previous outbreaks, most families prefer to care for patient at home and given the limited resources in this context; local materials were used at home in 2014 as ppe . http://www.cnn.com/2014/09/25/health/ebola-fatu-family/index.html given the reality of limited resources, and the fact that most families prefer to care for patient at home it would add more value also to consider experiences of those who cared for patient at home, the type of ppe used and opportunities in incorporating local reality into evidence-based guidelines for ppe. if applicable, is the statistical analysis and its interpretation appropriate? yes settings is not well described, consider discussing setting in more detail under a separate title. we are not sure how to respond to this question of the reviewer. we did an author's response: online survey among health workers who were deployed by msf or who to respond to the ebola outbreak in west africa early on in the epidemic. health workers worked in local hospitals, clinics or ebola treatment centers, but because we did not ask further information about these settings we cannot provide a more detailed description. clinicians express discomfort and safety, it may be interesting to know if at some point in the interviews they weighed in on safety versus comfort e.g. will the feeling of safety make them cope with discomfort? or does discomfort make safety inconsequential? we assume that the reviewer is referring to question 11 which asked, "please author's response: indicate how safe you felt by ticking a box for each aspect of personal protective equipment". as we have stated in the discussion, survey participants had difficulty answering this question because of the way the answer categories were phrased, e.g. "extremely low risk, i felt comfortable". in this answer category we wanted comfortable to mean "i am not worried about safety", but this was sometimes interpreted as "i am physically comfortable (e.g. not overheated, etc.)". if we had had more time for piloting, we would have been able to pick this up before sending out the survey. however, through comments from health workers it became clear that they indeed cope with discomfort because the ppe makes them feel safe and we have added the following sentence to the discussion: "health workers accept a certain degree of discomfort in return for the protection provided by ppe". i have answered 'partly' to the question "is the work clearly and accurately presented and does it cite the current literature?" as a small part of the methods may benefit clarity if texts are moved around. we hope that our amendments have improved the methods section. author's response: i have answered 'partly' to the question "are the conclusions drawn adequately supported by the results?" as it will be important to discuss discomfort versus safety of risk or clearly state if this was not evaluated by the study. we hope that our amendment has taken away the concern of the reviewer. author's response: this is an interesting piece and important in the context of infectious diseases. i will like to appreciate the authors for taking the initiative during such an emergency to collect such data. i will recommend the paper to be considered for indexing especially as it contributes towards developing guidelines for ppe which was more of a challenge to health workers during the outbreak. understanding their challenges and experiences especially in very humid temperatures is important. most importantly, the 2014 outbreak was a remarkable and most catastrophic outbreak. thus, using the outbreak as a point of focus adds value to the work considering that it pulled health workers from various countries. thank you for reviewing our paper and for making helpful comments and author's response: thank you for reviewing our paper and for making helpful comments and author's response: suggestions. see below our responses. why only physicians and nurses perspectives regarding ppe? i understand the relative risk for physicians and nurses as frontline workers is high, but other health workers are involved, and have recorded fatality rates, their experiences with ppe may also add value especially in the context of developing guidelines. maybe the authors should consider adding this to limitations. we agree with the reviewer about the importance of ppe for other health author's response: workers, for example cleaners, laboratory workers, burial teams and other workers. however, the focus of the who guideline which our study aimed to inform, was on healthcare workers and therefore we also focused our survey on this group. four or five likert is not explicit; it does not tell which questions were measured using scales of four and which used five and how they way categorize for-example., 1 indicating low or high? agree or somewhat agree? we agree with the reviewer that it would have been better to have used a author's response: comparable (e.g. 5-point scale) for all the questions. if we had more time for piloting, we may have picked this up before sending out the survey. now, the questions on safety and comfort had a 4-point scale and questions on communication, ability to provide care, and heat and dehydration had a 5-point scale. as can be seen in the questionnaire which is included in the supplementary material, we did not use coding in the answer categories. understand the sample size was small and is actually mentioned as a limitation, however, any data on number of nurses and physicians that were deployed by who and msf during the period of data collection for background purposes and to justify the limitation? as stated in the results section, we invited 192 health workers (166 from msf author's response: and 26 from who) to participate in the survey, but this included health workers outside the sampling frame (e.g. logisticians and water, sanitation and hygiene experts). unfortunately we do not have more detailed information on numbers deployed. the sentence under data analysis is not clear to me, maybe rephrasing to better explain to the audience "for the purpose of statistical analysis, we considered each participant's experience with a ppe item unique and independent." we have now added the following clarification to the methods section: "i.e. we author's response: did not account for the fact that the experience came from one and the same health worker". the survey assumes that all the participants speak and write english? language characteristic not mentioned considering that these affected countries some are french countries. if all participants were not english speaking how was it translated? especially as the authors mentioned that respondents could not comprehend some questions due to time constraint. yes, this is correct. we assumed that all participants could speak and write author's response: english and we did not translate the questionnaire. the miscomprehension was due to the fact that two questions were not phrased clearly, rather than the language skills of the survey participants. the literature highlights some gender differences for ppe amongst physicians and nurses especially in african context-assuming nurses are mostly women and physicians men--it would have been good to explore differences between nurses and physicians with regards to the specific ppe used. were physicians exposed to more sophisticated ppe than nurses? ppe used. were physicians exposed to more sophisticated ppe than nurses? this is a very interesting question. although our study was not designed to author's response: answer this question and the number of participants was too small to do any stratified analysis, i had a brief look at the data. we indeed found a higher proportion of physicians among males (91%) than among females (57%), but there were no obvious differences in robustness of ppe, when i compared gown or coverall use between males and females, or between physicians and nurses (varying between 32-36% using a gown). other comments that may be of interest to the authors: i understand the limitation of the paper is focused on participants in ebola treatment centers and only foreign deployed. however, guidelines should take into consideration local reality in terms of culture? based on previous outbreaks, most families prefer to care for patient at home and given the limited resources in this context; local materials were used at home in 2014 as ppe . http://www.cnn.com/2014/09/25/health/ebola-fatu-family/index.html given the reality of limited resources, and the fact that most families prefer to care for patient at home it would add more value also to consider experiences of those who cared for patient at home, the type of ppe used and opportunities in incorporating local reality into evidence-based guidelines for ppe. we acknowledge the importance of this issue brought up by the reviewer but it author's response: fell outside the scope of the study and the who guideline that we were aiming to inform. the benefits of publishing with f1000research: your article is published within days, with no editorial bias you can publish traditional articles, null/negative results, case reports, data notes and more the peer review process is transparent and collaborative your article is indexed in pubmed after passing peer review dedicated customer support at every stage for pre-submission enquiries, contact research@f1000.com report of a who/international study team we thank the following people for providing invaluable comments on the project proposal and questionnaire: patricia hudelson, gordon guyatt, martine verwey, doris bacalzo and elie akl. we are grateful to armand sprecher from médecins sans frontières for sending the questionnaire to his staff during the peak of the outbreak response. we are also grateful to the survey participants for making this study possible. participants could withdraw from the study at any time without providing any justification. due to the small number of survey participants, the detailed information collected, and the terms in the consent form approved by the who ethics review committee, which guaranteed participant anonymity, the individual-level data cannot be made available. requests for raw data can be dealt with on a case-by-case basis by contacting the corresponding author dr den boon, who will facilitate enquiries to the who ethics review committee.competing interests sdb and cv declare no competing interests. mf declares that his spouse is an employee at bristol myers squibb and owns company stock as part of her remuneration plan. sln declares that she is a member of the grading of recommendations assessment, development and evaluation (grade) working group, has published numerous papers related to grade, and that her career has benefited from this relationship. grade is the guideline process used by her employer, the world health organization, to develop guidelines. this study was funded by who core funds. no external funding was obtained.the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. i had difficulty reading the tables in the article. i thought maybe it was the way they were displaying on my computer, but nothing seemed to change when i clicked on them. please make these charts simple to read and clear. i need to see the tables to make sure your findings are adequately described. the article is really well written. i was very pleased with the quality of the writing and the honesty of the authors about their challenges. this is important work in the area of ppe use.while i know that this was quick work in a difficulty setting, i still feel like the article needs to do justice to personal protective equipment research of the past 20 years (at least since sars). the major section that needs more referencing is the discussion section. how do your findings compare to what we have found in epidemiological studies, simulation studies, and others on ppe. even if these studies were not done in the context of an outbreak of evd in africa, they should still be discussed. there is literature on some of these areas that would bring worthwhile context to your findings. are all the source data underlying the results available to ensure full reproducibility? yes no competing interests were disclosed. are all the source data underlying the results available to ensure full reproducibility? yes no competing interests were disclosed. competing interests: we have read this submission. we believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. well written paper on an important and largely ignored subject: 'health workers perspectives for guidelines'; also on top global health issue 'ebola virus disease'. study process was speedy and appropriate for the urgency needed for guidelines to be developed making this a good learning experience. however, there are a few points of attention listed below. i have also highlighted the sections relevant to my comments . here thank you for reviewing and approving our paper. see below our responses to author's response: your comments. we have made a number of changes in the text in response to your comments. 'the 2014-2016 evd outbreak in west africa was initially declared a public health emergency of international concern in early august 2014, coinciding with the decision to develop a who rapid advice guideline on the selection and use of ppe for evd care in outbreaks.' this statement will fit more within the background section, consider moving into background.we removed this sentence from the methods section and have added it, author's response: slightly modified, to the background section. 'we electronically surveyed international frontline physicians and nurses who participated in foreign medical teams deployed to the affected countries in early stages of the evd outbreak.' clearly stating time frame in the methods section within which survey was done will also be helpful for readers, although a time frame is given later under participants, it is not clear if this was for survey or the sampling. this time frame is also very early in the outbreak we send out the request for participation in september 2014 and have added author's response: this to the methods section. later we indicate that the survey was open for a 10-day period. the health workers eligible for participation were those who were deployed to west africa between march and september 2014 which was already stated in the methods section under participants. settings is not well described, consider discussing setting in more detail under a separate title. key: cord-270156-qrzjgzyk authors: cafferkey, j. j.; hampson, d. o.; ross, c.; kooner, a. s.; martin, g. f.; kinross, j. m. title: using hololensâ�¢ to reduce staff exposure to aerosol generating procedures during a global pandemic date: 2020-05-26 journal: nan doi: 10.1101/2020.05.24.20107193 sha: doc_id: 270156 cord_uid: qrzjgzyk rationale: covid-19 poses a unique challenge; caring for patients with a novel, infectious disease whilst protecting staff. some interventions used to give oxygen therapy are aerosol generating procedures. staff delivering such interventions require ppe and are exposed to a significant viral load resulting in sick days and even death. we aim to reduce this risk using an augmented-reality communication device: the hololens by microsoft. objectives: in a tertiary centre in london we aim to implement hololens technology, allowing other medical staff to remotely join the consulting clinician when in a high-risk patient area delivering oxygen therapy. the study primary outcome was to reduce the exposure to staff and demonstrate non-inferiority staff satisfaction when compared to not using the device. our secondary outcome was to reduce extrapolated ppe costs when using the device. methods: our study was conducted in march and april 2020, within a respiratory unit delivering aerosolising oxygen therapies (high flow nasal oxygen, continuous positive airway pressure and non-invasive ventilation) to patients with suspected or confirmed covid-19 infection. measurements: self-reported questionnaires to assess satisfaction in key areas of patient care. an infrared people counting device was also used to assess staff in and out of the unit. main results: mean self-reported time in the high-risk zone was less when using hololens (2.69 hours) compared to usual practice (3.96 hours) although this difference was not statistically significant (p = 0.3657). hololens showed non-inferiority when compared to usual practice in staff satisfaction score for all domains. furthermore, mean staff satisfaction score encouragingly improved when using hololens. self-reported ppe counts from this study showed 12 staff members changing ppe 25.8 times per shift, almost double the 13.5 times in the hololens count. conclusions: we have demonstrated hololens can reduce the number of staff exposed to aerosol generating areas in a novel infectious disease. our results show it did not impair communication, medical staff availability or end of life care. hololens technology may also reduce the use of ppe, which has equipment availability and cost benefits. this study provides grounding for further use of the hololens device by bringing a bedside experience to experts remote to the situation. covid-19 is a highly transmissible viral pathogen spread through respiratory droplets or contact with contaminated surfaces (1) . contact with respiratory secretions is a known risk factor for infection in healthcare workers (2, 3) . non-invasive ventilation imaging. the user interacts with these holographic objects using hand gestures or voice command, without the requirement for touch. hololens2™ has been deployed in medical education, surgery, and intensive care ward rounds (5, 6), but never before to protect staff from exposure to infectious disease in agp areas. in the cpap unit of a uk teaching hospital we implemented hololens2™ as a pragmatic technology-led improvement project to facilitate remote care during the covid-19 pandemic in a "red zone" where niv/cpap/hfno is delivered. pre-. cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may 26, 2020. . https://doi.org/10.1101/2020.05.24.20107193 doi: medrxiv preprint deployment practice was two or more staff donning personal protective equipment (ppe) for ward rounds and to review deteriorating patients. following deployment of hololens2™, one doctor would conduct the ward round wearing the device and other team members would remain protected in the "clean" area whilst participating virtually in care delivery. reviews of deteriorating patients by junior staff in the "red zone" would also be conducted with hololens2™ to facilitate remote senior clinical input. evaluation of the intervention saw ward staff (doctors, nurses and allied health professionals) completing self-report questionnaires comparing pre-and post-hololens2™ deployment. questions included time in "red zone", times donning /doffing and ten-point likert scales assessing multiple domains of communication and care delivery. an infrared device counted people in and out of the "red zone" (all-tag, united kingdom(7)/sensor development international, netherlands(8)). primary outcomes were: 1. number of staff exposed to agp environments before and after deployment of hololens2™, and 2. self-reported safety and acceptability of hololens2™. a secondary outcome was reduction in ppe use. local approval from imperial college healthcare nhs trust as a technology led quality improvement project was obtained. over 15 days a total of 57 patients were cared for in the unit. the hololens2™ was used on 13 of the 15 days; a greater proportion than anticipated in large part reflecting the reluctance of the clinical team to revert to usual practice following deployment. the number of staff entering and leaving the "red zone" was assessed for 36 hours of . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 26, 2020. . https://doi.org/10.1101/2020.05.24.20107193 doi: medrxiv preprint usual practice and 240 hours of hololens2™ use. average "crossings" per hour of the antechamber were 12.5 and 10.3 respectively, a reduction of 17.6%. 21 questionnaires were completed. average self-reported time in the "red zone" was less when using hololens2™ (2.69 hours vs. 3.96 hours, p=0.3657). all domains assessed with likert responses showed non-inferiority for care delivery when using the device. furthermore, the mean satisfaction score for all domains increased during days using hololens2™. we found decreased self-reported antechamber use and an increase in confidence in the communicating critical clinical information (table 1) . for each healthcare professional joining the ward round remotely when using hololens2 ™ a full set of ppe is saved. using self-reported donning/doffing counts, the use of hololens2 ™ led to a 48.7% reduction in the number of staff members donning/doffing each shift compared to usual practice (13.5 vs. 25.8). with this effect size, device purchase cost is covered in 212 days by ppe savings alone (9), and crucial ppe is saved at a time of international shortage. this novel use of mr technology can be implemented rapidly to materially reduce staff exposure to high-risk environments. critically, this does not impact quality of communication or staff perception of physician support. our pilot data signals mr technology may improve confidence in clinical practice in high-risk areas. this objective improvement in communication is consistent with our subjective experience: . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 26, 2020. . https://doi.org/10.1101/2020.05.24.20107193 doi: medrxiv preprint first person, real-time audio and visual information allows senior medics to "get a feel" for patients they are consulting on despite physical distance. an initial concern was device contamination, however, modifications to ppe protocols with infection prevention and control advice provided a satisfactory solution. we acknowledge that using hololens2 ™ in a novel disease with high ppe requirements may incur hidden risk, but on balance it is likely lower than exposing multiple additional staff to high-risk areas. our results indicate a reduction in the use of ppe; clearly warranted during the global pandemic to protect resources. furthermore, any ppe use is time consuming and risky; our intervention reduces its use. a key weakness is the time-limited analysis of staff entering and leaving the "red zone", impeding our ability to objectively assess staff exposure to high-risk environments. however, our experience is that this reflects strong adoption of the hololens2 ™ by the clinical team. whilst patients were universally accepting of the device, we acknowledge it does complicate critical non-verbal areas of communication like eye contact, and patient experience must be a measure of future implementation. finally, lack of randomization and lack of control for patient numbers introduces further potential bias. during implementation, we needed to address concerns about data security, patient safety and cost. our approach was necessarily pragmatic, rapidly delivering an intervention to protect staff during challenging times. our experience using the hololens2 ™ in high-risk clinical areas is promising, and reflects the ingenuity and flexibility needed during a pandemic. widespread concern about a second wave of covid-19 infection is compounded by the lack of an effective . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 26, 2020. . https://doi.org/10.1101/2020.05.24.20107193 doi: medrxiv preprint treatment and the inherent risk to healthcare workers. further assessment will include objective measures of patient safety, possible contamination of devices and effectiveness in protecting healthcare workers. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 26, 2020. . https://doi.org/10.1101/2020.05.24.20107193 doi: medrxiv preprint the "red zone". view of the hololens2 ™ user conducting the ward round. this is the view which is streamed to the junior team in the "clean area" during the ward round. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 26, 2020. . https://doi.org/10.1101/2020.05.24.20107193 doi: medrxiv preprint . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 26, 2020. . https://doi.org/10.1101/2020.05.24.20107193 doi: medrxiv preprint tables table 1. summary questionnaire responses from staff working in the cpap ward on shifts where usual practice was observed or hololens2 ™ was used. all statistical tests are mann whitney u tests unless otherwise specified. *unpaired t-test used. antechamber use n/a n/a n/a n/a 0.0082 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may 26, 2020. . https://doi.org/10.1101/2020.05.24.20107193 doi: medrxiv preprint figures figure 1. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may 26, 2020. . https://doi.org/10.1101/2020.05.24.20107193 doi: medrxiv preprint world health organization. coronavirus disease 2019 (covid-19): situation report, 73. geneva: world health organization initial viral load and the outcomes of sars risk factors for sars infection among hospital healthcare workers in beijing: a case control study severity of respiratory failure and outcome of patients needing a ventilatory support in the emergency department during italian novel coronavirus sars-cov-2 outbreak: preliminary data on the role of helmet cpap and non-invasive ventilation how to build a patient-specific hybrid simulator for orthopaedic open surgery: benefits and limits of mixed-reality using the microsoft hololens key: cord-305262-23qylbmg authors: rowan, neil j.; laffey, john g. title: unlocking the surge in demand for personal and protective equipment (ppe) and improvised face coverings arising from coronavirus disease (covid-19) pandemic – implications for efficacy, re-use and sustainable waste management date: 2020-09-10 journal: sci total environ doi: 10.1016/j.scitotenv.2020.142259 sha: doc_id: 305262 cord_uid: 23qylbmg currently, there is no effective vaccine for tackling the ongoing covid-19 pandemic caused by sars-cov-2 with the occurrence of repeat waves of infection frequently stretching hospital resources beyond capacity. disease countermeasures rely upon preventing person-to-person transmission of sars-cov2 so as to protect front-line healthcare workers (hcws). covid-19 brings enormous challenges in terms of sustaining the supply chain for single-use-plastic personal and protective equipment (ppe). post-covid-19, the changes in medical practice will drive high demand for ppe. important countermeasures for preventing covid-19 transmission include mitigating potential high risk aerosol transmission in healthcare setting using medical ppe (such as filtering facepiece respirators (ffrs)) and the appropriate use of face coverings by the general public that carries a lower transmission risk. ppe reuse is a potential short term solution during covid-19 pandemic where there is increased evidence for effective deployment of reprocessing methods such as vaporized hydrogen peroxide (30 to 35% vh2oh) used alone or combined with ozone, ultraviolet light at 254 nm (2000 mj/cm2) and moist heat (60 °c at high humidity for 60 min). barriers to ppe reuse include potentially trust and acceptance by hcws. efficacy of face coverings are influenced by the appropriate wearing to cover the nose and mouth, type of material used, number of layers, duration of wearing, and potentially superior use of ties over ear loops. insertion of a nose clip into cloth coverings may help with maintaining fit. use of 60 °c for 60 min (such as, use of domestic washing machine and spin dryer) has been advocated for face covering decontamination. risk of virus infiltration in improvised face coverings is potentially increased by duration of wearing due to humidity, liquid diffusion and virus retention. future sustained use of ppe will be influenced by the availability of recyclable ppe and by innovative biomedical waste management. since first reported as a cause of serious human pneumonia in wuhan, hubei, china in december 2019, the novel coronavirus covid-19 has spread worldwide with devastating consequences. at the time of writing (29 th august, 2020), there has been 25.1 million cases of covid-19 reported (in accordance with the applied case definitions and testing strategies in the affected countries) including 845,343 deaths (european centre for disease control and prevention, 2020) . there is evidence of resurgence of the sars-cov-2 globally with the emergence of second waves of infection in many countries (european centre for disease control and prevention, 2020) . hong kong is addressing its third wave of infections, where australia is battling a second wave of infection having previously reduced viral transmission cases close to zero. covid-19 has also emerged strongly in developing low-resource countries that already have significant healthcare challenges, such as across the african continent that is also challenged with acquired immunodeficiency syndrome (aids) and mycobacterium tuberculosis as co-morbidities (african centre for disease control and prevention, 2020) . currently, there is still no effective vaccine or anti-viral therapy for covid-19 with reliance upon the prevention of transmission by way of imposing a lockdown, cocooning, social distancing, and wearing of face masks in order to protect vulnerable groups and to safeguard frontline healthcare professionals. epidemiological studies show that social distancing prevents person-to-person transmission of sars-cov-2, which is relevant given that there is growing recognition that asymptomatic carriers may also contribute to this transmission (li et al., 2020) . there is evidence to suggest that covid-19 is a super-spreader of infectious airborne viral particles where several people can be infected at the same time (li et al., 2020) . publication from 1 january 2003 (as the first recorded human infection of sars-1 occurred in november 2002 (as per derraik et al., 2020) and 8 august 2020. titles and/or abstracts were screened by the first author and where appropriate, full text of individual research studies, opinion pieces and reviews were consulted. key words used were ppe; reuse; reprocessing; disinfection; decontamination; n95; covid-19; sars-cov-1; sars-cov-2; uv; hydrogen peroxide vapour (vh2o2); ozone; waste management; recycling. data extraction and rapid analysis was supplemented by conducting a short observation study where the first author noted the types of facemasks and face coverings worn by the public on entering a large shopping centre in the republic of ireland on 14 th and 15 th august 2020. at the time of initial writing (3 rd april, 2020) (rowan and laffey et al., 2020) , the number of confirmed covid-19 cases had reached 1 million, including 51,515 deaths, which highlights that a 25-fold increase in the prevalence of sars-cov-2 has occurred in only 4 months (european centre for disease prevention and control, 2020) . rowan and laffey (2020 had predicted an unprecedented high demand for ppe across the globe and therefore, it was prudent to consider ppe reuse as a potential option to meet the critical shortage in the supply chain for frontline hcws. rowan and laffey (2020) intimated that the structure of sars-cov-2 is such that is sensitive to harsh environmental stresses. moreover, the structure of sars-cov-2, and related coronaviruses, includes a rna genome, a protein capsid, and an outer envelope. viral inactivation is linked to the alteration of one of these structural elements by an environmental stress, such as, heating, ultraviolet light, and biocides (bentley et al., 2016; pinon and vialette, 2018; gorbalenya et al., 2020) . the proteins and lipids of the (li et al., 2016) , is such that these viruses are more likely to be sensitive to disinfection technologies (pinon and vialette, 2018; rowan and laffey, 2020) . kampf et al. (2020) had also analysed 22 studies of different human coronaviruses where sars, mers, hcov (but not including were efficiently inactivated by disinfection on variety of contact surface using 62 to 71% ethanol, 0.5% hydrogen peroxide, or 0.1% sodium hypocholorite within 1 min of exposure, but survived on untreated surfaces for up to 9 days. van doremalan et al. (2020) also conducted tests that showed that sars-cov-1 remains on plastic, stainless steel, copper and cardboard for up to 72 h. these and other studies have informed selection of many current disinfection procedures to address sars-cov-2 pandemic, including ppe reuse. given that disposable, plastic-based, ppe (gowns, eye protection, gloves, face masks, filtering facepiece respirators (ffrs)) are heat sensitive, existing healthcare technologies were considered to be either not available, unsuitable or not configured for reprocessing of ppe in healthcare for emergency use (rowan and laffey, 2020) . however, potential solutions for effective reprocessing of ppe that considered virus inactivation, material compatibility and device functionality (filtration efficacy, penetration, fit test and so forth) post processing included use of low temperature hydrogen peroxide vapour (vh2o2), ultraviolet germicidal light (uvgi), moist heat, and use of weak bleach for liquid decontamination (rowan and laffey, 2020; cdc, 2020) . mcevoy and rowan (2019) had published a comprehensive review on the background and efficacy of vh2o2 for terminal sterilization of medical devices that was used to provide supportive technical information in choice of procedures. this information was supported by prior findings of bentley et al. (2016) who reported on 4 log 10 viral titre reductions for the recalcitrant naked norovirus in a variety of hospital settings (stainless steel, glass, vinyl flooring, ceramic tile, pvc plastic cornering) using 30% w/w hydrogen peroxide vapour. rowan (2019) had also reviewed potential microbial mechanistic information underpinning uv disinfection that also provided supportive foundation knowledge for the potential use of pulsed light technology for ppe. journal pre-proof information underpinning these candidate technology solutions included best-published information of efficacy of these approaches to surface disinfection cornoavirus or related viruses and surrogate biological indicator organisms on different surface materials (kampf et al., 2020) . the fda had authorised use of vh2o2 technology, under emergency use authorization (eua), for the reprocessing of critical n95 face masks in the united states in order to help address covid-19 transmission. this was informed by columbus-based battelle process studies (battelle, 2016) . given exceptional circumstances, original equipment manufacturers (oems) of ppe had also suggested possible appropriate reprocessing strategies, but they also reiterated that their products had been manufactured with the sole intention of single use. the contingency plan to be adopted in hospitals on the west of ireland was to procure, install and seek approval from competent authority for the deployment of vh2o2 (bioquell bq50 system) for filtering face-piece respirators (ffrs) and surgical gowns, uv technologies (nanoclave low-pressure uvgi system and claranor pulsed light system) for simple ppe such as face shields, and use of mild sodium hypochlorite (4000ppm) for liquid decontamination of critical starmed hoods. the vh202, uvgi and mild liquid disinfection strategies have been set up, but there remains a requirement to gain trust and confidence by hcws for ppe reuse post treatments. several authors have reported on the viability of sars-cov1 and sars-cov-2 on various contact surface such as printed paper, printed tissue, cloth, wood, glass, banknotes, plastic, stainless steel, surgical mask layers over different environmental temperatures, relative humidity and durations (li et al., 2003; lai et al, 2005; pagat et al., 2007; chan et al., 2020; chin et al., 2020; fischer et al., 2020; kasloff et al., 2020; behzadinsaab et al., 2020; biryukov et al., 2020) . in general, lower environmental temperatures support the longer survival of sars-cov-2 on materials as reported by chin et al. (2020) where only a 0.7 log 10 reduction was observed for sar-cov-2 at 4°c after 14 days compared with 4.5 log 10 reduction at 22°c (room temperature) after 14 days and 4.5 log reduction at 37°c after just 2 days. similarly, also noted only a 2 log 10 reduction of sars-cov-1 at 4°c after 14 days when the virus was inoculated onto glass surfaces. the longer survival of sars-cov-2 at colder temperatures may have future implications for viral persistence on contaminated face coverings as we are approaching the winter flu season. however, public health practices that have been put in place to mitigate the spread of sars-cov-2 are likely to have a positive impact on the occurrence of influenza cases given that these viruses share similar modes of transmission to cause illness. derraik et al. (2020) comprehensively reported on the viability of sars-cov-1 and sars-cov-2 on different contact surfaces, without and with uv or heat treatments, and noted the importance of virus load and inoculum size on inactivation performance. lai et al. (2005) , who looked specifically at ppe, highlighted the variability in sars-cov-1 viability of 2 days on a disposable polypropylene gown and 24 h on a cotton gown for same 6 log 10 reduction. akin to studies reported by derraik et al. (2020) , we also observed that the majority of researchers used medium tissue culture infective dose (tcid 50 ) to report inactivation of sars-cov-1 and sars-cov-2 on various surfaces. kasloff et al. (2020) (rowan and laffey, 2020) . there is also a pressing need to explore attitudes, perceptions and possible barriers for use of reprocessed ppe by frontline clinicians and nurses that would entail conducting a social marketing study so as to inform overall acceptance and to overcome behaviour change factors for ppe reuse. increased use of face masks by people in communities in irish society is aligned with similar recommendations in other countries across the globe (rubio-romero et al., 2020; holland et al., 2020; jansson et al, 2020) . who (2020) also advocate that "use of face masks alone are insufficient to provide adequate level of protection, and other measures should also be adopted". who (2020) also advises for each country to apply a risk-based approach that considers benefits (such as reduction of potential risk of exposure), along with potential risk (such as self-contamination, false sense of security, impact of ppe shortage) when deciding to use facemasks by general population. the centre for disease control and prevention (2020) a short observational study of the types of face masks and face covering used by 1043 shoppers as they entered a large retail centre was conducted in the irish midlands on 14 th and 15 th august, 2020. findings revealed that 461 wore coverings with ear loops, 320 wore procedural masks with elastic ear loops, 140 wore kn95/n95 respirators, 38 wore face shields, 5 wore bandanas, 3 wore scarfs, and 56 shoppers did not wear face coverings. there was no evidence of anyone using surgical masks secured with ties. it was observed that 64 appeared to be wearing face masks or coverings over their mouth only, or below their chin, or j o u r n a l p r e -p r o o f were improperly fitting such that these did not cover the nose or mouth. some shoppers removed their face masks, or raised their face shields to the top of their head, in order to have conversations, which indicated a lack of understanding of their purpose and function. recnet evidence from fischer et al. (2020) with ffrs suggests that face masks and face coverings should consider use of adjustable cloth ties, as this design potentially offers better filtration efficacy of the virus compared to using a face coverings that have elasticated ear loops. creativity in the design of cloth coverings was observed including insertion of a clear panel to facilitate lip reading. face cloths are likely to be disinfected through use of domestic washing machine for re-use where combination of moist heat above 60°c and detergent will kill covid-19 rubio-romero et al., 2020) . . cdc (2020b) report that it is not known if face shields provide any benefit as source control to protect others from the spray of respiratory particles. cdc does not recommend use of face shields for normal everyday activities or as a substitute for cloth face coverings. if face shields are used without a mask, they should wrap around the sides of the wearer's face and extend to below the chin. (cdc, 2020; rowan and laffey, 2020) . some studies have been reported on the use of different regimes of heating for ppe processing. heating causes irreversible structural damage in virus proteins that prevents binding to host cells (derraik et al., 2020) ; the challenge is for thermal procedures is to eliminate sars-cov-2 with damaging ppe. the guiding principle, similar to the concept of pasteurization for use with heat sensitive foods, is that one can achieve a similar one-log reduction in viral load by reducing exposure time with increasing temperature. for example use 72°c for 15 seconds provides similar level of lethality to that of using a holding temperature of 60°c for 30 min. in general, heat treatment at 60°c for 30 min would lead to ca 4.6 to 7 log 10 reduction in sars-cov-2 (table 1) . however, doubling exposure duration at 60°c to 60 min would be prudent given the variability in heat inactivation studies reported j o u r n a l p r e -p r o o f for sars-cov-1 and sars-cov-2 (derraik et al., 2020) . for example, darnell and co-workers (2004) reported on residual infectivity after exposure of sars-cov-1 to heating at 65°c for 90 min. also, there is considerable variability in the manner by which the viruses have been tested by researchers that includes use of artificial solutions, surfaces and materials, with and without soiling, where the lack of harmonized procedures makes it challenging to appreciate significance of findings and relevance to practice, such as ppe (table 1) . variable factors influencing the efficacy of heat inactivation procedures for sars-cov-1 and sars-cov-2 include number of viruses present (viral load), presence of organic matter (soiling), temperature, humidity and duration of treatment (table 1) . song and co-workers (2020) reported on the use of heating of face masks in an oven at 56°c for 30 min combined with hot air from a hair dryer for 30 min to inactivate influenza virus without observing efficacy in filtering capacity. rubio-romero et al. (2020) noted that findings from this particular study was used by the international medical centre of beijing (2020) ffrs maintain their filtration efficiency after decontamination at 70°c for 30 min, although fit and deformation testing is not reported. price and chu (2020) and spanish society of preventive medicine, public health and hygiene (2020) recommend use of dry heat at 70°c for 30 min in a convection oven to ensure constant and uniform temperature maintenance. however, there is a general lack of information on the effect of dry heat on filtration, fit-test or deformity over several decontamination cycles (n95decon, 2020; rubio-romero et al., derraik et al., 2020) . the cdc (2020) stated that, based on limited research available as of april 2020, moist heat has shown promise as a potential method to decontaminate ffrs. the cdc's national institute for occupational safety and health (2020) reiterated that before using any decontamination method, it should be evaluated for its ability to retain 1) filtration performance, 2) fit characteristics achieved prior to decontamination, and 3) safety of the ffr for the wearer (e.g. by inactivating sars-cov-2). moist heat, consisting of 60°c and 80% relative humidity (rh) caused degradation in the filtration and fit performance of tested j o u r n a l p r e -p r o o f ffrs [berman et al., 2010; bergman et al., 2011; viscusi et al., 2011] . heimbuch et al. (2011) disinfected ffrs contaminated with hini influenza using moist heat of 65°c and 85% rh that achieved a minimum of 99.99% reduction in the test virus. cdc (2020) noted that one limitation of the most heat method is the uncertainty of disinfection efficacy for various pathogens. this is particularly relevant as there could be more than one respiratory virus or pathogen on contaminated ffrs in healthcare environment and during covid-19 pandemic. ozone can disrupt lipids and proteins in the cell envelope of viruses exposing vital genetic material, thus causing oxidative inactivation (rowan, 2019) . zhang et al (2004) had previously reported on decontamination of ffp respirators using ozone where sars-cov1 was inactivated using different concentrations of ozone solution disinfection with efficacy at 27.73 mg/l for 4 min exposure., toon (2020) also described the efficacy of ozone for decontaminating ppe where the relative humidity needed to be maintained above 50%, dennis et al. (2020) reported virucidal potentialof ozone where they implemented a simple disinfection-box system for treating ffrs. the authors recommended ozone concentrations at 10 to 20 ppm combined with an exposure of at least 10 min. dennis et al. (2020) note advantages of ozone that include rapid virucidal action that is effective for fibrous material, which included addressing crevices and shading. however, there is very limited information on ozone for broader ppe and medical device treatment due possibly to risk associated with its volatility. the majority of authorised approaches advocated by competent bodies deploy hydrogen peroxide vaporization (vh2o2) for emergency reprocessing of ppe where there is critical shortage (table 1) . jatta et al (2020) rowan and laffey, 2020) . the background and benefits of using vh2o2 as a reprocessing agent or sterilising modality for medical device application have been comprehensively reviewed by mcevoy and rowan, 2020. however, vh2o2 compatibility with cellulose-based materials in ppe needs consideration . grossman et al. (2020) noted that several vh2o2 sterilisation systems are currently approved for use under emergency use authorization (eua), but these technologies can be difficult to obtain due to the significant demand around the world. grossman and co-authors (2020) described the vh2o2 process (closed and sealed off room using bioquell z-2 disinfection cycle) for n95 respirators. these ffrs had been placed in tyvck pouches where the process includes conditioning, gassing, dwell, and aeration of the vh2o2. grossman and co-workers (2020) demonstrated a reproducible and scalable process for decontaminating n95 respirator within a large academic hospital and healthcare system. the cdc (2020) all phages which was below the limit of detection. viscusi et al. (2009) found that 9 ffr models (three particulate n95, three surgical n95 ffrs and three p100) exposed to one cycle j o u r n a l p r e -p r o o f of vh2o2 treatment using the sterrad 100s h2o2 gas plasma sterilizer (advanced sterilization products, irvine, ca) had filter aerosol penetration and filter airflow resistance levels similar to untreated models; however, bergman et al. (2010) found that three cycles of gas plasma treatment using the sterrad 100s h2o2 gas plasma sterilizer negatively affected filtration performance. table 1 lists the most frequently published papers on the decontamination of reuse of ppe using vh2oh. the cdc (2020) reported that ethylene oxide (eo) is not recommended as a decontamination method for ffrs as it is carcinogenic and teratogenic and may be harmful to the wearer, even at very low concentrations. niosh set a low exposure limit due to residual cancer risk below the quantitative limits of detection, i.e, preferring lowest feasible exposure (cdc, 2020). the cdc reviewed several studies where eo was shown to not harm filtration performance for the 9 tested ffr models. all tests were conducted for one hour at 55°c with eo gas concentration ranging from 725 to 833 mg/l viscusi et al., 2009; bergman et al., 2010) . also, six models that were exposed to three cycles of 736 mg/l eto all passed the filtration performance assessment (bergman et al., 2010) . ultraviolet (uv) irradiation causes inactivation of viruses by damaging rna or dna via a photo-dimerization process (darnell et al., 2004 the cdc (2020) also noted that ultraviolet germicidal irradiation (uvgi) is a promising method for ppe reuse, but stated that not all uv lamps provide the same intensity, thus treatment times would have to be adjusted accordingly (table 2) . moreover, uvgi is unlikely to inactivate all the viruses and bacteria on an ffr due to shadow effects produced by the multiple layers of the ffr's construction. the cdc (2020) noted that acceptable filtration performance was recorded for eleven ffr models exposed to various uv doses ranging from roughly 0.5-950 j/cm 2 and uvgi was shown to have minimal effect on fit. card et al. (2020) reported on the potential efficacy of ffp respirator decontamination using uvgi using biosafety cabinets that describes irradiation for 15-20 min per side with a fluence of 100 w/cm 2 . lowe et al. (2020) (2020) also advocates against use of uv disinfection of filtering facepiece respirators due to "shadowing effects produced by the multiple layers of the filtering respirators construction". rubio-romero et al. (2020) noted that the advantages of uv could be that  j/cm 2 of uv-c inactivates viruses similar to sars-cov2 on n95s that maintain fit and filtering performance after 10-20 cycles but shadowing may affect disinfection efficacy (n95descon, 2020c). straps also become degraded after multiple cycles of uv (mills et al., 2018) . table 3 . there has been a staggering increase in the production of ventilators and supply of single-use ppe to meet unprecedented demands globally (health products regulatory authority, 2020; global news wire, 2020). cocking (2020) (2020) platforms that will meet need for accelerate rate of usage so as to ensure no undue risks aligned with bringing together multi-actors, particularly competent authorities/regulators. there is a commensurate need for an understanding of the appropriateness and impact of different reprocessing modalities on materials when considering future reprocessing of ppe and medical devices (rowan and laffey, 2020) . there is an unprecedented surge in plastic-based ppe usage, arising a s consequence from the ongoing covid-19 pandemic, which constitutes a new form of single-use-plastic (sup) waste that will to plague our oceans posing a threat to our marine ecosystems (euronews, 2020) . shorelines have been littered with discarded ppe, such as masks and visors, with the gullets of birds stuffed with latex gloves, along with crabs tangled in face masks. marine conservation organisation oceansasia highlighted the growing number of single-use face masks being discovered during its plastic pollution research in the soko islands near hong kong (clark, 2020) . to provide context, republic of ireland is a small country with a population of ca 4.5 million, yet it's hcws require 9 million face masks per week at a cost to the exchequer of €1billion a year (farsaci, 2020) . nzediegwu and chang (2020) . the world health organization (2020) projected that supplies of ppe must increase 40% monthly to deal effectively with covid-19 pandemic. essential ppe includes an estimated 89 million medical masks, 76 million pairs of medical gloves and 1.6 million pairs of goggles. the increased demand for ppe is expected to be sustained beyond covid-19 with an estimated compound annual growth of 20% in facial and surgical masks supply from 2020 to 2025 . it is noteworthy that china produced 240 tons of medical waste daily during peak of pandemic in wuhan (singh et al., (2020) . horton and barnes (2020) reported that microplastics have now been found in the most remote places on earth, far away from human activities. in addition with climate-induced stress, microplastics may lead to enhanced multi-stress impacts, potentially affecting the health and resilience of species and ecosystems. the impact on ppe contamination on the marine environment has yet to be determined where there is significant gaps in knowledge. indiscriminate use and inappropriate disposal or mismanagement sups that have low biodegradation have led to accumulation of plastic debris in terrestrial and aquatic ecosystems globally . this will affect natural biota, agriculture, fisheries along with threatening human and animal health (jambeck et al., 2015) . despite recent progress made in plastic sustainability and waste management, silva et al. (2020) have noted widespread drawbacks in the use and management of plastics in the fight against covid-19 pandemic that area associated with government imposed partial and total lockdown of cities/regions/municipalities that has promoted greater use of sups, including ppe, by the general public and healthcare workers (tobías, 2020) . there has also been a shift towards mandatory use of ppe by the general public, along with frontline healthcare workers j o u r n a l p r e -p r o o f where silva et al. (2020) noted that over 50 countries are mandated to wear masks in public places. there is also a commensurate need for increased production of ppe globally. world health organisation (2020) had expressed concerns about use of masks by general public due to lack of correct handling, and disposal, and the shortage of this material in healthcare materials. silva et al. (2020) noted that surgical masks should not be worn longer than a few hours (such as 3 h) and should be appropriately discarded to avoid cross-contamination (i.e., in a sealed plastic bag). however, incorrect disposal of ppe is widespread and has been found in several public places and natural environments ngo oceans asia, 2020) . observed that masks are likely to degraded into smaller microplastic pieces as are made from nonwoven materials (e.g., spunbond and meltdown spunbond) often incorporating polypropylene and polyethylene. these authors also noted that significant enhancement in the usage of ppe and other sups is likely to result in an overload increase in waste generation that would disrupt viable options for effective waste management. many countries have classified all such hospital and household waste potentially contaminated with sars-cov2 as infectious that should be incinerated under high temperature (ensuring sterilization), followed by landfilling of residual ash (european commission, 2020; silva et al., ilyas et al., 2020) . ilyas and co-workers (2020) reviewed, and reported on the merit, of developing different disinfection technologies for handling covid-19-generated waste from separate collection to using various physical and chemical steps with view to reducing health and environmental risks. there is also a significant void in communication channels to general public about appropriate disposal of used face-masks and gloves during covid-19 that may require user behavioural change, such as exploiting health belief model through social marketing approaches (suanda et al, 2013; suanda et al., 2017) . however, silva et al. (2020) noted that not all countries are capable of managing such waste appropriately and are been forced to use direct landfills or open burning as alternative strategies. there is also commensurate concerns about the short, and more longer term, impact of burning considerable amount of plastic that may increase environmental footprint due to release of ghgs and undesirable j o u r n a l p r e -p r o o f hazardous compounds . as some items of ppe are lightweight, there is potential for them to be blown by wind to pollute natural environments including threatening terrestrial and aquatic biota, such as by entanglement. silva et al. (2020) noted that up 40,000 kg of masks may find their way inappropriately into the natural environment arising from wwf (2020) reporting of inappropriate disposal of only 1% for over 10 million masks introduced to the environment monthly. in order to allay environmental problems arising from covid-19 due to high demand on sups and ppe that produces increased medical waste, silva et al. (2020) advocated (1) in the short term, it is important to maintain the ppe supply chain in order to the ensure health and safety of our citizens and our frontline hcws. however, we now need to look at contingency planning in order to future proof against the potentiale environmental impact of increased single-use plastic (sup) ppe waste using sustainable solutions. opportunities will arise to address this challenge through seamlessly connecting research and entrepreneurial ecosystems that will generate a new pipe-line of potentially usable bioplastic products. this could be accelerated through multi-actor innovation hubs linked to healthcare, industry and academia (rowan and galanakis, 2020) . silva et al. (2020) noted that the replacement of plastic value chain from fuel-based raw materials and energy has been priorities, which features in many international agreements addressing a green and circular economy. silva et al. (2020) also noted that bio-based plastics supports are emerging, but at an early stage capturing a market share of ca. 2% due mostly to low-cost of fossil-based j o u r n a l p r e -p r o o f plastics, the intense requirement for land use and related financial investment, and undeveloped recycling and/or disposal routes. hatti-kaul et al. (2020) described screening for microbial strains for enhanced hydrolytic and biodegradation abilities for direct conversion of biomass (such as microalgae), extraction of value-added products, and synthesis (polymerisation) process. however, such potentially high-performance bio-based polymers, similar to physical properties of fossil fuel-counterparts (such as low degradability, high durability) , would need to be characterized and tested for suitability to match design specifications of future ppe including tolerance to thermal processing and potential re-use. oems of ppe, academia and regulators should play as strong role in informing the efficacy of bio-based reusable polymers for next-generation products that considers suitability from design, safety and life cycle assessment perspectives. end-of-life strategies need to be consider for waste management and recycling of ppe during covid-19 used by general public without compromising on safety, where landfill and waste-to-energy should be a last resort option . the rapid accumulation of plastic waste is driving international demand for renewable plastics with superior qualities (e.g., full biodegradability to co 2 without harmful by-products), as part of an expanding circular bioeconomy (karan et al., 2019). there has been increasing interest in the identification of alternatives to petroleum-based plastics for various industrial applications where desirable bio-based material properties would include ease of biodegradation and renewability (emadian et al., 2016; thakuv et al., 2018) . bioplastics partly or wholly made from biological materials, and not crude oil, represent an effective way of keeping the huge advantages of conventional plastics but mitigating their disadvantages (carbon commentary, 2011) . a bioplastic is a plastic that is made partly or wholly from polymers derived from biological sources such as sugar cane, potato starch or the cellulose from trees, straw and cotton (thakuv et al., 2018) . there presents an opportunity to exploit the 9 stages of technology readiness developed by nasa (straub, 2015) to evaluate the sustainability and maturity of emerging innovations for covid-19 that also addresses environmental friendliness as well as functionality. this strategy is particularly relevant as it address potentially sustainable products from conceptualisation to commercial deployment at higher technology readiness levels: this is particularly relevant given that industry would be familiar with this concept and would allow ease of transitioning for environmental impact. this evaluation of new bioplastics could include life cycle (ruiz-salmón et al., 2020) and ecotoxicological (garvey et al., 2015) assessments of different trophic levels reflecting impact on biodiversity that connects academia with industry partners and policy makers. o'neill et al. (2020) described development of freshwater aquaculture on cutaway peatlands using organic principles where vast quantities of microalgae, used as natural means of water quality waste remediation, could be used as test system for advancing bioplastic-based ppe innovation and recycling for circular economy developments. future green innovative research could be extended to new biopolymer-based wrapping and packaging (including for adjacent food industry) to investigate non-thermal treatments that encompass both complex viruses and parasites . a limiting factor in the production of alternative biomaterials for alternative to single-use ppe relates to thermal stability of materials for fabrication and potential for deformation due to thermal processes. skrzypczak et al. (2020) recently reported on a new 3d printing approach for meeting such a need where they j o u r n a l p r e -p r o o f described an affordable, self-replicating, rapid prototyper that would also make this approach more accessible to home-based 3d printing activities. also demonstrated potential for exploiting different forms of polymer processing (such as 3d printing and injection moulding) after novel vapour hydrogen peroxide and electron beam treatments that could be advance next-generation ppe and medical device technologies. in response to meeting threats of covid-19, there is substantially increased volumes of medical waste produced that also contains ppe, which presents unprecedented challenges for meeting effective waste management strategies globally with significant potential for overload of systems want et al. 2020 . have noted that the unprecedented demand has also impacted other industries reliant upon ppe including manufacturing, construction, oil and gas energy, transportation, firefighting and food production. also noted that this pandemic has substantially impacted upon how solid-waste management activities are performed as prior to covid-19 resource recycling and waste management were not regarded as essential services and were placed in lockdown. however, the strategically important disease mitigation role of waste management has been recognised given the need to properly dispose and handle sars-cov2 contaminated waste to avoid transmission (reuters, 2020; price et al., 2020) . wastes and their disposal has urged countries to treat waste management amid covid-19 as urgent and essential public service. these authors noted that ppe includes plastics as major constitutes representing ca 25% by weight, which if not recycled or their disposal may contribute substantially to hazardous environmental pollutants, such as dioxins or toxic metals. polypropylene is a common constituent of ppes, such as found in n95 masks, tyvek protective suits, gloves, and medical face shields. singh and co-workers (2020) also noted that the potential for recovery of polymers from mixed healthcare waste including ppe is challenging. this would be further influenced by the low-level of recycling worldwide and lack of government policies. noted that single-use ppe is not a sustainable that are easier to maintain are preferred in china. incineration is widely deployed as is deemed to be safe, simple and effective (ghodrat et al., 2017) where extreme high temperatures completely kill microorganisms along with converting organic matter into inorganic dust. however, hospitals vary in type of incineration approach depending upon waste preparation and flue gas purification that includes pyrolysis vaporization incinerator where organic components of waste are converted to flammable gases to avoid dust at temperatures above 850°c that reduces particle emission to air. report that these high temperatures is conducive to complete destruction of toxic and hazardous components, thereby reducing production of toxic pollutants such as dioxins due to low temperature combustion (zhu et al., 2008 wang et al., (2020) described chemical disinfection technologies for treatment of hospital waste that is typically used in combination with mechanical and crushing treatments in china. generally, crushed hospital waste are mixed with chemical disinfections such as sodium hypochlorite, calcium hypocholorite, chlorine dioxide for fixed contact times during which organic wastes are decomposed and microbial threats inactivated. chemical disinfection have desirable attributes including low effective concentrations, rapid action, stable performance and broad sterilisation efficacy for different types of microorganisms. these chemical disinfectants are generally used as are non-corrosive, safe, easily soluble in water but not easily affected by chemical or physical factors with low toxicity and reported to have no residual hazard post disinfection (chen and yang, 2016) . suggest that chemical disinfection technology could be considered when amount of waste is small. also reported on use of microwave disinfection as a means of energy saving, low action temperature, slow heat loss, light damage and low environmental pollutions with no residues or toxic wastes after disinfection, but requires strict control by special microwave devices. stated that microwave technology only used at present for treatment of biohazardous wastes, but the technology is been promoted as effective supplementation technology for incineration to enable diversification of hospital wastes in china. wang also reported that microwave technology can achieve logarithmic value for killing complex pathogens such as parasites and viruses at > 6 log along with killing j o u r n a l p r e -p r o o f of bacillus subtilis endospores at > 4 spores. also reported on high temperature steam disinfection (saturated water vapor with temperatures greater than 100 c) to kill microorganisms (zhang et al., 2016) . in china, a log kill of thermophilic lipobacillus endospores at > 5 logs is required. however, this approach has a low volume reduction rate and easily generates toxic volatile organic compounds during disinfection (teng et al., 2015) . from perspective of investment and operation costs, as well as economic and social benefit, high temperature incineration is still most popular approach to hospital waste disinfection in china. thus, there are pressing needs to define effective decontamination strategies for medical waste through appropriate management strategies will also contribute to global collective effort in reducing sars-covid-19 transmission along with future safeguarding our environment. there is extraordinary pressure to meet shortages in single-use ppe supply for our frontline clinicians and healthcare workers. ppe treatment is challenging as the constituent material, including single-use plastics (sups), are sensitive to harsh decontamination processes. there has been an unprecedented surge in the production of commercial and homemade cloth and fabric face coverings to offset this challenge and to help with preventing person-to-person transmission in the community setting. many countries across the globe are extending, decontaminating and reusing ppe where there is critical shortage for frontline healthcare workers (hcws), but under emergency use only. this unprecedented need will continue given the absence of a vaccine and occurrence of successive waves of sars-cov-2 globally; and, the likely high demand for ppe by the medical and nursing profession beyond covid-19. fischer, e.p., fischer, m.c., grass, d., henrion, i., warren, s. w., westman, e. (2020) . low cost measurement of facemask efficiency for following expelled droplets during speed . zhao et al. [n95s] liao et al. sickbert-be nnett et al. perencev ich et al. rubio-ro mero et al (2020) dangaville et al. (2020) [shortage] saini et al. [overalls] barceló (2 020) virkram et al. derraik et al. fisher and shaffer (2011 ) ma et al. o'hearn et al. grinivas an and peh (2020) lowe et al. mullerji et al. (2020) ahmed et al. european commissi on (2020 schwart z et al (2020) inagalei et al (2020) [duv-leds] toon (2020) [ozone] macintyre et al. boṧkoski et al. (2020) matin-rodri guez et al (2020) [pain] [n95s] (2010) (2020) fda (2020c) laffey (2020) rubio-ro mero et al. mackenzi e (2020) [househol macintyre et al (2015) toon (2020) [gowns] clark (2020) jatta et al (2020) liao et al (2020) batejat et al ( fda (2020 park (2020) ou et al. laffey (2020) [surgical toon (2020) [ozone] ou et al. ou et al. barceló ( ozog et a. daeschler (2020) perkins et al. heilingloh et al., (2020) pastorino et al. genus, species and strain of microorganism *provide appropriate culture collection reference number and/or include type strain for test microorganism(s) in studies *include bacillus atrophaeus and/or geobacillus stearothermophilus endospore along with test organisms *confirmation of identify of test microorganisms by biochemical, physiological, morphological, immunological and/or molecular means (provide name of supplier for rapid test kits) *method of storing cultures (cryoprotectant) and frequency of sub-culturing (using fresh microbial slope every month kept at 4°c where bacterial indicators used) initial inoculum * description of procedures for microbial cultivation including name of supplier company for media (to include in vitro analysis) * growth medium composition, growth temperature, ph, incubation time, and growth phase (exponential or stationary) * growth achieved under static or orbital cultivation (rpm) * confirm purity by identifying 3 randomly selected isolates recovery conditions and enumeration methods for test strains * composition of media used for recovery to include basal media or physiological saline as diluent * time and storage conditions between treatment and microbiological analysis * description of procedure for enumerating viral test strains post treatments, such as use of in vitro tissue culture procedures uv treatment medium properties and conditions for commercial: description of power unit used for generating pulses to include equipment name of the supplier company and model for prototype: adequate description of components including treatment chamber, electrical configurations and specifications auxiliary devices * temperature probe * thermophile power detector and software for total broad-spectrum dose received by sample * transmissivity sensor to monitor %uv transmittance ensure microbial population density is ≤ 5-log orders to mitigate against influence of protective shading effects include description of media composition, ph, aw j o u r n a l p r e -p r o o f composition of menstruum used as diluent for treated samples sufficient number of treatment trials and replications to provide statistical confidence of findings at 95% level; description of statistic test and version of software package (such as minitab or spss) description of method used to generate bacterial endospores (natural aged for 7 days or incorporation of manganese sulphate to expedite conversion of vegetative cells to spores on agar surfaces) include native microflora along with artificially seeded test microorganisms due to variability in resistance profile to pl consider occurrence of cavities in plant surface microstructures that may protect microorganisms from incident light due to shading as part of eua, the fda (2020) reviews the totality of scientific evidence for ppe reprocessing including specialist testing *testing submitted within previous applications supporting device clearance for other uses that considers different types of polymer materials, such as materials consistent with those found in compatible n95 respirators. *performance data such as sporicidal test, residual analysis, bioburden reduction validation demonstrating > 3 log reduction of a non-enveloped virus challenge; testing regarding material compatibility, functionality and filtration performance of compatible n95 respirators after multiple decontamination cycles *testing regarding residuals after decontamination of compatible n95 respirators. *typically, reprocessed ppe are discarded after 10 treatments as per respective factsheet for facilities and personnel furnished to fda j o u r n a l p r e -p r o o f j o u r n a l p r e -p r o o f barriers to reuse of ppe by healthcare workers include lack of knowledge to inform acceptance and discomfort over prolonged usage with potential for social marketing studies to inform trust and associated decision making rimmer (2020); mitchell (2020) evaluation of fitted filtration efficiency (ffe) showed that surgical masks with ties (71.5±5.5%) and procedural mask with ear loops (38.1±11.4%) exhibit lower ffe post vh2o2 treatment is lower than n95 respirators (98.5±0.4%). this suggests potential benefits of using head ties instead of ear loops for homemade face coverings and would help prevent slippage below nose during wearing. sickbert-bennett et al., 2020 disinfection performance studies for evaluating ppe reuse over single or several cycles use surrogate viruses or bacterial endospore indicators (bioburden typically at or below 10 6 ), where most sars-cov-2 strain(s)are studied using in vitro tissue culture infection models. most researcher won't have access to level 3 containment facilities rowan and laffey, (2020) ; derraik et al., evaluation of facemask and variety of commonly available non-certified face coverings for filtering expelled droplets during speech, sneezing and coughing revealed that variability from below 0.1% (fitted n95 mask) to 110% (fleece mask). sequence of decreasing efficacy n95 respiratory, combining cotton-polypropylene-cotton mask; combining layer cotton in pleated style mask; combining 2 layer cotton with pleated style mask; use of single layer cotton masks; knitted masks; double layer bandana; and fleece. fischer et al., 2020 improvised face masks and face coverings should be used as a last solution and for low risk situation as increased duration of wearing may increase risks of virus infiltration due to humidity, liquid diffusion and virus retention european centre for disease prevention and control (2020) use of common washing machine (ca 60°c for 30 min) combined with use of spin dryer appear effective for face cloth decontamination and reuse zhao et al. (2020) ; rubio-romero et al. (2020) ; hse, (2020) sars-cov2 is sensitive to commonly-used disinfectants on surface. however, lower environmental temperatures promote longer survival on surfaces, which may influence efficacy of mask derraik et al., (2020) j o u r n a l p r e -p r o o f bio-based building blocks and polymers in the world: capabilities, production, and applications -status quo and trends towards 2020 organ donation during the covid-19 pandemic assessment of inactivation procedures for sars-cov-2 an environmental and health perspective for covid-19outbreak: meteorology and air quality influence, sewage epidemiology indicator, hospitals disinfection, drug therapies and recommendations final report for the bioquell hydrogen peroxide vapor (hpv) decontamination for reuse of n95 respirators a surface coating that rapidly inactivates sars-cov-2 heat inactivation of the severe acute respiratory syndrome coronavirus 2 hydrogen peroxide vapour decontamination of surfaces artificially contaminated with norovirus surrogate feline calcivurus evaluation of multiple (3-cycle) decontamination processing for filtering facepiece respirators impact of three cycles of decontamination treatments on filtering facepiece respirator fit development of an advanced respirator fit-test headform increasing temperature and relative humidity accelerates inactivation of sars-cov-2 on surfaces efficacy of an automated multiple whole room ultraviolet c disinfection system against coronavirus mhv and mers-cov covid-19 pandemic and personal protective equipment shortage: protective efficacy comparing masks and scientific methods for respirator reuse bioplastics -an important component for global sustainability coronavirus disease (covid-19): guidance for k-12 school administrators on the use of cloth face coverings in schools factors affecting stability and infectivity of sars-cov-2 current status of medical wastes disinfection and disposal technologies 3d printed polymers are less stable than injected moulded stability of sars-cov-2 in different environmental conditions face masks, gloves and a new breed of plastic pollution ait and nuig explore ppe decontamination amid global shortage for covid19 global supply chain effects of covd-19 control measures personal protective equipment during the coronavirus disease (covid) 2019 pandemic -a narrative review effect of moist heat reprocessing on n95 respirators on sars-cov-2 inactivation and respirator function opinion to address the personal and protective equipment shortage in global community during covid-10 outbreak inactivation of the coronavirus that induces severe acute respiratory syndrome, sars-cov the international imperative to rapidly and inexpensively monitor community-wide covid-19 infection status and trends sterilization of disposable face masks by means of standardized dry and steam sterilization processes; an alternative in the fight against mask shortages due to covid-19 ecotoxicological assessment of pulsed ultraviolet light-treated water containing microbial species and cryptosporidium parvum using a microbiotest battery inactivation of parasite transmission stages -efficacy of treatments on foods of non-animal origin inactivation of parasite transmission stages -efficacy of treatments on foods of non-animal origin life cycle assessments of incineration treatment for sharp medical waste medtronic increasing ventilator production to address covid-19 pandemic trends and applications of resilience analytics in supply chain modeling: systematic literature review in the context of the covid-19 pandemic. environment systems and decisions the species severa acute respiratory shyndrom-related conronavirus: calssifying 2019-ncov and naming it sars-cov-2 institution of a novel process for n95 respiratory disinfection with vaporized hydrogen peroxide in the setting of the covid-19 pandemic at a large academic medical center disinfection and toxicological assessment of pulsed uv and pulsed-plasma gas-discharge treated water containing the waterborne protozoan enteroparasite cryptosporidium parvum ventilators use in the treatment of covid-19 -information collated by the hpra which type of personal protective equipment (ppe) and which method of donning or doffing ppe carries the least risk of infection for healthcare workers? evidence based dentistry susceptibility of sars-cov-2 to uv irradiation a pandemic influenza preparedness study: use of energetic methods to decontaminate filtering facepiece respirators contaminated with h1n1 aerosols and droplets selection of parameters for thermal coronavirus inactivation -a data-based recommendation microplastic pollution in a rapidly changing world: implications for remote and vulnerable marine ecosystems survival of enveloped and non-enveloped viruses on surfaces compared with other micro-organisms and impacts of suboptimal disinfection exposure survival of severe acute respiratory syndrome coronavirus survival study of sars virus in vitro clinical and transmission characteristics of covid-19 -a retrospective study of 25 cases from a single thoracic surgery department can n95 respirators be reused after disinfection? how many times? status of management of medical waste in 125 medical institutions personal protective equipment (ppe) for both anesthesiologists and other airway managers: principles and practice during the covid-19 pandemic decontamination of face masks with steam for mask reuse in fighting the pandemic covid-19: experimental supports face coverings, medical masks and disposable gloves reuse of n95 masks. engineering impact of covid-19 outbreak on clinical practice and training of young gastroenterologists: a european survey blood biomarkers for assessing headaches in healthcare workers after wearing biological personal protective equipment in a covid-19 field hospital decontamination of n95 masks against coronavirus: a scoping review terminal sterilization of medical devices using vaporized hydrogen peroxide: a review of current methods and emerging opportunities novel coronavirus 2019-ncov: prevalence, biological and clinical characteristics comparison with sars-cov and mers-cov processing of biomedical waste in plasma gasifier ultraviolet germicidal irradiation of influenza-contaminated n95 filtering facepiece respirators impact of the 2009 influenza a (h1n1) pandemic on canadian health care workers: a survey on vaccination, illness, absenteeism, and personal protective equipment cost-effectiveness analysis of n95 respirators and medical masks to protect healthcare workers in china from respiratory infections β-glucan extracts from the same edible shiitake mushroom lentinus edodes produce differential in-vitro immunomodulatory and pulmonary cytoprotective effects -implications for coronavirus disease no shortage of surgical masks at the beach coronavirus (covid-19) highlights. retrieved on improper solid waste management increases potential for covid-19 spread in developing countries. resources, conservation and recycling novel use of peatlands as future locations for the sustainable intensification of freshwater aquaculture production -a case study from the republic of ireland evaluation of decontamination methods for commercial and alternative respirator and mask materials -view from filtration aspect the importance of fit testing in decontamination of n95 respirators: a cautionary note evaluation of sars-coronavirus decontamination procedures personal protective equipment or healthcare workers during the covid-19 moving personal protective equipment into the community: face shields and containment of covid-19 covid-19 global pandemic planning: decontamination and reuse processes for n95 respirators survival of viruses in water covid-19 pandemic repercussions for the use and management of plastics pandemic repercussions on the use and management of plastics critical supply shortage -the need for ventilators and personal and protective equipment during the covid-19 pandemic simulated sunlight rapidly inactivates sars-cov-2 on surfaces discarded coronavirus masks clutter hong kong's beaches and trails management of used personal and protective equipment related to covid-19 in south korea pulsed light as an emerging technology to cause disruption for food and adjacent industries -quo vadis? disposable masks: disinfection and sterilization for reuse, and non-certified manufacturing, in the face of shortages during the covid-19 pandemic addressing challenges and opportunities of the european seafood sector under a circular economy framework decontamination and reuse of n95 respirators with hydrogen peroxide vapor to address worldwide personal protective equipment shortages during the sarscov-2 covid-19 rapid response call -phase 2 evaluating the efficacy of cloth facemasks in reducing particulate matter exposure filtration efficiency of hospital face mask alternatives available for use during the covid-19 pandemic rethinking and optimising plastic waste management under covid-19 pandemic: policy solutions based on redesign and reduction of single-use plastics and personal protective equipment environmentally sustainable management of used personal and protective equipment environmentally sustainable management of used personal and protective equipment open source high-temperature reprap for 3-d printing heat-sterilizable ppe and other applications n95 filtering facepiece respirators during the covid-19 pandemic: basics, types, and shortage solutions. malaysian efficacy and safety of decontamination for n95 respirator reuse -a systematic literature search and narrative synthesis in search of technology readiness level (trl) 10. aerospace science and technology identification of behavioural change strategies to prevent cervical cancer among malay women in malaysia social marketing -rebels with a cause a review of the perceived barriers within the health belief model on pap smear screening as a cervical cancer prevention measure effect of an e-learning module on personal protective equipment proficiency among prehospital personnel: web-based randomized controlled trial teaching adequate prehospital use of personal protective equipment during the covid-19 pandemic: development of a gamified e-learning module sustainability of bioplastics -opportunities and challenges. current opinion in green, sustainable chemistry new biotechnological routes for greener bioplastics from seaweed evaluating the national personal and protective equipment guidance for nhs healthcare workers during the covid-19 pandemic monitoring, sources, receptors, and control measures for three european union watch list substances of emerging concern in receiving waters -a 20 year systematic review evaluation of the lockdown for the sar-cov2 epidemic in italy and spain after follow up ozone disinfection could safely allow reuse of personal protective equipment inactivation of viruses on surfaces by ultraviolet germicidal irradiation disinfection of healthcare equipment -guideline for disinfection and sterilization in healthcare facilities face coverings for covid-19: from medical intervention to social practice development of a highly effective low-cost vaporized hydrogen peroxide-based method for disinfection of personal protective equipment for their selective reuse during pandemics impact of three biological decontamination methods on filtering facepiece respirator fit, odor, comfort, and donning ease evaluation of five decontamination methods for filtering facepiece respirators evaluation of the filtration performance of 21 n95 filtering face piece respirators after prolonged storage effect of decontamination on the filtration efficiency of two filtering facepiece respirator models effect of decontamination on the filtration efficiency of two filtering facepiece respirator models disinfection technology of hospital waste and wastewater suggestions for disinfection strategy during coronavirus disease-2019 (covid-19) pandemic in china transmission of sars-cov2: implications for infection control prevention shortage of personal protective equipment endangering world bank director general's opening remarks at the media briefing on covid-19 nello smalltimento di macherine e guanti serve responsabilità world wide fund for nature shelter hospital mode: how to prevent novel corona virus infection 2019(covid-19) hospital-acquired infection? strategies to reduce the global carbon footprint of plastics study on pyrolysis of typical medical waste materials by using tg-ftir analysis decontamination interventions for the reuse of surgical mask personal protective equipment: a systematic review ppe is designed for single-use for medical/nursing staff, but supply chain has been insufficient to meet global needs with many countries adopting reuse practices post deployment of technologies to meet emergency covid-19 use rowan and laffey (2020) ; derraik et al., (2020) there are limited technologies suitable for ppe reuse that reflects matched efficacy for reprocessing rubio-romero et al. (2020) differences in priority usage and decontamination technologies between higher risk medical environment (ppe) and lower risk community settings (face coverings) that have informed selection of technologies and approaches used derraik et al. (2020) evidence that ppe can be effectively reprocessed using technologies not readily available to public such as vh2o2, o3, low pressure uvc such as uvgi (2000 mj/cm 2 ) where variance in determining efficacy of uv dose between uv modalities influencing harmonious acceptance). generally, is greater disinfection using uva over uvb and uva.derraik et al., (2020) ; rowan, 2019; rubio-romero et al. (2020) high throughput vh2o2 can effectively disinfect, for example ,2,500 n95 respirators per 12 h shift at 3000-750 ppm hydrogen peroxide rubio-romero et al., (2020) mackenzie, (2020); perkins (2020) recommendation for wearing of face masks and coverings to prevent spread of covid-19 cdc (2020); ministry of health spain (2020); choice of technologies for reprocessing of ppe healthcare depends on the type and complexity of ppe (functionality, fit test, deformation, filtration efficacy) that are typically single use and thermally-sensitive with increasing challenges in the order face shields, gowns, ffrs (including disposable n95 respirators,) derraik et al., (2020) ; rubio-romero et al. (2020) evidence of extended use of n95 respirators such as 4 h (france, new zealand and sweden) to 40 h (mexico) kobayashi et al. (2020) physical irradiation technologies (gamma) and ethylene oxide (eo) are not appropriate for ppe reuse due to non-compatability with material composition or concerns over lingering residual toxic end-points produced during eo rowan and laffey (2020) j o u r n a l p r e -p r o o f wearing such as over winter flu season face shields are inferior to use of face masks where the latter is particularly relevant for combined use in healthcare settings to prevent infection through the eyes. rowan and laffey, (2020) an increasing trend towards development of smart coatings on materials for inactivation of sars-cov-2 and against other future potential pandemic viruses, along with provision for incorporation in ppe, mobile phones and so forth behzadinasab et al. 2020 .over 50 countries are now recommending facemasks by public that presents a new form single-use plastic waste silva et al., 2020 influence of soiling on critical ppeup to 14 days survival and retention of sars-cov-2 on surgical gowns. kasloff et al., 2020. there are opportunities for innovation in new bioplastic-based ppe and waste management as there is likely to be a high demand for ppe post covid-19 ilyas et al., 2020 there is an increase trend towards modelling recovery scenarios to investigate the potential impact of lockdown duration that is implemented to protect frontline hcws against covid-19 that may include provision for ppe costings against the cost associated with medical staff absenteeism or illness due to inadequate ppe. guan et al. (2020) ; thomas et al. (2020) ; ivanov et al. (2020) ; mukerji et al. 2017) use of artificial intelligence and deep learning could help identify high-risk patients and suggest appropriate types and use of ppe boṧkoski et al., (2020) j o u r n a l p r e -p r o o f the authors declare that they have no competing or conflict of interests.j o u r n a l p r e -p r o o f key: cord-277350-zwu254n6 authors: bianco, f.; incollingo, p.; grossi, u.; gallo, g. title: preventing transmission among operating room staff during covid-19 pandemic: the role of the aerosol box and other personal protective equipment date: 2020-05-24 journal: updates surg doi: 10.1007/s13304-020-00818-2 sha: doc_id: 277350 cord_uid: zwu254n6 the covid-19 pandemic is highly challenging for the operating room staff and healthcare workers in emergency departments. sars-cov-2 is a positive-sense single-stranded rna beta-coronavirus that primarily targets the human respiratory system, with fever, cough, myalgia, and pneumonia as the most common manifestations. however, since sars-cov-2 rna was detected in stool specimens much more attention has been paid to gastrointestinal symptoms such as loss of appetite, nausea, and diarrhea. furthermore, the expression of ace-2 receptors in absorptive enterocytes from ileum and colon suggests that these organs should also be considered as a potential high risk for sars-cov-2 infection. during aerosol-generating medical procedures (agmp; e.g. intubating and extubating patients or any surgical procedures), the production of both airborne particles and droplets may increase the risk of infection. in this situation, the surgical staff is strongly recommended to wear personal protective equipment (ppe). a transparent plastic cube, the so-called “aerosol box” (ab), has been recently designed to lend further protection against droplets and aerosol exposure during the agmp. the covid-19 pandemic is highly challenging for the operating room staff and healthcare workers in the emergency departments [1, 2] . secondary transmission occurs primarily via inhalation of droplets or airborne particle transmission and is common in the hospital setting [3] . during aerosol-generating medical procedures (agmp), the production of both airborne particles and droplets may increase the risk of infection. the world health organization (who) and the centers for disease control and prevention (cdc) defined a list of agmp, during which the use of personal protective equipment (ppe) should be recommended for all involved theater staff [4, 5] . ppe consists of head covering, eye protection, n95 mask, gloves, and long-sleeved gowns [6] . the main determinant of the risk of contagion is the total viral load in the secretions to whom the healthcare workers are exposed. for this reason, it is strongly recommended to limit as much as possible the period of close-proximity to the patients. with this regard, the "aerosol box" (ab) has been claimed as a valuable protective resource during open suctioning of airways and endotracheal intubation or extubation [7] . this system, originally designed by a taiwanese doctor on a simple cuboid with two access ports for arms [7] , appears as a low cost, space-efficient and easy to set up a solution to restrict the area of contact against expelled aerosol particles [7, 8] . ab consists of a disposable polycarbonate sheet box, which can be re-used after careful decontamination with an appropriate cleansing agent. in this study, we focus on the role of ppe and ab in preventing transmission among operating room staff. we report a retrospective case series of six covid-19 positive male patients undergoing emergent surgical treatment for gastrointestinal complications. clinical, operative, and postoperative details are described in table 1 . prior to surgery, the diagnosis of covid-19 was confirmed by reverse transcription-polymerase chain reaction (rt-pcr) testing and chest computed tomography. all intubations were undertaken under video-laryngoscope guidance through a 60 cm × 60 cm × 40 cm polycarbonate sheet ab (figs. 1, 2) with 4 circular (2 lateral and 2 posterior) ports. all laparoscopic procedures were performed in a negative pressure room by minimizing the use of electrocautery, reducing the trocars-size, and using the appropriate devices to filter released co2 for aerosolized particles [9] . postoperative admission to the intensive care unit (icu) for mechanical ventilation was planned for all patients. the novel coronavirus disease affects predominantly the upper airways, but gastrointestinal symptoms (gis) occur in up to one-third of patients. a recent meta-analysis including 60 studies and 4243 patients from six countries reported a prevalence of gis of 17.6% [10] . interestingly, almost half of the patients' stool sample tested positive for novel coronavirus rna. the high rate of small bowel involvement in our series is probably due to the expression of angiotensin-converting [11] . furthermore, ischemic complications are related to both the hypercoagulability state and the endothelial injury caused by covid-19. the mortality rate was consistent with that reported by kaafarani et al. [12] and maybe credited to the delayed surgical treatment resulting from the patient's fear and health system overload [13] . intubation is a high-risk aerosolizing procedure [4, 5] . a recent report emphasizes the looming threat of covid-19 infection to complicate the course of patients undergoing surgery [14] . at the same time, the risk of surgical team members' cross-infecting patients and other staff is high [6] . respiratory protection is mandatory during the covid-19 pandemic even if the evidence on ppe effectiveness is still low. in fact, two randomized controlled trials showed no differences in terms of infection rate among surgical masks and n95 [15, 16] . a recently developed global guidance for surgical care advises on the use of local protocols for ppe in the operating theatre, including scrubbing, donning, and doffing techniques [6] . it still remains uncertain whether covid-19 can be found in abdominal fluids or aerosols created during gas insufflation. decision making and agreed procedural steps for gaining access into the abdominal cavity strictly depend on such understanding. the risk of transmission of covid-19 during laparoscopy remains theoretical but cannot be ruled out, given oral, nasal, and ocular exposure. for this reason, it is good practice to check all instruments and the proper functioning of the suction system before starting the procedure; to use balloon trocars and create suitable holes for leak-free trocars insertion; to avoid leaks of smoke obstructing the surgical field, which should be removed via the vacuum suction device; and to fully deflate pneumoperitoneum before making a service incision, and at the end of the procedure prior to trocar extraction [9] . exposure to aerosol droplets represents a further potential source of infection when inserting or removing an endotracheal tube in the theatre. nevertheless, the aerosol box has raised some criticism concerning its innate features, namely that one box size does not fit all and the inability to warrant accurate manipulation of a gum elastic bougie or any other device used in securing an airway [17] . high-quality evidence supporting any aspect of ppe is lacking [18] . innovation should be encouraged, but caution should be applied. considering the high risk of disease transmission during agmp, we support the use of both ppe and ab to protect surgical staff during the current covid-19 outbreak. author contributions fb, pi, ug & gg contributed equally to this work: substantial contributions to the conception and design of the work; acquisition, analysis, and interpretation of data for the work. drafting the work and revising it critically for important intellectual content. final approval of the version to be published. agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy and integrity of any part of the work are appropriately investigated and resolved. conflict of interest all authors declare no personal conflict of interest. ethical approval this study was approved by our local ethics committee and written informed consent was obtained from all patients. all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/ or national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. this article does not contain any studies with animals performed by any of the authors. informed consent informed consent was obtained from all individual participants included in the study. the impact of covid-19 pandemic on surgical residency programmes in italy: a nationwide survey on behalf of the italian polyspecialistic society of young surgeons (spigc) what happened to surgical emergencies in the era of covid-19 outbreak? considerations of surgeons working in an italian covid-19 red zone characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention cal-manag ement -of-sever e-acute -respi rator y-infec tion-when-novel -coron aviru s-(ncov)-infec tion-is-suspe cted global guidance for surgical care during the covid-19 pandemic barrier enclosure during endotracheal intubation acute intestinal ischaemia in a patient with covid-19. tech coloproctol italian society of colorectal surgery recommendations for good clinical practice in colorectal surgery during the novel coronavirus pandemic gastrointestinal manifestations of sars-cov-2 infection and virus load in fecal samples from the hong kong cohort and systematic review and meta-analysis ace2-from the renin-angiotensin system to gut microbiota and malnutrition gastrointestinal complications in critically ill patients with covid-19 delayed benign surgery during the covid-19 pandemic: the other side of the coin covid-19 outbreak and surgical practice: unexpected fatality in perioperative period n95 respirators vs medical masks for preventing influenza among health care personnel: a randomized clinical trial surgical mask vs n95 respirator for preventing influenza among health care workers: a randomized trial intubation boxes for managing the airway in patients with covid-19 anaesthesia personal protective equipment during the coronavirus disease (covid) 2019 pandemic-a narrative review key: cord-017569-fv88n70v authors: hewlett, angela; vasa, angela m.; cieslak, theodore j.; lowe, john j.; schwedhelm, shelly title: viral hemorrhagic fever preparedness date: 2017-09-10 journal: infection prevention doi: 10.1007/978-3-319-60980-5_21 sha: doc_id: 17569 cord_uid: fv88n70v the 2014–2016 outbreak of ebola virus disease (evd) in west africa marked the 25th such occurrence but was noteworthy in its massive scope, causing more human morbidity and mortality than the previous 24 recorded outbreaks combined. as of april 2016, there were 28,652 cases resulting in at least 11,325 deaths, nearly all in the three nations of guinea, liberia, and sierra leone (centers for disease control and prevention. http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/index.html. accessed 2 june 2016). moreover, the 2014–2016 outbreak was the first in which patients, albeit few in number, were afforded sophisticated intensive care in the united states and in europe. this “high-level containment care” (hlcc) was provided in specially designed purpose-built biocontainment units (bcus). in this chapter, we explore the history and evolution of biocontainment, discuss its unique engineering and infection control modalities, and offer recommendations for the clinical and operational management of ebola and other viral hemorrhagic fevers (vhfs). the 2014-2016 outbreak of ebola virus disease (evd) in west africa marked the 25th such occurrence but was noteworthy in its massive scope, causing more human morbidity and mortality than the previous 24 recorded outbreaks combined. as of april 2016, there were 28,652 cases resulting in at least 11,325 deaths, nearly all in the three nations of guinea, liberia, and sierra leone [1] . moreover, the 2014-2016 outbreak was the first in which patients, albeit few in number, were afforded sophisticated intensive care in the united states and in europe. this "high-level containment care" (hlcc) was provided in specially designed purpose-built biocontainment units (bcus). in this chapter, we explore the history and evolution of biocontainment, discuss its unique engineering and infection control modalities, and offer recommendations for the clinical and operational management of ebola and other viral hemorrhagic fevers (vhfs). the modern concept of biocontainment had its birth in 1969 with the convergence of four separate events. in may of that year, michael crichton published the andromeda strain, and, while the work was clearly fictional, it debuted amidst a series of discussions leading up to president nixon's decision in november of that year to abandon the us offensive biological weapons program. nixon's decision was a prelude to ratification of the 1972 biological weapons convention and to the us ratification, in 1975, of the geneva protocols. at the time, nixon stated that "the united states has decided to destroy its entire stockpile of biological agents and confine its future biological research program to defensive measures." implicit in that decision was a shift in the focus of us efforts to defensive and medical countermeasure development that would include an emphasis on the management of patients potentially infected with highly hazardous human pathogens. this medical defense program would fall largely upon the newly created us army medical research institute of infectious diseases (usamriid), an entity which would inherit its defensive mission from the old army biological laboratory (abl). the year 1969 also witnessed the discovery of lassa virus by dr. jordi casals-ariet at yale university [2] . while attempting to characterize the new virus, dr. casals contracted lassa fever himself and fell critically ill but survived following the administration of convalescent serum from one of his patients. unfortunately, one of his technicians, juan roman, succumbed to the disease while conducting laboratory studies, causing dr. casals to move his research to a new maximum-security laboratory at the communicable disease center in atlanta (now the centers for disease control and prevention) and ushering in a new era of laboratory safety. finally, 1969 saw man's first journey to the moon, aboard apollo 11. in order to guard against the remote possibility that extraterrestrial pathogens might inadvertently accompany the returning astronauts, a new facility, the lunar receiving laboratory (lrl), was constructed, in consultation with abl experts, at the johnson manned spaceflight center in houston. the facility would receive spacecraft, equipment, and lunar samples from apollo 11 and from future apollo missions. moreover, it would serve as a quarantine facility for the returning astronauts from the apollo 11, 12, and 14 missions. included among the assets of the usamriid facility was a novel two-bed high-level containment care unit [3] . this unit, often referred to as "the slammer," presumably owing to the sound produced by the closure of its heavy steel airlock doors, opened in 1971 and included engineering controls analogous to those employed in biosafety level 4 (bsl-4) laboratories. the facility was designed to treat infected patients but also to provide confidence and a sense of security to scientists and to the community of frederick, maryland, in which it was located. during the period 1972-1985, 20 individuals were admitted to the slammer following laboratory or field exposure to a variety of bsl-4 pathogens [4] . a 21st patient (exposed to ebola in the laboratory) was admitted in 2004 [5] . of note, none of the 21 patients developed clinical evidence of infection. the slammer was decommissioned in 2012; a new usamriid building, slated to open in 2017, will not house a containment care unit. the intentional dissemination of anthrax via contaminated mail in october 2001, occurring just weeks after the world trade center assault and, ironically, attributed to a troubled usamriid scientist, convinced some civilian experts to move in the opposite direction and propose the creation of academic medical center-based hlcc facilities. outbreaks of severe acute respiratory syndrome (sars) and monkeypox in the spring of 2003 added impetus to these construction projects, sars because of its high mortality and apparent transmission via droplet nuclei and monkeypox owing to a resistance among fearful healthcare providers to treat victims of the disease [6] . during 2004-2005, a two-bed facility at emory university in atlanta and a ten-bed facility at the university of nebraska medical center in omaha opened; the facilities employed some (but not all) of the engineering controls contained within the usamriid facility. in 2005, leaders from these facilities, as well as usamriid and the centers for disease control and prevention (cdc), published consensus guidelines for the employment of hlcc units [7] . in that same year, the national institute of allergy and infectious diseases (niaid) contracted with saint patrick hospital in missoula mt to construct the first hlcc unit housed outside of a large university-based medical center in order to care for scientists exposed to bsl-3 and bsl-4 pathogens at the niaid's rocky mountain laboratories in nearby hamilton [8] . as of this writing, no patients have been cared for in this facility. in 2010, the special clinical studies unit at the national institutes of health adapted its seven-bed clinical research unit in order to provide hlcc. this facility, along with those at emory and nebraska, cared for 9 of the 11 victims of the 2014-2016 west african ebola outbreak managed in the united states. one patient was managed under hlcc conditions at bellevue hospital in new york, and one patient was managed at dallas presbyterian hospital. germany possesses seven hlcc facilities, four of which cared for evd victims during the 2014-2016 west african outbreak. some of these units have experience in treating patients infected with marburg and lassa viruses as well. biocontainment units in britain, france, spain, the netherlands, norway, switzerland, and italy also successfully cared for expatriate patients during the recent evd outbreak, and european nations have been pioneers in the development of hlcc doctrine [9, 10] . finally, china, at the height of the sars outbreak in 2003, constructed a 1000bed infectious disease treatment facility equipped with engineering controls designed to ameliorate the risk of airborne transmission of the sars coronavirus [11] . other nations in the region, such as singapore and south korea, are constructing hlcc facilities as well. the viral hemorrhagic fevers (vhfs) are caused by a heterogeneous group of viruses belonging to four taxonomic families and include: -the filoviruses, ebola, and marburg -the arenaviruses, which can be divided into old world (lassa) and new world (guanarito, junin, machupo, sabia) agents, the latter causing venezuelan, argentinian, bolivian, and brazilian hemorrhagic fevers, respectively -the flaviruses, yellow fever, dengue, kyasanur forest, and omsk -the bunyaviruses, crimean-congo hemorrhagic fever (cchf), rift valley fever (rvf), and a number of hantaviruses which cause hemorrhagic fever with renal syndrome (hfrs; hantaan, dobrova, seoul, and puumala) yellow fever has been known since at least 1647; is distributed throughout tropical africa, asia, and south america; and was the first disease shown, by walter reed, to be transmitted by mosquitos [12] . the remaining vhfs have, for the most part, been discovered within the last half-century and remain quite limited in their geographic distributions. although the vhf viruses share certain microbiologic characteristics (all are lipid-enveloped single-stranded rna viruses) and derive their name from the fact that some (but not all) patients experience clinically significant hemorrhage, they produce a diverse array of clinical symptoms and vary widely in their virulence. while massive hemorrhage occurs frequently with new world arenaviral infections, as well as rvf, cchf, certain hantaviruses, and yellow fever, it occurs less frequently with infections due to the filoviruses and rarely in lassa infections. renal failure is characteristic of hfrs and yellow fever but otherwise rare. rash is seen with dengue, lassa, and filovirus infections, but not with most other vhfs. icterus is prominent with yellow fever; tremors with the new world arenaviruses; deafness with lassa. pulmonary disease is prominent with kyasanur forest and omsk, as well as with certain hantaviruses. in addition, laboratory findings vary considerably among the vhfs. new world arenaviral infections characteristically cause a profound leukopenia, while hfrs patients often exhibit significant leukocytosis. thrombocytopenia can be marked in most vhfs but is usually not a prominent feature of lassa fever. these notable differences in presentation and symptomatology have implications for clinical care and infection control. the prodigious amount of vomiting and diarrhea seen in patients during the 2014-2016 evd outbreak, coupled with the very low infectious dose and high quantity of viral particles within these bodily fluids, makes meticulous attention to personal protection imperative. guidelines for the employment of such protection, as well as engineering and other controls, provide the basis for the remainder of this chapter. it is important to note that the causative agents of most vhfs need be handled under biosafety level 4 (bsl-4) conditions in the laboratory [13] . exceptions include yellow fever, rvf, and the hantaviruses, which require bsl-3 precautions. patients harboring any of these agents that present the risk of person-to-person transmission ideally should be managed under hlcc conditions. these agents would include the hantaviruses, as well all of the bsl-4 agents except rvf, kyasanur forest, and omsk viruses, which are transmitted to humans only via the bite of infected arthropods. high-level containment care facilities include enhanced engineering controls with the goal of providing safe and effective care to patients while optimizing infection prevention and control procedures [9] . two [7, 10] . however, formal standards for hlcc facility design features have not been established. the design of a hlcc unit should serve to minimize nosocomial transmission of infectious diseases by establishing a contained clinical isolation unit capable of housing all facets of patient care. hallmark hlcc engineering controls include care units that are physically separated from normal patient care spaces and maintained at negative pressure by independent air handling systems. at least 12 air exchanges per hour in patient rooms are accomplished using dedicated exhaust systems with high efficiency particulate air (hepa)-filtered effluent air. it is recommended that pressure status of patient care rooms be monitored with audible and visual alarms [14, 15] . individual patient care rooms should have the equipment necessary to support critically ill patients, self-closing doors, and handwashing sinks [7] . it is important to have established zones for employee donning and doffing, storage of personal protective equipment (ppe), and staff shower-out capability [7] . additionally, selection of nonporous and seamless construction materials is an ideal design component of hlccs that both minimizes the risk of environmental contamination and maximizes the ability to clean surfaces when contaminated. hlcc units should delineate high-risk areas ("hot" or "red" zones: patient room, laboratory), intermediate-risk areas ("warm" or "yellow" zones: anteroom, decontamination area, waste processing, doffing), and low-risk areas ("cold" or "green" zones: nurse station, clean supply room, staff egress changing area). establishment of these designated zones guides healthcare worker flow as well as implementation of protocols for cleaning, packaging of waste or clinical specimens, and decontamination of medical devices, reducing the potential for contamination as personnel and devices move through the hlcc. inclusion of laboratory and waste sterilization capabilities within hlcc units are also key features that help minimize the potential of transmission throughout the hospital [16, 17] . a double door pass through autoclave was identified as mandatory for hlcc unit through both consensus efforts [7, 18] . analogous pass through "dunk tanks" filled with disinfectant solution is useful in moving specimens from the hlcc to the laboratory and is particularly useful in facilities which lack a dedicated "in-unit" laboratory. implementation of telehealth strategies that enable communication with healthcare workers as well as provide a platform for remote patient assessment is important in reducing the number of healthcare workers with direct patient contact, thus limiting risk. the intermittent and sporadic utilization of hlcc units necessitates strong leadership. ideally, a hlcc leadership team should possess a robust set of diverse skills to include expertise in infectious disease and critical care, nursing, emergency management, industrial and environmental hygiene, research, laboratory, hospital administration, and public affairs. this leadership team should meet regularly to strategize and define drill objectives, plan educational efforts, promote research projects, and synchronize collaborative endeavors [19] . a robust activation checklist should be developed and drilled intermittently to assure that departments followed through on tasks assigned and that necessary items can be obtained in a timely fashion. this checklist should address unit stockage and supplies, equipment, medications, facilities activation procedures, and notification of departments and key individuals who will be involved in the activation of the unit and the care of the patient(s). numerous communication strategies are adaptable for use by hlcc team members. an electronic alert system with individual key numbers can be used to notify the hlcc team of drills and activation. an email distribution list can be used for less urgent information sharing. in order to organize the response for arriving patients, a modified hospital incident command system (hics) can be utilized, and the incident commander (ic) can support hlcc leaders in completing the activation checklist. moreover, the ic can facilitate coordination among the multiple agencies often involved in air and ground transport of patients to the patient care unit. although each facility may wish to tailor the composition of the hics team to their own particular needs, and each situation may require adjustment, key team members would typically include logisticians to plan to replenish ppe supply levels and address waste management issues, a public information officer (pio), medical technical specialists to include infectious disease physicians and nurse leaders to manage the clinical care of the patient and staffing within the patient care unit, a laboratorian to address testing logistics and specimen transport challenges, a clinical research expert to facilitate the use of experimental therapies when necessary, a nurse concierge or other dedicated individual to support family needs, and a behavioral health expert to address staff well-being as well as the psychological and emotional needs of patients and families. the pio is charged with responding to media requests, including those from social media sources. internal messaging within the organization should be done prior to release of any external information. internal messaging may be directed at administration, employees, and also patients (inpatients and outpatients) and their family members. press conferences with infectious diseases experts and others involved in patient care should be held to provide timely updates. it is also helpful to establish an information phone line staffed by the state or local health department to answer questions and provide education to the community. during activation, a concierge nurse or other patient advocate may prove helpful in the support of families of patients. this individual can assist by making advance contact with family members and arranging services such as airport transportation, accommodations, and meals. they can also serve as the liaison with family in the coordination of meetings to discuss the status of the patient, media information, and various other details. pastoral care staff should be available upon request during activation. the hlcc facilities in the united states that admitted patients infected with ebola virus disease (evd) have well developed teams of nurses who are able to provide skilled and effective patient care within their isolation units. recruiting and retaining qualified nursing staff willing and able to provide care for patients under emotionally and physically demanding hlcc conditions is the cornerstone to building a successful team. the staffing model must take into account the need for specialized nurses to provide quality care. the virulence of the disease in question, its mortality rate, the advanced levels of ppe required, and the propensity for infected patients to require complex interventions all influence the profile of staff selected to care for patients with vhf or other highly hazardous communicable diseases. the composition of the hlcc nursing team should reflect these needs. the centers in the united states that provided care for evd patients each required that a percentage of their core nursing staff possess critical care experience, with some institutions relying solely upon critical care nurses to staff their units [20] . in addition to critical care experience, it is essential to have nurses on the core team who have expertise in infectious diseases and have expressed an interest in caring for patients with highly hazardous communicable diseases [21] . the success of the nursing staff starts with a robust selection process. utilizing a formal interview process to determine qualifications and interest has been proven to be an effective method of selecting staff. once the interview is complete, the nursing leadership should contact the employee's current manager to discuss their clinical skills, teamwork skills, adaptability, dependability, and critical thinking skills. when staffing a unit that is only activated intermittently, an important consideration involves creating a process by which staff members can designate their availability on any given day. this can be accomplished in a multitude of ways; however, maintaining a consistent process is key to ensuring staff availability when needed. as the provision of nursing care must occur 24 h a day, 7 days a week, it is important that a schedule be created that accounts for all times. one way to achieve this is to mandate on-call shifts for dedicated staff. the on-call nurses are required to be at the unit within 60 min of being notified of activation. another option is to have each staff member fill out their availability and maintain a balanced schedule several weeks in advance. this allows staff members a level of autonomy to self-schedule. considerations for creating a nursing staff matrix include the design of the unit, the waste management strategy, the disease being treated, the acuity of the patient, the level of personal protective equipment (ppe) required, and the time that could be spent in the ppe [20, 22] . an important consideration is the need to minimize the number of staff that enters into the patient care area. the ability to utilize nursing staff in multiple roles can facilitate effective infection control by minimizing the footprint within potentially contaminated areas. in this effort, nursing staff become responsible for tasks that would typically be assigned to ancillary services within the standard hospital system, including routine cleaning and environmental services, phlebotomy, coordinating care needs, and unit clerk roles [20, 23] . consideration must also be given to the nurse-to-patient ratio necessary to provide safe care to a patient with vhf. the number of staff members required for a standard 12 h nursing shift must take into account the time limitations imposed on each staff member due to the use of advanced ppe. when providing the level of intensive care that these patients can require in addition to wearing ppe, it is necessary to adjust shift times and staffing ratios [24] . the staffing matrix utilized within hospitals that successfully cared for evd patients differed significantly from standard staffing ratios. within the nebraska biocontainment unit, six staff members were present on a day shift and five on the night shift (usually three nurses along with respiratory therapists and/or patient care technicians). healthcare staff was scheduled for 12 h shifts which were broken up into 4 h blocks to allow for the limitation of not wearing ppe for greater than 3-4 h at a time. designation of roles for each staff member on each shift can clarify expectations and ensure consistency within each role. the use of an autoclave for waste processing may necessitate the inclusion of a dedicated staff member to operate the machine. the special communicable diseases unit (scdu) at emory university utilized two to three nurses to staff the unit at all times when occupied, and it was recommended that nurses remove ("doff") ppe every 4 h to allow for personal needs and a break. at the highest level of ppe and patient care, three nurses were working in the scdu at one time, in 12-h shifts. they rotated in 4-h shifts between the patient room, the anteroom, and the nursing desk with each having designated responsibilities [20] . within each treatment facility, there are unique circumstances which will dictate the most efficient and safe nursing staffing practices. it is important to consider both staff safety and patient safety when determining which guidelines will be used to operate a unit caring for patients with vhf or other highly hazardous communicable infectious disease. nurses that join these teams must be individuals able to operate outside their normal routine by utilizing critical thinking skills, flexibility, and autonomy. these nurses are required to take responsibility for a wide array of clinical and nonclinical tasks and perform these in demanding clinical situations, which are skills that require practice, exceptional communication, and teamwork. caring for patients with highly hazardous communicable diseases is a true multidisciplinary effort, and choosing and maintaining an effective physician team illustrates this concept well. each center should tailor their physician team to fit their needs and the culture of the facility. in general, infectious diseases specialists have often led physician teams in the biocontainment setting; however this may not be appropriate in every facility. infectious diseases specialists monitor and manage infectious complications and coinfections and oversee the administration of antimicrobial agents, including experimental products. specialists in critical care medicine are an important asset in the care of patients with vhf, since some of these patients may have critical illness and require icu-level care, including mechanical ventilation, vasopressors, and other supportive care measures [25] . since invasive procedures are often necessary as well, it is critical to ensure that the physician team includes individuals who are experienced and comfortable performing these procedures. this skillset should be assessed by direct consultation with these physicians, since some may not feel comfortable performing invasive procedures in a high-risk isolation environment. training and drills involving critically ill patients, including performing invasive procedures in ppe, are an integral part of skill assessment and maintenance for the physician team. it is also important to involve other groups of physicians who may be needed in the care of a patient with vhf. pediatricians and pediatric intensive care specialists should be identified in the event that a pediatric patient must be cared for under hlcc conditions. similarly, obstetricians are an important part of the physician team since it is possible that a pregnant and/or laboring patient with suspected or confirmed vhf will need care in the isolation setting. nephrology specialists have been involved in the care of patients with vhf who developed renal failure, especially those who required dialysis [26] . relationships with other physician groups, including but not limited to surgery, emergency medicine, general internal medicine, and pathology, should be established as necessary in case consultative needs arise. it is important to note that some physician consultations can occur via telemedicine without the physician entering the patient care room. this serves to limit the number of physicians required to directly evaluate the patient at the bedside in order to decrease the possibility of exposure. when considering physician staffing models, it is important to note that physicians providing care to patients with evd or other vhf in the biocontainment setting may be unavailable for prolonged periods of time. this makes the ability to provide clinical care to other patients very difficult. thus it is important to consider backfilling other clinical responsibilities in order to provide dedicated time to the complex processes of donning and doffing ppe, performing procedures, and other aspects of biocontainment care. the most appropriate way to provide 24-h on-call coverage for patients with vhf must be evaluated, and this will vary depending on the current call structure in the medical facility [27] . the involvement of physicians in training (fellows, residents, etc.) in the care of patients with vhf in the biocontainment setting has been discussed, and generally it is felt that trainees should not be compelled to provide direct care for patients with vhf as a requirement of a clinical rotation due to excessive risk. however, physicians in training have entered the biocontainment setting on a volunteer basis to observe and assist in the management of patients with vhf via the telemedicine system, which provides educational opportunity without excessive risk. the use of ppe in clinical care to prevent the transmission of infectious diseases is not a new concept, yet in the context of viral hemorrhagic fever, ppe became the topic of much debate during the 2014-2016 evd outbreak. facilities who were tasked with providing care to infected individuals with evd faced multifaceted challenges related to the selection, procurement, and proper utilization of ppe, along with changing guidelines. personal protective equipment is worn to minimize exposure to infectious material and to protect the skin and mucous membranes from exposure to pathogens. ppe reduces, but does not eliminate, the risk of skin and clothing contamination with pathogens among healthcare personnel [28] . examples of ppe include items such as gowns, gloves, foot and eye protection, respirators, and full body suits. the occupational safety and health administration (osha) requires that employers protect their employees from workplace hazards that might cause injury. controlling a hazard at its source is the best way to protect employees. depending on the hazard or workplace conditions, osha recommends the use of engineering or work practice controls to manage or eliminate hazards to the greatest extent possible [29] . installing negative pressure air handlers to place a barrier between the hazard and the employees is an engineering con-trol; changing the way in which employees perform their work is a work practice control. when engineering, work practice, and administrative controls are not feasible or provide insufficient protection, ppe must be utilized to protect healthcare workers who are providing care to patients with infectious diseases. there are many variations of ppe available for purchase, and selecting the best version for the environment in which care must be delivered can be daunting. the versions of ppe used in hlcc units differed in the individual pieces used; however, the guiding principles remained the same. for healthcare workers caring for patients with evd, ppe that fully covers skin and clothing and prevents any exposure of the eyes, nose, and mouth is recommended to reduce the risk of accidental self-contamination of mucous membranes or broken skin [30] . varying levels of ppe are appropriate for use based upon the acuity of the patient, the volume of infectious bodily fluids (blood, vomitus, diarrheal stool) present, and the potential for aerosolization of these fluids [31] . providing this level of protection often requires that many pieces of ppe be worn; this can lead to an increased risk of fatigue and overheating. centers in the united states that treated patients with evd in 2014 utilized varying levels of ppe based on this stratified risk assessment [20, 23, 31] . in the nebraska biocontainment unit (nbu), the first level of ppe used completely disposable, and the second level incorporated the use of a powered air-purifying respirator (papr). first-level ppe consisted of fluid-impervious association for the advancement of medical instrumentation (aami) level 4 gown, n95 respirator, surgical hood, face shield, knee-high fluid-impervious boots, three pairs of gloves, and the addition of a second splash-resistant apron as needed (fig. 21.1) . the second level of ppe consisted of fluid-impervious coveralls, inner boot liners, outer boot covers, three pairs of gloves, and the papr hood with accompanying belt and blower motor. in the emory university special communicable diseases unit (scdu), varying levels of ppe based upon the risk assessment consisted of a completely disposable ensemble as well as a papr ensemble. the disposable ppe included a coverall, apron, booties, double gloves, face shield (goggles if face shield is not available), and a surgical mask. the papr level of ppe was comprised of a coverall, double gloves, booties, an apron, and the papr hood [20] ( fig. 21.2) . the equipment available for purchase through each institution may have differed; however, making selections based upon disease transmission and risk factors related to patient care rather than brand-specific products helped to ensure healthcare worker protection. the donning and doffing procedures require both vigilance and attention to detail. while ppe is effective at decreasing exposure to infected bodily fluids among healthcare workers, these healthcare workers are still at risk if this equipment is not removed in a manner that prevents exposure [32] . detailed guidance with the correct order of donning and doffing equipment should be readily visible on a chart posted within the patient care area. the process used to don and doff ppe should be followed exactly by all personnel every time it is performed and should be guided by a checklist. all staff members, regardless of title or position, are expected to hold one another accountable for adhering to the policies and procedures, including the appropriate use of ppe [22, 33, 34] . the donning and doffing process should incorporate the use of a donning partner who assists the healthcare worker in appropriate placement of ppe and a doffing partner who assists the healthcare worker in removing their ppe. this doffing partner helps to ensure that all steps in the process are completed in the proper order and technique. the physical exhaustion and emotional fatigue that can accompany the provision of care for patients infected with vhf may further increase the chance of an inadvertent exposure to bodily fluids on the outside of the ppe when performing the doffing process [32] . the cdc also recommends the presence of a trained observer when performing the doffing process [30] . the trained observer is available to provide immediate feedback if there is any inadvertent contamination of the healthcare worker. the doffing process can be complex and is considered to be a vulnerable area in which the healthcare providers may be inadvertently contaminated. simulation studies conducted using donning and doffing scenarios have shown high rates of self-contamination during the doffing process, especially during the removal of the gown and gloves, emphasizing the need for stringent protocols and supervision during this process [28] . the safe transport and prehospital care of patients with evd or other highly hazardous communicable diseases require enhanced infection control practices, which necessitate sound administrative policies, work practices, and environmental controls implemented through focused education, training, and supervision [35] . hlcc hospitals require partner emergency medical services (ems) capable of ensuring the safety of the hlcc transport medics and the public through implementation of infection control practices, policies, and procedures [9] . the ambulance environment is defined by confined space with limited air handling, and care is provided with reusable medical devices in acute situations. emergency vehicles have many compartments, shelves, patient care beds, and other high-touch areas that are difficult to clean. ambulance cleaning protocols have been established, but environmental contamination with nosocomial organisms continues to be documented [36] [37] [38] . a variety of specialized approaches have been established for hlcc transport. these include specialized truck and trailer ambulances (used in germany), hepa-filtered ground ambulance positioned aboard a hercules c130 aircraft (sweden), road ambulances with stretcher-based isolators (italy), and road ambulances draped to minimize contamination potential (united states) [39, 40] . hlcc transport medics should receive enhanced education and training on modes of transmission, the availability of vaccines, pre-and postexposure prophylaxis, and treatment modalities. competencybased training has also been recommended to develop and maintain ppe donning and doffing competency [32, 35, 41] . the transporting hlcc ambulance is commonly supported by an external transport team with extra supplies that facilitates communication with external support agencies (which may include law enforcement, airport operations, public health, and emergency management) and provides guidance for clinical decision-making when required [35, 39] . transition of the patient from the hlcc transport team to the hlcc unit team should be a highly scripted event, rigorously tested through planning and exercise [35] . following transition of care, the emergency vehicle should be decontaminated. hlcc facilities have utilized different decontamination methods; however the general principles of surface cleaning performed by personnel in ppe followed by appropriate waste disposal are maintained. vaporized hydrogen peroxide, chlorine dioxide, and ultraviolet light have all been used or proposed as adjunct decontamination strategies for emergency vehicles [40, 42, 43] . the clinical care of patients with vhf is largely supportive, and the ability to provide supportive care varies depending on the capabilities of the individual healthcare facility. generally, healthcare centers caring for patients with vhf should be ready to provide general supportive care and additional aggressive intensive care modalities when necessary and available. up until recently, little information regarding these care modalities was available given that outbreaks of vhf occurred in resource-limited settings. however during the 2014-2016 evd outbreak, patients who were managed in resourced settings in the united states and europe where aggressive supportive care was available had a much lower mortality rate when compared with that noted in previous reports from africa [44] . the clinical presentation of vhf may vary according to the etiology, the wide range of clinical severity, and multiple patient factors. it is important to note that the clinical presentation of vhf is non-specific; therefore it is important to evaluate patients with possible and confirmed vhf for other causes of symptoms, notably including malaria if the patient has a history of travel to an endemic area. the delivery of aggressive supportive care requires intravenous access, and the availability of this depends on the resource limitations of the healthcare facility. in resourcelimited settings, only peripheral iv placement may be feasible, whereas in resourced settings, central venous catheters (cvcs) are generally utilized. the placement of a cvc also enables healthcare workers to obtain blood samples without repeated venipuncture, reducing the risk of sharps injuries. antipyretic agents have been utilized to manage fever in patients with vhf. oral rehydration solutions and/or intravenous fluids may become necessary given the profound volume depletion that can result from vomiting and diarrhea. pharmacologic controls such as antiemetic and antidiarrheal medications have been utilized to control nausea, vomiting, and diarrhea. physical controls such as emesis bags and fecal management systems have been employed as well, since controlling these secretions is an important infection control modality in the healthcare setting. the monitoring and replacement of electrolytes is also an important aspect of supportive care in patients with vhf, since significant electrolyte disturbances have been observed [45] . nutritional support is often necessary, and when available, total parenteral nutrition has been utilized in patients with anorexia, nausea, and vomiting. patients with respiratory symptoms may require supplemental oxygen. bleeding complications can be treated with blood products and correction of coagulopathy. cases of encephalitis have been observed, and patients with agitation may require sedating medications. patients with vhf may also develop secondary infectious complications including bacterial sepsis, and these infections may be managed with antimicrobial therapy, which is often empiric since the availability of blood cultures is limited [46] . patients with vhf may present with, or may progress to, critical illness involving multi-organ failure and may require advanced life support including mechanical ventilation and dialysis. these interventions were utilized during the care of patients with evd in the united states and europe during the 2014-2016 outbreak [44] . in patients with respiratory failure, airway management was accomplished via intubation by rapid sequence induction and video laryngoscopy [27, 47] . renal failure was managed with continuous renal replacement therapy (crrt) in some centers. vasopressors have been utilized for blood pressure support in patients with vhf. an assessment of the use of other advanced cardiac life support measures like cardioversion and chest compressions should be discussed by healthcare facilities preparing to care for patients with vhf, with consideration of the potential benefits to the patient and the risks to healthcare workers. there are currently no fda-approved therapeutic agents available for the treatment of ebola or marburg virus disease, although many experimental drugs were used in the treatment of patients with evd during the 2014-2016 outbreak. since most of the use of these agents was employed in individuals and very small groups of patients, no definite conclusions can be made regarding efficacy. nonrandomized single-arm trials were conducted in africa evaluating certain therapeutics; however one was unable to reach any conclusions on the potential benefit of the viral rna polymerase inhibitor favipiravir, and another evaluating the small interfering rnas product tkm-130803 did not demonstrate improvement in survival [48, 49] . a randomized trial involving the triple monoclonal antibody cocktail zmapp was conducted, but although the estimated effect appeared beneficial, the result did not meet the statistical threshold for efficacy [50] . similarly, convalescent serum has been used in the management of patients with evd; however one study did not demonstrate a significant improvement in survival in patients administered convalescent plasma [51] . ribavarin has been shown to be effective in treatment of lassa fever [52] . the hospital discharge of patients with vhf is a complicated process and is dependent on many factors, including resolution or significant improvement of symptoms along with correlative virologic laboratory data. consultation with local and state health authorities and the cdc and/or who should occur to determine the recommended disease-specific discharge criteria for patients with vhf. the monitoring of laboratory parameters is a vital part of providing supportive care to patients with vhf, since these patients may have significant laboratory abnormalities on which clinical management is based. this is especially important in patients who are critically ill who require interventions like dialysis where laboratory parameters must be evaluated frequently and closely monitored. the ability to perform laboratory testing in a safe and effective manner requires significant planning prior to implementation. as a first step, the clinical care team should discuss which laboratory studies are necessary in order to care for the patient with vhf. this potential testing menu should be communicated to laboratory leadership, who should assess each test to determine if the sample can be processed safely. it is essential that the clinical care team have access to a menu of available laboratory tests and detailed information on the collection of specimens, including any special media required or recommended collection times. determining the location of the laboratory should take into account the capabilities of the facility. if feasible, laboratory testing should be performed in close proximity to the site of clinical care to eliminate the need for specimen transport, thereby increasing safety and decreasing turnaround time [19, 53] . point-of-care testing is desirable but is often not comprehensive, and additional testing may need to occur in the core laboratory or a special containment laboratory. it is important to note that some special containment laboratories may not have the equipment necessary to perform routine laboratory studies such as complete blood counts or metabolic panels, so these tests may need to be performed in the core laboratory if point-of-care testing is not available. a careful risk assessment should occur prior to implementation of any testing in order to minimize risk to the instruments and most importantly the laboratory staff [17] . viral load monitoring is helpful in patients with vhf, as the degree of viremia may predict the initial severity of disease and provide information on progression of disease during the treatment phase. the viral load is generally a component of discharge criteria as well [54, 55] . the transport of samples to the appropriate reference laboratory for viral load testing is a complicated process, and significant preplanning is necessary in order to facilitate this. the importance of stringent infection prevention and control, including environmental infection control, is heightened when providing hlcc for patients with vhf due to factors such as low infectious dose and potentially large volume of body fluids containing high concentrations of viral particles. these elements contribute to the significant yet manageable hazards posed by such care. perspectives and waste management strategies of two hlcc facilities have been reported [16] . robust packaging and disinfection procedures were employed by these two facilities in order to process evdassociated solid and liquid patient waste, contaminated patient linens, healthcare worker ppe and linens, contaminated medical devices, and other general medical waste. waste, linens, medical equipment, and other items potentially contaminated with pathogens such as ebola, lassa, marburg, and select other vhfs are categorized as category a infectious substances through the united nations and us department of transportation's hazardous materials regulations [56] . category a infectious substances require enhanced packaging and labeling along with security plans in preparation for transport [57] . materials that are sterilized by autoclaving or incineration are not required to be packaged and shipped as category a infectious substances. the quantity of waste generated through hlcc is significant with reports of over 1,000 lb of waste generated per patient [58] . management of such large quantities of infectious waste requires scalable strategies for packaging, storage, and security. solid waste disposal strategies include autoclaving and incineration. it is important to maintain autoclave validation logs to ensure appropriate function. several strategies have been employed for the transport of waste from the patient care room, including double bagging of waste and wiping the outside of the bag with bleach prior to transport. storage in waste-holding containers may be necessary while awaiting transport to the autoclave or incinerator. according to current recommendations, liquid waste can be safely disposed of in the sewer system. however, during the 2014-2016 ebola outbreak, some facilities utilized pretreatment strategies with a hospital-grade disinfectant prior to disposal of liquid waste [16] . fluid solidifiers were also used at some facilities in order to dispose of liquid waste into the solid waste stream. waste should only be handled by trained individuals in full ppe [59] . environmental cleaning during and after the care of patients with vhf is an important part of protecting healthcare workers, as well as other patients in the facility by maintaining the highest infection control standards. environmental cleaning for many vhfs, including ebola, should only be performed by trained individuals, and full ppe should be worn at all times during this process. daily cleaning of hlcc facilities generally consists of surface cleaning with an eparegistered disinfectant approved for use against non-enveloped viruses [60] . the terminal cleaning process varies by facility but generally consists of disposal of waste followed by surface cleaning with a hospital-grade disinfectant and disinfection of medical equipment. some facilities utilize a final decontamination step involving ultraviolet germicidal irradiation or vaporized hydrogen peroxide [16, 61] . this process should be monitored and documented by a trained infection control expert to ensure compliance with all procedures. the remains of a patient with ebola virus disease (evd) are considered highly infectious. it is important to remember that although the patient is deceased, the viral load may remain very high, and body fluids may remain infectious for an extended period of time postmortem [62] . there is significant risk for those who are handling the body if proper procedures and barriers are not employed. preparing the body for transportation to the mortuary must be done by trained staff in the patient care room as close to the time of death as possible [63] . when providing care for the deceased in the united states, it is most likely that these patients will be in a hospital setting and more stringent controls can be implemented. in addition to federal laws and guidelines that apply to mortuary workers, mortuary practices may also be subject to a variety of state, tribal, territorial, and local regulations. cdc recommends close collaboration with public health officials in the state or local jurisdiction, as well as with the licensed funeral director who has agreed to accept the bagged remains, to safely implement each step of the process [63] . the presence of a memorandum of understanding (mou) with key ancillary partners can facilitate safe and timely transfer of the remains of deceased patients. it is beneficial for any insti-tution that may provide care for patients with vhf to have an mou in place with a local mortuary service, crematorium, or cemetery. the highly infectious nature of the remains of a deceased victim of evd demands the use of increased protection for the healthcare worker. the recommended ppe for handling such remains includes a powered air-purifying respirator (papr), fluid-impervious coveralls, double gloves, and use of an outer apron [64] . adequate staffing during the care of the deceased is essential for safe execution of the procedures. the patient remains are first prepared and packaged within the patient room (hot zone) and transferred out into the hallway or anteroom (warm zone) and out of the patient care area (cold zone) for transport to final disposition [65] . the body of the deceased should not be washed or embalmed, medical devices should remain in place, and healthcare workers should not attempt to remove them. autopsies should not be performed unless specifically directed by the state health department and only after consultation with the cdc and state health department officials [63] . patient remains should be securely contained within the patient care area. the remains should be packaged using established guidance, which currently includes the use of multiple layers [63] . the first layer to form a protective barrier is a standard hospital issued mortuary bag, followed by a heat sealable chlorine-free material, and final securement is achieved by the use of a heavy duty morgue bag. each protective barrier that is added should be thoroughly disinfected before moving to the next step and again before being transported out of the hot zone. the patient remains should be transferred out of the hot zone with special attention paid to minimizing the cross contamination of zones. when the remains have been safely processed out of the patient care area, the transport team will assume care of the deceased. the composition of the transport team will vary; however it is important to consider state requirements for chain of custody when developing protocols. personnel serving on the transport team may include the servicing mortuary staff, state medical examiner, healthcare worker or leadership staff, and law enforcement personnel. cremation is recommended [63] . upon completion of cremation, the ashes may be returned to the family of the deceased as the risk of transmission of infection is no longer present [63] . when providing care for the deceased patient, the utmost level of dignity and respect for the deceased patient and his/her family should be maintained. during the 2014-2016 ebola outbreak, many healthcare facilities were faced with caring for patients who presented with symptoms compatible with evd and met certain epidemiologic criteria as defined by the cdc [66, 67] . these patients were termed "persons under investigation." in order to properly address quick isolation and care of persons under investigation for evd or other vhf, a travel and symptom triage tool is needed at check in areas within the healthcare environment. the tool can be a paper instrument with simple questions related to travel history and symptoms. alternatively, a more robust tool can be built within the electronic health record (ehr) to assess travel history, identifying specific countries and providing decision support prompts that then are matched up with presenting symptoms and correlated with cdc case definitions. alerts then appear within the ehr to notify caregivers of additional precautions required (e.g., give patient mask to wear, notify infectious diseases experts, isolate patient in a negative pressure room, etc.). whatever tool is used, it must be agile and quickly adapted to meet ever-changing emerging pathogen threats. once a patient screens positive for travel history and symptoms matching the cdc case definition, a process map can be used to provide step-by-step guidance to healthcare providers using a standardized approach. a protocol should be created for the emergency department, as well as for other ambulatory locations (outpatient clinics, radiology, etc.) where patients may present with symptoms. a positive screen result for epidemiologic risk and signs or symptoms consistent with viral hemorrhagic fever should trigger escalating personal protective equipment use and movement to a designated isolation area. the choice of isolation area is determined by each individual facility. a predetermined area within the emergency department can be utilized since this is often the point of entry for patients [68] . notification of appropriate personnel should then occur, including infection control professionals, area leadership, a designated infectious diseases physician, public health officials, and the laboratory. once the patient is isolated, security should be summoned to control the area and to maintain a log of staff entering the isolation zone. staff in ppe then perform an initial assessment of the patient and obtain additional details and history, including confirmation of epidemiologic history. specialists may be called in to assess the patient as well, or alternatively this may be accomplished via video technology in an effort to limit the number of individuals who enter the room. once the exam is completed, a consultation with local public health and cdc should be conducted, and testing requirements should be determined. it is important to ensure that the appropriate collection methods are utilized; these should be clarified with the public health laboratory prior to specimen collection [69] . a pui may require imaging studies. bedside studies are preferred from an infection control perspective but are not comprehensive, and additional studies that cannot be per-formed at the bedside may be necessary. robust predefined plans for patient transport to cardiac catheterization, ct, mri, and endoscopy should be developed. in addition, a pui may require surgical intervention. a predefined plan should be created, which outlines the preoperative timeout briefing, intraoperative care considerations to include type of ppe to be used by the surgical team, instrument handling and care, recovery of patient in the operating room, and subsequent cleaning and disinfection of the space, instruments, and waste management [70] . although there are no formal guidelines for the management of patients with suspected vhf in the operating room, there is information available from the american college of surgeons, who recommends against elective surgical procedures but states that emergency operations can be considered [71] . development of these processes along with defined drills involving the operating room staff will enhance the capability to successfully navigate through care of puis in need of surgical care. children differ from adults in myriad ways which potentially impact their vulnerability to the viral hemorrhagic fevers and present challenging management issues. developmentally, children are likely to be frightened by the sight of caregivers in ppe and may flail, tug, and pull at such equipment, creating additional risk for these caregivers. similarly, young children are unable to cooperate with their management, and the usual pediatric paradigm of family-centered care, which would enlist parents in assisting with such care, may be prohibitively hazardous in the setting of transmissible vhf such as ebola, marburg, or lassa. from a policy perspective, multiple factors complicate the care of children. certain medications that might be used in adults are contraindicated in children, are unavailable in liquid preparations, or are unfamiliar to pediatric practitioners. similarly, the use of investigational drugs may be more problematic in children. finally, pediatric-specific equipment, doctrine, and hlcc beds are often lacking. despite these apparent disadvantages, children have been consistently underrepresented among ebola victims. in the 1995 kikwit outbreak, children accounted for 27 of the 315 cases (9%), despite constituting 50% of the zairean population [72] . similar findings were obtained during the 2000 outbreak in gulu, uganda, where children represented 20 of the 218 cases (9%) [73] . moreover, these children had a case fatality rate of 40%, not dissimilar to the rate among adults. finally, in a study performed in guinea during the 2014-2016 outbreak, 147 of 823 cases (18%) occurred in children, again despite the fact that children constitute 50% of the population of guinea [74] . while these findings raise the possibility that children may be less susceptible to infection with ebola (and, perhaps, with other vhfs), it is likely that this diminished susceptibility derives mainly from social factors; young children are less likely to function as primary caregivers to dying family members, are thus less likely to have contact with body fluids, and are less likely to participate in intimate funereal preparations. management of the pregnant or laboring patient with vhf is similarly problematic; maternal and infant mortality are extraordinarily high in virtually all of the vhfs, although maternal survival has been reported following fetal loss associated with ebola infection and uterine evacuation has been shown to improve survival of pregnant women with lassa fever [75, 76] . fetal and neonatal loss among women with lassa fever has been reported to be as high as 87%, and there are no reports of neonates born to ebola-infected mothers surviving beyond 19 days [76, 77] . vertical transmission of yellow fever appears to occur very rarely, and few reports of affected pregnant women exist for the remaining vhfs [78] . in light of this paucity of information, it is difficult to make specific recommendations for the management of the pregnant woman with vhf. nonetheless, meticulous planning must be undertaken by facilities that might be called upon to care for pregnant vhf patients. such planning should address, among others, questions regarding where and when delivery should occur, what equipment is required, and how complications like bleeding should be managed. this final question that raises, perhaps, the most vexing issue associated with the care of newborns and children with contagious vhfs is under what circumstances might parents or other nonmedical caregivers be permitted to remain at the beside of an infected child. parents might assist in reducing the anxious flailing of a toddler, thereby diminishing risk to hcws. they are also afforded the opportunity to participate in family-centered care, thus emotionally benefitting both parent and child. these considerations must be balanced, however, against the reality that parents then become, in a sense, additional patients, requiring assistance in donning and doffing ppe and running the risk of inadvertent breaks in containment by non-skilled individuals. an expert panel recently met to discuss these considerations, although the subject is likely to remain controversial [79] . training healthcare workers in the provision of care to patients with vhf presents many challenges. one of the challenges involves maintaining readiness and keeping team members engaged when these specialized patient care areas are not activated. the implementation of a consistent and structured training schedule facilitates staff engagement by incorporating activities of varying intensity. incorporating complex functional exercises, tabletop exercises, skill-focused drills, competency evaluations, and team-building activities builds a strong foundation from which the patient care team can further develop. educational sessions on emerging infectious diseases may also be helpful to maintain readiness and interest. developing an annual training calendar that is available to team members in advance sets the expectation for the team members and also helps to minimize scheduling conflicts for required attendance. bringing healthcare workers together to train regularly enables the formation of a cohesive functional team rather than a collection of individuals. when considering the provision of intensive care to patients with evd, the challenges are heightened. these patients often require invasive interventions which involve the skills of anesthesiologists and critical care physicians, as well as nurses proficient in managing the ongoing care of critically ill patients. the interventions must be implemented while wearing advanced levels of ppe, thus potentially limiting the dexterity of the providers. training regimens for healthcare workers should allow for the development and refinement of specific policies and procedures, addressing critical issues like donning and doffing ppe, waste processing, the insertion of central venous catheters, endotracheal intubation, the use of continuous renal replacement therapy, advanced cardiac life support (acls) and pediatric advanced life support (pals) plans and protocols, and the plan for extraction and provision of care for a provider who has a medical emergency in the patient care area. providing routine training for key personnel ensures the opportunity for healthcare workers to gain confidence in their ability to perform the procedures, as well as to build a firm foundation of processes for many aspects of care [22] . developing and exercising detailed policies to guide cares within the unit, as well as maintaining an expert staff, are key components to maintaining preparedness. training ensures that healthcare workers are knowledgeable and proficient in donning and doffing ppe before caring for a patient with vhf. comfort and proficiency when donning and doffing are only achieved by repeatedly practicing correct use of ppe. when providing training and assessing competency in ppe, healthcare workers should perform required duties while wearing ppe. this could include inserting an intravenous device, assisting with perineal care after an incontinent episode, processing waste in the patient care area, or charting an assessment. training should be customized for the intended audience and effectively relay essential information. healthcare workers who are unwilling or unable to fulfill these requirements should not be included in the patient care team. with regard to maintenance of skills, it is imperative that a culture of safety be fostered within the care team, where the focus is on effective teamwork to accomplish the goal of safe, high-quality patient care [80] . all staff must feel empowered to identify and take action to prevent errors from occurring and to improve the patient care environment. this sense of empowerment can be developed during routine training and preparedness exercises in preparation for the reality of patient care. the provision of care for patients with evd or other vhf is a complex process necessitating that close attention be paid to multiple infection control modalities. engineering and facility controls such as negatively pressurized rooms within designated care areas are ideal; however the most important assets needed to provide safe and effective care for patients with vhf or other highly hazardous communicable diseases are a trained team and a collection of well-developed and practiced protocols. in order to increase preparedness for highly hazardous communicable diseases in the united states following the ebola outbreak of 2014-2016, the cdc and department of health and human services (dhhs) developed a three-tiered system to screen and manage patients with suspected or confirmed evd. under this system, facilities with high-level containment care capability are designated as "ebola treatment centers" (etc). as of this writing, approximately 55 such centers have applied for designation and funding; among them are ten designated as regional referral centers by dhhs (one in each of its ten geographic regions) [81] . in addition, other hospitals would be designated as "ebola assessment hospitals" (eah), able to manage and isolate persons under investigation (pui) until a diagnosis of ebola virus disease (evd) can be confirmed or refuted. finally, remaining hospitals ("frontline facilities") would receive training in order to improve their ability to isolate potential ebola victims until they could be transferred to an eah or etc. within this network, the provision of patient care can be optimized, protocols practiced and improved, and research on investigational drugs and products streamlined. although this system represents a vast improvement in hospital preparedness in the united states, isolation bed capacity remains limited [82] . the us department of health and human services, the assistant secretary for preparedness and response (aspr), the centers for disease control and prevention (cdc), and emory university, nebraska medicine, and bellevue hospital center comprise the national ebola training and education center (netec) [83] . initiated in 2015, the netec program supports the education and training of healthcare facilities in order to enhance preparedness for ebola and other highly infectious diseases. although there remains a significant amount of education and work to be done in this area, this collaborative effort, along with the tiered network of hospitals, represents a significant improvement in preparedness. the invisible enemy: a natural history of viruses isolation and biocontainment of patients with highly hazardous infectious diseases the "slammer": isolation and biocontainment of patients exposed to biosafety level 4 pathogens managing potential laboratory exposure to ebola virus by using a patient biocontainment care unit why were doctors afraid to treat rebecca mclester? new york times designing a biocontainment unit to care for patients with serious communicable diseases: a consensus statement preparing a community hospital to manage work-related exposures to infectious agents in biosafety level 3 and 4 laboratories framework for the design and operation of high-level isolation units: consensus of the european network of infectious diseases infection control in the management of highly pathogenic infectious diseases: consensus of the european network of infectious diseases the sars epidemic: treatment; beijing hurries to build hospital complex for increasing number of sars patients yellow jack and geopolitics: environment, epidemics, and the struggles for empire in the american tropics biosafety in microbiological and biomedical laboratories guideline for isolation precautions: preventing transmission of infectious agents in health care settings guidelines for design and construction of hospitals and outpatient facilities environmental infection control considerations for ebola safety considerations in the laboratory testing of specimens suspected or known to contain ebola virus facing highly infectious diseases: new trends and current concepts planning and response to ebola virus disease: an integrated approach emory healthcare ebola preparedness protocols ebola virus disease: preparedness and infection control lessons learned from two biocontainment units critical care for the patient with ebola virus disease: the nebraska perspective the nebraska biocontainment unit policies and procedures preparing for critical care services to patients with ebola successful delivery of rrt in ebola virus disease lessons learned: critical care management of patients with ebola in the united states contamination of health care personnel during removal of personal protective equipment united states department of labor-occupational safety and health administration guidance on personal protective equipment (ppe) to be used by healthcare workers during management of patients with confirmed ebola or persons under investigation (puis) for ebola who are clinically unstable or have bleeding, vomiting, or diarrhea in u.s. hospitals, including procedures for donning and doffing ppe personal protective equipment processes and rationale for the nebraska biocontainment unit during the 2014 activations for ebola virus disease protecting healthcare workers from ebola: personal protective equipment is critical but not enough clinical challenges in isolation care learning from ebola: interprofessional practice in the nebraska biocontainment unit transport and management of patients with confirmed or suspected ebola virus disease bacterial pathogens in ambulances: results of unannounced sample collection a preliminary investigation into bacterial contamination of welsh emergency ambulances regulations for disinfection of ambulance services european concepts for the domestic transport of highly infectious patients considerations for safe ems transport of patients infected with ebola virus cluster of severe acute respiratory syndrome cases among protected healthcare workers -toronto, canada decontamination of rooms, medical equipment and ambulances using an aerosol of hydrogen peroxide disinfectant evaluation of ambulance decontamination using gaseous chlorine dioxide clinical management of ebola virus disease in the united states and europe clinical care of two patients with ebola virus disease in the united states a case of severe ebola virus infection complicated by gram-negative septicemia severe ebola virus disease with vascular leakage and multiorgan failure: treatment of a patient in intensive care experimental treatment with favipiravir for ebola virus disease (the jiki trial): a historically controlled, single-arm proof-of-concept trial in guinea experimental treatment of ebola virus disease with tkm-130803: a single-arm phase 2 clinical trial evaluation of convalescent plasma for ebola virus disease in guinea lassa fever laboratory test support for ebola patients within a high-containment facility criteria for discharge of patients with ebola virus diseases in high-income countries clinical management of patients with viral haemorrhagic fever. a pocket guide for the front-line health worker department of transportation. 49 cfr parts 171, 172, 173, and 175 hazardous materials: infectious substances; harmonization with the united nations recommendations department of transportation. dot guidance for preparing packages of ebola contaminated waste for transportation and disposal nebraska biocontainment unit perspective on disposal of ebola medical waste safe handling, treatment, transport and disposal of ebola-contaminated waste interim guidance for environmental infection control in hospitals for ebola virus nebraska biocontainment unit patient discharge and environmental decontamination following ebola care new who safe and dignified burial protocol -key to reducing ebola transmission. world health organization guidance for safe handling of human remains of ebola patients in u.s. hospitals and mortuaries guidance on personal protective equipment (ppe) to be used by healthcare workers during management of patients with confirmed ebola or persons under investigation (puis) for ebola who are clinically unstable or have bleeding, vomiting, or diarrhea in u.s. hospitals, including procedures for donning and doffing ppe the nebraska biocontainment unit. the nebraska biocontainment unit policies and procedures centers for disease control and prevention. case definition for ebola virus disease (evd) ebola or not? evaluating the ill traveler from ebola-affected countries in west africa development and use of mobile containment units for the evaluation and treatment of potential ebola virus disease patients in a united states hospital emergency department processes for the evaluation and management of person under investigation for ebola virus disease ebola surgical protocols enhance safety of patients and personnel surgical protocol for possible or confirmed ebola cases ebola hemorrhagic fever: why were children spared? ebola hemorrhagic fever among hospitalized children and adolescents in northern uganda: epidemiologic and clinical observations ebola virus disease and children: what pediatric health care professionals need to know dilemmas in managing pregnant women with ebola: 2 case reports a prospective study of maternal and fetal outcome in acute lassa fever infection during pregnancy live neonates born to mothers with ebola virus disease: a review of the literature perinatal transmission of yellow fever, brazil parental presence at the bedside of a child with suspected ebola: an expert discussion teaching the culture of safety centers for disease control and prevention. hospital preparedness: a tiered approach current capabilities and capacity of ebola treatment centers in the united states infect key: cord-264479-s20oacr9 authors: bern-klug, mercedes; beaulieu, elise title: covid-19 highlights the need for trained social workers in nursing homes date: 2020-05-25 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.05.049 sha: doc_id: 264479 cord_uid: s20oacr9 nan core features of psychosocial care in a crisis include access to information and emotional support 2 . this editorial provides examples of how nursing home social workers are adapting the way they connect with residents and families during the pandemic and concludes with suggestions. some of the information comes from experiences shared by nursing home social workers who have participated in weekly online support sessions initiated in april by the national nursing home social work network https://clas.uiowa.edu/socialwork/nursing-home/national-nursing-home-social-work-network .these weekly support sessions provide an anonymous space for social services staff around the country to share experiences and ideas about coping with covid-19 challenges. the editorial also highlights the needs for trained social workers in nursing homes. one of the first topics to surface during the online support sessions was the shortage of personal protective equipment (ppe). many nursing homes around the country still struggle to get enough ppe for the nursing staff who provide hands-on care. in nursing homes experiencing ppe shortages, the lack of equipment means activities and social services staff cannot safely enter resident rooms. much of the psychosocial care provided to these residents now occurs over the phone, computer, or through direct care staff. in nursing homes where ppe is available, training on how to use it safely may not be. this leaves untrained activities and social service staff with a false sense of security and vulnerable to catching and spreading the virus. in some nursing homes, staff members are expected to re-use the ppe. in others, there is not enough ppe for families who want to visit dying loved ones. some hospice workers are arriving at nursing homes to provide services to residents but lack their own ppe. the ppe shortage endangers the physical health of residents and staff and damages emotional health as well. during our weekly online support sessions, social workers shared they are as deeply concerned about bringing covid-19 home to their families as they are about bringing covid to the nursing home. in part because of the lack of ppe, social workers are spending more time on the phone and on the internet communicating with residents. some of these contacts can happen directly between the social worker and the resident. other contacts must be facilitated by busy nursing staff who have access to ppe. cooperation, coordination and collaboration among staff can improve care provided to residents and enhances communication with concerned family members. while a core function of the social work role has always been to anticipate, assess and address resident psychosocial needs, social workers have also been key liaisons between the family and the facility. during a pandemic, that connection is more important than ever, and often occurs over the phone. engaging in this level of conversation with anxious family members requires skill. not all nursing homes have a staff person skilled in delivering bad news, listening to distraught families, and helping to identify and affirm family resilience. the federal government requires only nursing homes with more than 120 beds to hire one fte social services staff member, and that person does not have to hold a degree or license in social work 3 . the unrealistic staffto-resident ratio and the disregard of professional standards has been a problem for decades. the inadequacy of this lax regulatory stance toward the credentials of the key onsite professional responsible for psychosocial care is even more apparent during a crisis when residents, families and staff are simultaneously and chronically in distress. nursing homes are being inundated with phone calls from families concerned about their loved one contracting covid and about the impact of social isolation. families have a lot of questions. some questions have no answers. families wonder why the nurse hasn't called them back in two days and why no one picks up the phone. suspicion brews. families hold themselves responsible for being there for their loved one 4 . this sense of responsibility is heightened during a crisis. families want their mother/brother/sister to know they are not forgotten and have not been abandoned. the nursing staff to provide resident care. one social worker disclosed that while some families use these phone calls to vent their anger, others ask how they can help; she followed up with "…and then a large box of home-made masks appears later in the week." what else are social workers doing during these phone calls? a social worker engages constructively and compassionately with families by using skills acquired as part of a social work education, including: active listening, crisis management, anger deescalation, situation stabilization, emotion processing, problem solving, decision-making support, boundary setting assistance, advance care planning, transitions of care discussions, validation of family connectiveness, role playing, role affirmation, clarifying, reflecting, interpreting, reassuring, and meaning-making 5, 6 . social workers also advocate on behalf of residents and families, provide information on a wide range of topics including health insurance, resident rights, and how to connect with the local foodbank. social workers with a reasonably sized case load can be expected to provide more frequent and comprehensive support to families compared with social workers with large caseloads. even before the pandemic, the most qualified and these conversations can be difficult when the resident and family member disagree on appropriate goals of care for residents. they can also be difficult when residents are not cognitively capable of participating and family members disagree among themselves. sometimes these conversations are difficult because they reflect the mistrust that is present in the larger social context of racism, ageism, and ableism. for example, during a phone conversation with an african american daughter one social worker was asked, "are you saying the same thing to whites?" these delicate conversations call for expertise and compassion. during our online support sessions, social workers discuss the fine line they walk daily between reassuring family members and not over promising. by keeping family expectations realistic today, disappointment can be diminished tomorrow. for example, many families would like the staff to help them connect daily by phone or computer with their loved one. most nursing homes don't have the staff capacity for that, even if they have a spare laptop or tablet. from the family's perspective it doesn't seem to be asking much for a ten-minute daily face-time session, yet from the staff perspective it requires much more than ten minutes to organize, prepare and safely deliver a phone or internet session. many nursing home policies and procedures developed pre-covid are inadequate during covid, including some end-of-life policies. in most nursing homes, the only family members now allowed to visit are those whose relative is actively dying. even then, the number of family members is limited. some family members tell social workers they are afraid to enter the nursing home for fear they will catch covid and are equally afraid they will never forgive themselves if they don't visit in-person to say goodbye. social workers can help people sort out their feelings, understand ppe options, gain the information they need to weigh the risks, and reach a decision they can live with. in nursing homes with multiple covid deaths, social workers leave work with a pit in their stomach from the phone conversations with family members to discuss what to do with the decedent's body and their belongings. most nursing homes do not have an on-sight morgue and many lack sufficient storage space for decedents' possessions. a strong social work presence has always been necessary in nursing homes; the pandemic underscores the need. after the pandemic, the need will continue. because we are working with people in physically, emotionally and socially vulnerable circumstances, many of whom are approaching the last chapter of their life, we know that psychosocial concerns will be ever-present. if we are serious about improving the quality of care and the quality of life in nursing homes, we must be serious about psychosocial care. we need to be concerned with fractures of bones yes of course, but we also need to address a resident's fractured broken heart. we need to do all we can to prevent wounds on the skin, yes of course and we also need to prevent wounds on the soul 7 . this pandemic has exposed many ways the country can better support nursing homes and nursing homes can better care for residents and families. including degreed and licensed social workers as part of the core team is a basic way to provide psychosocial care in nursing homes and enhance resident quality of life. • securing ppe for staff is necessary but not sufficient. training must be provided to all staff. a good source is: https://www.cdc.gov/coronavirus/2019ncov/hcp/using-ppe.html • develop and communicate a protocol for securing ppe and training for family members who come to visit residents who are approaching the end of life. • let residents and families know what format (social media, newsletters, phone calls) and frequency of communication they can expect from the facility. clear, consistent, truthful information from a trusted source is an important factor to help individuals and organizations adapt. • squash rumors and build a sense of inclusion by keeping all staff updated and informed. encourage questions. • have a mechanism for staff who are in touch with families to relay concerns and compliments back to the whole staff. • consider hosting "drop-in" online support sessions for family members. if staff are not available to coordinate, hire a local mental health provider or enlist a trained volunteer. • regularly recognize the hard work of staff in concrete ways. • maintain a "nurturing environment" which provides the necessary resources, security, and support to facilitate individual and organizational adaptation. adaptation is key to resilience 1 . resilience as effective functional capacity: an ecological-stress model psychosocial crisis management: the unexplored intersection of crisis leadership and psychosocial support. risk, hazards, & crisis in public policy code title 42 section 13951. requirements for, and assuring quality of care in, skilled nursing facilities family members' responsibilities to nursing home residents standards for social work services in long-term care facilities psychosocial assessment of nursing home residents via mds 3.0: recommendations for social service training, staffing, and roles in interdisciplinary care transforming palliative care in nursing homes: the social work role key: cord-269900-7mzyib4r authors: ierardi, anna maria; wood, bradford j.; gaudino, chiara; angileri, salvatore alessio; jones, elizabeth c.; hausegger, klaus; carrafiello, gianpaolo title: how to handle a covid-19 patient in the angiographic suite date: 2020-04-10 journal: cardiovasc intervent radiol doi: 10.1007/s00270-020-02476-8 sha: doc_id: 269900 cord_uid: 7mzyib4r this is a single-center report on coordination of staff and handling of patients during the outbreak of the covid-19 (coronavirus disease 2019) in a region with high incidence and prevalence of disease. the selection of procedures for interventional radiology (ir), preparation of staff and interventional suite before the arrival of patients, the facility ventilation systems and intraand post-procedural workflow optimization are described. the control measures described may increase the cost of the equipment, prolong procedural times and increase technical difficulties. however, these precautions may help control the spread of covid-19 within the healthcare facility. the corona pandemic covid-19 (coronavirus disease 2019) has created a crisis in healthcare systems across the globe. although interventional radiology (ir) is not among the leading forces in the fight against the virus, ir remains an important part of healthcare systems. therefore, it is necessary that appropriate ir services can also be provided under these extreme circumstances. such services include critical emergency interventions, such as embolization procedures to treat hemorrhage, and endovascular treatment of acute ischemic stroke. in addition, depending on the specific circumstances, oncology patients and cases of critical limb ischemia also need urgent treatment. however, the current outbreak may find some ir services unprepared to safely perform these important services. in this document, preemptive measures and potential challenges that are most relevant to the practice of ir are described based on the experience of an ir unit deeply affected by covid-19. the novel human coronavirus, known as severe acute respiratory syndrome coronavirus 2 (sars-cov-2), emerged in wuhan, china at the end of 2019. the rapid global expansion of this outbreak is the result of an efficient human-to-human transmission of the coronavirus disease (covid-19) [1] . the high viral loads in upper respiratory tract samples indicate that virus transmission via respiratory secretions, in the form of droplets ([ 5 l) or aerosols (\ 5 l), may be most likely [2] . surfaces contaminated by people coughing or sneezing on them represent another way of contamination [2] . viable virus could be detected in aerosols up to 3 h post-aerosolization; its half-life on surfaces seems to depend on the contaminated surfaces. laboratory tests reveal viable virus up to 4 h on copper, up to 24 h on cardboard and up to 2-3 days on plastic and stainless steel [3] . due to the high rate of aerosol transmitted infections and permanence on surfaces, segregation is one of the basic principles for prevention of new viral infections. this also accounts for patients who are referred for an ir procedure. there is a need for decentralization of services and segregation of patients in response to the risk of nosocomial transmission of infection. execution of ir procedures in situations with suspected airborne infections needs particular precautions to reduce the risk of transmission to the healthcare workers. as far as possible, procedures on patients with suspected or confirmed covid-19 infection should be performed at a specially designed isolation facility. in our hospital, every patient and healthcare worker has to undergo rt-pcr testing (real-time reverse transcription polymerase chain reaction) for the qualitative detection of nucleic acid from covid-19. uncertain cases are managed as infected ones, and healthcare workers with suspected infection are kept away from the hospital (preventive quarantine). luckily this has not been required yet, perhaps in part due to attention to these recommendations and guidelines. the isolated patients should not take the conventional routes to the angiographic suite, but use (when possible) dedicated elevators and designated routes, and stay as short as possible in the recovery area. waiting for the procedure and the performance of any preparatory tasks or paperwork that can be done directly in the procedure room should be done there, so as to minimize contamination along the route (while remaining vigilant about in-room sterility). few ir services are equipped with physically separate outpatient, inpatient and isolation facilities. where the service is not equipped, the solution may be to explore temporal segregation of services to different groups of patients. if possible, procedures for non-infected patients should be performed in the first hours of the day, and those to the infected in the second part of the workday. it is also possible to take advantage of resources from other departments (cardiology or even operating theaters), supplemented with portable fluoroscopic units, to reduce the frequency of these patients in the ir services to a minimum. every ir service must comply with the advice and directives given by each hospital, which depend on the location and the role that the hospital has in the geographic area, and also on the severity of the regional covid-19 dissemination. our protocols were implemented in accordance with advice from the directors of the hospital and the administrative service. it could be necessary to postpone non-urgent procedures until a patient's risk status is further evaluated. one approach is to continue with urgent and non-deferrable oncologic procedures, while postponing an appropriate number of other elective cases. our hospital is located in the area where infections are highly concentrated; therefore, the intensity of covid-19 exposure is very high. in order to limit the risk of transmission between patients, and between patients and healthcare workers, the ir workflow has been reorganized. procedures for life-threatening conditions (e.g., embolizations for bleeding, thrombectomy for stroke, acute mesenteric ischemia, endovascular aortic aneurysm repair for aortic ruptures), non-deferrable oncologic treatments (e.g., interventional procedures bridge to liver transplant, selected percutaneous ablations, chemoembolizations and biliary drainages, and few others), and organ-saving procedures (e.g., percutaneous nephrostomy, urgent diabetic foot angioplasty, prophylactic occlusion balloon placement for the prevention of postpartum hemorrhage due to morbidly adherent placenta) are performed whenever deemed to be necessary on a daily basis. moreover, selected central vascular accesses and percutaneous thrombectomy of dyalitic fistulas were carried out. after multidisciplinary evaluation, bedside procedures (e.g., ultrasound-guided percutaneous abscess drainage and few biopsies) were performed. rigorous training is necessary, especially in the initial phase. written protocols should be available in every ir service and on hand for all operators. careful hand hygiene, correct wearing of protective equipment and strict adherence to infection control procedures will ensure continued and complete compliance, balancing any critical equipment shortages as well. before a patient is called down for a procedure, it is mandatory that all pre-procedure preparations have been completed. this will reduce the unnecessary amount of time patients spend in the department. all the staff of the angiographic suite must use personal protective equipment (ppe), according to accepted infectious disease and epidemiology guidelines. these include masks, gowns, gloves, eye protection (goggles or face shield) and shoe covers. sterile barriers (gown and gloves) must be worn by operators in addition to other protective equipment. all non-essential and mobile equipment should be moved out of the angiographic suite to avoid possible contamination. fixed and essential contact surfaces within the room need to be covered with clear drapes. switches and control panels should be covered by plastic that should be changed between patients (fig. 1 a, b) . non-disposable materials (linen, etc.) should be avoided. clean and contaminated work areas must be clearly separated. administrative staff, office workers and employees in the administrative areas of the ir service, who are not directly involved in the procedures but localized in ir services, should be kept away from the path of the patient and maintain a minimal distance of two meters from the patient. they do not require ppe [4] . in our ir unit, we have 5 employees, including secretaries and administrative workers; in these weeks we reduced their presence to 2 per week from 8:00 a.m. to 3:00 p.m. instead of 8:00 a.m. to 7:00 p.m., to limit their exposure. the same scheme has been adopted for interventional radiologists: per week only 5 (2 for neuro and 3 for body) go to the hospital where they cover ir procedures and replace the peripherally inserted central catheter (picc) team for covid-19 and non-covid-19 patients (picc team is now employed in ''covid-area''). staggering staff into team shifts minimizes impact of large exposures or full team exposures. geographic isolation of covid-19 positive patients should occur in designated suites only, in order to minimize different room exposures and familiarize cleaning staff with the same rooms. our ir service is equipped with 2 angiographic suites; during the peak pandemic, only one remained open, mainly because technical and nursing staff were recruited elsewhere where more staff were needed. this approach facilitates cleaning protocols and limits the transit between the 2 rooms. modern angiographic suites may be equipped with a ventilation system similar to operating rooms; especially pressurized positive air has a vertical airflow and 12-15 air exchanges in the angiosuite per hour. based on the available evidence, and as reported above, the covid-19 virus is transmitted between people through close contact and droplets, exposure to particles in the air, or after touching contaminated objects and surfaces [2] . consultation with local epidemiology expertise should be undertaken to assess the status of current suite ventilation, and whether positive, negative, filtered, or recirculating air is present. such knowledge can assist in the development of specific and standardized workflow protocols that match the ventilation requirements to the degree of specific isolation. that being said, covid isolation in the angiosuites may not require dedicated extra ventilation systems. however, high efficiency particulate air (hepa) filtration systems in the angiographic suites may represent the best way to protect staff. dedicated negative pressure rooms with air filtration may be ideal for covid, especially in procedure rooms, but potentially also in waiting rooms, bathrooms and soiled equipment or decontamination rooms, when feasible. enhanced workflows within procedural suites should be structured so that each member is clear about their role. the world health organization (who) recommends the use of appropriate ppe for standard, contact and airborne precautions [4] ( fig. 2a-c) . aerosol-generating procedures usually performed in an angiographic suite may include biopsy, fine needle aspiration, insertion of nasogastric or naso-jejunal feeding tubes, percutaneous gastrostomy, esophageal, gastric or duodenal dilatation and/or stenting, tracheal dilatation and/or stenting, and bronchial artery embolization (for the risk of heavy bouts of coughing due to hemoptysis) [5] . for thoracentesis or paracentesis sample preparations, transfer should be avoided, or if absolutely necessary, be performed with needle tip below fluid surfaces to minimize aerosolization. when carrying out these procedures on covid-19 patients, the who recommends n95 or ffp2 standard masks or equivalent, and gowns, gloves, eye protection, aprons and shoe covers [4, 6] . n95 masks are equivalent to ppe masks, designed to achieve a very close facial fit and protect the wearer from airborne particles; they are tested to block at least 95% of very small (0.3 l) test particles. ffp2 masks have a minimum of 94% filtration of particles (0.4 l) percentage (fig. 3) . according to the internal guidelines of our hospital, all staff members and every person operating in the same room as a positive or suspected covid-19 patient have to wear n95 or ffp2 masks. moreover, all non-intubated patients who are either infected, or suspected of infection, who arrive in the ir service must wear a ffp2 mask, and should undergo patient hand washing prior to arrival. remember that airway manipulation and intubation may represent special added risk circumstances and that this may of course occur urgently. powered air-purifying respirator (papr) is a positive pressure respirator system that protects inhalation of harmful substances. it is a battery-driven blower mounted in a helmet, equipped with a mask and eye protection. the blower is equipped with filters depending on the type of hazard present (e.g., chemical, biological, radiological, nuclear agents) [5] . in singapore in 2003, during severe acute respiratory syndrome (sars) outbreak, services used hepa filters with 99.97% filtering efficiency for particles 0.3 lm or larger [5] . papr in angiographic suites was used in 2003 for sars, as well as today for multi-drug resistant tuberculosis and contagious aerosol-generating procedures associated with covid-19/sars-cov-2 infection. however, there are constant updates about covid-19 and therefore recommendations may change in the immediate future, so attention to who and cdc and other global authority websites is recommended [6] [7] [8] [9] . several websites are indicated in table 1 . these measures may add to the complexity and duration of a procedure. fortunately, this is only in the initial period, as most individuals have been able to adapt and improve with time, as well as to develop practice and familiarity. sterility should not be compromised as a result of donning and removing ppe. practice minimizes self-contaminations during doffing, as well as sterility breakdowns. electronic training is also beneficial for safe doffing, especially where glove doffing may easily self-contaminate staff. in many cases, during ir procedures it is a common practice for staff to leave the suite and stay in the control room during image acquisitions to limit radiation exposure. on balance, we believe it is advisable for staff to stay inside the angiosuite protected by lead shields to avoid cross-contamination of less adequately protected staff outside the suite or in the control room. the doors of the positive pressure interventional suite must be closed during the entire procedure to prevent contamination. to minimize the in and out movement from the potentially contaminated room, the staff must remain close to the angiographic table with ppe and sterile equipment. a radiographer, with full ppe but non-sterile, could help control the angiographic table and any additional equipment. one or two more staff members, a radiographer and/ or a nurse, may be stationed outside the angiographic room to help and assist the staff in the room (communication should be done by microphone, if available), without room to room travel. although ir conditions do not recapitulate clinical, environmental, nor human-to-human transmission modes of coronavirus, a very recent report studied aerosolized virus in the experimental setting [3] . the virus remains viable for days on surfaces, and although fomite transmission is plausible, there is no definitive consensus at the moment. viable virus was detected in a lab setting in the air 3 h post-aerosolization and up to 6 h later on copper, 24 h on cardboard, and 2-3 days on stainless steel or plastic such as polypropylene. aerosol virus half-life was 2.7 h, while the half-life on steel was 13 h and 16 h on plastic. this information may have profound implications for room decontamination between ir procedures, surgery, or even imaging, but it remains unclear how this might specifically translate into decontamination practices or standard operating procedures [3] . in the present document, we can only refer to precautions adopted in ir services in the affected areas. at the end of the procedure, the staff leaves the procedure room. healthcare workers (ir, radiographer and nurse) are required to remove the ppe using the adjacent small room, in order to avoid contamination of themselves or their colleagues (fig. 4) . used ppe must be collected in dedicated disposal bags. access to the workstations in the reporting area and the writing of the post-procedure report by the ir are only allowed after removal of the ppe and proper hand washing. strict personal discipline is needed. correct cleaning of the imaging equipment and the proper disposal of instruments and supplies must be ensured. non-disposable instruments must be put in antiseptic solution before sterilization. staff cleaning the room are required to have medical masks, gowns, heavy duty gloves, eye protection (if risk of splash from organic material or chemicals), and boots or closed work shoes [4] . room cleaning should be delayed, if the patient fluctuation volumes allow, to allow time for air exchange. an ideal time delay may be set for room cleaning between patients, but depends on local, national, and/or global guidelines. see ventilation section for guidance, and consult with and follow local epidemiology guidelines and policies. some centers will delay one hour before allowing cleaning staff to even enter the room, and cleaning staff are required to wear masks. exposed surfaces in the angiosuite, including monitors, keyboards and console panels, must be cleaned with 70% ethanol or chlorhexidine-ethanol wipes. floors must be cleaned with disinfectant (1:40 diluted bleach, sodium hypochlorite 1/1000 ppm). taking down the sterile drapes and wiping down surfaces takes approximately 30 min. immediately after, the room needs to be ventilated for a specific amount of time (consult with local standard operating procedures for time, but typically is at least 30-60 min). waiting another 30 min with a closed door may be recommended before the next patient can access the room. vacuuming floors is contraindicated, in order to reduce risk of aerosolization of potentially infectious material. room turn-over takes about 90 min. ultrasound-guided interventions should be performed at the patient's bedside in their negative flow isolation room to minimize movement of infected patients, and the associated risk of nosocomial transmission of infection. therefore, ultrasound (us) should become the modality of choice for image guidance in an increasing number of interventions. the us machine must be completely protected with clear transparent plastic before it enters the patient's room. the procedure can be normally carried out after covering the transducer with a sterile probe cover. sterile probe cover should be carefully placed, with attention to reduction of contamination risk, or 2 probe covers may be used. strict attention to probe cover removal is required post-procedure (with full ppe and eye protection) to avoid contamination. at the end of the procedure, the plastic covers must be removed and thrown away before leaving the room, with strict decontamination. all equipment must be cleaned with chlorhexidine-ethanol wipes, including the wheels of the ultrasound equipment. dedicated ultrasound equipment should be marked and sequestered for contaminated use and decontamination cycles. the control measures described are important to minimize intra-institutional spread of sars-cov-2 and covid-19, and should not be underestimated, nor taken as set in stone. guidelines will evolve and will have local variations. consult frequently with your local hospital policies, infectious diseases, and epidemiology services. call them when in doubt. pre-, intra-and post-procedural approaches for ir workflow have been described in the setting of an ir unit highly exposed to covid-19 (table 2 ). in our department until now, no incidents between non-infected sars-cov-2 viral load in upper respiratory specimens of 186 infected patients aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 rational use of personal protective equipment for coronavirus disease 2019 (covid-19): interim guidance is your interventional radiology service ready for sars?: the singapore experience anesthetic management of patients with suspected 2019 novel coronavirus infection during emergency procedures radiology department preparedness for covid-19: radiology scientific expert panel what is needed to make interventional radiology ready for covid-19? lessons from sars-cov epidemic dã©jã  vu or jamais vu? how the severe acute respiratory syndrome experience influenced a singapore radiology department's response to the coronavirus disease (covid-19) epidemic acknowledgements the opinions are those of the authors in their personal capacity and do not necessarily represent the opinions of the national institutes of health nor the us government.funding no fundings have been received for the present paper. conflict of interest authors declare that they have no conflict of interest.ethical approval all procedures performed were in accordance with the ethical standards of the institutional research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards.informed consent not applicable.consent for publication all authors give their consent for publication. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. non-essential and mobile equipment should be moved out of the angiographic suite. fixed and essential contact surfaces need to be covered with clear drapes 6 careful hand hygiene, correct wearing of protective equipment, n95 or ffp2 masks and gowns, gloves, eye protection, aprons and shoe covers, are recommended 7reduce at minimum secretaries, office workers and employers in the administrative areas of the ir service to limit their exposition is strongly suggested 8 likewise, interventional radiologists rotations (possibly per week) are necessary to limit their exposition 9locations where the operators should dress and undress are separate 10 all non-intubated patients who arrive in the ir service must wear a ffp2 mask 11 used ppe must be collected in dedicated disposal bags key: cord-272585-346ef6qy authors: lombardi, jm; bottiglieri, t; desai, n; riew, kd; boddapati, v; weller, m; bourgois, c; mcchrystal, s; lehman, ra title: addressing a national crisis: the spine hospital and department's response to the covid-19 pandemic in new york city date: 2020-05-31 journal: spine j doi: 10.1016/j.spinee.2020.05.539 sha: doc_id: 272585 cord_uid: 346ef6qy in a very brief period, the covid-19 pandemic has swept across the planet leaving governments, societies and healthcare systems unprepared and under-resourced. new york city now represents the global viral epicenter with roughly one third of all mortalities in the united states. to date, our hospital has treated thousands of covid-19 positive patients and sits at the forefront of the united states response to this pandemic. the goal of this paper is to share the lessons learned by our spine division during a crisis when hospital resources and personnel are stretched thin. such experiences include management of elective and emergent cases, outpatient clinics, physician redeployment and general health and wellness. as peak infections spread across the united states, we hope this article will serve as a resource for other spine departments on how to manage patient care and healthcare worker deployment during the covid-19 crisis. although from an early age i'd learned from charles darwin and others that species adapt naturally to their environment, in the moment, that adaptation is often a painful process. the onset of covid-19 and the changes forced upon us by science, common sense, and our survival instinct have been a strong reminder of the challenges true adaptation involves. this spring's events have felt familiar to me -i'd already lived a similar experience. in the first weeks after taking command of joint special operations command (jsoc), it became apparent we were losing the battle to al qaeda in iraq (aqi). jsoc, america's elite counter-terrorist task force, was built to operate in small teams conducting elegant, but infrequent, precise strikes. we were the most efficient and effective counter terrorism force in existence -but we were not adaptable. we'd never really had to be. al qaeda in iraq (aqi), however, changed the rules by morphing faster than our slow, but precise, operations could counter. a target, or fleeting opportunity, that was located in the morning was typically gone by evening. against an enemy that operated differently than anything we had seen before, we had to change. unsure of what the right answer was, we started from the reality that the one course of action for which we had reliable data, the status quo, was failing. so, we adopted a policy of "question how we do everything". nothing was held sacredwe needed to find out what worked to defeat aqi and we needed to do it quickly. it was disconcertingly disruptive for a force inclined to developing and then refining to near perfection our tactics, but it worked. we iterated adaptations until jsoc became instinctively flexible and wickedly fast. the reality for most organizations is that they do not adapt until they are forced to do so. what is often touted as a leader's foresight or vision was really driven by the reality of a burning platformchange or grow irrelevant; adapt or die. for america's healthcare teams, the fight against covid-19 is not just the search for a vaccine or management of ventilators. it is adapting every aspect of managing the care of patients. leveraging virtual interaction, mining growing bodies of data, and realizing that not all care will wait until we return to status quo anteit has to continue on now, but safely. and it must be delivered by healthcare professionals who are performing the extraordinarily complex tasks they always have, but now in the vastly more difficult covid-19 environment. all this is doable, because it has to be. it's also possible because the patient-centric mindset that drives the people who've chosen to care for others will drive it. it isn't easy and won't get much easier -but it's working and will only get better. on december 31 st , 2019, local health officials in the chinese province of hubei reported 41 cases of a mysterious pneumonia to the world health organization (who) 1 . while viral pneumonias are commonplace, this cluster was particularly unusual in that a high percentage of patients was responding poorly to typical supportive measures and becoming critically ill. it was soon recognized that this illness was being caused by a never-before-seen coronavirus subsequently named the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) with its infectious manifestation termed the coronavirus disease 2019 (covid-19) 2-3 . the outbreak was reportedly centered on a wet market in the city of wuhan, china, but quickly spread 4 the speed and intensity with which the virus spread has left governments and healthcare systems unprepared, under-resourced and without enough personnel to adequately respond. particularly hard hit has been new york city, which is now one of the global viral epicenters. as of april 28 th , there were a staggering 17,682 mortalities in new york city alone, representing over 30% of all covid-19-related deaths in the united states 6 . according to the university of washington's institute for health metrics and evaluation (ihme), the peak hospitalization rate in new york will occur during the second week of april, preceding the majority of the united states 7 . our institution has been on the forefront of the covid-19 pandemic, as we treated "patient zero" in new york city, who presented to our emergency department (ed) on february 28 th . to date, we have treated over 5,000 covid-19 positive inpatients in the epicenter of the viral pandemic with strained resources. our experiences may serve as a model for other institutions to prepare as their regions approach peak infection. therefore, the purpose of this paper was to describe our orthopaedic departments' approach towards 1) management of elective cases and outpatient visits, 2) management of "emergent" surgical cases, 3) redeployment of orthopaedic personnel, and lastly 4) maintaining protection and well-being within the department. published data by healthcare providers in asia and europe demonstrated that the most substantial threat to covid-19 patient morbidity and mortality was the lack of adequate critical care resources including intensive care unit (icu) beds and respiratory support [8] [9] . early reports from lombardy, italy, exposed the strain of widespread community transmission on hospital icu capacity 10 consultation or a telemedicine consultation. telemedicine visits were found to be noninferior with 98% of virtual visits rated as "good" or "very good" by surgeons 23 there can be ambiguity when attempting to determine which surgical procedures are elective, urgent or emergent. additionally, conflict may arise among healthcare providers when attempting to prioritize cases in the setting of severely limited personnel, resources and ventilators. therefore, our institution sought to create a two-step process to determine both the urgency of cases and the order in which they should proceed. first, a directive was given to create clear guidelines for determining surgical urgency from both an institutional as well as a departmental/divisional standpoint. those cases that met institutional and departmental criteria were then directed to an independent hospital panel that would determine their priority. at the time all elective cases were cancelled, our institution published criteria for case escalation, which would serve as a basis for categorizing the urgency of cases across all sites. (figure 2 ) emergent cases were classified as those that are life or limb-threatening and would require access to the operating room within 30 minutes. these cases would allow for "bumping" of any service into any available operating room when applicable. urgent cases were defined as those requiring an operating room within eight hours and would allow for "bumping" within their surgical service (i.e. orthopaedics bumps orthopaedics). add-on cases were defined as those that should be performed within 24-48 hours, lending priority to long bone fractures. lastly, the "to consider" classification was given to those patients whose cases were not time sensitive, but whose discharge from the hospital was pending surgical intervention. the institution published a sample list of cases across all specialties and where they fall into the criteria for escalation. to date, there are no published articles detailing how to best allocate resources and prioritize urgent/emergent cases within a spine division during times of crisis. on april anonymous to the public and employees of our institution. we have received many calls from colleagues across the country whose hospitals have established an intradepartmental committee to determine which cases are urgent or semi-emergent. yet without anonymity, it is impossible to remove personal interests from the decisionmaking, which may be at odds with key members of the team. when making decisions on the urgency and priority of cases, this committee takes into account guidelines from the cdc, who, new york state department of health and new york city department of health, as well as appropriate subspecialty academy guidelines. in an environment with limited hospital resources and personnel, this committee serves to remove the ethical and legal burden from surgeons while also serving the best interests of not only the patient but also the community as a whole. it is important to note that there are limitations to this system, which include review of cases by surgeons and/or lay people that is outside of their direct area of expertise. 30 . it is not currently the standard of care for surgeons to be wearing n95 masks while operating, thus potentially exposing them to substantial risk in the period following intubation. with this understanding, the use of n95 masks and full-face shields has quickly become implemented into our operative ppe protocol. in an effort to protect both our patients as well as our staff, our institution has mandated that all patients be tested for covid-19 with a nasal swab viral pcr when admitted to the hospital and prior to proceeding to the operating room. recognizing these potentially devastating risks to the operative team, our department developed a protocol in conjunction with the department of anesthesia that is designed to minimize exposure to aerosolized viral particles. we identified three distinct phases during the surgical episode where attention should be paid in order to limit transmission: 1) or preparation, 2) intubation and 3) extubation. during this phase, one should remove all non-essential equipment from the operating room such as iv poles, iv pumps, rapid infusor systems, suture cart etc. medication and equipment expected to be needed during the case should be removed from the anesthesia cart and the drug-dispensing unit and placed on a clean, easily wipeable surface. one should close all drawers, cover the anesthesia cart and drug-dispensing unit with a plastic drape, and try to avoid accessing it during the case. one should have emergency medication and equipment nearby in a closed bag, so it is easily accessible if needed but does not get contaminated during the procedure. the anesthesia machine has to be protected with a hepa filter. with very few exceptions, most spine surgeries require endotracheal intubation. operating rooms are a positive pressure environment. therefore it is recommended that if a negative pressure room is available, the patient should be intubated there and then transported back to the operating room. if such a room is not available, the intubation will take place in the operating room. after preparation of the or as detailed above, all non-essential personnel, including the surgical team, should leave the room. all anesthesia providers must wear ppe including n-95 masks, impermeable gowns, face shields or goggles, double gloves, shoes and head covers. additionally, a transparent drape should be placed over the patient's head, neck and shoulder area to contain the area of potential respiratory expectorants during induction. this drape can be removed after completion of the intubation process. the patient should be pre-oxygenated for several minutes. a rapid-sequence induction to achieve optimal intubating conditions in the shortest possible time is the preferred method of induction. this avoids mask ventilation with highly aerosolizing potential. a video-laryngoscope is preferred for intubations as it allows the anesthesia provider to keep greater distance from the patient's oral cavity. the endotracheal tube cuff should be inflated immediately, the endotracheal tube (ett) should be connected to the anesthesia circuit and etco2 confirmed. it is vital at this time to adequately secure the endotracheal tube. although an endotracheal intubation is an aerosolizing procedure, an unsecured airway over the whole length of the surgery may have greater potential to create aerosolized viral particles than the intubation itself. for auscultation of breath sounds a disposable stethoscope should be used. patients presenting for spine surgery, in particular surgery involving the cervical spine, frequently require other methods of securing the airway. in order to protect the patient from further injuries to a potentially unstable cervical spine or in patients with an anatomically difficult airway, a fiber-optic or an awake fiber-optic intubation is often the only safe method of endotracheal intubation. these procedures carry a very high risk of contaminating the environment by respiratory expectorants and should be avoided if possible. if necessary, they should be performed in a negative pressure environment. putting the patient in a prone position usually requires disconnection of the ett from the circuit in order to minimize risk of ett displacement. in these patients the anesthesia practitioner should carefully weigh the risk of ett displacement versus aerosolizing infectious material when disconnecting the ett. the surgical team is advised to re-enter the operating room only after the air has circulated through one cycle, which will vary depending on the specific number of air changes per hour set by that institution. the surgical team and support staff are advised to wear n95 masks throughout the procedure with appropriate eye protection. if the situation requires an awake fiber-optic intubation in the positive pressure environment of the operating room, the surgical team should consider entering the operating room after the air has circulated through several cycles in order to reduce the viral load in the air. standard ppe with an n95 respirator and eye protection is of course paramount for all practitioners entering the operating room. if a negative pressure room is available, the patient should be transferred after completion of surgery for removal of the endotracheal tube. it is recommended to cover the patient's face and upper torso with a clear plastic drape and extubate under that cover in order to avoid dispersing infectious material. standard ppe has to be worn and all non-essential personnel should leave the room, whether extubating in a negative pressure environment or in the operating room. patients should be extubated to nasal cannula, face tent or nonrebreather facemask. high flow nasal cannula and bi-pap should be avoided due to the high potential for viral aerosolization from these oxygen-supplying modalities. if possible, nebulized medications should likewise be avoided because of the highly aerosolizing nature of this application method. it became clear from an early point that the prospect of orthopaedic surgeon redeployment to other areas of need within the hospital was a distinct possibility. this was due in part to anecdotal reports of redeployment in viral epicenters as well as through correspondence with colleagues in europe and asia. moreover, on march 23 rd , the governor of new york mandated that all hospitals within the state increase their icu capacity by 50% 31 . this increase in capacity had to be met with an increase in skilled workforce including nursing staff as well as physicians. by march 28 th , exactly one month following the presentation of patient zero to our institution, the first orthopaedic team was redeployed to the ed. in order to spread the burden evenly across our department, a committee was convened by remote meeting and charged with planning redeployment strategically. it was decided to deploy teams of two providers to the ed, composed of one attending and one resident. each volunteer was asked to submit his or her age and medical comorbidities, which were kept anonymous to the rest of the department. risk factors for severe covid-19 infections were identified and included age >60, htn, dm, cv disease, obesity and immunosuppression 32 . other considerations taken into account included child-care needs and ability to quarantine from members of the household. lastly, those who had a known or suspected prior covid-19 exposure and had recovered were placed at the top of the list under the assumption that they had obtained short-term immunity, although at this time it is unclear if or when immunity to sars-cov-2 is conferred. ( figure 6 ) an antibody test, when available, will also help in the risk stratification as a significant number of healthcare workers have likely been exposed but are asymptomatic or have a mild illness with immunity. housing outside of primary residences was made available for volunteer faculty and house staff to help eliminate concerns about spreading the virus to one's family. faculty and house staff were then ranked for deployment depending on their risk stratification. it is vital to note that although redeployment was an important initiative to our department during this time of crisis, our primary concern was to maintain an adequate workforce to meet all orthopaedic surgical demands at our institution. when structuring the redeployment schedule, the risk to providers must be considered. it became clear that the number of exposures and duration of exposure should be limited to avoid overburdening clinicians in covid positive areas. while 12-24 hour shifts may be preferred among some surgeons, we advocated for shorter, 6-8 hour shifts to spread the risk out over a larger number of clinicians. the logistics of this type of deployment limit the number of times in each shift that ppe needs to be donned and doffed and also reduces fatigue. ultimately deployment shifts were split between multiple departments which further limited repeated exposure to our team. (figure 7) . these teams would rotate to ensure that needs in the ed were met at all hours of the day, every day of the week. initially, orthopaedic surgeons and urologic surgeons shared ed coverage. eventually, otolaryngology and ophthalmology joined the redeployment efforts. the staffing for these deployments should be based upon the skill set of the respective surgical services. several of the spine surgeons (and especially the neurosurgeons) have intensive care unit (icu) experience, and may be better off deployed to assist with the ventilated patients. due to aggressive measures taken by the hospital to divert low acuity patients, the total number of daily ed visits was not dramatically increased. however, the acuity of patients who necessitated prolonged icu stays rose significantly. this led to increased critical care needs within the ed and the icu. while the precise duties of redeployment vary depending on the assigned location, the overall role of the orthopaedic surgeon was to provide support to the critical care team. typical duties included obtaining arterial blood gasses for ventilated patients, placing orogastric and nasogastric tubes, assessing for adequate sedation, adjusting ventilator settings, monitoring vitals, ordering blood pressure support and sedative medications, communicating between medical and consulting teams, and even aiding in patient transport between the units. particularly challenging was the preservation of ppe due to its critically short supply. due to the virus' capacity to be aerosolized, n95 masks are recommended wherever aerosolizing procedures are commonly performed, primarily the ed and the icu 30 . these procedures include intubation, extubation, bronchoscopy, cardiopulmonary resuscitation (cpr), non-invasive positive pressure ventilation (nippv), high flow nasal cannula, and nebulization. ideally these procedures would be performed in a negative pressure room, but with the high volume of patients necessitating these procedures in the ed it was not deemed possible. given the significant shortage of ppe, each provider was given one n95 mask at the beginning of his/her shift and expected to wear that mask throughout the shift or until it was visibly soiled. in order to prevent the n95 from becoming contaminated by droplets, it was covered with a typical surgical mask followed by a face shield. when the n95 mask had to be removed, such as for eating or drinking outside of the unit, the surgical mask would be replaced, allowing the respirator to be in times of crisis, the similarities between physicians and soldiers become more evident. both professions play an irreplaceable role in our society, seeking to serve for the greater good of the public. the following lessons have been adapted from soldiers' accounts in the battlefield and applied to our experiences during the covid-19 pandemic 33 . 1. embrace the buddy system: the environment that healthcare providers face during the covid-19 pandemic will in many ways be unfamiliar. this includes exposure to a novel pathogen that can endanger the health of physicians working on the front line. having a "battle buddy" will serve as a physical and psychological crutch to keep providers out of harm's way. during our department's redeployment, battle buddies were charged with making sure their partner always had proper ppe, maintained safe procedural practices, and assisted in collective medical decision-making. 2. prepare for the unexpected: rarely in our nation's history have healthcare systems been stretched so thin in such a short amount of time. it is vital for departments to remain flexible and prepared for worst-case scenarios. this includes lack of adequate ppe, team members unable to contribute due to illness, surges of new patients and absence of typical support staff. taking the time to reflect on "what can go wrong" will enable institutions and departments to be better prepared. 3. this is a team effort: in every organization there are members who contribute to varying degrees. it is vital for the leaders in each department to recognize what each of their members' strengths and weaknesses are and to utilize them appropriately. by involving the entire department in decision making and redeployment, leaders can achieve camaraderie and a common sense of purpose. in our department, we recognized who was at higher risk for complications from the covid-19 pandemic and deprioritized them for redeployment. those providers instead increased their telemedicine visits as their primary contribution. our department recognized the dangers that fatigue can have on physicians who were deployed to covid positive areas. any lapse in stringent airborne and droplet precautions can have catastrophic repercussions. for this reason we implemented battle buddies, abbreviated and rotating shifts, and frequent breaks into our redeployment plan. time away from the hospital also helped to alleviate the emotional or psychological stressors that physicians were exposed to. it has been shown that in times of national and international disasters, there can be an increased mental health burden on the population 34 city, such as the september 11 th attacks, task forces were assembled for crisis management. similarly, population-based strategies are currently being employed today. on a more individual level, our department started a "buddy" system, as described previously, at the beginning of the isolation period to ensure active engagement with peers. we also established connections with our departments of psychology and psychiatry for individuals to engage with mental health support as needed. engagement of faculty with meetings arranged through teleconference platforms was implemented early on to maintain education and peer interaction. throughout the covid-19 pandemic, in an effort to maintain resident learning and training, our department has continued all educational conferences by use of teleconference software. this includes departmental meetings such as the monthly morbidity and mortality conference. the och spine hospital began with monday and wednesday morning educational video teleconferences, and maintained our usual wednesday "huddle" (rotating between research meetings, morbidity and mortality conference, attending meetings and high-risk case conferences). additionally, we have established a wednesday morning national educational series among several institutions, and a thursday evening meeting that is attended by over 200 surgeons worldwide. these allow us to maintain our national and international platform, and garner information from other institutions that are at different stages of the pandemic. it is important to note that social distancing for healthcare workers also includes distancing within the home. we have recommended that clinicians who are redeployed pack a second set of clothes to change into after doffing the uniform they used to treat the covid-19 positive patients. they are recommended to then remove those clothes prior to entering their home, sometimes through an accessory entrance if possible, and place everything in a laundry bag to be immediately cleaned. they should then proceed immediately to the shower to decontaminate. it is recommended to use a different bathroom than other occupants in the household. if this is not possible, one should immediately clean the bathroom with disinfectant after use. surgical masks are donned in the home and social distancing during meals and other interactions should apply. if allowable, one should sleep in a separate part of the house or apartment. some clinicians prefer housing quarters away from the home although this has not been explicitly recommended by health authorities. each institution should attempt to provide resources for available housing. it is well documented that routine physical activity can have a profound impact on both overall health as well as mental wellbeing [36] [37] . this is particularly true when socially isolating and remaining less active at home. multiple phone and computer applications are available to help stimulate physical activity routines 38 . it is advisable to decrease regular exercise routines to 75% of the prior level of fitness to help stimulate the immune system and avoid paradoxical immunosuppression 39 . regular nutrition and hydration are also necessary for optimal performance. part of the rationale for recommending a shorter duration of shifts is to avoid dehydration or the repeated donning/doffing that would be required over the course of a 12-hour shift to maintain adequate hydration and nutrition. physicians and surgeons often work continuously without a break in crisis scenarios and busy wards, leading to depletion of glycogen stores and dehydration. if one must work longer shifts, administrators should be sure to have a safe space for doffing and storing ppe for hydration and snack breaks. additionally, supplying food can help to increase the likelihood that clinicians will eat during a long shift. while we are hopefully nearing the apex of the curve in new york city, we know from other countries that this pandemic and its devastating effects will continue to roll across the united states in the coming months. we wanted to write this paper to provide some basic guidance, tips and pearls that we have learned as the "tip of the spear" in our country's fight against the pandemic. we recognize that the above recommendations are the product of clinical expertise at a single institution with currently limited knowledge of the covid-19 pathogen. as such, treatment protocols, resource utilization and deployment strategies are likely to change as more is understood about this disease process and the unique challenges it places on every affected institution. looking ahead, we know life will forever be different. similar to the world wars and 9/11, these events transform our very fabric of existence. as general mcchrystal stated in the foreword, in combating any enemy, an age-old axiom is to "improvise, adapt and overcome." indeed, the resiliency of the american spirit and those of our healthcare heroes will eventually overcome this invisible enemy. it will now be up to our country's leadership to prepare for the next catastrophe, pandemic, war or other challenge. we will be better prepared next time, and hope this experience serves to inform hospital systems across the united states and the rest of the world. as george santayana stated in 1905, and winston churchill paraphrased in his speech in 1948, "those who fail to learn from history are condemned to repeat it." early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia a new coronavirus associated with human respiratory disease in china clinical characteristics of coronavirus disease 2019 in china a pneumonia outbreak associated with a new coronavirus of probable bat origin who declares covid-19 a pandemic novel coronavirus and orthopaedic surgery: early experiences from singapore papa giovanni xxiii bergamo hospital at the time of the covid-19 outbreak: letter from the warfront critical care utilization for the covid-19 outbreak in lombardy, italy: early experience and forecast during an emergency response the coronavirus disease 2019 global pandemic: a neurosurgical treatment algorithm aaos guidelines for elective surgery during the covid-19 pandemic. available at association asc: statement from the ambulatory surgery center association regarding elective surgery and covid-19 trend of spine surgeries in the outpatient hospital setting versus ambulatory surgical center national trends in ambulatory surgery for intervertebral disc disorders and spinal stenosis: a 12-year analysis of the national surveys of ambulatory surgery population-based trends in volumes and rates of ambulatory lumbar spine surgery. spine (phila pa 1976) medicare telemedicine healthcare provider fact sheet telemedicine and emerging technologies for health care in allergy/immunology inpatient teledermatology: diagnostic and therapeutic concordance among a hospitalist, dermatologist, and teledermatologist using store-and-forward teledermatology a retrospective cohort study to assess the impact of an inpatient infectious disease telemedicine consultation service on hospital and patient outcomes robot assisted surgical ward rounds: virtually always there telemedicine and orthopaedic care. a review of 2 years of experience quality of care for remote orthopaedic consultations using telemedicine: a randomised controlled trial. bmc health services research telemedicine through the use of digital cell phone technology in pediatric neurosurgery: a case series covid-19 guidelines for triage of orthopaedic patients urgent and emergent cases the orthopaedic forum survey of covid-19 disease among orthopaedic surgeons in wuhan, people's republic of china the oral surgery response to coronavirus disease (covid-19). keep calm and carry on coronavirus (covid-19) outbreak: what the department of endoscopy should know aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 new york state mandates an increase in hospital bed capacity clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study. the lancet ten tips for a crisis: lessons from a soldier psychological interventions in times of crisis mental health status of doctors and nurses during covid-19 epidemic in china. available at ssrn 3551329 a meta-analysis of physical activity in the prevention of coronary heart disease the influence of physical activity on mental well-being. public health nutrition the 10 best fitness apps exhaustive submaximal endurance and resistance exercises induce temporary immunosuppression via physical and oxidative stress key: cord-026765-cw4rh1on authors: dingle, m.; irshad, h.; mckernon, s.; taylor, k. title: altered exodontia techniques date: 2020-06-12 journal: br dent j doi: 10.1038/s41415-020-1726-0 sha: doc_id: 26765 cord_uid: cw4rh1on nan excipients apart from water. this has reduced the product expiration to 28 days, however this will be extended in due course as the solution is self-preserving. we have followed the s. j. challacombe et al. dosing protocols as accurately as possible (to standardise the dosing), and we anticipate the that the product will be available mid-may, initially in a 5l presentation, primarily for dentists, while a nasal and throat spray will follow in late may primarily for pre-procedural use in the hospital setting. while it cannot now be claimed that my position is unbiased, i can claim my intention from the start of this project was to find a low cost intervention to potentially break the link of patient to healthcare worker transmission. it has been very pleasing to have one's research intention and findings validated by s. j. challacombe et al., amongst others, and it is these validations that have motivated and enabled the speedy provision of ready to use povidone iodine for dentists and for preprocedural applications in the hospital setting. j following an intensive exploration regarding the use of videne as a potential product, we came to the conclusion that it is preferential to completely avoid phenol, a component of videne, as this represents an unnecessary risk. we have therefore produced a product in partnership with a pharmacy specials nhs manufacturer, which contains no sir, we write to inform your readers about techniques for non-surgical exodontia we have adapted to at liverpool university dental hospital during the covid-19 pandemic. as part of the avoidance of aerosol generating sir, i am the chief of dentistry at a tertiary care hospital in the biggest metropolis of pakistan. the first documented case of covid-19 in our country was reported in late february at our very own hospital. as cases in our population grew the dental clinic went on an emergency only protocol and to date we have provided dental care to almost 500 patients and performed approximately over 100 dental emergency procedures. during this period we also had 11 patients who subsequently underwent covid-19 testing for various non-dental reasons; later, two patient visits were verified as confirmed covid-19 cases. whilst the average infection rate for our surgery colleagues at the hospital was 20%, the dental clinic has had zero infections amongst 60 dental staff members including faculty and residents. 1 this fortuitousness can be attributed to strict administrative and engineering controls, and provision of adequate personal protective equipment (ppe) immediately after consulting recommendations which came out from national health services and the american dental association. sir, social distancing measures are predicted to last for some time but networking and faceto-face contact have always been important in the world of dentistry. for example, picking up and trying on a pair of loupes at a trade show cannot be emulated over the internet. ideally, the exhibition industry will return to its pre-covid-19 status. yet, social distancing may well become a way of life, and in that case it will be interesting to see the effect on the future of dental events. n. axiotis, l. benson, manchester, uk https://doi.org/10.1038/s41415-020-1749-6 special attention towards ppe and initiating a respiratory programme including fit testing for all our dental staff were key elements of our success. 2 furthermore, donning and doffing measures for ppe were reinforced to all staff members; adequate training via online meetings and hands-on exercises were provided; and each staff member was asked to observe one another and provide constructive feedback to improve these procedures every day. i would also like to acknowledge the unwavering support from our leadership and department of infection control during this pandemic; the provision of an adequate supply of ppe was dynamically managed and stocked up, which went a long way towards uplifting staff morale. as there is still limited understanding of the covid-19 disease, it is important to share the learnings from our experiences to help build the evidence-base. once any new guidelines come into place we can recalibrate our responses and adjust our priorities. f. umer sir, i would like to share my thoughts and experiences on how covid-19 has affected me as a year 13 student, applying to university to study dentistry this september. unfortunately our a-level examinations have been cancelled this summer. this means that instead of receiving our final grades, determining meeting our offers for university, our results will be based on grades predicted by our teachers based on past exams and schoolwork. if we are not satisfied with our predicted grades on a-level results day, we have the option to appeal and sit alternative exams during the autumn or next year. therefore, we were advised by our schools to continue revising to complete the specification of our subjects in case the appeal process is necessary. this circumstance of a retake will probably void our current university offers. i am majorly concerned about being successfully admitted to dental school this september, having already battled through the incredibly competitive personal statement, interview process and securing my offer. my fellow students and i are experiencing a number of difficulties. we are also troubled about our early dental school career possibly being spent in lockdown instead of in university, as i understand the importance of being orientated with the introduction of the course and the onsite facilities available. this is particularly essential for first year students. sir, now that roche's sars-cov-2 antibody test has been approved by public health england, might it be reasonable for dental practice generally and sdcep in particular to take this into consideration? a patient who has tested positive could be viewed as reasonably safe for agps, with normal ppe. i do understand that we have a lot still to learn, but we need some decent working hypotheses. in the larger picture, we might be able to help roll out broader testing, take the load off our medical colleagues and help the public and especially the nhs and carers get back to work safely. this is in line with scottish government policy. 1 dental patients could also be tested on their examination appointment by the dentist; results are rapid and follow up could be quickly organised to book positive patients in for agps. dentists will need some phlebotomy training. many of us have experience in this but may need updating and being taught the specific requirements of the elecsys anti-sars-cov-2 serology test; others do not have such experience and will need a somewhat more extended course. perhaps the practicalities of such training could be investigated by nes. in scotland a mechanism for reimbursement already exists within the sdr; 3601 -taking of material for pathological examination: per course of treatment £14.00 (£11.20). this would be a good mechanism for reporting results via practitioners' services, to the wider nhs and sir, the region of madrid (population 6.6 million) is one of europe's regions most affected by covid-19 with around 60,000 cases officially reported (beginning of may). on 14 march 2020 the spanish government decreed a state of alarm under which the whole population was subjected to compulsory home confinement. a few days later, the general dental council of spain advised that due to a general shortage of ppe, practices which do not have this equipment available would immediately cease to operate, including cases involving dental emergencies. consequently, only 5% of the dental clinics remained open for urgent dental care. we present a preliminary analysis of some aspects of urgent dental care performed by a dentist in this region (17 march-3 may) who was on call 24 hours a day, six days a week, with the support of an assistant. before an appointment patients underwent a telephone interview by the dentist; none reported covid-19 symptoms nor contact with infected persons. following this protocol, patients were then seen at the practice within one hour. some 25% were treated between midnight and 6 am. the time span between the presentation of symptoms and the request for urgent consultation was usually over ten days. the majority of patients (75%) had received treatment involving only the usual medication. at all times, the dentist used appropriate ppe, minimising the use of aerosol generating procedures. total patients seen were 187 (98 women; 89 men; aged 20 months-87 years). seven were children under the age of 12 and 12 were over 75. the most common diagnosis (50%) was acute periapical periodontitis, with associated abscess (19% of cases), irreversible pulpitis (13%), complications of third molar pericoronitis (7%), periodontal abscesses procedures (agps) we have been avoiding the use of a surgical handpiece where possible, removing bone with rongeurs, bone chisel/ osteotome (with a mallet) and bone files and using chisels to divide teeth (with a mallet). 1 the importance of a good pre-operative clinical and radiographic assessment as well as fully informing the patient of potential treatment and risks involved is essential. these older techniques are useful to avoid additional ppe issues and environmental issues associated with agps. m. dingle, h. irshad, s. mckernon, k. taylor, liverpool, uk change in surgical practice amidst covid 19; example from a tertiary care centre in pakistan role of respirators in controlling the spread of novel coronavirus (covid-19) among dental health care providers: a review coronavirus covid-19 impacts to dentistry and potential salivary diagnosis key: cord-299346-f13xly6q authors: awad, mohamed e.; rumley, jacob c.l.; vazquez, jose a.; devine, john g. title: perioperative considerations in urgent surgical care of suspected and confirmed coronavirus disease 2019 orthopaedic patients: operating room protocols and recommendations in the current coronavirus disease 2019 pandemic date: 2020-04-10 journal: j am acad orthop surg doi: 10.5435/jaaos-d-20-00227 sha: doc_id: 299346 cord_uid: f13xly6q by april 7, 2020, severe acute respiratory syndrome coronavirus 2 was responsible for 1,383,436 confirmed cases of coronavirus disease 2019 (covid-19), involving 209 countries around the world; 378,881 cases have been confirmed in the united states. during this pandemic, the urgent surgical requirements will not stop. as an example, the most recent centers of disease control and prevention reports estimate that there are 2.8 million trauma patients hospitalized in the united states. these data illustrate an increase in the likelihood of encountering urgent surgical patients with either clinically suspected or confirmed covid-19 in the near future. preparation for a pandemic involves considering the different levels in the hierarchy of controls and the different phases of the pandemic. apart from the fact that this pandemic certainly involves many important health, economic, and community ramifications, it also requires several initiatives to mandate what measures are most appropriate to prepare for mitigating the occupational risks. this article provides evidence-based recommendations and measures for the appropriate personal protective equipment for different clinical and surgical activities in various settings. to reduce the occupational risk in treating suspected or confirmed covid-19 urgent orthopaedic patients, recommended precautions and preventive actions (triage area, ed consultation room, induction room, operating room, and recovery room) are reviewed. many guidelines and recommendations have been established to reduce the occupational risk while educating surgeons to make them better prepared to operate on hiv-positive patients. 2 the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease 2019 ), which seems to be highly contagious and has easily spread worldwide, is a much different virus causing a much different disease. orthopaedic surgeons should be fully aware of the current situation regarding the covid-19 pandemic and prepare to take proper precautions against the occupational risk of exposure, especially in asymptomatic and mildly symptomatic surgical patients. by april 7, 2020, the sars-cov-2 was responsible for 1,383,436 confirmed cases of covid-19, involving 209 countries around the world; 378,881 cases have been confirmed in the united states. as an example, centers of disease control and prevention (cdc) reports an estimated 2.8 million trauma patients hospitalized in the united states. in addition, 791,000 older patients are treated in emergency departments for fall injuries each year. 3 gleaning from the trauma literature, these data suggest an increased likelihood of engaging in covid-19 orthopaedic patients in our hospitals. thousands of healthcare providers (hcp) have been infected with covid-19, despite their adherence to infection control measures. 4 approximately 14% of spain's confirmed cases are in medical professionals, per the spanish minister of health. despite the current definitions for diagnosing symptomatic covid-19 patients, the transmission from an asymptomatic carrier has been documented between 25% and 50%. 5 it is necessary for the orthopaedic community to be prepared for this global pandemic emergency. this is an occupational hazard not only to orthopaedic surgeons and other health-care providers but also to the families and neighbors of exposed healthcare providers. there is still no definitive consensus of the pandemics' behavior, covid-19 mode of transmission, diagnostic criteria, and management protocols. preparation for a pandemic involves considering the increasing levels of protection and infection control and how they should be implemented during different phases of the pandemic. in the or setting, these measures include the following: modification of healthcare infrastructure and processes, educating staff and patients, implementing infection control strategies, and administrative and clinical measures. the surgical management of traumatic injuries requires a complex environment with multiple stakeholders including surgeons, anesthesiologists, nurses, or attendants, and medical staff; it can be a real challenge to align the perspectives and concerns of all parties the primary aim of this article is to help define the covid-19 crisis and discuss effective management strategies. this article provides a brief summary of the current situation and understanding of the pandemic, diagnostic criteria, and attempts to forecast the extent and prognosis. finally, recommending precautions and preventive actions to reduce the occupational risk in treating clinically suspected/confirmed covid-19 surgical patients. the cdc and world health organization instituted guidelines for routine infection prevention measures after the worldwide spread of the sars-cov-2 virus. hcp are recommended to wear a simple surgical mask and perform regular hand washing when contacting low-risk individuals to protect against contamination. hcps in high-risk areas should adhere to infection prevention and control practices, which includes the appropriate use of engineering controls (negative pressure rooms), administrative controls, and personal protective equipment (ppe) ( to minimize the risk of transmissibility and cross-infection, the cdc has recommended airborne, droplet, and contact precautions. this includes the mandatory use of ppe which includes gowns, gloves, face masks, and either n-95, p100, or ffp2 respirators with a face shield/googles or powered air-purifying respirator (papr) to minimize the risk of transmissibility and cross-infection. 6 per cdc recommendations, a clinically suspected/ confirmed covid-19 patient should wear a cloth face covering, over nose, and mouth and a surgical mask should be reserved for hcp and first responders. 6 unfortunately, these ppe recommendations for both providers and patients will fail to prevent transmission if frequent surfaces decontamination, enhanced aq : 4 hand hygiene, and avoiding self-contamination are not carefully considered. providers must focus on meticulous hand hygiene and disinfecting personal items, such as stethoscopes, phones, id tags, laptops, dictation devices, etc. a route to minimize exposure and contact between triage to induction room, or, and then to recovery rooms should be frequently cleaned and disinfected. it is recommended for an environmental services worker to increase the flowchart demonstrating the the recommended use of personal protective equipment for different activities at various settings managing suspected/clinically coronavirus disease 2019 patients. frequency to disinfect the most contaminated and most touched surfaces, such as the elevator buttons, door handles, light switches, grab rails, and etc. a recent study examined the most contaminated objects and ppe in the hospitals of wuhan, china. of the samples collected from hcp using ppe (hand sanitizer dispensers, gloves, and protective eyewear/full-face shield), 12.9% were positive for sars-cov-2 rna. the highest rates of contamination were found on hand sanitizer dispensers, gloves, goggles/face-shields at a rate of 20.3%, 15.4%, and 1.7%, respectively. 7 face masks and respirators; which to use? the cdc had recommended that hcps closely interacting with clinically suspected/confirmed covid-19 patients should wear n-95 respirators, along with gowns, gloves, and protec-tive eyewear. with the current global demand and shortage of ppe, the supply chain of specialized respirators cannot meet demand but the looser fitting surgical face masks might be an acceptable alternative. 6 notably, most respirators (eg, n-95) require training to properly fit them around the maxillofacial region to ensure appropriate fitting. our recommendations for using face masks and respirators varies depending on the setting and activity ( ½t1 table 1 of note, the regular surgical helmet cannot replace the need of respirator while operating on suspected/ confirmed covid-19 patients. donning eye protection equipment is recommended because the inoculation of the conjunctival mucous membrane is a mode of transmission. 8, 9 our recommendations for using protective eyewear are the following: • prioritize eye protection equipment for certain selected surgical procedures, ie, during aerosol-generating procedures (splashes, sprays, etc) and where there is prolonged face-to-face or close contact with a suspected or confirmed covid-19 patients. • full-face shield (if available) or goggles can be issued to each provider. • consider using safety goggles with extensions to cover the sides of eyes. • consider using disposable prescription eyewear shields (for those who wear prescribed glasses) • during supply shortage, use eye protection equipment beyond the manufacturer-designated expiration date. • during supply shortage, follow and adhere to the manufacturer instructions for reuse and disinfection. if these instructions are not provided, consider the cdc recommendations. 10 • association of the advancement of medical instrumentation (aami) ratings are based on the level of fluid protection in the critical zone or chest region of the surgical gown. the aami level should be checked on the packaging because they may come in several different designs, materials, and colors. • nonsterile, disposable, or reusable-aami level-ii gowns (frequently seen as disposable isolation gowns) are appropriate for use by pro-viders during routine covid-19 patient care. • surgical gowns aami-level-iii (typically those found in operating rooms) or coveralls should be prioritized for surgical and aerosolized blood-generating procedures. table 1 provides our recommendation in this regard based on different settings and activities. • double gloves are recommended when handling covid-19 patients as an extra precaution to minimize contaminating ors items, equipment, and surfaces. the outer pair should be pulled off before touching equipment or surfaces in other areas of or. 11 • surgical cap should be used per routine protocols. covid-19 is presumed to spread directly via infectious respiratory droplets and close contact (because sars-cov-2 cannot survive without a carrier). 12 however, these transmission modes do not explain all cases. recent data have shown that covid-19 might survive and be transmitted indirectly from virus contamination of common surfaces and objects after virus aerosolization in a confined space with by infected individuals. 12 the incubation period for covid-19 is approximately 4 days, and studies suggest that it may range anywhere from 2 to 14 days. [13] [14] [15] a recent study investigating sars-cov-2 from clinical specimens found that rna virus detected in blood samples from confirmed covid-19 patients (3 of 307; 1%). 16 huang et al 17 reported that 15% of patients with laboratory confirmed covid-19 had viral rna in their plasma. the implications of these findings are still unclear, and there are no reported cases of transfusiontransmitted coronaviruses through april 5, 2020. however, continued vigilance is essential. despite studies detecting viral rna in the serum or plasma of confirmed/suspected covid-19 patients, blood transmission and infectivity are still not fully understood. because there is little evidence and vague guidelines for blood transfusion in the current setting, it is recommended to recuse anyone with symptoms or signs of respiratory illness from blood donation. 18 the us fda has suggested to retrieve and quarantine any blood products collected in the 28 days before, or after, either covid-19 disease onset or possible exposure to individuals who are covid-19 positive. 18 theoretically, viremia in patients with asymptomatic or confirmed covid-19 patients could pose a risk of transmissibility to the orthopaedic team during aerosolized blood-generating procedures. 19 the use of high-speed drills, bone saws, reamers, electrocautery, and ultrasonic scalpels generate significant amounts of aerosols, increasing the risk of viral contamination of the environment. 20 a recent canadian study described lowfidelity simulation training to evolve the modified ppe used for aerosolgenerating procedures of suspected/ confirmed covid-19 patients and assess the sites of contamination 21 the spread of the aerosolized respiratory secretions and contamination sites were visualized with a commercial powder product and ultraviolet light. they demonstrated a significant amount of contamination on the provider's neck, base of the wrist, and their lower pants and shoes. these sites, however, are probably not associated with a direct method of transmission for sars-cov-2. however, there are definite sources of self-contamination during ppe doffing. in addition, the disposable aami level-iii fluid-resistant, surgical gowns or coveralls are recommended because they detected no contamination of scrubs beneath the surgical gown compared with reusable surgical gowns (aami, level-ii). the aami, level-ii gowns were permeable to aerosolized secretions. the recommended ppe for performing respiratory aerosol or aerosolized blood-generating procedures for suspected/confirmed covid-19 patients (table 1) : • papr is preferred for long operations (if available) • fitted, niosh-certified n-95 mask, with the following: • eye protection; goggles (covered sides of eyes) or full-face shields (if available) respirator and change it between encounters. reuse of protective eyewears, such as full-face shields and goggles, will be allowed if these are individually assigned to each member and regularly get disinfected. reuse practice is permitted for a single person use (no-sharing). reuse and reprocessing of the n-95 mask guidelines have been released by the cdc and include the use of ultraviolet light processing, hydrogen peroxide in either liquid or vaporized state, and moist heating decontamination. 24 these guidelines should be reviewed at length before attempting reprocessing of equipment to prevent potentially catastrophic error. extended use refers to the practice of using the same respirators for repeated close contact encounters with multiple patients, without doffing it between the encounters. this practice might be preferred over reuse, assuming this would reduce the risk of self-contamination through frequent donning and doffing of the same equipment. these practices vary between institutions especially for using n-95 masks. theoretically, the hcp could extend this and tolerate wearing n-95 masks for up to 8 to 12 hours. 25, 26 however, most providers usually take breaks during shifts for lunch/toilets. therefore, extended use beyond 4 hours might be impractical in most settings, 27 although limited reuse practice could be adopted with negative or low-risk patients. 28 within crisis situations and high-risk environments, especially at crowded triage and ed, rigor in following the designed and recommended measures for all hcp and patients is crucial. 29 (1) ask patients to wear a cloth face covering (a scarf or bandana) or face mask on the patient (regardless of the covid-19 test results) at arrival, promoting cough etiquette, and providing tissues and for hand hygiene. the main principles of the staff segregation, physical restructure, and the designed workflow should focus on reducing exposure and contamination, ensuring adherence to ppe, and subsequent decontamination. ideally, two types of hospital segregation should be done. locationbased segregation of orthopaedic staff reduces the potential risk of cross-infection. orthopaedic surgeons, for example, should not be performing screening examinations on the general public because of the risk of exposure. geographic segregation within the or complex limits the or traffic, decreases the exposure, and minimizes the contamination zone. 30 with the rapid increase in the number of covid-19 patients, orthopaedic staff should be segregated into those who are treating suspected/confirmed covid-19 patients and those who are treating noninfective patients when possible is not. this however may not be possible in smaller hospital systems and practices. besides screening and isolation of high-risk, confirmed covid-19 patients, strict and frequent screening of the segregated or staff is mandatory. members of the segregated or exposed staff should immediately report any signs of illness and must be taken off duty immediately. in addition, all contact events between patients and staff must be recorded so that contact lation, open airway suction as much as possible. (5) regional anesthesia is recommended over general anesthesia (when using regional anesthesia, patients must always wear surgical masks). it is a system-saving, necessary act to plan and restructure our surgical care pathways and protocol during covid-19 pandemic to protect our community and patients and conserve our valuable resources. the restructure should mainly focus on developing a reasonable plan for operating on emergent and urgent cases. dedicating a covid-19 pre-, intra-, and post-operating spaces and training the administrative and surgical staff on the appropriate use of ppe and covid-19 care pathways to the best of a hospital's ability minimizes exposure and contamination. (1) if there is suspected covid-19 diagnosis, the surgical planning should be re-evaluated immediately. (2) prepare and set up a separate, isolated or with separate ventilation system (in case of confirmed covid-19 case). (3) dedicated ors should have a separate atmospheric air inlet and outlet exhaust system. recent studies highlighted the necessity to isolate and operate on suspected/ confirmed covid-19 patients within negative pressure or/ isolation room to disseminate the viral load. 21, 22, 28, 32 however, heating, ventilation, and air conditioning system in most of the us operating rooms is designed to provide positive pressure. considering the current poorly controlled situation, adding a portable, selfcontained high efficiency particulate air filtration system to the hospital heating, ventilation, and air conditioning systems would economically create a negative pressure that meets the osha and cdc tb guidelines. 34 (4) when possible, entry to the or must be only through the anesthetic induction room. (5) all or doors should be well sealed once the patient is transferred in (except one door). 38 ; to schedule followup, [39] [40] [41] [42] for routine monitoring, [43] [44] [45] and management of recovery issues as needed. [46] [47] [48] in addition, the use of telemedicine-based services for surgical wound care has proven to be feasible and safe in the early postoperative evaluation. 49, 50 both time and cost savings contribute toward high patient satisfaction. 39 a randomized controlled trial demonstrated that there was no significant difference in patient satisfaction between telemedicine and face-to-face follow-up visits in an orthopaedic trauma cohort. 41 another study after total joint arthroplasty showed that telemedicine significantly reduce the cycle "appointment" time with an average skype follow-up call per patient that was 2.71 minutes shorter than face-to-face visits. 42 research showed that for every 23 miles away from clinic, there is 111% probability that a patient will more likely prefer using telemedicine for their postoperative follow-up. 48 surgeons form different specialties have expressed their satisfaction after using these telemedicine modalities to deliver postoperative care. 44, 48, 50, 51 notably, telemedicine revealed high levels of provider-perceived quality of medical history (82%) and therapeutic management (85%), compared with traditional face-to-face visits (72%) and (86%), respectively. 52,53 preparation, practice, and following telemedicine start-up checklists would be useful to ensure effective implementation of telemedicine. 54 , 55 the current focus should be directed in evolving more secured modalities to protect patient's confidentiality and keep their medical records away from any anticipated breach. the current infectious risk on healthcare personnel would have negative consequences, if they are not adequately prepared, trained, or equipped to mitigate the risk. orthopaedic educators should educate their fellows, residents, students, and ancillary teams in preventing exposure to and the spreading of covid-19. the care teams must learn how to protect themselves during a pandemic. refresher training regarding the standard use of ppe is a necessity in this global pandemic. a recent study at the university of illinois chicago 56 assessed the ppe doffing practices of healthcare workers. the study demonstrated that 90% of observed ppe doffing was incorrect regarding the doffing sequence, doffing technique, or use of appropriate ppe. 56 another survey showed that 14.9% of healthcare personnel did not receive previous training for appropriate ppe doffing practices. 57 training and education might flatten the curve of crossinfection and self-contamination. training and education of the surgical staff should be continually emphasized. it is imperative that all staff be taught the proper sequential methods of donning and doffing of ppe and mask-fitting techniques to minimize the risk of self-contamination. frequent audits of infection control must be conducted. a trained observer should be assigned for each emergent operation to identify the weaknesses and implement the necessary steps. simulation-based training might be required to improve the team communication during medical crisis 58 to establish competencies in ppe donning and doffing practices and workflow in induction, operating, and recovery rooms. simulation can mimic different clinical scenarios to integrate knowledge to practice, evaluate the providers' performances, and build up self-and team-confidence for real-life cases. lockhart et al 21 demonstrated that simulation was a powerful tool to test and adapt ppe as compared to baseline recommendations alone. using simulation-based training could be an effective method to replicate highly contiguous covid-19 cases in a safe, yet challenging, situation without jeopardizing the team safety. covid-19 is a major and sudden public health crisis, followed by a series of emergency response measures for community and healthcare services. the uncertainty of understanding the pandemic behavior and the definitive ways for its prevention cause psychological pressures on both the public and hcps. the public panic and fear of getting infected can increase the burden and use of healthcare services. the surgeons should be fully aware of the psychological pressure on the patients and their families. the knowledge, counseling, education, and support may mitigate the psychological pressure in fighting the pandemic. apart from the fact that this pandemic certainly involves many important health, economic, and community ramifications, it also requires several initiatives to mandate what measures are most appropriate to prepare for mitigating the occupational risks. these initiatives include understanding the different aspects in disease and transmission control in the ongoing pandemic. strict adherence to cdc and world health organization evidence-based guidelines for ppe and environmental hygiene enhances the safety and improves the mitigation of infection in emergent orthopaedic practice. nevertheless, we think that these recommended measures might optimize the healthcare services provided to confirmed covid-19 patients and should reduce the risk of occupational transmission to other patients and healthcare professionals. hhs office for civil rights secures corrective action and ensures florida orthopedic practice protects patients with hiv from discrimination updated u.s. public health service guidelines for the management of occupational exposures to hiv and recommendations for postexposure prophylaxis presumed asymptomatic carrier transmission of covid-19 prevention: interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings environmental contamination of the sars-cov-2 in healthcare premises: an urgent call for protection for healthcare workers protecting health-care workers from subclinical coronavirus infection novel coronavirus disease 2019 (covid-19): the importance of recognising possible early ocular manifestation and using protective eyewear control and prevention: strategies to optimize the supply of ppe and equipment infection control and anesthesia: lessons learned from the toronto sars outbreak indirect virus transmission in cluster of covid-19 cases early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study detection of sars-cov-2 in different types of clinical specimens clinical features of patients infected with 2019 novel coronavirus in wuhan, china food and drug administration: important information for blood establishments regarding the novel coronavirus outbreak coronavirus disease 2019: coronaviruses and blood safety characterization of aerosols produced by surgical procedures simulation as a tool for assessing and evolving your current personal protective equipment: lessons learned during the coronavirus disease (covid-19) pandemic practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-ncov) patients cdc conference call centers for disease control and prevention: decontamination and reuse of filtering facepiece respirators. 2020. available at respirator tolerance in health care workers physiologic and other effects and compliance with long-term respirator use among medical intensive care unit nurses considerations for recommending extended use and limited reuse of filtering facepiece respirators in health care settings preparing for a covid-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore supporting the health care workforce during the covid-19 global epidemic infection control measures for operative procedures in severe acute respiratory syndrome-related patients anaesthesia and sars preparing for covid-19: early experience from an intensive care unit in singapore special article: personal protective equipment for care of pandemic influenza patients: a training workshop for the powered air purifying respirator could air filtration reduce covid-19 severity and spread? new england complex systems institute intubation of sars patients: infection and perspectives of healthcare workers covid-19: consider cytokine storm syndromes and immunosuppressio pulmonary involvement in patients with hemophagocytic lymphohistiocytosis current use of telemedicine for postdischarge surgical care: a systematic review the role of telemedicine in postoperative care telehealth follow-up in lieu of postoperative clinic visit for ambulatory surgery: results of a pilot program prospective randomized controlled trial using telemedicine for follow-ups in an orthopedic trauma population: a pilot study effectiveness of telemedical applications in postoperative follow-up after total joint arthroplasty use of the videophone to collect quality of life data from burn patients development of a remote monitoring satisfaction survey and its use in a clinical trial with lung transplant recipients take two and text me in the morning: optimizing clinical time with a short messaging system telemedicine through the use of digital cell phone technology in pediatric neurosurgery: a case series utility of smartphone camera in patient management in urology a pilot study of telemedicine for post-operative urological care in children feasibility and safety of surgical wound remote follow-up by smart phone in appendectomy: a pilot study evaluating patient usability of an image-based mobile health platform for postoperative wound monitoring monitoring functional capability of individuals with lower limb amputations using mobile phones efficiency, satisfaction, and costs for remote video visits following radical prostatectomy: a randomized controlled trial telemedicine in the time of coronavirus personal protective equipment doffing practices of healthcare workers are health care personnel trained in correct use of personal protective equipment? using simulation-based education to improve team communication during a massive transfusion protocol in the or key: cord-009432-0ahamczt authors: ip, vivian; özelsel, timur j. p.; sondekoppam, rakesh v.; tsui, ban c. h. title: vid-19 pandemic: the 3r’s (reduce, refine, and replace) of personal protective equipment (ppe) sustainability date: 2020-04-14 journal: can j anaesth doi: 10.1007/s12630-020-01653-0 sha: doc_id: 9432 cord_uid: 0ahamczt nan literature regarding the transmission risk of the coronavirus disease (covid-19) to healthcare providers (hcp) is largely from early case reports/series or other clinical reports, both of which require critical appraisal. timely recommendations for critical care and anesthesiology teams in managing covid-19 patients are vital to the wellbeing of hcp. 1 in light of a global shortage of personal protective equipment (ppe), drastic measures are being taken to preserve it. the 3r-mantra of sustainability (reduce, refine, and replace) not only applies to ''green anesthesia'' practice, 2 but is also well-suited to ppe preservation. reduce. the first step is to eliminate all unnecessary use of ppe. deferring all non-urgent surgeries preserves hospital resources and simultaneously reduces transmission of coronavirus. rigorous screening measures for staff and visitors safeguards the hospital environment, and in turn also reduces the number of people in the hospital further contributing to infection containment. indeed, this reduction strategy is similar to the current practice of public health policy across the globe of ''social distancing'', ''shelter in place'', and public gathering bans to avoid any non-essential contact in an attempt to ''flatten'' the pandemic curve and to prevent overwhelming the healthcare system. refine. understanding the mode(s) of covid-19 transmission is still evolving. the world health organization continues to recommend droplet and contact precautions for general care but airborne precautions for hcps performing aerosol-generating medical procedures (agmp) in covid-19 patients. a on the other hand, us centers for disease control and prevention (cdc) now recommends the use of respirator masks as part of the first line of protection of hcp caring for suspected covid-19 patients. b in the presence of community spread, many centres in the us are already treating all untested surgical patients as presumed infectious. this could likely become the standard in all canadian healthcare facilities, which will further drain ppe reserves. modalities to increase airborne and contact/droplet ppe supplies other than procurement of currently used products will need to be explored. the need to refine the current culture of using disposable ppe to sustainable ppe solutions is essential for demand to meet supply-ideally, before a pandemic. approved (in effect, a refine measure) reusable industrial respirators in clinical settings to address the acute shortage. c decontamination and reclamation of used ppe d have also been widely disseminated; however, the safety of such practices is not well-supported with robust evidence. although this presents a unique opportunity to preserve the limited supplies of ppe while reducing the environmental burden from their eventual disposal, the safety and efficacy of reusable ppe must be carefully studied prior to implementation and recommendation. more importantly, hcps must also refine their skillset by understanding, simulating, and practicing donning and doffing both their disposable and reusable equipment properly and safely. 3 replace. replacement of agmp should be considered whenever feasible. in the midst of ppe shortage, regional anesthesia is an elegant and environmentally sustainable modality to circumvent the need of agmp associated with general anesthesia. 4 during this time of uncertainty, hcps need to be extra vigilant in protecting themselves, including the likelihood of encountering asymptomatic covid-19 patients. despite ppe being a scarce resource, we should not compromise the safety for hcp by limiting use. instead, we need to develop and implement ways to embrace sustainable solutions both for the current pandemic and for the future. innovative ideas such as a 3r approach may be one such resource-conscious solution. conflicts of interest none. editorial responsibility this submission was handled by dr. hilary p. grocott, editor-in-chief, canadian journal of anesthesia. practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-ncov) patients re-defining the 3r's (reduce, refine, and replace) of sustainability to minimize the environmental impact of inhalational anesthetic agents simulation as a tool for assessing and evolving your current personal protective equipment: lessons learned during the coronavirus disease (covid-19) pandemic practical considerations for performing regional anesthesia: lessons learned from the covid-19 pandemic publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations letter authorizing emergency use of all disposable filtering facepiece respirators emergency use authorization (eua) for the emergency use of the battelle ccds critical care decontamination system tm key: cord-032498-5ugoi1tu authors: smith, peter m.; oudyk, john; potter, guy; mustard, cameron title: the association between the perceived adequacy of workplace infection control procedures and personal protective equipment with mental health symptoms: a cross-sectional survey of canadian health-care workers during the covid-19 pandemic: l’association entre le caractère adéquat perçu des procédures de contrôle des infections au travail et de l’équipement de protection personnel pour les symptômes de santé mentale. un sondage transversal des travailleurs de la santé canadiens durant la pandémie covid-19 date: 2020-09-21 journal: can j psychiatry doi: 10.1177/0706743720961729 sha: doc_id: 32498 cord_uid: 5ugoi1tu objectives: to examine the relationship between perceived adequacy of personal protective equipment (ppe) and workplace-based infection control procedures (icp) and mental health symptoms among a sample of health-care workers in canada within the context of the current covid-19 pandemic. methods: a convenience-based internet survey of health-care workers in canada was facilitated through various labor organizations between april 7 and may 13, 2020. a total of 7,298 respondents started the survey, of which 5,988 reported information on the main exposures and outcomes. anxiety symptoms were assessed using the generalized anxiety disorder (gad-2) screener, and depression symptoms using the patient health questionnaire (phq-2) screener. we assessed the perceived need and adequacy of 8 types of ppe and 10 different icp. regression analyses examined the proportion of gad-2 and phq-2 scores of 3 and higher across levels of ppe and icp, adjusted for a range of demographic, occupation, workplace, and covid-19-specific measures. results: a total of 54.8% (95% confidence interval [ci], 53.5% to 56.1%) of the sample had gad-2 scores of 3 and higher, and 42.3% (95% ci, 41.0% to 43.6%) of the sample had phq-2 scores of 3 and higher. absolute differences of 18% (95% ci, 12% to 23%) and 17% (95% ci, 12% to 22%) were observed in the prevalence of gad-2 scores of 3 and higher between workers whose perceived ppe needs and icp needs were met compared to those who needs were not met. differences of between 11% (95% ci, 6% to 17%) and 19% (95% ci, 14% to 24%) were observed in phq-2 scores of 3 and higher across these same ppe and icp categories. conclusions: our results suggest strengthening employer-based infection control strategies likely has important implications for the mental health symptoms among health-care workers in canada. 11% (95% ci, 6% to 17%) and 19% (95% ci, 14% to 24%) were observed in phq-2 scores of 3 and higher across these same ppe and icp categories. conclusions: our results suggest strengthening employer-based infection control strategies likely has important implications for the mental health symptoms among health-care workers in canada. objectifs : examiner la relation entre le caractère adéquat perçu de l'équipement de protection personnel (epp) et les procédures de contrôle des infections (pci) en milieu de travail et les symptômes de santé mentale au sein d'unéchantillon de travailleurs de la santé du canada, dans le contexte de la pandémie covid-19 en cours. méthodes : un sondage de commodité sur internet des travailleurs de la santé du canada auquel ont collaboré diverses organisations professionnelles entre le 7 avril et le 13 résultats : un total de 54,8% (intervalle de confianceà 95% 53,5%à 56,1%) de l'échantillon avait des scores au gad-2 de trois et plus, et 42,3% (icà 95% 41,0%à 43,6%) de l'échantillon avait des scores au phq-2 de trois et plus. des différences absolues de 18% (icà 95% 12%à 23%) et de 17% (icà 95% 12%à 22%) ontété observées dans la prévalence des scores au gad-2 de trois et plus entre les travailleurs qui percevaient que leurs besoins d'epp et de pciétaient comblés, comparéà ceux dont les besoins n'étaient pas comblés. des différences entre 11% (icà 95% 6%à 17%) et 19% (icà 95% 14%à 24%) ont eté observées dans les scores au phq-2 de trois et plus dans les mêmes catégories d'epp et de pci. conclusions : nos résultats suggèrent qu'un resserrement des stratégies de contrôle des infections par l'employeur a probablement des implications importantes pour les symptômes de santé mentale chez les travailleurs de la santé du canada. keywords occupational health, mental health, workplace safety, covid-19 the covid-19 pandemic is having profound impacts on workers across the globe. 1 based on previous outbreaks, such as sars, it is recognized that health-care workers will be one of the occupational groups at highest risk of disease transmission. 2, 3 this increased risk along with concomitant increases in workload and fear of infecting family and household members will likely be associated with poorer mental health in this population. 4, 5 within a conceptual model of occupational health and safety vulnerability, 6 the combination of hazards exposure and inadequacy of protections at the workplace level will be associated with increased risk of injury and illness. 7 a recent systematic review documented that distrust in infection control procedures (icp) and inadequate provision of personal protective equipment (ppe) was associated with worse mental health among health-care workers. 5 pathways linking inadequate icp and ppe to mental health within a healthcare setting include lack of control over personal risk of infection, and associated increases in the risk of infection of family and other household members, as well as increased workload due to increased infection among coworkers and patients. 5, 8, 9 the objective of this study is to examine the relationship between perceived adequacy of ppe and workplace-based icp and anxiety and depression symptoms among a large sample of health-care workers in canada, within the context of the current covid-19 pandemic. we hypothesize that increased adequacy of both ppe and icp is associated with a lower severity of anxiety and depressive symptoms. ppe and icp sit in different locations on the hierarchy of controls, with ppe referring to items worn by workers to prevent infection, while icp refers to changes in how workers perform their duties or the use of engineering controls in the workplace. 10 as such, it is of interest to understand whether there is an interaction present in the association between ppe and icp and symptoms of anxiety or depression, or whether the associations between ppe and icp, and symptoms of anxiety or depression are additive. in april 2020, an online survey was developed by the occupational health clinic for ontario workers with input from the members of an ad hoc pandemic survey group consisting of union health and safety representatives, activists, and academics. the survey was disseminated to health-care workers across canada via various labor organizations. the current article focuses on responses to the survey between april 7, 2020, and may 13, 2020. the survey was not limited to particular groups of health-care workers or particular types of health-care settings. the survey was available in english and french. a total of 7,833 respondents opened the survey link, of which 7,298 answered at least 1 question. the convenience-based sampling precludes estimating a response rate. however, based on the labour force survey, approximately 965,686 persons were employed in healthcare occupations in the health and social assistance sector in canada during this time period, 11 which would suggest our sample represents 7.6% of the entire target population. respondents were asked questions from the generalized anxiety disorder (gad-2) screener 12 and the patient health questionnaire (phq-2) screener. 13 the range of possible scores for each scale is between 0 and 6. previous studies have observed that a cut point of 3 or greater on the gad-2 has a likelihood ratio of 5.0 for generalized anxiety disorder and 5.2 for any anxiety disorder. 12 for the phq-2, a cut point of 3 or greater had a likelihood ratio of 2.9 for predicting major depression. 13 both measures were developed to screen for potential clinical disorders and to estimate symptom severity in health surveys; however, neither is diagnostic as a standalone measure. respondents were asked questions on their perceptions of the adequacy and supply of 8 different types of ppe and the adequacy of implementation of 10 different icp to reduce covid-19 transmission. ppe items included gloves, eye protection/goggles, face shields, gowns, hand sanitizer, surgical/procedural masks, n95 masks, and powered air particular respirators (paprs). response options were appropriate type and adequate supply; appropriate type, but inadequate supply; inappropriate type, but adequate supply; inappropriate type and inadequate supply; needed, but not available at all; not sure/don't know what is appropriate; and not applicable. we defined the need for a given ppe as when respondents endorsed one of the first 5 categories (compared to not sure/don't know and not applicable). we defined that need being met when respondents endorsed the first category (appropriate type and adequate supply). icp items included screening of incoming patients, having symptomatic patients wearing masks, keeping patients with respiratory symptoms isolated from other patients and staff, restricted access and controlled flow of covid patients though the facility, ventilation systems, airborne infection isolation rooms, personal hygiene facilities/locker rooms, house cleaning/disinfection practices, laundry cleaning practices, and waste disposal practices. response options were appropriate and adequately implemented, appropriate but inadequately implemented, inappropriate, lacking, not sure/don't know what is appropriate, and not applicable. we defined the need for a given icp as when respondents endorsed one of the first 4 categories (compared to not sure/ don't know and not applicable). we defined that need being met when respondents endorsed the first category (appropriate and adequately implemented). respondents were grouped based on the proportion of their ppe and icp needs that were met: those who had all their ppe and icp needs met, those who had over half of their ppe and icp needs met, those who had less than half of their ppe and icp needs met, and those who did not have any of their ppe or icp needs met. information was also collected on respondent age, gender, whether they identified as a visible minority, their province of residence, and whether they lived in an urban, suburban, or rural community. information was also collected on the type of health-care facility in which they worked, their current job tenure, and their current hours of work per week. covid-19-related exposures included how much contact respondents had with covid-19 patients, the number of patients and workers at their workplace who have been infected with covid-19 (suspected, presumed, or confirmed), whether they had experienced covid-19 symptoms, and whether they had received training in relation to covid-19 and in the donning and doffing of ppe. the original sample of respondents who opened the survey and passed through the informed consent and answered at least 1 question totaled 7,298. of this sample, 341 (4.7% of the sample) did not respond to the 2 gad-2 questions, with another 39 (0.5% of the sample) not responding to the 2 phq-2 questions. as these questions were asked at the start of the survey, most of these respondents did not answer any further questions, leaving a sample of 6,918. of this sample, 808 respondents (11.1% of the sample) did not respond to the questions on ppe, with another 122 additionally not responding to questions on icp. this left a sample of 5,988 respondents (82.1% of the initial sample) with complete information on our outcomes and main independent variables. we compared scores for our 2 mental health outcomes between respondents with information on the main exposure compared to those with missing information. we did not observe any statistical differences across groups in relation to gad-2 scores but did observe a slight trend for respondents with missing information on our independent variables to have lower scores on the phq-2 than respondents who were not missing information. where respondents were missing information on covariates, we defined a separate level of that variable for those with missing information to maximize the sample available. 14 the size of missingness across covariates varied from less than 1% for measures describing the numbers of patients and workers with covid-19, and contact with covid-19 patients, to approximately 14% of the sample for information on the type of facility where they were employed. initial analyses examined the distributions of outcomes, independent variables, and covariates. to examine the relationship between perceived adequacy of ppe and icp with symptoms of anxiety and depression, we ran separate regression models. models were run examining the adjusted prevalence of respondents with gad-2 and phq-2 scores of 3 and higher. we also ran separate regression models where the gad-2 and phq-2 scores were included as continuous outcomes, and log-binomial models examining the relative risk of having gad-2 and phq-2 scores of 3 and higher (given the prevalence of these outcomes in our data). the relationship between ppe and icp adequacy and the outcomes in each of these models was similar, so only adjusted prevalence estimates are reported in this article. interaction between ppe and icp was examined by including an interaction term in the regression model. regression models were examined for multicollinearity between measures. slight collinearity between variables for missing responses to province and geographical density was noted; however, the relationships between the independent variable and outcomes did not change when one of these variables were omitted, compared to when both were included in the model. models were run using proc surveyreg in sas version 9.4, 15 with the variance around each proportion estimated using a jackknife estimation procedure. the distribution of the gad-2 and phq-2 scores across the sample is presented in figure 1 . we observed respondents in every possible level of both measures. a total of 54.8% (53.5% to 56.1%) of the sample had gad-2 scores of 3 and higher, and 42.3% (41.0% to 43.6%) of the sample had phq-2 scores of 3 and higher. table 1 presents the responses to questions on ppe and icp. respondents reported needing most types of ppe, with the exception of paprs. unmet needs were highest for n95 masks and surgical procedural masks, followed by face shields, eye protection, and gowns. self-reported needs for icp related to covid-19 transmission were generally lower than for ppe, with the highest needs for screening incoming patients and cleaning and disinfecting practices. the highest unmet needs were for personal hygiene and locker facilities, followed by screening of patients, having symptomatic patients wearing masks, and cleaning and disinfecting practices. descriptive information on the sample is provided in table a1 in the online appendix of this article. the majority of respondents were female (91%), worked in hospitals (67%), were from the province of ontario (56%), from urban centers (59%), and were working between 30 and 54 hours per week (75%). experiences with covid-19 differed across the sample with 39% of the sample having direct contact or working within 6 feet of covid-19 patients, almost 60% reporting that 1 or more patients in their workplace have covid-19, one-third reporting that their coworkers may have covid-19, and just over one-fifth personally experiencing covid-19 symptoms. table 2 presents the distribution of the proportion of ppe and icp needs that were met and the adjusted proportion of respondents who had gad-2 and phq-2 scores of 3 and higher. although unmet needs were more common for icp than for ppe, less than 20% of the sample had all of their ppe needs met or all their icp needs met. after adjustment for study covariates, we observed a graded relationship between the proportion of ppe and icp needs that were not met with an increasing proportion of respondents having gad-2 and phq-2 scores of 3 and higher. among the sample with 100% of their ppe needs met, 43% had gad-2 scores of 3 or higher. this increased to 60% for those with none of their needs met; an absolute difference of 17.6% (12.1% to 23.1%). similar relationships were observed for icp needs and for phq-2 scores over 3. comparisons of proportions indicated statistically significant differences across all levels of ppe and icp needs being met for both outcomes with 2 exceptions. these were for differences in the proportion of phq-2 scores of 3 and higher for respondents with 1% to 49% of ppe needs met compared to those with none of their ppe needs met and for respondents with 100% of their icp needs met and respondents with 50% to 99% of their needs met. we conducted a test for the trend in prevalence for each outcome across exposure groups. apart from the trend for ppe needs and gad-2 scores, which was linear, all other trend analyses indicated a nonconstant difference between the prevalence of the outcome across levels of the exposure, with the largest increases in prevalence generally seen when moving from 50% to 99% of needs met to 1% to 49% of needs met. other variables associated with anxiety symptoms in our regression models were having ppe training needs not met (compared to met), working in a long-term care facility (compared to a hospital), identifying as female, younger age, having covid-19 symptoms, being in direct contact with covid-19 patients (compared to no contact), not knowing how many coworkers in the facility have covid-19 (compared to no coworkers having covid-19), not knowing how many patients in the facility have covid-19, and knowing 20 or more patients who have covid-19 (compared to knowing no patients having covid-19). respondents from british columbia had lower prevalence of anxiety symptoms compared to respondents from ontario. similar relationships were observed in regression models where phq-2 was the outcome. the variance in gad-2 scores and phq-2 scores explained by all variables in the regression model was 14% and 12%, respectively. exact estimates for all variables are available from the authors on request. we did not observe any interactive relationship between adequacy of ppe and icp with either outcome. as such, risks for ppe and icp can be considered additive. to put this in context, among respondents who had adequate ppe and icp, the prevalence of gad-2 scores of 3 and higher was 34.8% (19.9% to 49.8%), while among respondents who had none of their ppe and icp needs met, the prevalence of gad-2 scores of 3 and higher was 71.6% (56.1% to 87.0%). this equates to an absolute difference of 36.7% (28.8% to 44.6%). for phq-2 scores of 3 and higher, the prevalence was 24.9% (13.5% to 36.2%) among respondents with adequate ppe and icp, 54.4% (41.3% to 67.5%) for respondents with none of their ppe and icp needs met, and 29.6% (21.1% to 38.1%) absolute difference in the prevalence between these groups. the covid-19 pandemic is placing increasing strain on health-care workers globally. understanding and addressing the mental health among the health-care workforce is an essential component of the response and management of covid-19 at the population level. 1, 4 within this context, it is important to identify modifiable workplace factors that are associated with mental health outcomes. 5 in this sample of almost 6,000 health-care workers in canada, we observed a graded relationship between the perceived adequacy of ppe provision and icp implementation with symptoms of anxiety and depression, with lower symptoms among respondents whose ppe and icp needs were being met. these findings are consistent with a recent systematic review that suggested that employer-based infection control strategies were an important component to minimize psychological ill-health among health-care workers. 5 we observed high prevalence rates of anxiety and depression symptoms in our sample (55% screened positive for anxiety symptoms and 42% for depression symptoms). the review mentioned above 5 identified 7 quantitative studies that have examined levels of mental health distress among health-care workers during the current covid-19 pandemic (2 published and 5 in preprint), all among chinese healthcare workers. [16] [17] [18] [19] [20] [21] [22] two of these studies used the gad-7 and phq-9 survey instruments to assess anxiety and depression, 16, 19 which are somewhat comparable to our study as the gad-2 and phq-2 consist of the first 2 items on these instruments. in these 2 studies, 14% to 15% of the respondents had phq-9 scores of 10 and higher. the cut point for the gad-7 differed in these studies from greater than or equal to 7, and greater than or equal to 10, with proportions of anxiety also differing from 24% to 12%, respectively. 16, 19 although direct comparability between the gad-2 and gad-7, and the phq-2 and phq-9 is hampered by the different response distributions for the various questions, 23 it would appear that levels of anxiety and depression symptoms in our sample (55% and 42%) are considerably higher than those reported in these chinese samples. some of this difference may be due to cultural factors. for example, recent studies from the united kingdom and ireland have reported levels of depression symptoms (using the phq-9 score of 10 or more) and anxiety symptoms (using the gad-7 score of 10 or more) during the covid-19 pandemic are between 20% and 22% in general population samples. 24, 25 given that we might expect higher levels among health-care workers, the levels of depression and anxiety symptoms reported in our sample are plausible. as such, greater surveillance and action concerning the mental health of healthcare workers during and post the covid-19 pandemic appear warranted as does the ongoing assessment of anxiety and depression symptoms. the results of this study should be interpreted considering the following strengths and limitations. first, the gad-2 and phq-2 were developed for screening purposes and are not equivalent to formal clinical diagnoses for anxiety and depression. our sample was convenience-based, with survey respondents primarily made aware of the survey through labor organizations. in addition, participation across some provinces, in particular quebec where covid-19 cases were highest during the study period, was low, despite the survey being available in both official languages. our nonresponse analysis indicated that respondents with missing data on our exposures had slightly lower phq-2 scores than those with complete information. as such, we suggest caution in generalizing the prevalence of mental health conditions in our sample to all health-care workers in canada, in particular those in quebec. to better understand the potential for selection bias, we compared the distribution of age, gender, and job tenure in our sample to estimates from health-care workers in canada from the march and april 2020 labour force surveys. 11 we noted similar distributions in our sample to this representative sample of healthcare labor force participants. our sample had slightly fewer respondents aged 18 to 24 years (4% vs. 7%), and slightly more respondents aged 35 to 44 years (28% vs. 25%), a higher proportion of women (91% vs. 84%), a lower proportion of respondents with job tenure of 2 years and less (16% vs. 23%), and fewer part-time workers (15% vs. 25%). we do not believe that participation through labor organizations would significantly bias our sample as 73% of health-care workers in canada are members of a union or have a collective bargaining agreement. 11 finally, given we have respondents across all levels of our exposures and all levels of our outcomes, the relationships we have observed between exposures and outcomes are likely still valid. 26 , 27 the results in this article only reflect the experiences of health-care workers between april 7 and may 13, 2020. the number of covid-19 cases and the number of hospitalizations have reduced considerably since the end of our survey. for example, the average number of covid-19 cases per day in canada during our study period was 1,520, while between june 13 (1 month after our survey) and the end of june, the average number of cases per day in canada was 357. 28 it is also likely that there have been concurrent changes in the adequacy of ppe and icp in health-care settings. the ongoing assessment of ppe and icp adequacy, and the mental health of health-care workers, is warranted to better understand these changes. our exposure was based on perceived need for, and subsequent adequacy of, ppe and icp. it is possible that our observed associations are primarily due to greater perceived numbers of ppe or icp needs, as more overall needs could be associated with more unmet needs. in addition, it is possible that respondents who report more symptoms of anxiety and depression were more likely to perceive greater ppe and icp needs. to examine this possibility, we did run regression models with additional adjustment for the number of ppe needs and the number of icp needs. the inclusion of these 2 measures did not meaningfully change the estimates presented in table 2 (results available from authors on request). in conclusion, we observed very high levels of depression and anxiety symptoms using validated screening instruments in a sample of health-care workers in canada during the peak of the covid-19 pandemic. we also observed important numbers of health-care workers with perceived unmet needs related to both ppe and icp related to covid-19 disease transmission. absolute differences of 18% and 17% were observed in the prevalence of gad-2 scores of 3 and higher between workers whose perceived ppe and icp needs were met compared to those who needs were not met. differences of between 11% and 19% were observed in the prevalence of phq-2 scores of 3 and higher across these same ppe and icp categories. our results suggest strengthening employerbased infection control strategies could have important implications for mental health symptoms among healthcare workers. the covid-19 pandemic: major risks to healthcare and other workers on the front line severe acute respiratory syndrome (sars) and healthcare workers heroes of sars: professional roles and ethics of health care workers psychological effects of sars on hospital staff: survey of a large tertiary care institution occurrence, prevention and management of psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis the development of a conceptual model and self-reported measure of occupational health and safety vulnerability the relationship between occupational health and safety vulnerability and workplace injury the psychological impact of quarantine and how to reduce it: rapid review of the evidence the importance of low control at work and home on depression and anxiety: do these effects vary by gender and social class? realigning the conventional routes of transmission: an improved model for occupational exposure assessment and infection prevention labour force survey: public use microdata files. statistics canada's data liberation initiative anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection the patient health questionnaire-2: validity of a two-item depression screener missing data: five practical guidelines the sas system for windows, release 9 factors associated with mental health outcomes among healthcare workers exposed to coronavirus disease 2019 mental health survey of 230 medical staff in a tertiary infectious disease hospital for covid-19 emotional responses and coping strategies of nurses and nursing college students during covid-19 outbreak covid-19 in wuhan: immediate psychological impact on 5062 health workers psychological impact of the coronavirus disease 2019 (covid-19) outbreak on healthcare workers in china the prevalence and influencing factors for anxiety in medical workers fighting covid-19 in china: a cross-sectional survey study of the mental health status of medical personnel dealing with new coronavirus pneumonia statistics canada. canadians' mental health during the covid-19 pandemic anxiety, depression, traumatic stress, and covid-19 related anxiety in the uk general population during the covid-19 pandemic anxiety and depression in the republic of ireland during the covid-19 pandemic why representativeness should be avoided commentary: should we always deliberately be non-representative? open access epidemiologic data and an interactive dashboard to monitor the covid-19 outbreak in canada the institute for work & health and the occupational health clinics for ontario workers are supported through funding from the ontario ministry of labour, training and skills development (mltsd). we thank members of the ad hoc pandemic survey group for their help in the survey design and dissemination. data in aggregated form are available from the authors on request. the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the author(s) received no financial support for the research, authorship, and/or publication of this article. peter m. smith, phd https://orcid.org/0000-0001-8286-4563 supplemental material for this article is available online. the analyses, conclusions, opinions, and statements expressed herein are solely those of the authors and do not reflect those of the moltsd; no endorsement is intended or should be inferred. key: cord-281403-yl7jdarm authors: le, aurora b.; brooks, erin g.; mcnulty, lily a.; gill, james r.; herstein, jocelyn j.; rios, janelle; patlovich, scott j.; jelden, katelyn c.; schmid, kendra k.; lowe, john j.; gibbs, shawn g. title: u.s. medical examiner/coroner capability to handle highly infectious decedents date: 2018-11-06 journal: forensic sci med pathol doi: 10.1007/s12024-018-0043-2 sha: doc_id: 281403 cord_uid: yl7jdarm in the united states of america, medical examiners and coroners (me/cs) investigate approximately 20% of all deaths. unexpected deaths, such as those occurring due to a deceased person under investigation for a highly infectious disease, are likely to fall under me/c jurisdiction, thereby placing the me/c and other morgue personnel at increased risk of contracting an occupationally acquired infection. this survey of u.s. me/cs′ capabilities to address highly infectious decedents aimed to determine opportunities for improvement at me/c facilities serving a state or metropolitan area. data for this study was gathered via an electronic survey. of the 177 electronic surveys that were distributed, the overall response rate was n = 108 (61%), with 99 of those 108 respondents completing all the questions within the survey. at least one me/c responded from 47 of 50 states, and the district of columbia. select results were: less than half of respondents (44%) stated that their office had been involved in handling a suspected or confirmed highly infectious remains case and responses indicated medical examiners. additionally, me/c altered their personal protective equipment based on suspected versus confirmed highly infectious remains rather than taking an all-hazards approach. standard operating procedures or guidelines should be updated to take an all-hazards approach, best-practices on handling highly infectious remains could be integrated into a standardized education, and evidence-based information on appropriate personal protective equipment selection could be incorporated into a widely disseminated learning module for addressing suspected or confirmed highly infectious remains, as those areas were revealed to be currently lacking. increased international travel and exchange are factors that escalate the risk for rapid transmission of emerging and reemerging infectious diseases, and highly infectious diseases (hids). while neither the centers for disease control and prevention (cdc) nor the world health organization (who) has formally published a current standard list of pathogens deemed to be highly infectious, multiple 'priority' pathogens (e.g. coronaviruses, viral hemorrhagic fever viruses, bacillus anthracis, yersinia pestis) are frequently cited as requiring advanced resources, protocols, and training to minimize risk of disease transmission and mortality [1] [2] [3] . the 2014-2016 west africa ebola virus disease (evd) outbreak, for example, challenged the capabilities, capacities, and efficacy of healthcare facilities in caring for patients with a highly infectious pathogen both abroad and in the united states [4] [5] [6] [7] [8] [9] [10] [11] [12] . in addition to the direct clinical care provided to patients with confirmed and suspected evd, public health departments and other affiliated sectors including emergency management, clinical and research laboratories, medical waste management, and mortuary services collaborated with medical providers to optimize and support patient care while reducing the risks to environmental and public safety [13] [14] [15] [16] [17] . due to the highly infectious nature of evd, comprehensive aspects of infection prevention-including appropriate handling of highly infectious remains-had to be carefully considered and planned to contain disease spread. careful handling of highly infectious remains was particularly imperative given that viral loads were found to be high immediately after an evd-infected individual died, thereby posing hazardous to pathology and mortuary personnel [16, 18, 19] . the risk of infection for death care sector workers posed by hids was exemplified by the 2016 infection of a german mortuary worker with lassa fever following the processing of remains previously unknown to be infected with lassa virus [20] . at the height of the 2014-2016 outbreak, the cdc published guidelines for handling evd-infected human remains informed by evidence-based best practices to address the transmission risk posed to workers [18] ; however, a recent gap analysis survey of the u.s. death care sector-specifically of funeral homes and crematories-revealed that most were unaware of these guidelines. overall, the study found a lack of up-to-date education, training and resources provided to this industry to safely manage potential or confirmed highly infectious remains scenarios [21] . as evd is now re-emerging in other regions of africa [22] and incidence and mortality of other infectious diseases is globally on the rise, the concerns raised in this study remain ever relevant. thus, it is imperative for those working with potentially infected human remains to receive the requisite training and resources to enable effective disease containment and prevent secondary transmission. in the united states of america (u.s.), medical examiners and coroners (me/cs) investigate approximately 20% of all deaths. typically, mes are physicians, usually pathologists specializing in forensic pathology, who are appointed government officials. they are charged with investigating unexpected, suspicious, and unnatural deaths in order to determine cause and manner of death and perform autopsies as needed. coroners, conversely, could be non-physicians or nonpathologist physicians who are elected or appointed at the county level; they look into deaths similar to those investigated by mes. coroners largely rely upon pathologists to perform the autopsies. unexpected deaths, such as those occurring due to a deceased person under investigation (pui) for a hid, are likely to fall under me/c jurisdiction, thereby placing the me/c and other morgue personnel at increased risk of contracting an occupationally acquired infection [23, 24] . historically, me/cs have often been among the first to encounter infectious disease outbreaks. for instance, me/c offices were instrumental in recognizing outbreaks of diseases such as hantavirus pulmonary syndrome, west nile encephalitis, and novel severe acute respiratory syndrome coronavirus (sars-cov) [25] [26] [27] . while the cdc recommends that no autopsy be performed for a confirmed patient with ebola virus disease, it is likely that if a patient were to die from an unidentified hid that an autopsy would be conducted [18] . additionally, me/c offices play a critical role in discovering the pathogenesis of infectious diseases as well as providing a means of disease surveillance on a global level [28, 29] . in puerto rico, me/c autopsy samples have been used to track dengue virus fatalities, while in south asia they have diagnosed deaths due to emergent nipah virus. me/c offices have also helped demonstrate the lethality of pediatric influenza and confirmed deaths due to creutzfeldt-jakob disease (cjd) [30] [31] [32] . despite the essential role me/c offices play in public health, there have been multiple published reports of considerable obstacles to effective infectious disease and mortality surveillance including the following: inadequate morgue biosafety infrastructure, lack of appropriate staff training/ educational updates, and critical shortages in the numbers of forensic pathologists [31] [32] [33] . uncertainties persist on the capabilities of me/c offices to address increasing baseline case volumes, of which the majority are lower risk infectious disease scenarios. disease containment, in this setting, including prevention of secondary transmission, is critical for the benefit of public health, emergency management, medicine, and the general public. given the critical role me/cs play in this endeavor, and the apparent lack of resources dedicated to this sector of the workforce to protect themselves from potential occupational exposures, this study was conducted to evaluate what protocols are in place for suspected or confirmed highly infectious remains, as well as determining levels of training among u.s. me/cs to handle highly infectious remains. total population purposive sampling was utilized for this nonexperimental design, as each state has its own unique death investigation system [34] . a contact list of me/c offices serving populations of 300,000 or greater was compiled for each state by the national association of medical examiners (name) ad hoc committee for bioterrorism and infectious disease. this minimum population limit was selected in an effort to avoid duplication of survey results, as geographic areas with smaller populations often outsource to larger me/ c offices. an electronic survey with questions created by the authors was distributed via qualtrics© (software version 2016.17, provo, ut) through a link in an email solicitation (indiana university institutional review board exemption protocol #1711094822). survey questions included: demographic information (e.g. title, population served, state), personal protective equipment (ppe) worn in different infectious scenarios, procedures performed in different infectious scenarios, duration of training received, biosafety level (bsl) capabilities, and jurisdictional handling of highly infectious remains. the name ad hoc committee for bioterrorism and infectious disease sent email solicitations from december 5, 2017 to february 6, 2018 to encourage responses from me/c offices nationwide, ensuring a comprehensive view of u.s. me/c practices. the survey was closed after 9 weeks. data from qualtrics© was exported and data was analyzed utilizing sas version 9.4 (copyright (c) 2002-2012 by sas institute inc., cary, nc, us). frequencies and percentages were used to summarize question responses and chi-square tests were performed to investigate associations between variables; only significant findings were reported and individual states were not named to protect the identity of the state me/c. all responses to questions were voluntary so response rates between questions varied. of the 177 electronic surveys that were distributed, the overall response rate was n = 108 (61%), with 99 of those 108 completing all the questions within the survey. at least one me/c responded from 47 of 50 states, and the district of columbia; three states were excluded because their largest me/c office did not serve a population size of 300,000 or greater. medical examiners represented the majority of respondents (68%), followed by coroners (18%) and 'other' titles (14%) (e.g. forensic pathologist, deputy coroner, sheriff-coroner). there appeared to be a difference in distribution of professions across the region, with mes being more evenly distributed than other titles. each u.s. region, as delineated by the department of health and human services, had at least 3 medical examiners, while several regions had zero or one respondent who selected 'coroner" or 'other'. for coroners, 35% were from the midwest (il, in, mi, mn, oh, and wi) and 40% of those who selected 'other' were from the west coast (az, ca, hi, and nv) [35] . twenty-five percent of respondents worked in an office that served a population size between 300,000-500,000; 16% served 500,001-750,000; 15% served 750,001 up to 1 million and 44% of respondents came from an office that served a population greater than 1 million people. when asked which entity was responsible for their office's oversight, 60% stated a government agency, 16% public safety or law enforcement, 13% 'other' (academic medical center or university, city or county health department, political subdivision, or self), 8% state health department, and 3% a forensic laboratory. respondents were asked to select all ppe worn when performing standard duties, i.e. when no known infectious disease outbreak was occurring locally or regionally or was reported to the me/c (table 1) . 'other' optional items of ppe listed were: a plastic apron over the surgical gown (n = 6), waterproof sleeve covers (n = 5), hair nets/bonnets (n = 2), dedicated autopsy socks (n = 1), and one respondent noted use of a tyvek suit for standard duties. for comparison, respondents were asked to select what ppe they would wear when performing duties on suspected or confirmed highly infectious remains (table 1) . 'other' optional items of ppe listed were: disposable apron (n = 7), waterproof sleeves (n = 5), hair net/bonnet (n = 2), self-contained breathing apparatus (scba) (n = 1), hazardous waste and emergency response standard (hazwoper) gear (n = 1), tyvek suit (n = 1), and two layers of clothes (cloth and plastic) (n = 1). four respondents stated their office would not perform autopsies on such cases. slightly more than half of respondents (56%; 61/108) stated their office staff had received training on donning and doffing ppe in suspected or confirmed cases of highly infectious remains; nearly one-third (32%) (18/56) reported the amount of cumulative training in hours per person, on average per year, was 1 h or less while 29% (16/56) spent between 1 and 2 h of training. the entity that provided the ppe training varied widely among respondents. common responses included: in-house staff (n = 16), state or local health department (n = 7), an affiliated university (n = 6), occupational health or a safety and compliance coordinator external to the me/c office (n = 6), online-based training (n = 3), risk or emergency management (n = 3), an infectious disease or infection control specialist (n = 3), or individuals highly trained in hazardous materials (hazmat) external to the me/c office (n = 2). in the event of suspected highly infectious remains, respondents were asked what procedures would be permissible and performed by their office ( table 2 ). the most frequent responses for 'other' were: dependent on a case-by-case basis/contingent upon suspected pathogen (n = 16), sending the remains to the appropriate biocontainment facility (n = 3), and one noted a written policy for handling highly infectious remains does not exist and would require discussion with multiple stakeholders, including the safety committee to evaluate risk. for comparison, respondents were asked which procedures or tasks would be performed in the event of confirmed highly infectious remains (table 2) . 'other' responses echoed those in a suspected case where it was dependent on the circumstances and suspected pathogen, or only as required by the cdc or local health department (n = 16). one respondent stated they would decline jurisdiction if no circumstance beyond the confirmed infectious disease made it reportable. less than half of respondents (44%; 44/101) stated that their office had been involved in handling a suspected or confirmed highly infectious remains case. the most commonly encountered highly infectious pathogens were: cjd and unclassified prions (n = 21); forms of tuberculosis (including extremely drug-resistant [xdr-tb] and multiple drug resistant [mdr-tb]) (n = 13); forms of meningitis (streptococcus pneumoniae, meningococcal) (n = 9); anthrax (bacillus anthracis) (n = 6); suspected cases of ebola and other hemorrhagic fevers (n = 4); human immunodeficiency virus (hiv) a percentages add up to more than 100% because this question was multiple-select a percentages add up to more than 100% because this question was multiple-select (n = 3); h1n1 influenza (swine strain) (n = 3); and sars (n = 2). while just under half of the respondents stated their office had been involved in handling such remains (44%; 44/101), those cases do not appear equally distributed across regions. no respondents from upper west coast states (al, id, or, wa) reported office involvement, while all respondents from east coast states (ct, me, ma, nh, ri, vt) reported office involvement. other regions had between 22% to 60% of respondents reporting office involvement. eighty-one percent (81/100) of respondents did not have a biosafety level 3 (bsl-3) facility within their office to conduct examinations in suspected highly infectious cases; some did have bsl-1 capabilities (40%; 31/77) and bsl-2 capabilities (60%; 46/77). table 3 provides definitions of the bsl levels [36] . in regard to the location at which autopsies were performed in a suspected highly infectious remains case, 58% (47/81) stated there was a separate autopsy area where no other autopsies were being performed at the same time; 20% (16/81) stated they do not examine suspected highly infectious remains at their facility; and 22% indicated 'other', which include not having a separate room/in the regular autopsy area (n = 4), altering protocol to limit staff and only have that single case autopsied at the time if there was not a separate room available (n = 3), performing autopsy in a negative pressure disaster portable morgue unit (n = 1), and that autopsy was contingent on the case load and space available (n = 1). one open-ended comment emphasized that it was case dependent, and that "tb gets autopsied, ebola straight to the funeral home" . this statement raises concern as the study by le et al. that surveyed the level of education and training received by u.s. funeral home and crematory personnel on highly infectious disease mitigation and management revealed large gaps in knowledge, including incorrectly marking routes of exposure for evd [21] . more than half (62%; 62/100) indicated that their staff was not trained to carry out specialized decontamination procedures following autopsy of suspected or confirmed highly infectious remains. of those who had been trained on decontamination procedures, the most frequent response for the average cumulative length of training in hours per year per person was 1 h or less (20%; 7/35), followed by 2 h (17%; 6/35). additionally, a little over one-third of respondents (34%; 33/ bsl-2 builds upon bsl-1 but includes additional precautions and facility features which are appropriate for work with moderate-risk microorganisms that are associated with human disease of varying severity. laboratory access is restricted when work is conducted. enhanced engineering controls and personal protection is needed. ppe typically includes lab coats and gloves; eye protection and face shields as needed. in addition to the sink for handwashing, there should also be an eyewash station. all aerosol or splash-generating procedures should be performed in a biological safety cabinet (bsc). there must be an autoclave or alternate method of decontamination for proper waste disposal, and the facility must have self-closing, lockable doors. an example of an organism appropriate for use in a bsl-2 laboratory is human immunodeficiency virus (hiv). biosafety level-3 (bsl-3) bsl-3 builds upon the requirements of bsl-2 but includes additional precautions and facility features which are appropriate for work with microorganisms which cause serious or potentially fatal disease through respiratory transmission. access to the facility is restricted and controlled at all times. in addition to all the aforementioned ppe, respirators may be worn and are required when experimentally infected animals are present. all microorganisms must be handled within a bsc. a hands-free sink and eyewash station must be available near an exit, exhaust air cannot be recirculated and the facility must have sustained directional airflow from clean areas to more contaminated areas. lastly, entrance into the facility is through two sets of self-closing, locking doors. an example of an organism appropriate for use in a bsl-3 laboratory is severe acute respiratory syndrome (sars) coronavirus. a these definitions are paraphrased from those provided by the centers for disease control and prevention [36] 97) indicated staff were trained to handle and transport (i.e. package and ship) specimens for suspected highly infectious cases. if staff were trained, specimens were sent most frequently to one or two of the following locations: the cdc (n = 14), state reference laboratory (n = 13), the national prion disease pathology surveillance center (npdpsc) at case western reserve university for prion diseases (n = 4), or an academic medical center/hospital laboratory (n = 3). of those that had received training on handling and transporting specimens, the most frequent response for the average cumulative length of training in hours per year per person was 1 h (41%; 11/27), followed by less than 1 h (11%; 3/27). there was a statistically significant relationship determined between those answering "no" to their office being involved in handling highly infectious remains and those answering "no" to receiving training to safely handle/transport the specimens. for those who answered "no" to involvement, 78% had no training for transporting specimens and 21% did; however, for those who answered "yes" to office involvement, only 51% had training for transporting specimens and 49% did not. when asked what their jurisdiction permitted for highly infectious remains, 13% (16/124) stated embalming was permitted, 15% (18/124) traditional burial practices, 25% (31/124) cremation and 47% (58/124) were unsure. 1 survey respondents also had the opportunity to provide open-ended comments at the end of the survey; 26 respondents did. comments included: a desire for formalized or more frequent training in the area of handling highly infectious remains (n = 7); a need for more resources or a lack of preparedness or appropriate facilities to address highly infectious remains (n = 7); the difficulty of answering questions pertaining to newly emerging and re-remerging highly infectious diseases because policies had not been written or revised (n = 4); a need to formalize and update protocols (n = 3); and a need for better funding to attract more prospective forensic pathologists to practice and to purchase greater stocks of ppe since what was available was expired or on back-order (n = 1). select direct quotations and themes included that the, "national infrastructure for autopsy biosafety is woefully inadequate" and a perception of being overlooked/neglected in infection control training but still an office "they hand bodies off to" without regard for the limited training and resources. as sudden unexpected deaths fall under medical examiner/ coroner jurisdiction, they may play a fundamental role in the response to infectious disease deaths. if communication between various health sectors is unclear or protocols have not been established by the local health department, there is a risk for occupational exposure for all parties involved, and the potential for a me/c to be exposed to a highly infectious death that has yet to be confirmed. the logistical challenges associated with the response to highly infectious pathogens is demanding for public health sectors focused on the treatment and management of living patients. the role of the death care sector in effective disease surveillance and containment of infectious diseases is often overlooked; including the fundamental role of me/cs. me/cs frequently investigate deaths with little clinical information on the circumstances preceding death. hence, it is crucial to for me/cs to have robust, up-todate education and training in potential highly infectious remains handling, ppe donning and doffing, and clear protocols used when handling human remains that stress universal precautions. to determine what training areas are insufficient or need to be supplemented, this survey evaluated current me/c office capability to handle highly infectious remains. this survey provided a national view of the handling of highly infectious remains by capturing a sample of me/cs from nearly every state and washington d.c. medical examiners comprised the majority of the survey respondents and were more evenly geographically distributed than coroners. nearly half of the respondents served large counties or metropolitan areas with populations of greater than one million people, highlighting the large populations that may be covered by a single me/c office. additionally, most me/c offices, including the body storage areas (morgues), are under government oversight. in order to gauge circumstance-dependent ppe use among me/cs, respondents were asked for standard ppe ensembles worn during routine autopsies and those worn for autopsies on suspected or confirmed highly infectious remains (table 1) . slightly more than half (52%) reported wearing an n95 respirator during routine autopsies and this increased to only 68% for autopsies on suspected or confirmed highly infectious remains. other higher level ppe such as a powered-air purifying respirator (increased by over 30%), tyvek suit, hazwoper gear and scba also showed an increase. a surgical mask was worn by 35% in standard autopsies and by 6% of me/cs for a suspected or confirmed highly infectious case. typically, at minimum an n95 is recommended for protection against aerosolized particles arising such as tb, monkeypox, sars and others, rather than a surgical mask [37] . additionally, an autopsy is inherently an aerosol-generating procedure, even organisms that might normally require only large droplet precautions (i.e. surgical mask) can be aerosolized at autopsy due to oscillating saws, aspirating hoses, etc. and thus require added respiratory precautions (i.e. n95 respirator or papr) [33, 38, 39] . use of a face shield rather than glasses/goggles also has been shown to reduce contamination of respirators by particles but only 59% of me/c respondents routinely wear them [40] . the following ppe changes occurred for suspected or highly infectious remains: the use of inner gloves, a face shield, and boot/shoe cover wear increased by 6%, 17%, and 7%, respectively, while donning eye protection decreased by 4%. usage of a n95 respirator increased by more than 15% and the use of a powered-air purifying respirator notably increased by nearly 30%. higher level ppe, such as a tyvek suit, hazwoper gear and scba also were used when autopsies were performed on suspected or confirmed highly infectious remains. of concern, these results indicate me/c alter their ppe based on suspected versus confirmed highly infectious remains rather than taking an all-hazards approach. despite some improvements in more protective ensembles in the suspected increased risk cases, the amount of training received by respondents was lacking. little more than half (56%) of respondents had received training on donning and doffing ppe in such scenarios, with the 61% of those who did have ppe training having spent an average of only 2 h or less per person per year on the topic. additionally, the entity that provided ppe training widely varied (e.g. in-house staff, affiliated university, safety and compliance departments), and no information was collected on the survey on the expertise level of those delivering trainings. the lack of reproducible training time and variability of training entity suggest that more standardized training might be of benefit. designating a knowledgeable public organization to offer standardized training modules could lead to the following: (1) standardization of the organizational source of training; (2) content of training materials and modules based on reproducible, evidence-based best practices commonly found in the me/c field; and (3) subscription to online training as it will likely be the most cost-effective and convenient means of training, as was proven successful in healthcare [41] . moreover, best practices and evidence-based studies have demonstrated that regular training for donning and doffing high level ppe in highly infectious scenarios provide substantially better occupational safety and health outcomes for the employee [6] . in the event of suspected or confirmed highly infectious remains, most me/c offices stated that the situation was handled on a case-by-case basis, depending on the pathogen that was suspected and required detailed conversations with all stakeholders. as shown in table 2 , procedures did vary between what would be performed with a suspected highly infectious body versus a confirmed infectious body. in a confirmed case, all but one of the listed procedures as decreased compared to a suspected case (e.g. complete autopsy [27% decrease], washing or cleaning of the body [17% decrease], body storage in freezer [20% decrease]). the only increase was, "bypass office and have body directly transported to funeral home/crematorium" by 21% which, as previously mentioned, may result in funeral home and crematory personnel being placed at risk. fewer than 50% of me/c offices having been involved with handling a suspected or confirmed case, demonstrating a lack experience in handling highly infectious remains. when asked which suspected or confirmed pathogens were encountered, however, many noted category a or b pathogens (table 4 ) [1, 2] that require specific deactivation and decontamination procedures-of which only approximately onethird (38%) of respondents had received training in. it is possible that after such an event that the me/c office would hire an appropriate contractor to conduct the appropriate deactivation and decontamination; however, the possibility remains [1, 2] that the task could go to individuals within the me/c offices without proper training. while most offices did not have a bsl-3 facility, nearly twothirds (60%) of those without a bsl-3 did have bsl-2 capabilities. however, if 40% have only bsl-1 capability, then these morgues would essentially be considered appropriate for work only with agents not known to consistently cause disease in healthy human adults per cdc guidelines [42] . in essence, a sizeable percentage of morgues in the u.s. are not equipped to safely perform autopsies on human remains with a large number of infections, especially those highly infectious disease autopsies. in addition to improved training, more investment in morgue infrastructure would be necessary to enhance their capabilities. anecdotally, some larger me/c offices have a computerized tomography (ct) scanner in which triple bagged sealed infectious remains can undergo virtual autopsy. these bags can be constructed with portals to collect needed specimens for microbiologic/virologic studies. the triple bagging prevents leaks and contamination and the remains can safely be sent to funeral home. it would also be beneficial to have list of pathologists and support personnel in each me/c office who could volunteer to take vaccines to handle certain cases with suspected contagious diseases (i.e. smallpox, etc.). approximately 20% of respondents reported that they did not examine suspected or confirmed highly infectious remains at their facility. given the lack of proper bsl facilities, this would be appropriate. slightly more than 20% noted the lack of space and/or a lack of staff in their offices as a limitation for being able to perform autopsies of suspected or confirmed highly infectious remains in a separate room or alone. for biosafety, it is recommended that autopsy facilities should have a minimum of 12 air exchanges per hour, be negatively pressurized relative to surrounding office spaces, and exhaust air outside of the facility and away from areas of high pedestrian traffic. morgue laminar air flow should travel from clean to progressively less clean areas with downdraft table ventilation to decrease personnel exposure to aerosolized pathogens [32, 39] . it is likely that significant financial investment would be required to retrofit many existing morgues to meet these standards. another option would be to have jurisdictional planning to transport suspected or confirmed cases to known centers that currently have the necessary bsl capability; again, body transportation would incur costs but likely lower costs than that associated with retrofitting many existing morgues. in addition to improved morgue biosafety, it would also benefit me/c facilities to have better publicized, easily accessed, and clearly laid-out protocols for various infectious scenarios in which limited autopsy (e.g. brain-only in suspected cjd cases) or no autopsy (e.g. evd cases) is currently recommended. when asked about level of training to handle and transport specimens for suspected highly infectious cases, only onethird of respondents had received this training with 20% spending on average less than 1 h per year per person on the topic. nearly half of respondents (47%) were unsure of what their jurisdiction permitted in the case of highly infectious remains for ultimate disposal, and alarmingly, 13% of respondents stated their jurisdiction permitted embalming and 15% traditional burial. for evd, for example, the recommended procedure is cremation to ensure complete deactivation of the virus in order to prevent spread to workers and the environment; those who were killed by the disease will have high viral loads present in their body post-mortem [43] . while needs for funding, resources, supplies and appropriate capabilities may be universal across the death care sector, this survey's results strongly suggest that it would benefit state or regional-specific me/cs to have standardized education and training throughout the u.s [24] . likewise, open-ended comments from respondents indicated a need for augmented up-to-date formalized trainings, as well as revised written policies and procedures, and enhanced resources (including facilities and funding). there were general perceptions of unpreparedness to address highly infectious remains, budgetary constraints and a weak national structure regarding autopsy biosafety, and a lack of incorporation of me/c offices into infection control planning despite me/c office involvement with highly infectious remains. there were limitations to this study. because of the study's exploratory nature, the survey was not validated beyond subject matter expert vetting. additionally, the survey only included me/c offices that served larger populations; smaller offices may still encounter hid cases if they do not outsource larger nearby offices. therefore, this study may not be generalizable to smaller offices (i.e. those serving populations <300,000). also, the survey instrument was designed to allow respondents to check multiple boxes when asked about the use of ppe. the results, therefore, were not clear whether the respondent meant the ppe would be used simultaneously or one instead of the other. for example, a face shield and respirator may be used simultaneously or a face shield may be used instead of a respirator. additionally, a limitation related to potential response bias may exist. although this study was not funded, there could have been sponsor bias on behalf of the respondents, as the survey was distributed by members of name, thereby potentially affecting the candidness of their responses. lastly, non-responses may have arisen because it would not appeal to prospective participants to take a survey about a topic for which they are not trained out of concern their answers may not be "correct." nevertheless, this study addresses a critical gap about what is known and unknown about u.s. me/c capabilities to handle highly infectious remains. in conclusion, this survey of u.s. medical examiners and coroners' capabilities to address highly infectious decedents presents opportunities for improvement at me/c facilities serving their state or metropolitan area. standard operating procedures or guidelines (sops or sogs) should be updated to take an all-hazards approach, best-practices on handling highly infectious remains could be integrated into a standardized education, evidence-based information on appropriate ppe selection could be integrated into a widely disseminated learning module, and existing relationships with the local health department, funeral homes and crematories could be bolstered to develop a multi-sectoral concept of operations for addressing suspected highly infectious remains. while some issues will require greater capital and resources to address-such as retrofitting facilities to meet better biosafety recommendations, or more financial resources to enhance operation-the hope is that this study will draw attention to these more systemic issues and stimulate a call to action from the appropriate entities. 1. u.s. medical examiners/coroners play a critical role in death investigation, yet their capabilities to address highly infectious remains are unknown. occupationally-acquired infection. 3. this survey, with respondents from nearly every u.s. state, revealed current levels of medical examiner/ coroner training and education to address suspected or confirmed highly infectious remains. 4. questions, and thereby results, focus on permissible autopsy procedures, personal protective equipment, and biosafety-level facility capabilities. 5. medical examiners/coroners could benefit from updates to standard operating procedures and standardized education on handling suspected or highly infectious remains that taken an all-hazards approach. niaid emerging infectious diseases/pathogens list of blueprint priority diseases infection control in the management of highly pathogenic infectious diseases: consensus of the european network of infectious disease clinical care of two patients with ebola virus disease in the united states ebola virus disease cluster in the united states ebola virus disease: preparedness and infection control lessons learned from two biocontainment units caring for patients with ebola: a challenge in any care facility lessons learned: critical care management of patients with ebola in the united states reflections on interprofessional team-based clinical care in the ebola epidemic: the nebraska medicine experience current capabilities and capacity of ebola treatment centers in the united states safe management of patients with serious communicable diseases: recent experience with ebola virus clinical management of ebola virus disease in the united states and europe nebraska biocontainment unit perspective on disposal of ebola medical waste considerations for safe ems transport of patients infected with ebola virus transport and management of patients with confirmed or suspected ebola virus disease us ebola treatment center clinical laboratory support nebraska biocontainment unit patient discharge and environmental decontamination after ebola care guidance for safe handling of human remains of ebola patients in u. s. hospitals and mortuaries the contribution of ebola viral load at admission and other patient characteristics to mortality in a medecins sans frontieres ebola case management centre control measures following a case of imported lassa fever from togo a gap analysis of the united states death care sector to determine training and education needs pertaining to highly infectious disease mitigation and management ebola situation reports: democractic republic of the congo infectious disease surveillance by medical examiners and coroners overview of medical examiner/coroner systems in the united states: development, current status, issues and needs the pathology of human west nile virus infection hantavirus pulmonary syndrome in the united states: a pathological description of a disease caused by a new agent biosafety level 3 laboratory for autopsies of patients with severe acute respiratory syndrome: principles, practices, and prospects three decades of responding to infectious disease outbreaks operational research during the ebola emergency role of the medical examiner in zika virus and other emerging infections cdc grand rounds: discovering new diseases via enhanced partnership between public health and pathology experts emerging infectious diseases and the medical examiner medical examiners, coroners, and biologic terrorism death investigation systems department of health & human services. regional offices hospital respiratory protection program toolkit: resources for respirator program administrators aerosol generation during bone-sawing procedures in veterinary autopsies biosafety considerations for autopsy efficacy of face shields against cough aerosol droplets from a cough simulator personal protective equipment in health care: can online infection control courses transfer knowledge and improve proper selection and use? guidelines for safe work practices in human and animal medical diagnostic laboratories age and ebola viral load correlate with mortality and survival time in 288 ebola virus disease patients acknowledgments we would like to extend our gratitude to the members of the national association of medical examiners (name) ad hoc committee for bioterrorism and infectious disease for their support of this research and distribution of the survey; these members include: second author erin brooks (chair), paul chui, karen kelly, john matthew lacy, micheline lubin, lakshmanan sathyavagiswaran, leah schuppener, suzanne utley-bobak, and steven white. additionally, we acknowledge the national institute of environmental health sciences (niehs) worker training program (wtp) ebola biosafety and infectious disease response training uh4 information, grant number uh4 5es027055. while the grant funding did not contribute to the development and distribution of this gap analysis survey, the program did highlight the need to explore research in this area. lastly, we also thank from the university of nebraska medical center: elizabeth beam and at harvard t.h. chan school of public health: paul biddinger for their partnership and support. conflict of interest none of the authors have any conflicts of interest to disclose.ethical approval this study was deemed exempt by indiana university institutional review board (protocol #1711094822).informed consent survey participants were informed of potential risks and benefits prior to taking the voluntary survey. this informed consent survey was reviewed by the institutional review board and approved as part of the exemption in the aforementioned protocol number. key: cord-281099-l2i7r1bp authors: izzetti, rossana; gennai, stefano; nisi, marco; barone, antonio; giuca, maria rita; gabriele, mario; graziani, filippo title: a perspective on dental activity during covid‐19: the italian survey. date: 2020-08-13 journal: oral dis doi: 10.1111/odi.13606 sha: doc_id: 281099 cord_uid: l2i7r1bp objectives: during the months of march and april 2020, italy saw an exponential outbreak of covid‐19 epidemic. dental practitioners were particularly limited in their routine activity, and the sole performance of urgent treatments was strongly encouraged during the peak of the epidemic. a survey among dental professionals was performed between 6(th)‐13(th) of april, in order to evaluate the status of dental practice during covid‐19 in italy. materials and methods: an online anonymous questionnaire was administered to retrieve data on the dental procedures performed, the preventive measures adopted, and the predictions on the future changes in dentistry following the pandemic. results: the survey was completed by 3,254 respondents and, according to the results obtained, dental activity was reduced by the 95% and limited to urgent treatments. the majority of the surveyed dentists employed additional personal protective equipment compared to normal routine, although in a non‐negligible number of cases difficulty in retrieving the necessary equipment was reported. conclusions: the survey provided a snapshot of dental activity during the sars‐cov‐2 outbreak. overall, following the peak of the epidemic, it is probable that dental activities will undergo some relevant changes prior to fully restart. covid-19 has seen in the last few months a worldwide diffusion, with more than 9 million cases confirmed (https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd 40299423467b48e9ecf6). italy was the country with the earliest diffusion in europe. lockdown was disposed at the end of february in some northern regions, lombardy and veneto, to limit the exponential increase in the number of infected subjects, and was followed on the 9 th of march by the rest of the country due to the rapid escalation in the numbers of contagion. the highest number of active cases (108, 237) was registered on the 20 th of april, and was followed by a slow, progressive decrease, which led to the complete end of the lockdown on the 3 rd june 2020. during the peak of the epidemic, dental care was considered an essential service. however, italian regulations imposed to limit as much as possible routine activity during the lockdown, as only urgent procedures which could not be postponed could be performed. as a matter of fact, the straightforward transmission route of sars-cov-2, the relatively close contact with the patient, and aerosol generation during the majority of dental procedures concur to exposing dental practitioners to a higher risk of contagion, (izzetti et al. 2020 , peng et al. 2020 . indeed, sars-cov-2 is transmitted through aerosol and droplets, and has a relatively long resistance in aerosol for up to 3 hours (van doremalen et al. 2020) . numerous guidelines and recommendations on resuming dental activities are released these days (cochrane oral health 2020) . standard procedures appear insufficient in protecting from sars-cov-2, and thus specific measures to prevent virus transmission should be adopted to safeguard the health of both patients and oral care providers (izzetti et al. 2020 , peng et al. 2020 . in particular, several steps have been added for the correct management of dental patients in order to identify subjects at higher risk of being infected. phone and in-office triage, along with temperature recording, have become routine procedures to investigate the presence of symptoms suggestive for covid-19 and behaviours which may have caused contagion (izzetti et al. 2020 . moreover, covid-19 has led to a re-design of the dental office, from the waiting room to the clinical setting, and has made necessary the adoption of personal protective equipment (ppe) also for non-clinical staff (izzetti et al. 2020 ). during the lockdown, a survey on the current status of dental profession was performed, with the aim to give insight into how dentistry was changing and what were the expectations for the future. in the accepted article present work, the acute impact of the covid-19 pandemic on the dental profession in italy and the predictions on the impact on dentistry are reported. this article is protected by copyright. all rights reserved after a protocol preparation and approval from the committee on bioethics of the university of pisa (review no. 11/2020), a questionnaire for dental practitioners, aimed at investigating various aspects of dental activity during the early stages of the covid-19 pandemic, was specifically developed for the study. initially, the preliminary questionnaire was pre-tested on 20 subjects prior to administration on a national scale. for all the items of the questionnaire, an intraclass correlation coefficient (icc) >0.80 was considered satisfactory. in cases of items with icc values <0.80, the questionnaire was edited in order to increase icc. an online platform was directly emailed by the national federation of medical doctors and dentists (federazione nazionale ordine dei medici chirurghi e odontoiatri, commissione albo odontoiatri -fnomceo) to all the provincial coordinators with the request for distribution among colleagues. an open invitation was posted on social media and promoted via professional networks. the survey was administered between the 6 th april and the 13 th april 2020. the questionnaire (appendix 1) addressed the following dimensions: -demographic and professional status -professional activity during the epidemic -adherence to preventive measures -questions on the future perspectives of dental practice the demographic and professional status section aimed at collecting data on age, gender, practice location, professional background, and practice organization (number of dental chairs, collaborators, dental assistants). the status of dental activity was investigated in terms of types of treatments performed and number of procedures per week. the adherence to the preventive measures suggested by the italian dental institutions and associations was investigated according to four domains previously identified (izzetti et al. 2020) . in particular, these domains were: in-office triage and dental office preparation (phase ii) -post-dental treatment management of the dental office (phase iv) a focus on highly epidemic areas, registering the higher number of cases, was also performed in order to evaluate the potential presence of differences between the regions in northern italy and the rest of the country. this article is protected by copyright. all rights reserved finally, the subjective predictions on the potential changes occurring in dental practice following the pandemic were investigated, in order to give an overview of the professionals' point of view. sample size estimation for representativeness was set at 1,491 responses, considering a ci of 95%, an error of 2% and maximum heterogeneity in a population of 50,000 subjects. overall, the total number of dental professionals in italy is reported to be around 62,000, although unofficially it would appear that the active dentists are approximately 45,000 (according to the national federation of medical doctors and dentists -fnomceo; https://portale.fnomceo.it/). data analysis was conducted using spss version 26 (ibm). descriptive and inferential statistics were provided. chi-square and fisher-yates tests were used to compare categorical parameters and frequencies. non-parametric correlation analyses were performed with spearman rank analyses. data were graphically tested for normality, and logarithmic or square root transformations were made as needed before applying the adequate non-parametric tests. statistical significance was set with a p-value of 0.05. a total of 3,254 respondents completed the survey, representing about the 5.25% of italian dental professionals. the study sample's geographic distribution reflected the distribution of general dental population. the sample was representative of the general dental population in italy per gender and age. the characteristics of the respondents are illustrated in table 1 . in the results, only significant data are presented. at the time of the survey (6 th -13 th april, 2020), 99.7% of participants reduced the activity to urgent treatments or totally stopped working. as per the procedures performed, the treatment of pulpitis, prosthesis de-cementation, and abscess were the most common urgent procedures provided (table 1) . the mean number of procedures performed per week was 5.27/dentist. overall, it is estimated that the surveyed professionals have guaranteed 11,778 urgent dental treatments from the start of the lockdown (9 th march 2020) to the date of the survey. phone triage this article is protected by copyright. all rights reserved phone triage was performed by the 95% of the sample, and 98.8% assessed the presence of symptoms suggestive for covid-19. moreover, the potential risk of contact with infected subjects was also investigated by the majority of surveyed dentists (table 2) . in-office triage and dental office preparation unlike phone triage, the in-office triage questionnaire was performed by 49.5% of dentists. only the 25.2% performed temperature recording, using in the majority of cases a contactless thermometer. the set-up of the waiting room (non-clinical area) was adapted to the new situation by almost the totality of the sample, by providing a hydro-alcoholic solution for hand disinfection, removing objects at risk of contamination, and reorganizing the schedule in order to guarantee social distancing. environment disinfection of the dental setting (clinical area) was mostly provided using isopropyl alcohol and sodium hypochlorite. in 99.1%, clinical staff performed hand washing for 20-40 seconds, while the 55.7% also performed hand disinfection with a hydro-alcoholic solution prior to wearing gloves. ppe involved the use of gown, cap, masks, and eye protections. in the 50.3% of cases, two pairs of gloves were used (table 2) . in almost 90% of cases, patients were asked to perform a mouth rinse prior to dental treatment, in the majority of cases using hydrogen peroxide. in 88.5% of cases, measures were adopted to limit aerosol production, while the four-hands technique was used only in 37.8% (table 2) . post-dental treatment management of the dental office room ventilation was provided after dental treatment in 98.1% of cases. almost the totality of the sample repeated hand washing and disinfection after removing the gloves at the end of the procedure (table 2) . in table 3 , a comparison between lombardy and veneto and the rest of the italian regions is provided. overall, in highly epidemic areas, compliance with preventive measures was higher. the 57.2% of dental professionals reported being able to retrieve ppe in northern italy, a slightly lower percentage compared to the 59.9% reported on average in other regions. in northern regions, more than 90% of dental professionals endorsed being informed on the preventive measures to be adopted during covid-19. moreover, in highly epidemic areas a slower re-start of routine activity was expected ( figure 1 ). this article is protected by copyright. all rights reserved questions on future perspectives of dental practice the majority of the sample expected some changes in the dental profession following the epidemic, in particular regarding ppe and dental office set-up in terms of schedule and preparation for treatment. while an increasing use of ppe was reported by the 60% of the surveyed professionals, 90.4% reported difficulty in accessing ppe supply and an increase in ppe costs. the 80.6% feared a reduction in dental activity after the pandemic. the mean expected time of return to routine dental activity was thought to be around 4.9 months whilst the majority of the surveyed dentists reported a maximum period of 3 months as the threshold of economical sustainability. a positive correlation (p<0.05) was found between the decrease in dental activity and the expected time of return to regular activity. in particular, the higher was the percentage decrease in dental activity, the longer was the time expected for the return to regular activity ( figure 2 ). the mean time estimated for managing treatment suspension without affecting patient's health was thought to be up to 2 months by the 78.3% of the surveyed dentists. in 82.7% of cases, it was believed that standard procedures could be adopted again but increasing protection against aerosol should be needed. after the beginning of the lockdown, dental activity was reduced by 95%. in particular, almost the totality of the surveyed sample (99.7%) performed only urgent treatments, consistently with the italian government recommendations (circolare del ministero della salute n. 7422 del 16 marzo 2020). all the dental professionals showed a high level of adherence to the preventive measures suggested (izzetti et al. 2020 ). phone triage was performed by 95% of the sample. triage, both at the telephone or in-hospital, has been widely employed in several medical fields, in particular emergency care, where it is adopted to assess the need for hospitalization (boggan et al. 2020 almost all the sample provided re-organization of the waiting room in order to limit the number of surfaces which could transmit infection (izzetti et al. 2020) . although thorough disinfection with alcoholbased solutions or chloro-derivatives may inactivate the virus on the surfaces, it is reported that sars-cov-2 can persist on surfaces up to 9 days (kampf et al. 2020) , and has an estimated median half-life of approximately 5.6 hours on stainless steel and 6.8 hours on plastic (van doremalen 2020). the presence of infectious sars-cov-2 was investigated also on surgical masks, where the virus was found to persist for up to 7 days, although being susceptible to standard disinfection methods . therefore, removing all the unnecessary objects from the waiting room is an effective measure to limit the risks of infection (ada 2020). correct hand washing is effective in controlling the diffusion of various diseases (goldberg 2017) . performing hand washing for at least 60 seconds is an effective measure in removing potential infectious microorganisms, especially if associated with the use of hydro-alcoholic solutions which contribute to the inactivation of enveloped viruses, including coronaviruses (lotfinejad et al. 2020). the combination of hand washing and disinfection is, therefore, the best practice in providing virus elimination. ppe use is crucial to protect health care workers from sars-cov-2 due to the relatively easy way of transmission. in particular, adequate provision of ppe is the first measure to ensure the safety of health care workers (lancet 2020). several protocols have been suggested to correctly protect from covid-19, providing the protection of eyes, nasal and oral mucosa. in our survey, we found that the majority of this article is protected by copyright. all rights reserved dental professionals employed the correct set of ppe, therefore suggesting a high sensitivity towards personal protection. however, it is essential to highlight the reported difficulty in obtaining ppe, which could have limited a wider use. considering dental treatment, almost all dentists prescribed a mouth rinse prior to the beginning of the procedure. while the majority employed hydrogen peroxide, a non-negligible number of professionals employed chlorhexidine. such a result is consistent with the findings of cagetti and co-workers (2020) in their survey on the dental professionals of northern italy, where in the 50% of cases the use of chlorhexidine-based mouth rinse was reported. in this sense, it would be advisable to evaluate the effects of chlorhexidine on sars-cov-2. however, it is not to be forgotten that saliva is a viral reservoir, thus posing the problem of the actual effectiveness of mouth rinsing prior to treatment. finally, as much as the oral cavity might be virus free, the mere breathing activity of the patient would contribute to the diffusion of the virus in the dental setting. the awareness of the risks related to aerosol generation was demonstrated by the large number of dentists that reported minimization of aerosol-generating procedures, and the adoption of dedicated strategies. the risks related to dental aerosols were previously highlighted during the spread of the severe acute respiratory syndrome (sars) between 2002 and 2004, when the control of aerosols was claimed as a necessary part of dental infection control procedures (harrel 2004 , harrel & molinari 2004 . moreover, the tropism of sars-cov-2 for ace2 cell receptors and the viral presence in saliva represent a non-negligible risk factor xu et al. 2020) . limiting aerosol by working manually is important. however, this is not always possible, thus several measures may be useful to limit aerosol production (izzetti et al. 2020; meng et al. 2020; peng et al. 2020) , with the use of surgical aspiration, the limitation in the use of handpieces, and four-hands technique appearing the most effective. however, in our survey, the four-hands technique was not widely employed. finally, post-treatment management was correctly carried out in most cases, providing room ventilation and surface disinfection, due to the reported viral persistence both in aerosol and on surfaces (van doremalen et al. 2020). the most critical aspect of this survey is the fact that data are self-reported, particularly for items such as those asking respondents to recall granular behaviours carried out by themselves and their staff. this article is protected by copyright. all rights reserved moreover, given their profession, respondents may have been likely to be uniquely focused on their patients' oral health (and possibly focused on maintaining their practice from a financial standpoint), which may have influenced their opinions about the speed at which regular dental practice should be allowed to resume. finally, respondents were not explicitly asked to weigh all the aspects against noteworthy risks that characterize this unprecedented situation. following the peak of the epidemic, numerous doubts arose as per the dental activities to be fully restarted, mostly regarding the use of adequate ppe and the management of aerosols produced by the use of handpieces. moreover, it was overall observed an attitude towards a modification of dental practice, a relatively slow return to regular activity, and a concern towards treatment management after suspension. italian dental professionals massively embraced novel and numerous precautions to minimize the professional contagion risk as indicated by the adoption in more than 90% of cases of the majority of the key suggestions provided. it is also likely that these changes might be perpetual as the 70.9% of the sample reports uncertainty on the virus eradication in influencing medium-long term disinfection and clinical protocols. however, the adoption of ppe was strongly influenced by its accessibility (40.3% reported complicated retrieval). thus, the availability of ppe impacts the overall scenario. accordingly, the vast majority (97.3%) showed uncertainties in the professional sentiment about the future. lastly, it is important to highlight that the abrupt stop of dental activity during the epidemic has left uncompleted an extremely high number of treatments. this is worrying and of concern, as it is believed by the 78.3% that even 2 months more without completing actual treatments would be prejudicial to the oral health of patients. in conclusion, with the present survey, we aimed to take a photograph of the situation of italian dentistry during the pandemic. it is remarkable that, despite numerous uncertainties and difficulties, dental health care professionals kept ensuring urgent treatments to the population in these dire times, providing the best standard of care possible while adhering to the preventive measures suggested by national institutions and associations. this article is protected by copyright. all rights reserved tables table 1. summary of sample characteristics. global this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved figure 2. scattered plot of the correlation between the dental activity decrease during the epidemic and the expected time of return to regular activity. the dental professionals who experienced higher decrease ada interim guidance for minimizing risk of covid-19 transmission incubation period of 2019 novel coronavirus (2019-ncov) infections among travellers from wuhan, china effectiveness of acute care remote triage systems: a systematic review covid-19 outbreak in north italy: an overview on dentistry. a questionnaire survey a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster epidemiologic and clinical characteristics of novel coronavirus infections involving 13 patients outside wuhan, china epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study recommendations for the re-opening of dental services: a rapid review of international sources 2019 novel coronavirus-important information for clinicians guideline implementation: hand hygiene clinical characteristics of coronavirus disease 2019 in china airborne spread of disease--the implications for dentistry aerosols and splatter in dentistry: a brief review of the literature and infection control implications state 2019-ncov case investigation team (2020). first case of 2019 novel coronavirus in the united states clinical features of patients infected with 2019 novel coronavirus in wuhan covid-19 transmission in dental practice: brief review of preventive measures in italy rapid design and implementation of an integrated patient self-triage and self-scheduling tool for covid-19 persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents covid-19: protecting health-care workers prevention and control of new coronavirus infection in department of stomatology accepted article this article is protected by copyright. all rights reserved coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine transmission routes of 2019-ncov and controls in dental practice stability and infectivity of coronaviruses in inanimate environments transmission of 2019-ncov infection from an asymptomatic contact in germany effectiveness of remote triage: a systematic review consistent detection of 2019 novel coronavirus in saliva accepted article key: cord-281762-qwlfikfl authors: shorten, george d. title: personal protective equipment during the covid-19 pandemic (letter #1) date: 2020-08-07 journal: can j anaesth doi: 10.1007/s12630-020-01784-4 sha: doc_id: 281762 cord_uid: qwlfikfl nan lockhart et al. have reviewed the importance and use of personal protective equipment (ppe) for anaesthesiologists and other airway managers. 1 they point out that ''ppe donning and doffing requires education and practice prior to their use during patient care'', going on to state that '' the more unfamiliar staff is with ppe, the more likely they will incorrectly don and doff it''. weissman et al. 2 have expressed the need for fundamental research to inform ppe recommendations, particularly in the setting of tracheal intubation. they cite the recent work of feldman et al. 3 who showed that, in a simulated setting, currently recommended ppe may not prevent exposure of those who perform tracheal intubation. one critical aspect of the efficacy of ppe in protecting healthcare workers (hcws) is the manner in which donning is performed. a closer examination of training in donning and doffing ppe is warranted. during the coronavirus disease pandemic, the circumstances under which donning and doffing of ppe is being learned, trained, and subsequently performed may be suboptimal. although no overview exists of the training practices for donning and doffing ppe, it is likely that it is less than ideal. ideally, in designing a training program for a new procedure, one would: 1) share a description of the procedure with ''trainees'' that contains unambiguous definitions of each step, and common and critical errors; 2) apply a pre-training preparation standard; 3) provide real-world materials (e.g., ppe) for repeated deliberate practice; 4) provide multiple training sessions based on performance; and 5) undertake an ''exit'' assessment. the ''graduate trainee'' would then transfer their newly acquired skills into the real world with experienced supervision. of course, one might argue that the current pandemic requires that prompt action is required during which perfect is the enemy of good. in fact, scientifically rigorous training methodology exists which ensures that a newly learned procedure is performed competently. the discipline of anesthesiology has been at the forefront of training to a pre-defined level of competency. 4 proficiencybased progression and other forms of metrics-based training decrease the incidence of errors amongst novice practitioners and the evidence of its consistent efficacy is particularly strong for procedural skills. 5 it is possible that the difficulties in donning and doffing ppe are underestimated. seal-testing a face mask and minimizing the risk of fogging googles are particularly amenable to error. the key resource for such training (characterisation of the procedure as steps and errors) is shareable at little or no cost. when the stakes are as high as the health and continued contribution of hcws, we should use the best tools available, especially those that are consistently effective. disclosures none. personal protective equipment (ppe) for both anesthesiologists and other airway managers: principles and practice during the covid-19 pandemic covid-19 and risks posed to personnel during endotracheal intubation exposure to a surrogate measure of contamination from simulated patients by emergency department personnel wearing personal protective equipment european section/board of anaesthesiology/ european society of anaesthesiology consensus statement on competency-based education and training in anaesthesiology proficiency-based progression training: an 'end to end' model for decreasing error applied to achievement of effective epidural analgesia during labour: a randomised control study key: cord-285960-1zuhilmu authors: conly, john; seto, w. h.; pittet, didier; holmes, alison; chu, may; hunter, paul r. title: use of medical face masks versus particulate respirators as a component of personal protective equipment for health care workers in the context of the covid-19 pandemic date: 2020-08-06 journal: antimicrob resist infect control doi: 10.1186/s13756-020-00779-6 sha: doc_id: 285960 cord_uid: 1zuhilmu currently available evidence supports that the predominant route of human-to-human transmission of the sars-cov-2 is through respiratory droplets and/or contact routes. the report by the world health organization (who) joint mission on coronavirus disease 2019 (covid-19) in china supports person-to-person droplet and fomite transmission during close unprotected contact with the vast majority of the investigated infection clusters occurring within families, with a household secondary attack rate varying between 3 and 10%, a finding that is not consistent with airborne transmission. the reproduction number (r(0)) for the sars-cov-2 is estimated to be between 2.2–2.7, compatible with other respiratory viruses associated with a droplet/contact mode of transmission and very different than an airborne virus like measles with a r(0) widely cited to be between 12 and 18. based on the scientific evidence accumulated to date, our view is that sars-cov-2 is not spread by the airborne route to any significant extent and the use of particulate respirators offers no advantage over medical masks as a component of personal protective equipment for the routine care of patients with covid-19 in the health care setting. moreover, prolonged use of particulate respirators may result in unintended harms. in conjunction with appropriate hand hygiene, personal protective equipment (ppe) used by health care workers caring for patients with covid-19 must be used with attention to detail and precision of execution to prevent lapses in adherence and active failures in the donning and doffing of the ppe. the mechanisms of transmission (airborne, droplet, contact, vector or common vehicle) for microorganisms supports a specific combination of barrier precautions chosen on the basis of a point-of-care risk assessment by the health care worker (hcw) [1, 2] . any person who is in close contact (generally considered to be within 1 m) with someone who has respiratory symptoms (e.g., sneezing or coughing) is at risk of being exposed to potentially infective respiratory droplets. moreover, droplet transmission may also produce fomites on any surface in the immediate environment around the infected person. airborne transmission refers to the presence of microbes within droplet nuclei (generally considered to be particles < 5-10 μm in diameter), which result from the evaporation of larger droplets and/or exist within dust particles and may remain in the air for long periods of time and may be transmitted to others over longer distances such as the measles virus [2] [3] [4] . however, it is important to recognize that in the course of medical care, aerosols of particles generally considered to be < 5-10 μm may be generated in certain procedures considered to be "aerosol-generating medical procedures" (agmp) and transmitted at limited distances beyond 1 m, which has been referred to as "opportunistic" airborne transmission and airborne precautions are appropriate for these settings [4] . within the context of the general understanding of the routes of droplet and opportunistic airborne transmission, controversy exists about the relative contribution and importance of the routes of each of them related to specific viruses. for example a systematic review of the literature concluded that influenza virus transmission in humans occurs only over short distances consistent with predominantly the droplet route [5] , but tellier suggested that limited aerosol transmission over longer distances can occur in addition to droplet transmission [6, 7] . it is recognized that there is a continuum of transmission routes between large droplet and aerosol and it is an important concept. particles of a variety of sizes are expelled from the human airway during coughing, sneezing, talking and medical procedures. the aerobiology of expired large droplets and smaller particles and the transmission dynamics to allow for a replication competen and tinfection competent virus to establish an invasive infection in humans is complex. the size of the particles and the distance the particles may be expelled is variable and depends on many factors, including the size distribution of the particles, the propulsive force generated by the individual or the procedure, the relative humidity, evaporation level, settling velocity, direction and velocity of air flow, the number of air changes per hour, temperature, crowding and other environmental factors. in addition there is variability in the type of the respiratory virus in question, the dispersion, quantity, and distribution of the virus within the droplets and smaller particles, the stability of the virus, its replication and infection competence, ability to enter the respiratory tract, ability to bind to specific host cell receptors and to establish invasive infection in a susceptible host. the process is further complicated by debate regarding how well the use of quantitative polymerase chain reaction (pcr) techniques performed on respiratory specimens can be interpreted with respect to recovery of viable virus and its titer, depending on the timing of presentation and stage of illness [8] [9] [10] [11] [12] . regardless of the uncertainties, one certainty is that the use of personal protective equipment (ppe) including gloves, gowns, medical masks and eye protection in combination with patient placement in adequately ventilated single rooms represents one component of the infection prevention and control (ipc) response to prevent transmission of pathogenic microorganisms to hcws [1, 2] . however the effectiveness of ppe depends on its availability, the proper physical environmental controls, adequate staff training, strict adherence to hand hygiene and appropriate human behaviour [13, 14] . currently available evidence supports that the predominant route of human-to-human transmission of the sars-cov-2 is through respiratory droplets and/or contact routes [1, [15] [16] [17] [18] [19] . the report by the world health organization (who) joint mission on coronavirus disease 2019 (covid19) in china which analyzed the experience with 75,465 cases supports person-to-person droplet and fomite transmission during close unprotected contact, with the majority of sars-cov-2 transmission occurring within families in close contact with each other [16] . the vast majority (78-85%) of the investigated infection clusters occurred within families, with a household secondary attack rate varying between 3 and 10%, a finding that is not consistent with airborne transmission [16] . the reproduction number (r 0 ) for the sars-cov-2 was estimated to be between 2.0-2.5, compatible with influenza and other respiratory viruses typical for a droplet/contact mode of transmission and very different than a classical airborne virus such as measles which is estimated to have a r 0 of greater than 10 and widely cited to be between 12 and 18 [16, 20] . other detailed reports have also been consistent, finding a r 0 of 2.2-2.7 for sars-cov-2 [21, 22] . multiple clinical and epidemiologic reports have now lent considerable support that the predominant route of human-to-human transmission of the sars-cov-2 is through respiratory droplets and/or contact routes and do not support significant airborne transmission. an investigation of 25 close contacts sitting within 2 m of a symptomatic index case with cough and a presymptomatic case, both confirmed to have covid-19, multiple exposed flight crew members and potentially all 350 passengers on board an airplane during a 15-h flight revealed no evidence of transmission of sars-cov-2 [19] supporting a droplet as opposed to airborne transmission route. although the cases were reported to be wearing masks on the flight, it is not possible to wear masks during eating and drinking and the filtration capacity of the mask would not likely have been adequate for the entire 15 hour flight. another report in a clinical setting in which 41 health care workers (hcws) were exposed for over 10 min and within 2 m of a patient with confirmed covid-19 during an intense and difficult intubation and non-invasive ventilation scenario, involving multiple agmps, revealed no transmission events of sars-cov-2 with repetitive testing of all the hcws [23] . the majority (85%) of the hcws were wearing a medical mask and other appropriate ppe while the remainder wore an n95 respirator. another recent investigation of an initially undiagnosed covid-19 patient with severe pneumonia with a confirmed high frequency of coughing and receiving oxygen therapy at 8 l/min who was nursed in an open 10 bed cubicle of a general ward for 35 h, with minimal spacing between patients, led to an exposure of 71 staff and 49 patients, including 7 staff and 10 patients who fulfilled the criteria of 'close contact' (within two metres of the index case for a > 15 min or had performed agmps without a n95 respirator), identified no sars-cov-2 nosocomial transmission events [24] . all patients and 6/7 staff with close contact tested negative for covid-19 despite inconsistent use of medical masks by the patients and either use of medical masks or n95 respirators by the hcws. in total 76 tests were performed on 52 contacts of which all were negative, and all other identified contacts remained asymptomatic during the 28 day post-contact surveillance period [24] . the authors concluded that sars-cov-2 is not spread by the airborne route and that basic infection control measures, including the use of medical masks, hand and environmental hygiene are adequate to prevent nosocomial transmission of sars-cov-2. another recent study of 48 persons involved in a nosocomial outbreak of sars-cov-2 infections in the pediatric dialysis unit of the university hospital of münster found that after contact with the index case, 7 hcws, 3 patients and one accompanying person became infected. all had either cumulative 15 min of faceto-face contact or were hcws with exposure within a distance of ≤ 2 m, which occurred without use of any ppe. of the remaining contacts who had shared the same indoor environment without face-to-face contact or who had contact but at a distance of > 2 m but without any use of ppe, none were found to be positive for covid-19 on testing [25] . additional data supporting that airborne transmission is not a predominant mode of transmission and therefore that n95 respirators or their equivalent are not required for routine use is accruing from sites which use only medical masks as the component of ppe in the care of covid-19 patients but have a well-trained and prepared staff complement. there have been an estimated 5544 person hours of continuous hcw exposure to 132 covid-19 inpatients, using ppe consisting of gowns, gloves, medical masks, and face shields or goggles for routine care and the addition of a n95 respirator for any agmps within "designated" covid-19 medical wards at 4 acute care hospitals in calgary, canada over the first 2 months of care delivery with no nosocomial sars-cov-2 transmission events documented in any hcws to date [26] . data from studies that sampled surfaces in the environment for the presence of sars-cov-2 rna in the immediate airspace surrounding infected patients who had known significant viral loads in their respiratory secretions have provided both negative and positive results [17, 18, [27] [28] [29] [30] . several studies have now reported positive results for the presence of sars-cov-2 rna in air samples but in extremely low copy numbers/m 3 or per liter of air sampled and would be highly unlikely to represent viable virus [28] [29] [30] . no studies to date have been able to find viable sars-cov-2 within air samples [30] . even if viable virus were to be found in air samples, it would need to be demonstrated that sars-cov-2 in the samples was both replication and infection competent in the context of health care settings where ppe is being used appropriately in conjunction with diligent hand hygiene to consider that airborne transmission represents a significant mode of transmission. a recent experimental laboratory study suggested that aerosol transmission of sars-cov-2 is plausible, because they demonstrated that the virus can remain viable in aerosols for 3 h based on their experimental design. however, they used a collison 3-jet nebulizer to shear a large volume liquid suspension of a high viral inoculum to generate aerosolized viral particles which were then impacted against a hard surface inside a drum [31] . this mode of artificial mechanical aerosol production has been used for testing bioterrorism agents [32, 33] and has little relevance to a coughing patient with covid-19 in the clinical setting and does not offer evidence that the virus is routinely present in aerosols at the bedside. another report suggested that based on laser light scattering observations, loud speech could emit oral droplet nuclei of about 4um in size that persist as a slowly descending cloud which remain airborne for more than 8 min and theoretically could contain viable virus capable of being inhaled into the lungs [34] . however this conjecture is dependent on the independent action hypothesis (iah) and the authors readily admit that there is no evidence the iah is valid for humans and sars-cov-2.other reports have suggested that airborne transmission is a significant route of transmission for the sars-cov-2; the title of one report suggests that the world should face the reality that the virus is airborne [35] [36] [37] . these studies represent opinion pieces, one systematic review of mainly modelling plus some experimental studies, and brief case reports which do not utilize robust methods to rule out contact or fomite transmission or opportunistic airborne transmission. a recent who report indicated that sars-cov-2 rna has been detected in in feces in 30% of cases within a few days of symptom onset and live virus was cultivated from stools in some cases [16] . this latter observation and our knowledge of the extensive transmission that has emerged in hundreds of outbreaks of norovirus on cruise ships raises the possibility of the fecal-oral route as an additional means of transmission for sars-cov-2 which deserves attention and further study [38] [39] [40] . a recent report from the diamond princess cruise ship reported that before disinfection, sars-cov-2 rna was identified on multiple surfaces up to 17 days after cabins were vacated from both symptomatic and asymptomatic infected passengers suggesting widespread contamination but likely no viable virus was present [41] . similar extensive environmental contamination of surfaces by sars-cov-2 from infected patients has been reported [18] . additional evidence is emerging about the recognition of contact as a major route of transmission with a recent report from china finding poor hand hygiene before and after contact with patients and improper ppe as significantly associated with hcw with poor hand hygiene being retained in the logistic regression with the highest relative risk [42] . guidance from the who states that "health care workers should wear a medical face mask (herein after termed medical mask) when entering a room where patients suspected or confirmed of being infected with sars-cov-2 are admitted and in any situation of care provided to a suspected or confirmed case". the use of a particulate respirator at least as protective as a us national institute for occupational safety and health (niosh)-certified n95, european union (eu) standard ffp2, or equivalent, is recommended when performing aerosol-generating medical procedures [1, 2] . some jurisdictions and professional societies have suggested that the precautionary principle [43] should be applied in the event of an outbreak of any new respiratory virus. in the context of the current covid-19 outbreak, several institutions initially issued guidance indicating that particulate respirators (designed to protect against 95% of airborne particulates when tested against a 0.3-μm particles) should be used as a component of the ppe for the hcws, rather than medical masks. persisting with this approach and the subsequent differences in recommendations for the type of masks creates risk perception disparities for hcws, which may be increased in jurisdictions in the world with limited or no access to particulate respirators, and in the event of domestic or global supply disruptions. strict adherence to the use of administrative controls and using medical masks as a component of ppe were shown to be effective with no reported transmission events to hcws during the sars outbreak in 2003 [44, 45] and in one setting without the use of airborne isolation rooms [45] . although the appropriate use of fit tested particulate respirators as a component of ppe may be equally effective compared the use of medical masks for hcws in the management of patients infected with coronavirus strains including sars-cov-2, it is important to note that there were multiple reports documenting sars coronavirus transmission to hcws despite the use of particulate respirators in conjunction with other ppe in accordance with guidelines which reflect failures to prevent transmission to hcws using them [46] [47] [48] [49] [50] [51] [52] . the mechanisms of transmission in these latter settings are not well understood but draw attention to the points that the use of particulate respirators as a component of ppe do not provide infallible levels of protection to hcws. it is likely that these failures relate to inappropriate use or self contamination events. multiple studies using systems-based human factors analysis have demonstrated that lapses in adherence and active failures in the donning and doffing of ppe resulting in self-contamination, which may be the genesis of inoculation events leading to transmission of pathogens to hcws [53, 54] . a review of the literature following the sars outbreak in 2003 suggested that for ppe to be effective, its use should be as uncomplicated as possible and focus on key principles, strict adherence to protocols including those related to appropriate use of ppe, high compliance, and lend itself to achieve the highest level of effectiveness in preventing hcw transmission events [55, 56] . these studies suggest there is a need to simplify the ppe processes to ensure that compliance may be achieved. there were multiple reports of sars among hcws in hospital outbreaks reported from canada, china, hong kong, taiwan and vietnam followed by mers outbreaks with hcw transmission events in the middle east and south korea which were caused by a very similar coronavirus to the sars-cov-2. these hospital outbreaks serve to focus attention on the critical importance of ipc practices, including appropriate ppe use, and having adequate training and knowledge among hcws to ensure that ppe, barrier precautions and hand hygiene practices are used appropriately [1, 2, 14] . the single most important concept identified in the management of patients affected by viruses transmitted by the droplet/contact route is the precision of execution in the use of ppe, and which should be the primary focus rather than on the type of mask used by hcws as a component of ppe. the findings from multiple systematic reviews and meta analyses over the last decade have not demonstrated any significant difference in the clinical effectiveness of particulate respirators compared to the use of medical masks when used by hcws in multiple health care settings for the prevention of respiratory virus infections, including influenza [57] [58] [59] . a recent large well conducted cluster randomized multi-center, multi-year pragmatic effectiveness study study no evidence of greater clinical effectiveness of particulate respirators compared to medical masks in the prevention of acquisition of laboratory confirmed influenza in hcws [60] . one of the systematic reviews commented about the harms of particulate respirators, especially when worn for prolonged periods [57] . other studies have demonstrated side effects associated with the use of particulate respirators including facial dermatitis from the respirator components, increased work of breathing, respiratory fatigue, impaired work capacity, increased oxygen debt, early exhaustion at lighter workloads, elevated levels of co 2 , increased nasal resistance, and increased noncompliance events leading to self-contamination (adjustments, respirator or face touches, under-the-respirator touches, and eye touches) [61] [62] [63] [64] [65] [66] [67] . these side effects are not encountered with the same frequency with the appropriate use of medical masks. an additional study has suggested pregnant women were not able to maintain their minute ventilation and had decreased oxygen uptake and increased carbon dioxide production even at rest [55] . the effects on the developing fetus are unknown. studies of the use of particulate respirators in clinical settings have demonstrated anywhere between 44 and 97% of hcws do not use the respirators properly [68] . our view is that the weight of the scientific evidence to date indicates that particulate respirators offer no advantage over medical masks as a component of ppe for the prevention of respiratory viral infections transmitted by the droplet/contact route, when used for routine care in clinical settings. to date, the available evidence supports that the predominant route of transmission of sars-cov-2 is consistent with the droplet/contact route. there are potential unintended consequences of the use of particulate respirators that put hcws at risk particularly with prolonged use, which have not been associated with the use of medical masks. hcws should be apprised accordingly in an open and transparent manner regarding potential harms of particulate respirators in jurisdictions where particulate respirators are chosen for routine use as a component of ppe. in addition, particulate respirators are more costly, require fit testing, necessitate additional time and resources, do not provide an adequate fit in individuals with beards, and may provide a false sense of security. moreover, in the current covid-19 pandemic, shortages have been documented from overuse such that respirators were not available in settings where agmps are performed and where is evidence for their need. regardless of whether jurisdictions choose the precautionary principle with consequent use of particulate respirators instead of medical masks as a component of ppe for routine care of covid-19 patients, this choice must not detract from the critical importance of emphasizing that ppe is only one measure within a bundle that comprises administrative, environmental and engineering controls, as described in who's infection prevention and control of epidemic-and pandemic-prone acute respiratory infections in health care [2] . ppe used by hcws caring for patients with covid-19 must be used with attention to detail and precision of execution which involves selecting the proper ppe and being trained in how to correctly don, doff and dispose of itwithout self-contaminating oneself in the process, the latter underscoring the importance and attention required for hand hygiene. additional evidence on the use of medical masks and respirators needs to be generated to help define and inform knowledge gaps as we learn more about the covid-19 epidemic and hcw practices. coronavirus disease (covid-19) technical guidance: infection prevention and control. geneva: world health organization infection prevention and control of epidemicand pandemic-prone acute respiratory infections in health care. geneva: world health organization the spread of influenza and other respiratory viruses: complexities and conjectures airborne transmission of communicable infection--the elusive pathway transmission of influenza a in human beings aerosol transmission of influenza a virus: a review of new studies recognition of aerosol transmission of infectious agents: a commentary droplet fate in indoor environments, or can we prevent the spread of infection? indoor air how far droplets can move in indoor environments-revisiting the wells evaporation-falling curve airborne spread of infectious agents in the indoor environment measurements of airborne influenza virus in aerosol particles from human coughs influenza virus survival in aerosols and estimates of viable virus loss resulting from aerosolization and air-sampling the 2003 sars outbreak and its impact on infection control practices infection prevention and control during health care when novel coronavirus (ncov) infection is suspected. geneva: world health organization a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating personto-person transmission: a study of a family cluster report of the who-china joint mission on coronavirus disease 2019 (covid-19). geneva: world health organization escalating infection control response to the rapidly evolving epidemiology of the coronavirus disease 2019 (covid-19) due to sars-cov-2 in hong kong air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) from a symptomatic patient lack of covid-19 transmission on an international flight2020 the basic reproduction number (r0) of measles: a systematic review early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia nowcasting and forecasting the potential domestic and international spread of the 2019-ncov outbreak originating in wuhan, china: a modelling study covid-19 and the risk to health care workers: a case report risk of nosocomial transmission of coronavirus disease 2019: an experience in a general ward setting in hong kong first reported nosocomial outbreak of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) in a pediatric dialysis unit covid-19 scientific advisory group. covid risk to healthcare workers a field indoor air measurement of sars-cov-2 in the patient rooms of the largest hospital in iran aerodynamic analysis of sars-cov-2 in two wuhan hospitals detection of air and surface contamination by sars-cov-2 in hospital rooms of infected patients transmission potential of sars-cov-2 in viral shedding observed at the university of aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 overcoming challenges to develop countermeasures against aerosolized bioterrorism agents: appropriate use of animal models the collision nebulizer: description, performance and application the airborne lifetime of small speech droplets and their potential importance in sars-cov-2 transmission airborne transmission of sars-cov-2: the world should face the reality airborne or droplet precautions for health workers treating covid-19? covid-19 outbreak associated with air conditioning in restaurant enteric involvement of coronaviruses: is faecal-oral transmission of sars-cov-2 possible? acute gastroenteritis on cruise ships -united states norovirus outbreaks on commercial cruise ships: a systematic review and new targets for the public health agenda risk factors of healthcare workers with corona virus disease 2019: a retrospective cohort study in a designated hospital of wuhan in china risk factors of healthcare workers with corona virus disease 2019: a retrospective cohort study in a designated hospital of wuhan in china the precautionary principle: a legal and policy history. copenhagen: world health organization effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (sars) lack of sars transmission among public hospital workers epidemiologic study and containment of a nosocomial outbreak of severe acute respiratory syndrome in a medical center in kaohsiung the outbreak of sars at tan tock seng hospital--relating epidemiology to control cluster of severe acute respiratory syndrome cases among protected health-care workers -toronto, canada control measures for severe acute respiratory syndrome (sars) in taiwan cluster of cases of severe acute respiratory syndrome among toronto healthcare workers after implementation of infection control precautions: a case series infection control and sars transmission among healthcare workers world health organization. sars outbreak in the philippines identification and characterization of failures in infectious agent transmission precaution practices in hospitals: a qualitative study human factors risk analyses of a doffing protocol for ebola-level personal protective equipment: mapping errors to contamination protecting health care workers from sars and other respiratory pathogens: organizational and individual factors that affect adherence to infection control guidelines research gaps in protecting healthcare workers from sars and other respiratory pathogens: an interdisciplinary, multi-stakeholder, evidence-based approach physical interventions to interrupt or reduce the spread of respiratory viruses effectiveness of n95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis effectiveness of masks and respirators against respiratory infections in healthcare workers: a systematic review and meta-analysis n95 respirators vs medical masks for preventing influenza among health care personnel: a randomized clinical trial adverse skin reactions to personal protective equipment against severe acute respiratory syndrome--a descriptive study in singapore skin reactions following use of n95 facial masks allergic contact dermatitis from formaldehyde textile resins in surgical uniforms and nonwoven textile masks effects of long-duration wearing of n95 respirator and surgical facemask: a pilot study physiologic and other effects and compliance with long-term respirator use among medical intensive care unit nurses respiratory consequences of n95-type mask usage in pregnant healthcare workers-a controlled clinical study use and efficacy of tuberculosis infection control practices at hospitals with previous outbreaks of multidrug-resistant tuberculosis publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we are thankful to nicole lamont and jenine leal for reference checks and editing assistance. authors' contributions jc, whs, dp, ah, mc, prh contributed to the conception of this work. all authors were provided a draft of the manuscript for comments and were provided with an opportunity to present revisions. jc wrote the initial drafts of the manuscript and collated comments from the principal authors engaged in the conception of the work and later comments from all authors. all authors were provided a final version of the manuscript for approval. this commentary was unfunded.availability of data and materials not applicable.ethics approval and consent to participate not applicable. not applicable. the authors declare that they have no competing interests. the members of the world health organization (who) covid-19 infection prevention and control research and innovation advisory group who participated in the development of this manuscript, provide independent advice to who in their capacity as individuals with expertise in infection prevention and control.author details 1 university of calgary and alberta health services, calgary, alberta, canada. 2 university of hong kong , hong kong, china. 3 university of east anglia, norwich, uk. 4 hopitaux universitaires de genève, geneva, switzerland. 5 imperial college, london, united kingdom. 6 colorado school of public health, aurora, colorado, usa.received: 4 june 2020 accepted: 9 july 2020 key: cord-131678-rvg1ayp2 authors: ponce, marcelo; sandhel, amit title: covid19.analytics: an r package to obtain, analyze and visualize data from the corona virus disease pandemic date: 2020-09-02 journal: nan doi: nan sha: doc_id: 131678 cord_uid: rvg1ayp2 with the emergence of a new pandemic worldwide, a novel strategy to approach it has emerged. several initiatives under the umbrella of"open science"are contributing to tackle this unprecedented situation. in particular, the"r language and environment for statistical computing"offers an excellent tool and ecosystem for approaches focusing on open science and reproducible results. hence it is not surprising that with the onset of the pandemic, a large number of r packages and resources were made available for researches working in the pandemic. in this paper, we present an r package that allows users to access and analyze worldwide data from resources publicly available. we will introduce the covid19.analytics package, focusing in its capabilities and presenting a particular study case where we describe how to deploy the"covid19.analytics dashboard explorer". in 2019 a novel type of corona virus was first reported, originally in the province of hubei, china. in a time frame of months this new virus was capable of producing a global pandemic of the corona virus disease (covid19), which can end up in a severe acute respiratory syndrome (sars-cov-2). the origin of the virus is still unclear [4, 5, 6] , although some studies based on genetic evidence, suggest that it is quite unlikely that this virus was human made in a laboratory, but instead points towards cross-species transmission [7, 8] . although this is not the first time in the human history when humanity faces a pandemic, this pandemic has unique characteristics. for starting the virus is "peculiar" as not all the infected individuals experience the same symptoms. some individuals display symptoms that are similar to the ones of a common cold or flu while other individuals experience serious symptoms that can cause death or hospitalization with different levels of severity, including staying in intensive-care units (icu) for several weeks or even months. a recent medical survey shows that the disease can transcend pulmonary manifestations affecting several other organs [9] . studies also suggest that the level of severity of the disease can be linked to previous conditions [10] , gender [11] , or even blood type [12] but the fundamental and underlying reasons still remain unclear. some infected individuals are completely asymptomatic, which makes them ideal vectors for disseminating the virus. this also makes very difficult to precisely determine the transmission rate of the disease, and it is argued that in part due to the peculiar characteristics of the virus, that some initial estimates were underdetermining the actual value [13] . elderly are the most vulnerable to the disease and reported mortality rates vary from 5 to 15% depending on the geographical location. in addition to this, the high connectivity of our modern societies, make possible for a virus like this to widely spread around the world in a relatively short period of time. what is also unprecedented is the pace at which the scientific community has engaged in fighting this pandemic in different fronts [14] . technology and scientific knowledge are and will continue playing a fundamental role in how humanity is facing this pandemic and helping to reduce the risk of individuals to be exposed or suffer serious illness. techniques such as dna/rna sequencing, computer simulations, models generations and predictions, are nowadays widely accessible and can help in a great manner to evaluate and design the best course of action in a situation like this [15] . public health organizations are relying on mathematical and data-driven models (e.g. [16] ), to draw policies and protocols in order to try to mitigate the impact on societies by not suffocating their health institutions and resources [17] . specifically, mathematical models of the evolution of the virus spread, have been used to establish strategies, like social distancing, quarantines, self-isolation and staying at home, to reduce the chances of transmission among individuals. usually, vaccination is also another approach that emerges as a possible contention strategy, however this is still not a viable possibility in the case of covid19, as there is not vaccine developed yet [18, 19] . simulations of the spread of virus have also shown that among the most efficient ways to reduce the spread of the virus are [20] : increasing social distancing, which refers to staying apart from individuals so that the virus can not so easily disperse among individuals; improving hygiene routines, such as proper hand washing, use of hand sanitizer, etc. which would eventually reduce the chances of the virus to remain effective; quarantine or self-isolation, again to reduce unnecessary exposure to other potentially infected individuals. of course these recommendations based on simulations and models can be as accurate and useful as the simulations are, which ultimately depend on the value of the parameters used to set up the initial conditions of the models. moreover these parameters strongly depend on the actual data which can be also sensitive to many other factors, such as data collection or reporting protocols among others [21] . hence counting with accurate, reliable and up-to-date data is critical when trying to understand the conditions for spreading the virus but also for predicting possible outcomes of the epidemic, as well as, designing proper containment measurements. similarly, being able to access and process the huge amount of genetic information associated with the virus has proben to shred light into the disease's path [22, 23] . encompassing these unprecedented times, another interesting phenomenon has also occurred, in part related to a contemporaneous trend in how science can be done by emphasizing transparency, reproducibility and robustness: an open approach to the methods and the data; usually refer as open science. in particular, this approach has been part for quite sometime of the software developer community in the so-called open source projects or codes. this way of developing software, offers a lot of advantages in comparison to the more traditional and closed, proprietary approaches. for starting, it allows that any interested party can look at the actual implementation of the code, criticize, complement or even contribute to the project. it improves transparency, and at the same time, guarantees higher standards due to the public scrutiny; which at the end results in benefiting every one: the developers by increasing their reputation, reach and consolidating a widely validated product and the users by allowing direct access to the sources and details of the implementation. it also helps with reproducibility of results and bugs reports and fixes. several approaches and initiatives are taking the openness concepts and implementing in their platforms. specific examples of this have drown the internet, e.g. the surge of open source powered dashboards [24] , open data repositories, etc. another example of this is for instance the number of scientific papers related to covid19 published since the beginning of the pandemic [25] , the amount of data and tools developed to track the evolution of pandemic, etc. [26] . as a matter of fact, scientists are now drowning in publications related to the covid19 [27, 28] , and some collaborative and community initiatives are trying to use machine learning techniques to facilitate identify and digest the most relevant sources for a given topic [29, 30, 31] . the "r language and environment for statistical computing" [1, 2] is not exception here. moreover, promoting and based on the open source and open community principles, r has empowered scientists and researchers since its inception. not surprisingly then, the r community has contributed to the official cran [32] repository already with more than a dozen of packages related to the covid19 pandemic since the beginning of the crisis. in particular, in this paper we will introduce and discuss the covid19.analytics r package [3] , which is mainly designed and focus in an open and modular approach to provide researchers quick access to the latest reported worldwide data of the covid19 cases, as well as, analytical and visualization tools to process this data. this paper is organized as follow: in sec. 2 we describe the covid19.analytics , in sec. 3 we present some examples of data analysis and visualization, in sec. 4 we describe in detail how to deploy a web dashboard employing the capabilities of the covid19.analytics package providing full details on the implementation so that this procedure can be repeated and followed by interested users in developing their own dashboards. finally we summarize some conclusions in sec. 5. the covid19.analytics r package [3] allows users to obtain live 1 worldwide data from the novel covid19. it does this by accessing and retrieving the data publicly available and published by two main sources: the "covid-19 data repository by the center for systems science and engineering (csse) at johns hopkins university" [33] for the worldwide and us data, and the city of toronto for the toronto data [34] . the package also provides basic analysis and visualization tools and functions to investigate these datasets and other ones structured in a similar fashion. the covid19.analytics package is an open source tool, which its main implementation and api is the r package [3] . in addition to this, the package has a few more adds-on: • a central github repository, https://github.com/mponce0/covid19.analytics where the latest development version and source code of the package are available. users can also submit tickets for bugs, suggestions or comments using the "issues" tab. • a rendered version with live examples and documentation also hosted at github pages, https: //mponce0.github.io/covid19.analytics/; • a dashboard for interactive usage of the package with extended capabilities for users without any coding expertise, https://covid19analytics.scinet.utoronto.ca. we will discuss the details of the implementation in sec. 4. • a "backup" data repository hosted at github, https://github.com/mponce0/covid19analytics. datasets -where replicas of the live datasets are stored for redundancy and robust accesibility sake (see fig. 1 ). one of the main objectives of the covid19.analytics package is to make the latest data from the reported cases of the current covid19 pandemic promptly available to researchers and the scientific community in what follows we describe the main functionalities from the package regarding data accessibility. the covid19.data function allows users to obtain realtime data about the covid19 reported cases from the jhu's ccse repository, in the following modalities: • aggregated data for the latest day, with a great 'granularity' of geographical regions (ie. cities, provinces, states, countries) • time series data for larger accumulated geographical regions (provinces/countries) • deprecated : we also include the original data style in which these datasets were reported initially. the datasets also include information about the different categories (status) "confirmed"/"deaths"/"recovered" of the cases reported daily per country/region/city. this data-acquisition function, will first attempt to retrieve the data directly from the jhu repository with the latest updates. if for what ever reason this fails (eg. problems with the connection) the package will load a preserved "image" of the data which is not the latest one but it will still allow the user to explore this older dataset. in this way, the package offers a more robust and resilient approach to the quite dynamical situation with respect to data availability and integrity. in addition to the data of the reported cases of covid19, the covid19.analytics package also provides access to genomics data of the virus. the data is obtained from the national center for biotechnology information (ncbi) databases [35, 36] . table 1 shows the functions available in the covid19.analytics package for accessing the reported cases of the covid19 pandemic. the functions can be divided in different categories, depending on what data they provide access to. for instance, they are distinguished between agreggated and time series data sets. they are also grouped by specific geographical locations, i.e. worldwide, united states of america (us) and the city of toronto (ontario, canada) data. the time series data is structured in an specific manner with a given set of fields or columns, which resembles the following format: "province.state" | "country.region" | "lat" | "long" | ... sequence of dates ... one of the modular features this package offers is that if an user has data structured in a data.frame organized as described above, then most of the functions provided by the covid19.analytics package for analyzing time series data will just work with the user's defined data. in this way it is possible to add new data sets to the ones that can be loaded using the repositories predefined in this package and extend the analysis capabilities to these new datasets. sec. 3.5 presents an example of how external or synthetic data has to be structured so that can use the function from the covid19.analytics package. it is also recommended to check the compatibility of these datasets using the data integrity and consistency checks functions described in the following section. due to the ongoing and rapid changing situation with the covid-19 pandemic, sometimes the reported data has been detected to change its internal format or even show some anomalies or inconsistencies 1 . for instance, in some cumulative quantities reported in time series datasets, it has been observed that these quantities instead of continuously increase sometimes they decrease their values which is something that should not happen 2 . we refer to this as an inconsistency of "type ii". some negative values have been reported as well in the data, which also is not possible or valid; we call this inconsistency of "type i". when this occurs, it happens at the level of the origin of the dataset, in our case, the one obtained from the jhu/ccesgis repository [33] . in order to make the user aware of this, we implemented two consistency and integrity checking functions: • consistency.check: this function attempts to determine whether there are consistency issues within the data, such as, negative reported value (inconsistency of "type i") or anomalies in the cumulative quantities of the data (inconsistency of "type ii") • integrity.check: this determines whether there are integrity issues within the datasets or changes to the structure of the data alternatively we provide a data.checks function that will execute the previous described functions on an specified dataset. data integrity. it is highly unlikely that the user would face a situation where the internal structure of the data or its actual integrity may be compromised. however if there are any suspicious about this, it is possible to use the integrity.check function in order to verify this. if anything like this is detected we urge users to contact us about it, e.g. https://github.com/mponce0/covid19.analytics/issues. data consistency. data consistency issues and/or anomalies in the data have been reported several times 1 these are claimed, in most of the cases, to be missreported data and usually are just an insignificant number of the total cases. having said that, we believe that the user should be aware of these situations and we recommend using the consistency.check function to verify the dataset you will be working with. nullifying spurious data. in order to deal with the different scenarios arising from incomplete, inconsistent or missreported data, we provide the nullify.data function, which will remove any potential entry in the data that can be suspected of these incongruencies. in addition ot that, the function accepts an optional argument stringent=true, which will also prune any incomplete cases (e.g. with nas present). similarly to the rapid developments and updates in the reported cases of the disease, the sequencing of the virus is moving almost at equal pace. that's why the covid19.analytics package provides access to good number of the genomics data currently available. the covid19.genomic.data function allows users to obtain the covid19's genomics data from ncbi's databases [36] . the type of genomics data accessible from the package is described in table 2 . although the package attempts to provide the latest available genomic data, there are a few important details and differences with respect to the reported cases data. for starting, the amount of genomic information available is way larger than the data reporting the number of cases which adds some additional constraints when retrieving this data. in addition to that, the hosting servers for the genomic databases impose certain limits on the rate and amounts of downloads. in order to mitigate these factors, the covid19.analytics package employs a couple of different strategies as summarized below: • most of the data will be attempted to be retrieved live from ncbi databases -same as using src='livedata'. • if that is not possible, the package keeps a local version of some of the largest datasets (i.e. genomes, nucleotides and proteins) which might not be up-to-date -same as using src='repo'. • the package will attempt to obtain the data from a mirror server with the datasets updated on a regular basis but not necessarily with the latest updates -same as using src='local'. these sequence of steps are implemented in the package using trycath() exceptions in combination with recursivity, i.e. the retrieving data function calling itself with different variations indicating which data source to use. as the covid19.analytics package will try present the user with the latest data sets possible, different strategies (as described above) may be in place to achieve this. one way to improve the realiability of the access to and avialability of the data is to use a series of replicas of the datasets which are hosted in different locations. fig. 1 summarizes the different data sources and point of access that the package employs in order to retrieve the data and keeps the latest datasets available. genomic data as mentioned before is accessed from ncbi databases. this is implemented in the covid19.genomic.data function employing the ape [37] and rentrez [38] packages. in particular the proteins datasets, with more than 100k entries, is quite challenging to obtain "live". as a matter of fact, the covid19.genomic.data function accepts an argument to specify whether this should be the case or not. if the src argument is set to 'livedata' then the function will attempt to download the proteins list directly from ncbi databases. if this fail, we recommend using the argument src='local' which will provide an stagered copy of this dataset at the moment in which the package was submitted to the cran repository, meaning that is quite likely this dataset won't be complete and most likely outdated. additionaly, we offer a second replica of the datasets, located at https://github.com/mponce0/covid19analytics.datasets where all datasets are updated periodically, this can be accessed using the argument src='repo'. in addition to the access and retrieval of the data, the covid19.analytics package includes several functions to perform basic analysis and visualizations. table 3 shows the list of the main functions in the package. description main type of output data acquisition covid19.data obtain live* worldwide data for covid19 virus, from the jhu's ccse repository [33] return dataframes/list with the collected data covid19.toronto.data obtain live* data for covid19 cases in the city of toronto, on canada, from the city of toronto reports [34] return dataframe/list with the collected data covid19.us.data obtain live* us specific data for covid19 virus, from the jhu's ccse repository [33] return dataframe with the collected data genomics covid19.genomic.data c19.refgenome.data c19.fasta.data c19.ptree.data c19.nps.data c19.np_fasta.data obtain genomic data from ncbi databases -see table 2 in the reported data, this is mostly given by the province/city and/or country/region. in order to facilitate the processing of locations that are located geo-politically close, the covid19.analytics package provides a way to identify regions by indicating the corresponding continent's name where they are located. i.e. "south america", "north america", "central america", "america", "europe", "asia" and "oceania" can be used to process all the countries within each of these regions. the geographicalregions function is the one in charge of determining which countries are part of what continent and will display them when executing geographicalregions(). in this way, it is possible to specify a particular continent and all the countries in this continent will be processed without needing to explicitly specifying all of them. reports. as the amount of data available for the recorded cases of covid19 can be overwhelming, and in order to get a quick insight on the main statistical indicators, the covid19.analytics package includes the report.summary function, which will generate an overall report summarizing the main statistical estimators for the different datasets. it can summarize the "time series" data (when indicating cases.to.process="ts"), the "aggregated" data (cases.to.process="agg") or both (cases.to.process="all"). the default will display the top 10 entries in each category, or the number indicated in the nentries argument, for displaying all the records just set nentries=0. the function can also target specific geographical location(s) using the geo.loc argument. when a geographical location is indicated, the report will include an additional "rel.perc" column for the confirmed cases indicating the relative percentage among the locations indicated. similarly the totals displayed at the end of the report will be for the selected locations. in each case ("ts" or/and "agg") will present tables ordered by the different cases included, i.e. confirmed infected, deaths, recovered and active cases. the dates when the report is generated and the date of the recorded data will be included at the beginning of each table. it will also compute the totals, averages or mean values, standard deviations and percentages of various quantities, i.e. • it will determine the number of unique locations processed within the dataset • it will compute the total number of cases per case type • percentages -which are computed as follow: for the "confirmed" cases, as the ratio between the corresponding number of cases and the total number of cases, i.e. a sort of "global percentage" indicating the percentage of infected cases with respect to the rest of the world covid19.analytics "internal" rsync/git -when a new release is push to cran "internal" scripts src="livedata" src="repo" src="local" https://github.com/mponce0/covid19analytics.datasets figure 1 : schematic of the data acquision flows between the covid19.analytics package and the different sources of data. dark and solid/dashed lines represent api functions provided by the package accesible to the users. dotted lines are "internal" mechanisms employed by the package to synchronize and update replicas of the data. data acquisition from ncbi servers is mostly done utilizing the ape [37] and rentrez [38] packages. for "confirmed" cases, when geographical locations are specified, a "relative percentage" is given as the ratio of the confirmed cases over the total of the selected locations for the other categories, "deaths"/"recovered"/"active", the percentage of a given category is computed as the ratio between the number of cases in the corresponding category divided by the "confirmed" number of cases, i.e. a relative percentage with respect to the number of confirmed infected cases in the given region • for "time series" data: it will show the delta (change or variation) in the last day, daily changes day before that (t − 2), three days ago (t − 3), a week ago (t − 7), two weeks ago (t − 14) and a month ago (t − 30) when possible, it will also display the percentage of "recovered" and "deaths" with respect to the "confirmed" number of cases the column "globalperc" is computed as the ratio between the number of cases for a given country over the total of cases reported -the "global perc. average (sd: standard deviation)" is computed as the average (standard deviation) of the number of cases among all the records in the data -the "global perc. average (sd: standard deviation) in top x" is computed as the average (standard deviation) of the number of cases among the top x records a typical output of the summary.report for the "time series" data, is shown in the example 4 in sec. 3 . in addition to this, the function also generates some graphical outputs, including pie and bar charts representing the top regions in each category; see fig. 2 . totals per location & growth rate. it is possible to dive deeper into a particular location by using the tots.per.location and growth.rate functions. these functions are capable of processing different types of data, as far as these are "time series" data. it can either focus in one category (eg. "ts-confirmed", "ts-recovered", "ts-deaths",) or all ("ts-all"). when these functions detect different types of categories, each category will be processed separately. similarly the functions can take multiple locations, ie. just one, several ones or even "all" the locations within the data. the locations can either be countries, regions, provinces or cities. if an specified location includes multiple entries, eg. a country that has several cities reported, the functions will group them and process all these regions as the location requested. totals per location. the tots.per.location function will plot the number of cases as a function of time for the given locations and type of categories, in two plots: a log-scale scatter one a linear scale bar plot one. when the function is run with multiple locations or all the locations, the figures will be adjusted to display multiple plots in one figure in a mosaic type layout. additionally, the function will attempt to generate different fits to match the data: • an exponential model using a linear regression method • a poisson model using a general linear regression method • a gamma model using a general linear regression method the function will plot and add the values of the coefficients for the models to the plots and display a summary of the results in the console. it is also possible to instruct the function to draw a "confidence band" based on a moving average, so that the trend is also displayed including a region of higher confidence based on the mean value and standard deviation computed considering a time interval set to equally dividing the total range of time over 10 equally spaced intervals. the function will return a list combining the results for the totals for the different locations as a function of time. growth rate. the growth.rate function allows to compute daily changes and the growth rate defined as the ratio of the daily changes between two consecutive dates. the growth.rate function shares all the features of the tots.per.location function as described above, i.e. can process the different types of cases and multiple locations. the graphical output will display two plots per location: • a scatter plot with the number of changes between consecutive dates as a function of time, both in linear scale (left vertical axis) and log-scale (right vertical axis) combined • a bar plot displaying the growth rate for the particular region as a function of time. when the function is run with multiple locations or all the locations, the figures will be adjusted to display multiple plots in one figure in a mosaic type layout. in addition to that, when there is more than one location the function will also generate two different styles of heatmaps comparing the changes per day and growth rate among the different locations (vertical axis) and time (horizontal axis). furthermore, if the interactivefig=true argument is used, then interactive heatmaps and 3d-surface representations will be generated too. some of the arguments in this function, as well as in many of the other functions that generate both static and interactive visualizations, can be used to indicate the type of output to be generated. table 4 lists some of these arguments. in particular, the arguments controlling the interactive figures -interactivefig and interactive.display-can be used in combination to compose an interactive figure to be captured and used in another application. for instance, when interactive.display is turned off but interactivefig=true, the function will return the interactive figure, so that it can be captured and used for later purposes. this is the technique employed when capturing the resulting plots in the covid19.analytics dashboard explorer as presented in sec. 4.2. finally, the growth.rate function when not returning an interactive figure, will return a list combining the results for the "changes per day" and the "growth rate" as a function of time, i.e. when interactivefig is not specified or set to false (which its default value) or when interactive.display=true. when is turned off, but interactivefig=true, the function will return the interactive figure, so that it can be captured and used for later purposes. trends in daily changes. the covid19.analytics package provides three different functions to visualize the trends in daily changes of reported cases from time series data. • single.trend, allows to inspect one single location, this could be used with the worldwide data sliced by the corresponding location, the toronto data or the user's own data formatted as "time series" data. • mtrends, is very similar to the single.trend function, but accepts multiple or single locations generating one plot per location requested; it can also process multiple cases for a given location. • itrends function to generate an interactive plot of the trend in daily changes representing changes in number of cases vs total number of cases in log-scale using splines techniques to smooth the abrupt variations in the data the first two functions will generate "static" plots in a compose with different insets: • the main plot represents daily changes as a function of time • the inset figures in the top, from left to right: total number of cases (in linear and semi-log scales), changes in number of cases vs total number of cases changes in number of cases vs total number of cases in log-scale • the second row of insets, represent the "growth rate" (as defined above) and the normalized growth rate defined as the growth rate divided by the maximum growth rate reported for this location plotting totals. the function totals.plt will generate plots of the total number of cases as a function of time. it can be used for the total data or for a specific or multiple locations. the function can generate static plots and/or interactive ones, as well, as linear and/or semi-log plots. plotting cases in the world. the function live.map will display the different cases in each corresponding location all around the world in an interactive map of the world. it can be used with time series data or aggregated data, aggregated data offers a much more detailed information about the geographical distribution. the covid19.analytics package allows users to model the dispersion of the disease by implementing a simple susceptible-infected-recovered (sir) model [39, 40] . the model is implemented by a system of ordinary differential equations (ode), as the one shown by eq.(1). where s represents the number of susceptible individuals to be infected, i the number of infected individuals and r the number of recovered ones at a given moment in time. the coefficients β and γ are the parameters controlling the transition rate from s to i and from i to r respectively; n is the total number of individuals, i.e. n = s(t) + i(t) + r(t); which should remain constant, i.e. eq.(1) can be written in terms of the normalized quantities, although the ode sir model is non-linear, analytical solutions have been found [41] . however the approach we follow in the package implementation is to solve the ode system from eq.(1) numerically. the function generate.sir.model implements the sir model from eq.(1) using the actual data from the reported cases. the function will try to identify data points where the onset of the epidemic began and consider the following data points to generate proper guesses for the two parameters describing the sir ode system, i.e. β and γ. it does this by minimizing the residual sum of squares (rss) assuming one single explanatory variable, i.e. the sum of the squared differences between the number of infected cases i(t) and the quantity predicted by the modelĩ(t), the ode given by eq.(1) is solved numerically using the ode function from the desolve and the minimization is tackled using the optim function from base r. after the solution for eq.(1) is found, the function will provide details about the solution, as well as, plot the quantities s(t), i(t), r(t) in a static and interactive plot. the generate.sir.model function also estimates the value of the basic reproduction number or basic reproduction ratio, r 0 , defined as, which can be considered as a measure of the average expected number of new infections from a single infection in a population where all subjects can be susceptible to get infected. the function also computes and plots on demand, the force of infection, defined as, f inf ection = βi(t), which measures the transition rate from the compartment of susceptible individuals to the compartment of infectious ones. for exploring the parameter space of the sir model, it is possible to produce a series of models by varying the conditions, i.e. range of dates considered for optimizing the parameters of the sir equation, which will effectively "sweep" a range for the parameters β, γ and r 0 . this is implemented in the function sweep.sir.models, which takes a range of dates to be used as starting points for the number of cases used to feed into the generate.sir.model producing as many models as different ranges of dates are indicated. one could even use this in combination to other resampling or monte carlo techniques to estimate statistical variability of the parameters from the model. in this section we will present some basic examples of how to use the main functions from the covid19.analytics package. we will begin by installing the covid19.analytics package. this can be achieved in two alternative ways: 1. installing the latest stable version of the package directly from the cran repository. this can be done within an r session using the install.packages function, i.e. > install.packages("covid19.analytics") 2. installing the development version from the package's github repository, https://github.com/ mponce0/covid19.analytics using the devtools package [42] and its install_github function. i.e. # begin by installing devtools if not installed in your system > install.packages("devtools") # install the covid19.analytics packages from the github repo > devtools::install_github("mponce0/covid19.analytics") after having installed the covid19.analytics package, for accessing its functions, the package needs to be loaded using r's library function, i.e. the covid19.analytics uses a few additional packages which are installed automatically if they are not present in the system. in particular, readxl is used to access the data from the city of toronto [34] , ape is used for pulling the genomics data from ncbi; plotly and htmlwidgets are used to render the interactive plots and save them in html documents, desolve is used to solve the differential equations modelling the spread of the virus, and gplots, pheatmap are used to generate heatmaps. lst. 1 shows how to use the covid19.data function to obtain data in different cases. # obtain all the records combined for " confirmed " , " deaths " and " recovered " cases # for the global ( worldwide ) * aggregated * data covid19 . data . allcases <-covid19 . data () # obtain time series data for global " confirmed " cases covid19 . confirmed . cases <-covid19 . data ( " ts -confirmed " ) # reads all possible datasets , returning a list covid19 . all . datasets <-covid19 . data ( " all " ) # reads the latest aggregated data of the global cases covid19 . all . agg . cases <-covid19 . data ( " aggregated " ) # reads time series data for global casualties covid19 . ts . deaths <-covid19 . data ( " ts -deaths " ) # read " time series " data for the city of toronto toronto . ts . data <-covid19 . data ( " ts -toronto " ) # this can be also done using the covid19 . toronto . data () fn tor . ts . data <-covid19 . toronto . data () # or get the original data as reported by the city of toronto tor . df . data <-covid19 . toronto . data ( data . fmr = " orig " ) # retrieve us time series data of confirmed cases us . confirmed . cases <-covid19 . data ( " ts -confirmed -us " ) # retrieve us time series data of death cases us . deaths . cases <-covid19 . data ( " ts -deaths -us " ) # or both cases combined us . cases <-covid19 . us . data () listing 1: reading data from reported cases of covid19 using the covid19.analytics package. in general, the reading functions will return data frames. exceptions to this, are when the functions need to return a more complex output, e.g. when combining "all" type of data or when requested to obtain the original data from the city of toronto (see details in table 3 ). in these cases, the returning object will be a list containing in each element dataframes corresponding to the particular type of data. in either case, the structure and overall content can be quickly assessed by using r's str or summary functions. one useful information to look at after loading the datasets, would be to identify which locations/regions have reported cases. there are at least two main fields that can be used for that, the columns containing the keywords: 'country' or 'region' and 'province' or 'state'. lst. 2 show examples of how to achieve this using partial matches for column names, e.g. "country" and "province". # read a data set data <-covid19 . data ( " ts -confirmed " ) # look at the structure and column names str ( data ) names ( data ) # find ' country ' column country . col <-pmatch ( " country " , names ( data ) ) # slice the countries countries <-data [ , country . col ] # list of countries print ( unique ( countries ) ) # sorted table of countries , may include multiple entries print ( sort ( table ( countries ) ) ) # find ' province ' column prov . col <-pmatch ( " province " , names ( data ) ) # slice the provinces provinces <-data [ , prov . col ] # list of provinces print ( unique ( provinces ) ) # sorted table of provinces , may include multiple entries print ( sort ( table ( provinces ) ) ) listing 2: identifying geographical locations in the data sets. an overall view of the current situation at a global or local level can be obtained using the report.summary function. lst. 3 shows a few examples of how this function can be used. # a quick function to overview top cases per region for time series and aggregated records report . summary () # save the tables into a text file named ' covid19 -summaryreport _ currentdate . txt ' # where * currrentdate * is the actual date report . summary ( savereport = true ) # summary report for an specific location with default number of entries report . summary ( geo . loc = " canada " ) # summary report for an specific location with top 5 report . summary ( nentries =5 , geo . loc = " canada " ) # it can combine several locations report . summary ( nentries =30 , geo . loc = c ( " canada " ," us " ," italy " ," uruguay " ," argentina " ) ) a typical output of the report generation tool is presented in lst. 4. typical output of the report.summary function. this particular example was generated using report.summary(nentries=5,graphical.output=true,savereport=true), which indicates to consider just the top 5 entries, generate a graphical output as shown in fig. 2 and a to save text file including the report which is the one shown here.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~# #### ts -confirmed cases --data dated : 2020 -06 -25 :: 2020 -06 -26 13:10:01 # #### ts -deaths cases --data dated : 2020 -06 -25 :: 2020 -06 -26 13:10:02 # #### ts -recovered cases --data dated : 2020 -06 -25 :: 2020 -06 -26 13:10:02 # #### aggregated data --ordered by confirmed cases --data dated : 2020 -06 -26 :: 2020 -06 -26 13:10:03 # #### aggregated data --ordered by deaths cases --data dated : 2020 -06 -26 :: 2020 -06 -26 13:10:03 # #### aggregated data --ordered by recovered cases --data dated : 2020 -06 -26 :: 2020 -06 -26 13:10:03 # #### aggregated data --ordered by active cases --data dated : 2020 -06 -26 :: 2020 -06 -26 13:10:03 * statistical estimators computed considering 3781 independent reported entries * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * overall summary * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * statistical estimators computed considering 266 / 266 / 253 independent reported entries per case -type * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * a daily generated report is also available from the covid19.analytics documentation site, https: //mponce0.github.io/covid19.analytics/. the covid19.analytics package allows users to investigate total cumulative quantities per geographical location with the totals.per.location function. examples of this are shown in lst. 5. # totals for confirmed cases for " ontario " tots . per . location ( covid19 . confirmed . cases , geo . loc = " ontario " ) # total for confirmed cases for " canada " tots . per . location ( covid19 . confirmed . cases , geo . loc = " canada " ) # total nbr of confirmed cases in hubei including a confidence band based on moving average tots . per . location ( covid19 . confirmed . cases , geo . loc = " hubei " , confbnd = true ) # total nbr of deaths for " mainland china " tots . per . location ( covid19 . ts . deaths , geo . loc = " china " ) # ## # read the time series data for all the cases all . data <-covid19 . data ( 'ts -all ') # run on all the cases tots . per . location ( all . data , " japan " ) # ## # total for death cases for " all " the regions tots . per . location ( covid19 . ts . deaths ) # or just tots . per . location ( covid19 . data ( " ts -confirmed " ) ) listing 5: calculation of totals per country/region/province. in addition to the graphical output as shown in fig. 3 , the function will provide details of the models fitted to the data. similarly, utilizing the growth.rate function is possible to compute the actual growth rate and daily changes for specific locations, as defined in sec. 2.2. lst. 6 includes examples of these. # read time series data for confirmed cases ts . data <-covid19 . data ( " ts -confirmed " ) # compute changes and growth rates per location for all the countries growth . rate ( ts . data ) # compute changes and growth rates per location for ' italy ' growth . rate ( ts . data , geo . loc = " italy " ) # compute changes and growth rates per location for ' italy ' and ' germany ' growth . rate ( ts . data , geo . loc = c ( " italy " ," germany " ) ) # #### # combining multiple geographical locations : # obtain time series data tsconfirmed <-covid19 . data ( " ts -confirmed " ) # explore different combinations of regions / cities / countries # when combining different locations , heatmaps will also be generated comparing the trends among these locations growth . rate ( tsconfirmed , geo . loc = c ( " italy " ," canada " ," ontario " ," quebec " ," uruguay " ) ) growth . rate ( tsconfirmed , geo . loc = c ( " hubei " ," italy " ," spain " ," united ␣ states " ," canada " ," ontario " ," quebec " ," uruguay " ) ) growth . rate ( tsconfirmed , geo . loc = c ( " hubei " ," italy " ," spain " ," us " ," canada " ," ontario " , " quebec " ," uruguay " ) ) # turn off static plots and activate interactive figures growth . rate ( tsconfirmed , geo . loc = c ( " brazil " ," canada " ," ontario " ," us " ) , staticplt = # static and interactive figures growth . rate ( tsconfirmed , geo . loc = c ( " brazil " ," italy " ," india " ," us " ) , staticplt = true , interactivefig = true ) listing 6: calculation of growth rates and daily changes per country/region/province. in addition to the cumulative indicators described above, it is possible to estimate the global trends per location employing the functions single.trend, mtrends and itrends. the first two functions generate static plots of different quantities that can be used as indicators, while the third function generates an interactive representation of a normalized a-dimensional trend. the lst. 7 shows examples of the use of these functions. fig. 6 displays the graphical output produced by these functions. # single location trend , in this case using data from the city of toronto tor . data <-covid19 . toronto . data () single . trend ( tor . data [ tor . data $ status == " active ␣ cases " ,]) # or data from the province of ontario ts . data <-covid19 . data ( " ts -confirmed " ) ont . data <-ts . data [ ts . data $ province . state == " ontario " ,] single . trend ( ont . data ) # or from italy single . trend ( ts . data [ ts . data $ country . region == " italy " ,]) # multiple locations ts . data <-covid19 . data ( " ts -confirmed " ) mtrends ( ts . data , geo . loc = c ( " canada " ," ontario " ," uruguay " ," italy " ) ) # multiple cases single . trend ( tor . data ) # interactive plot of trends # for all locations and all type of cases itrends ( covid19 . data ( " ts -all " ) , geo . loc = " all " ) # or just for confirmed cases and some specific locations , saving the result in an html file named " itrends _ ex . html " itrends ( covid19 . data ( " ts -confirmed " ) , geo . loc = c ( " uruguay " ," argentina " ," ontario " ," us " ," italy " ," hubei " ) , filename = " itrends _ ex " ) listing 7: calculation of trends for different cases, utilizing the single.trend, mtrends and itrends functions. the typical representations can be seen in fig. 6. most of the analysis functions in the covid19.analytics package have already plotting and visualization capabilities. in addition to the previously described ones, the package has also specialized visualization functions as shown in lst.8. many of them will generate static and interactive figures, see table 3 for details of the type of output. in particular the live.map function is an utility function which allows to plot the location of the recorded cases around the world. this function in particular allows for several customizable features, such as, the type of projection used in the map or to select different types of projection operators in a pull down menu, displaying or not the legend of the regions, specify rescaling factors for the sizes representing the number of cases, among others. the function will generate a live representation of the cases, utilizing the plotly package and ultimately open the map in a browser, where the user can explore the map, drag the representation, zoom in/out, turn on/off legends, etc. # retrieve time series data ts . data <-covid19 . data ( " ts -all " ) # static and interactive plot totals . plt ( ts . data ) # totals for ontario and canada , without displaying totals and one plot per page totals . plt ( ts . data , c ( " canada " ," ontario " ) , with . totals = false , one . plt . per . page = true ) # totals for ontario , canada , italy and uruguay ; including global totals with the linear and semi -log plots arranged one next to the other totals . plt ( ts . data , c ( " canada " ," ontario " ," italy " ," uruguay " ) , with . totals = true , one . plt . per . page = false ) # totals for all the locations reported on the dataset , interactive plot will be saved as " totals -all . html " totals . plt ( ts . data , " all " , filename = " totals -all " ) # retrieve aggregated data data <-covid19 . data ( " aggregated " ) # interactive map of aggregated cases --with more spatial resolution live . map ( data ) # or live . map () # interactive map of the time series data of the confirmed cases with less spatial resolution , ie . aggregated by country live . map ( covid19 . data ( " ts -confirmed " ) ) listing 8: examples of some of the interactive and visualization capabilities of plotting functions. the typical representations can be seen in fig. 7 . last but not least, one the novel features added by the covid19.analytics package, is the ability of model the spread of the virus by incorporating real data. as described in sec. 2.2, the generate.sir.model function, implements a simple sir model employing the data reported from an specified dataset and a particular location. examples of this are shown in lst.9. the generate.sir.model function is complemented with the plt.sir.model function which can be used to generate static or interactive figures as shown in fig. 8 . the generate.sir.model function as described in sec.2 will attempt to obtain proper values for the parameters β and γ, by inferring the onset of the epidemic using the actual data. this is also listed in the output of the function (see lst.10), and it can be controlled by setting the parameters t0 and t1 or deltat, which are used to specify the range of dates to be considered for using when determining the values of β and γ. the fatality rate (constant) can also be indicated via the fatality.rate argument, as well, as the total population of the region with tot.population. # read time series data for confirmed cases data <-covid19 . data ( " ts -confirmed " ) # run a sir model for a given geographical location generate . sir . model ( data , " hubei " , t0 =1 , t1 =15) generate . sir . model ( data , " germany " , tot . population =83149300) generate . sir . model ( data , " uruguay " , tot . population =3500000) generate . sir . model ( data , " ontario " , tot . population =14570000 , add . extras = true ) # the function will aggregate data for a geographical location , like a country with multiple entries generate . sir . model ( data , " canada " , tot . population =37590000 , add . extras = true ) fig.(8) , also raises an interesting point regarding the accuracy of the sir model. we should recall that this is the simplest approach one could take in order to model the spread of diseases and usually more refined and complex models are used to incorporate several factors, such as, vaccination, quarantines, effects of social clusters, etc. however, in some cases, specially when the spread of the disease appears to have enter the so-called exponential growth rate, this simple sir model can capture the main trend of the dispersion (e.g. left plot from fig.8 ). while in other cases, when the rate of spread is slower than the freely exponential dispersion, the model clearly fails in tracking the actual evolution of cases (e.g. right plot from fig.8) . finally, lst. 11 shows an example of the generation of a sequence of values for r 0 , and actually any of the parameteres (β, γ) describing the sir model. in this case, the function takes a range of values for the initial date t0 and generates different date intervals, this allows the function to generate multiple sir models and return the corresponding parameters for each model. the results are then bundle in a "matrix"/"array" object which can be accessed by column for each model or by row for each paramter sets. # read timeseries data ts . data <-covid19 . data ( " ts -confirmed " ) # select a location of interest , eg . france # france has many entries , just pick " france " fr . data <-ts . data [ ( ts . data $ country . region == " france " ) & ( ts . data $ province . state == " " ) ,] # sweep values of r0 based on range of dates to consider for the model ranges <-15:25 deltat <-35 params _ sweep <-sweep . sir . models ( data = fr . data , geo . loc = " france " , t0 _ range = ranges , deltat = deltat ) # the parameters --beta , gamma , r0 --are returned in a " matrix " " array " object print ( params _ sweep ) as mentioned before, the functions from the covid19.analytics package also allow users to work with their own data, when the data is formated in the time series strucutre as discussed in sec.2.1.2. this opens a large range of possibilities for users to import their own data into r and use the functions already defined in the covid19.analytics package. a concrete example of how the data has to be formatted is shown in lst. 12. the example shows how to structure the data in a ts format from "synthetic" data generated from randomly sampling different distributions. however this could be actual data from other places or locations not accesible from the datasets provided by the package, or some researchers may have access to their own private sets of data too. the example also shows two cases, where the data can include the "status" column or not, and whether it could be more than one location. as a matter of fact, we left the "long" and "lat" fields empty but if one includes the actual coordinates, the maping function live.map can also be used with these structured data. # ts data structure : # " province . state " " country . region " " lat " " long " dates . . . # first let ' s create a ' fake ' location fake . locn <-c ( na , na , na , na ) # names for these columns names ( fake . locn ) <-c ( " province . state " ," country . region " ," lat " ," long " ) # let ' s set the dates dates . vec <-seq ( as . date ( " 2020 / 1 / 1 " ) , as . date ( " 2020 / 4 / 09 " ) , " days " ) # data . vecx would be the actual values / cases data . vec1 <-rpois ( length ( dates . vec ) , lambda =25) # can also add more cases data . vec2 <-abs ( rnorm ( length ( dates . vec ) , mean =135 , sd =15) ) data . vec3 <-abs ( rnorm ( length ( dates . vec ) , mean =35 , sd =5) ) # this will names the columns as your dates names ( data . vec1 ) <-dates . vec names ( data . vec2 ) <-dates . vec names ( data . vec3 ) <-dates . vec # merge them into a data frame with multiple entries synthetic . data <-as . data . frame ( rbind ( rbind ( c ( fake . locn , data . vec1 ) ) , rbind ( c ( fake . locn , data . vec2 ) ) , rbind ( c ( fake . locn , data . vec3 ) ) ) ) # finally set you locn to somethign unqiue , so you can use it in the generate . sir . model fn synthetic . data $ country . region <-" mylocn " # one could even add " status " synthetic . data $ status <-c ( " confirmed " ," death " ," recovered " ) # or just one case per locn synthetic . data2 <-synthetic . data [ , -ncol ( synthetic . data ) ] synthetic . data2 $ country . region <-c ( " mylocn " ," mylocn2 " ," mylocn3 " ) # now we can use this ' synthetic ' dataset with any of the ts functions # data checks integrity . check ( synthetic . data ) consistency . check ( synthetic . data ) data . checks ( synthetic . data ) # quantitative indicators tots . per . location ( synthetic . data ) growth . rate ( synthetic . data ) single . trend ( synthetic . data2 [3 ,] ) mtrends ( synthetic . data ) # sir models synthsir <-generate . sir . model ( synthetic . data2 , geo . loc = " mylocn " ) plt . sir . model ( synthsir , interactivefig = true ) sweep . sir . models ( synthetic . data2 , geo . loc = " mylocn " ) listing 12: example of structuring data in a ts format, so that it can be used with any of the ts functions from the covid19.analytics package. the covid19.analytics package provides access to genomics data available at the ncbi databases [35, 36] . the covid19.genomic.data is the master function for accesing the different variations of the genomics information available as shown in gtypes <-c ( " genome " ," fasta " ," tree " , " nucleotide " ," protein " , " nucleotide -fasta " ," protein -fasta " , " genomic " ) each of these functions return different objects, lst. 14 shows an example of the different structures for some of the objects. the most involved object is obtained from the covid19.genomic.data when combining different types of datasets. # str ( results ) list of 7 $ refgenome : list of 3 .. $ livedata : chr [1:29903] " a " " t " " t " " a " ... .. $ repo : chr [1:29903] " a " " t " " t " " a " ... .. $ local : chr [1:29903] " a " " t " " t " " a " . 29903] " a " " t " " t " " a " ... .. .. -attr ( * , " species " ) = chr " severe _ acute _ respiratory _ syndrome _ coronavirus _ 2 " .. $ local : list of 1 .. .. $ nc _ 045512.2: chr [1:29903] " a " " t " " t " " a " ... .. .. -attr ( * , " species " ) = chr " severe _ acute _ respiratory _ syndrome _ coronavirus _ 2 " $ ptns : list of 2 .. $ repo : chr [1:117619] " yp _ 009742608 " " yp _ 009742609 " " yp _ 009742610 " " yp _ 009742611 " ... .. $ local : chr [1:117619] " yp _ 009742608 " " yp _ 009742609 " " yp _ 009742610 " " yp _ 009742611 " ... : chr [1:11142] " 2020 -01 -13 t00 :00:00 z " " 2020 -07 -17 t00 :00:00 z " " 2020 -07 -17 t00 :00:00 z " " 2020 -07 -17 t00 :00:00 z " ... : chr [1:11142] " severe ␣ acute ␣ respiratory ␣ syndrome -related ␣ coronavirus " " severe ␣ acute ␣ respiratory ␣ syndrome -related ␣ coronavirus " " severe ␣ acute ␣ respiratory ␣ syndrome -related ␣ coronavirus " " severe ␣ acute ␣ respiratory ␣ syndrome -related ␣ coronavirus " .. : chr [1:11142] " homo ␣ sapiens " " homo ␣ sapiens " " homo ␣ sapiens " " homo ␣ sapiens " ... .. $ isolation _ source : chr [1:11142] " " " " " " " " ... .. $ collection _ date : chr [1:11142] " 2019 -12 " " 2020 -06 -14 " " 2020 -06 -13 " " 2020 -06 -13 " ... .. $ biosample : chr [1:11142] " " " samn15488404 " " samn15488426 " " samn15488426 " ... .. $ genbank _ title : chr [1:11142] " severe ␣ acute ␣ respiratory ␣ syndrome ␣ coronavirus ␣ 2 ␣ isolate ␣ wuhan -hu -1 , ␣ complete ␣ genome " " severe ␣ acute ␣ respiratory ␣ syndrome ␣ coronavirus ␣ 2 ␣ isolate ␣ sars -cov -2 / human / ind / gbrc242 / 2020 , ␣ complete ␣ genome " " severe ␣ acute ␣ respiratory ␣ syndrome ␣ coronavirus ␣ 2 ␣ isolate ␣ sars -cov -2 / human / ind / gbrc264a / 2020 , ␣ complete ␣ genome " " severe ␣ acute ␣ respiratory ␣ syndrome ␣ coronavirus ␣ 2 ␣ isolate ␣ sars -cov -2 / human / ind / gbrc264b / 2020 , ␣ complete ␣ genome " ... $ proteins : ' data . frame ': 117619 obs . of 20 variables : .. $ accession : chr [1:117619] " yp _ 009742608 " " yp _ 009742609 " " yp _ 009742610 " " yp _ 009742611 " ... .. $ sra _ accession : chr [1:117619] " " " " " " " " ... .. $ release _ date : chr [1:117619] " 2020 -03 -30 t00 :00:00 z " " 2020 -03 -30 t00 :00:00 z " " 2020 -03 -30 t00 :00:00 z " " 2020 -03 -30 t00 :00:00 z " ... .. $ species : chr [1:117619] " severe ␣ acute ␣ respiratory ␣ syndrome -related ␣ coronavirus " " severe ␣ acute ␣ respiratory ␣ syndrome -related ␣ coronavirus " " severe ␣ acute ␣ respiratory ␣ syndrome -related ␣ coronavirus " " severe ␣ acute ␣ respiratory ␣ syndrome -related ␣ coronavirus " .. : chr [1:117619] " leader ␣ protein ␣ [ severe ␣ acute ␣ respiratory ␣ syndrome ␣ coronavirus ␣ 2] " " nsp2 ␣ [ severe ␣ acute ␣ respiratory ␣ syndrome ␣ coronavirus ␣ 2] " " nsp3 ␣ [ severe ␣ acute ␣ respiratory ␣ syndrome ␣ coronavirus ␣ 2] " " nsp4 ␣ [ severe ␣ acute ␣ respiratory ␣ syndrome ␣ coronavirus ␣ 2] " ... $ sra : list of 2 .. $ sra _ info : chr [1:6] " this ␣ download ␣ ( via ␣ ftp ) ␣ provides ␣ coronaviridae ␣ family -containing ␣ sra ␣ runs ␣ detected ␣ with ␣ ncbi ' s ␣ kmer ␣ analysis ␣ ( stat ) ␣ tool . ␣ " " it ␣ provides ␣ corresponding ␣ sra ␣ run ␣ ( srr ) ,␣ sample ␣ ( srs ) ,␣ and ␣ submission ␣ ( sra ) ␣ accessions , ␣ as ␣ well ␣ as ␣ biosample ␣ an " | _ _ truncated _ _ " the ␣ stat ␣ kmer ␣ analysis ␣ was ␣ performed ␣ via ␣ a ␣ two -step ␣ process ␣ with ␣ a ␣ 32 -mer ␣ coarse ␣ database ␣ and ␣ a ␣ 64 -mer ␣ fine ␣ database . ␣ " " the ␣ database ␣ is ␣ generated ␣ from ␣ refseq ␣ genomes ␣ and ␣ the ␣ viral ␣ genome ␣ set ␣ from ␣ nt ␣ using ␣ a ␣ minhash -based ␣ approach . ␣ " ... .. $ sra _ runs : ' data . frame ': 26776 obs . of 5 variables : .. .. $ acc : chr [1:26776] " err1857120 " " err1857132 " " err3955908 " " err3955909 " ... .. .. $ sample _ acc : chr [1:26776] " ers1572626 " " ers1572627 " " ers2783634 " " ers2783635 " ... .. .. $ biosample : chr [1:26776] " samea1 008836 68 " " same a10088 4418 " " samea4965217 " " samea4965218 " ... .. .. $ sra _ study : chr [1:26776] " erp021740 " " erp021740 " " erp111280 " " erp111280 " ... .. .. $ bioproject : chr [1:26776] " " " " " " " " ... $ references : list of 2 .. $ : chr " covid19 . analytics ␣ --␣ local ␣ data " .. $ : chr " / users / marcelo / library / r / 4.0 / library / covid19 . analytics / extdata / " listing 14: objects composition for the example presented in lst. 13 one aspect that should be mentioned with respect to the genomics data is that, in general, these are large datasets which are continuously being updated hence increasing theirs sizes even more. these would ultimately present pragmatical challenges, such as, long processing times or even starvation of memory resources. we will not dive into major interesting examples, like dna sequencing analysis or building phylogenetics trees; but packages such as ape, apegenet, phylocanvas, and others can be used for these and other analysis. one simple example we can present is the creation of dynamical categorization trees based on different elements of the sequencing data. we will consider for instance the data for the nucleotides as reported from ncbi. the example on lst. 15 shows how to retrieve either nucleotides (or proteins) data and generate categorization trees based on different elements, such as, hosting organism, geographical location, sequences length, etc. in the examples we employed the collapsibletree package, that generates interactive browsable trees through web browsers. # retrieve the nucleotides data nucx <-covid19 . genomic . data ( type = ' nucleotide ' , src = ' repo ') # identify specific fields to look at len . fld <-" length " acc . fld <-" accession " geoloc . fld <-" geo _ location " seq . fld <-" sequence _ type " host . fld <-" host " seq . limit1 <-25000 seq . limit1 <-29600 seq . limit2 <-31000 # selection criteria , nucleotides with seq . length between 29600 and 31000 selec . ctr .1 <-nucx $ length < seq . limit2 & nucx $ length > seq . limit1 # remove nucletoides without specifying a " host " listing 15: example of how to generate a dynamic browsable tree using some of information included in the nucleotides dataset. some of these trees representations are shown in fig. 9 . in this section we will present and discuss, how the covid19.analytics dashboard explorer is implemented. the main goal is to provide enough details about how the dashboard is implemented and works, so that users could modify it if/as they seem fit or even develop their own. for doing so, we will focus in three main points: • the front end implementation, also know as the user interface, mainly developed using the shiny package • the back end implementation, mostly using the covid19.analytics package • the web server installation and configuration where the dashboard is hosted the covid19.analytics dashboard explorer is built using the shiny package [43] in combination with the covid19.analytics package. shiny allows users to build interactive dashboards that can work through a web interface. the dashboard mimics the covid19.analytics package commands and features but enhances the commands as it allows users to use dropdowns and other control widgets to easily input the data rather than using a command terminal. in addition the dashboard offers some unique features, such as a personal protective equipment (ppe) model estimation, based on realistic projections developed by the us centers for disease control and prevention (cdc). the dashboard interface offers several features: 1. the dashboard can be run on the cloud/web allowing for multiple users to simultaneously analyze the data with no special software or hardware requirements. the shiny package makes the dashboard mobile and tablet compatible as well. 2. it aids researchers to share and discuss analytical findings. 3. the dashboard can be run locally or through the web server. 4. no programming or software expertise is required which reduces technical barriers to analyzing the data. users can interact and analyze the data without any software expertise therefore users can focus on the modeling and analysis. in these times the dashboard can be a monumental tool as it removes barriers and allows a wider and diverse set of users to have quick access to the data. 5. interactivity. one feature of shiny and other graphing packages, such as plotly, is interactivity, i.e. the ability to interact with the data. this allows one to display and show complex data in a concise manner and focus on specific points of interest. interactive options such as zoom, panning and mouse hover all help in making the user interaction enjoyable and informative. 6. fast and easy to compare. one advantage of a dashboard is that users can easily analyze and compare the data quickly and multiple times. for example users can change the slider or dropdown to select multiple countries to see the total daily count effortlessly. this allows the data to be displayed and changed as users analysis requirements change. the dashboard can be laucnhed locally in a machine with r, either through an interactive r session or in batch mode using rscript or r cmd batch or through the web server accessing the following url https://covid19analytics.scinet.utoronto.ca. for running the dashboard locally, the covid19.analytics package has also to be installed. for running the dashboard within an r session the package has to be loaded and then it should be invoked using the following sequence of commands, > library(covid19.analytics) > covid19explorer() the batch mode can be executed using an r script containing the commands listed above. when the dashboard is run locally the browser will open a port in the local machine -localhost:port-connection, i.e. http://127.0.0.1. it should be noted, that if the dashboard is launched interactively within an r session the port used is 5481 -http://127.0.0.1:5481-, while if this is done through an r script in batch mode the port used will be different. to implement the dashboard and enhance some of the basic functionalities offered, the following libraries were specifically used in the implementation of the dashboard: • shiny [43] : the main package that builds the dashboard. • shinydashboard [44] : this is a package that assists us to build the dashboard with respect to themes, layouts and structure. • shinycssloaders [45] : this package adds loader animations to shiny outputs such as plots and tables when they are loading or (re)-calculating. in general, this are wrappers around base css-style loaders. • plotly [46] : charting library to generate interactive charts and plots. although extensively used in the core functions of the covid19.analytics , we reiterate it here as it is great tool to develop interactive plots. • dt [47] : a datatable library to generate interactive table output. • dplyr [48] : a library that helps to apply functions and operations to data frames. this is important for calculations specifically in the ppe calculations. the r shiny package makes developing dashboards easy and seamless and removes challenges. for example setting the layout of a dashboard typically is challenging as it requires knowledge of frontend technologies such as html, css3 and bootstrap4 to be able to position elements and change there asthetic properties. shiny simplifies this problem by using a built in box controller widget which allows developers to easily group elements, tables, charts and widgets together. many of the css properties, such as, widths or colors are input parameters to the functions of interest. the sidebar feature is simple to implement and the shiny package makes it easy to be compatible across multiple devices such as tablets or cellphones. the shiny package also has built in layout properties such as fluidrow or columns making it easy to position elements on a page. the library does have some challenges as well. one challenge faced is theme design. shinydashboard does not make it easy to change the whole color theme of the dashboard outside of the white or blue theme that is provided by default. the issue is resolved by having the developer write custom css and change each of the various properties manually. the dashboard contains two main components a sidebar and a main body. the sidebar contains a list of all the menu options. options which are similar in nature are grouped in a nested format. for example the dashboard menu section called "datasets and reports", when selected, displays a nested list of further options the user can choose such as the world data or toronto data. grouping similar menu options together is important for making the user understand the data. the main body displays the content of a page. the content a main body displays depends on the sidebar and the selected menu option the user selects. there are three main generic elements needed to develop a dashboard: layouts, control widgets and output widgets. the layout options are components needed to layout the features or components on a page. in this dashboard the layout widgets used are the following: • box: the boxes are the main building blocks of a dashboard. this allows us to group content together. • tabpanels: tabpanels allow us to create tabs to divide one page into several sections. this allows for multiple charts or multiple types of data to be displayed in a single page. for example in the indicators page there are four tabs which display four different charts with mosaic tab displaying the charts in different configurations. • header and title: these are used to display text, title pages in the appropriate sizes and fonts. an example describing these elements and its implementation is shown in lst. 16 . ␣ table ' ) , h4 ( ' world ␣ data ␣ of ␣ all ␣ covid ␣ cases ␣ across ␣ the ␣ globe ') , column (4 , selectinput ( ns ( " category _ list3 " ) , label = h4 ( " category " ) , choices = category _ list ) ) , column (4 , downloadbutton ( ns ( ' downloaddata ') , " download " ) ) , withspinner ( dt :: datatableoutput ( ns ( " table _ contents " ) ) ) ) } listing 16: snippet of a code that describes the various features used in generating a dashboard. the ns(id) is a namespaced id for inputs/outputs. withspinner is the shiny cssloaders which generates a loading gif while the chart is being loaded. shiny modules are used when a shiny application gets larger and complicated, they can also be used to fix the namespacing problem. however shiny modules also allow for code reusability and code modularity as the code can be broken into several pieces called modules. each module can then be called in different applications or even in the same application multiple times. in this dashboard we break the code into two main groups user interface (ui) modules and server modules. each menu option has there own dedicated set of ui and associated server modules. this makes the code easy to build and expand. for each new menu option a new set of ui and sever module functions will be built. lst. 16 is also an example of an ui module, where it specifies the desing and look of the element and connect with the active parts of the application. lst. 20 shows an example of a server function called reportserver. this type of module can update and display charts, tables and valueboxes based on the user selections. this same scenario occurs for all menu options with the ui/server paradigm. another way to think about the ui/server separation, is that the ui modules are in charge of laying down the look of a particular element in the dahboard, while the sever is in charge of dynamically 'filling' the dynamical elements and data to populate this element. control widgets, also called input widgets, are widgets which users use to input data, information or settings to update charts, tables and other output widgets. the following control widgets were used in this dashboard: • numericalinput: a textbox that only allows for numerical input which is used to select a single numerical value. • selectinput: a dropdown that may be multi select for allowing users to select multiple options as in the case of the country dropdown. figure 10 : screenshot from the "covid19.analytics dashboard explorer", "mosaic" tab from the 'indicators' category. four interactive figures are shown in this case: the trends (generated using the itrends function), totals (genrated using the totals.plt function) and two world global representations of covid19 reported cases (generated using the live.map function). the two upper plots are adjusted and re-rendered according to the selection of the country, category of the data from the input boxes. • slider: the slider in our dashboard is purely numerical but used to select a single numerical value from a given range of a min and max range. • download button: this is a button which allows users to download and save data in various formats such as csv format. • radiobuttons: used to select only one from a limited number of choices. • checkbox: similar in purpose to radiobuttons that also allow users to select one option from a limited number of options. output control widgets are widgets that are used to display content/information back to the user. there are three main ouput widgets used in this dashboard: • plotlyouput: this widget output and creates plotly charts. plotly is a graphical package library used to generate interactive charts. • rendertable: is an output that generates the output as an interactive table with search, filter and sort capabilities provided out of the box. • valuebox: this is a fancy textbox with border colors and descriptive font text to generate descriptive text to users such as the total number of deaths. the dashboard contains the menus and elements shown in 17 and described below: • indicators: this menu section displays different covid19 indicators to analyze the pandemic. there are four notable indicators itrend, total plot, growth rate and live map, which are displayed in each of the various tabs. itrend displays the "trend" in a log-log plot, total plot shows a line graph of total number, growth rate displays the daily number of changes and growth rate (as defined in sec. 2.2), live map shows a world map of infections in an aggregated or timeseries format. these indicators are shown together in the "mosaic" tab. • models: this menu option contains a sub-menu presenting models related to the pandemic. the first model is the sir (susceptible infection recovery) which is implemented in the covid19.analytics package. sir is a compartmental model to model how a disease will infect a population. the second two models are used to estimate the amount of ppe needed due to infectious diseases, such as ebola and covid19. • datasets and reports: this section provides reporting capability which outputs reports as csv and text files for the data. the world data subsection displays all the world data as a table which can be filtered, sorted and searched. the data can also be saved as a csv file. the toronto data displays the toronto data in tabular format while also displaying the current pandemic numbers. data integrity section checks the integrity and consistency of the data set such as when the raw data contains negative numbers or if the cumulative quantities decrease. the report section is used to generate a report as a text file. • references: the reference section displays information on the github repo and documentation along with an external dashboards section which contains hyperlinks to other dashboards of interest. dashboards of interest are the vaccine tracker which tracks the progress of vaccines being tested for covid19, john hopkins university and the canada dashboard built by the dall lana school of epidemiology at the university of toronto. • about us: contact information and information about the developers. in addition to implementing some of the functionalities provided by the covid19.analytics package, the dashboard also includes a ppe calculator. the hospital ppe is a qualitative model which is designed to analyze the amount of ppe equipment needed for a single covid19 patient over a hospital duration. the ppe calculation implemented in the covid19.analytics dashboard explorer is derived from the cdc's studies for infectious diseases, such as ebola and covid19. the rationality is that ebola and covid19 are both contagious infections and ppe is used to protect staff and patients and prevent transmission for both of these contagious diseases. the hospital ppe calculation estimates and models the amount of ppe a hospital will need during the covid19 pandemic. there are two analysis methods a user can choose to determine hospital ppe requirement. the first method to analyze ppe is to determine the amount of ppe needed for a single hospitalized covid19 patient. this first model requires two major component: the size of the healthcare team needed to take care of a single covid19 patient and the amount of ppe equipment used by hospital staff per shift over a hosptialization duration. the model is based off the cdc ebola crisis calculation [49] . alhough ebola is a different disease compared to covid19, there is one major similarity. both covid19 and ebola are diseases which both require ppe for protection of healthcare staff and the infected patient. to compensate the user can change the amount of ppe a healthcare staff uses per shift. that information can be adjusted by changing the slider values in the advanced setting tab. the calculation is pretty straightforward as it takes the ppe amount used per shift and multiplies it by the number of healthcare staff and then by the hospitalization duration. the first model has two tabs. the first tab displays a stacked bar chart displaying the amount of ppe equipment user by each hospital staff over the total hospital duration of a single patient. it breaks each ppe equipment by stacks. the second tab panel called advanced settings has a series of sliders for each hospital staff example nurses where users can use the slider to change the amount of ppe that the hospital staff will user per shift. the second model is a more recent calculation developed by the cdc [50] . the model calculates the burn rate of ppe equipment for hospitals for a one week time period. this model is designed specifically for covid19. the cdc has created an excel file for hospital staff to input their information and also an android app as well which can be utilized. this model also implemented in our dashboard, is simplified to calculate the ppe for a one week setting. the one week limit was implemented for two reasons, first to limit the amount of input data a user has to enter into the system as too much data can overwhelm and confuse a user; second because the covid19 pandemic is a highly fluidic situation and for hospital staff to forecast their ppe and resource equipments greater than a one week period may not be accurate. note that this model is not accurate if the facilitiy recieves a resupply of ppe. for resupplied ppe start a new calculation. there are four tab panels to the burn rate calculation which displays charts and settings. the first tab daily usage displays a multi-line chart displaying the amount of ppe used daily, ∆p p e daily . the calculation for this is a simple subtraction between two consecutive days, i.e. the second day (j + 1) from the first day (j) as noted in eq. (6) . the tab panel called remaining supply shows a multi line chart the number of days the remaining ppe equipment will last in the facility. the duration of how long the ppe equipment can last in a given facility, inversely depends on the amount of covid19 patients admitted to the hospital. to calculate the remaining ppe one calculates the average amount of ppe used over the one week duration and then divides the amount of ppe at the beginning of the day by the average ppe usage, as shown in eq. (7), where t denotes the time average over a t period of time. the third panel called ppe per patient displays a multi line chart of the burn rate, i.e. the amount of ppe used per patient per day. eq.(8) represents the calculation as the remaining ppe supply divided by the number of covid19 patients in the hospital staff during that exact day. the fourth tab called advanced settings is a series of show and hide "accordians" where users can input the amount of ppe equpiment they have at the start of each day. there are six collapsed boxes for each ppe equipment type and for covid19 patient count. expanding a box displays seven numericalinput textboxes which allows users to input the number of ppe or patient count for each day. the equations describing the ppe needs, eqs. (6, 7, 8) are implemented in the shiny dashboard using the dplyr library. the dplyr library allows users to work with dataframe like objects in a quick and efficient manner. the three equations are implemented using a single dataframe. the advanced setting inputs of the burn rate analysis tab are saved into a dataframe. the ppe equations -eqs. ( the back-end implementation of the dashboard is achieved using the functions presented in sec.2 on the server module of the dashboard. the main strategy is to use a particular function and connect it with the input controls to feed the needed arguments into the function and then capture the output of the function and render it accordingly. let's consider the example of the globe map representation shown in the dashboard which is done using the live.map function. lst. 19 shows how this function connects with the other elements in the dashboard: the input elements are accessed using input$... which in this are used to control the particular options for the displaying the legends or projections based on checkboxes. the output returned from this function is captured through the renderplotly({...}) function, that is aimed to take plotly type of plots and integrate them into the dashboard. # livemap plot charts on the three possible commbinations output $ ts _ livemap <-output $ ts2 _ livemap <-output $ ts3 _ livemap <-output $ ts4 _ livemap <-renderplotly ({ legend <-input $ sel _ legend projections <-input $ sel _ projection live . map ( covid19 . data ( " ts -confirmed " ) , interactive . display = false , no . legend = legend , select . projctn = projections ) }) listing 19: example of how the live.map function is used to render the ineractive figures display on the dashboard. another example is the report generation capability using the report.summary function which is shown in lst. 20. as mentioned before, the input arguments of the function are obtained from the input controls. the output in this case is rendered usign the rendertext({...}) function, as the output of the original function is plain text. notice also that there are two implementations of the report.summary, one is for the rendering in the screen and the second one is for making the report available to be downloaded which is handled by the downloadhandler function. reportserver <-function ( input , output , session , result ) { output $ report _ output _ default <-rendertext ({ # extract the vairables of the inputs nentries <-input $ txtbox _ nentries geo _ loc <-input $ geo _ loc _ select6 ts <-input $ ddl _ ts capture . output ( report . summary ( graphical . output = false , nentries = nentries , geo . loc = geo _ loc , cases . to . process = ts ) ) } , sep = '\ n ') report <-reactive ({ nentries <-input $ txtbox _ nentries geo _ loc <-input $ geo _ loc _ select6 ts <-input $ ddl _ ts report <-capture . output ( report . summary ( graphical . output = false , nentries = nentries , geo . loc = geo _ loc , cases . to . process = ts ) ) return ( report ) }) output $ downloadreport <-downloadhandler ( filename = function () { paste ( " report -" , sys . date () ," . txt " , sep = " " ) } , content = function ( file ) { writelines ( paste ( report () ) , file ) } ) } listing 20: report capabilites implemented in the dashboard using the report.summary function. the final element in the deployment of the dashboard is the actual set up and configuration of the web server where the application will run. the actual implementation of our web dashboard, accessible through https://covid19analytics.scinet.utoronto.ca, relies on a virtual machine (vm) in a physical server located at scinet headquarters. we should also notice that there are other forms or ways to "publish" a dashboard, in particular for shiny based-dashboards, the most common way and perhaps straighforward one is to deploy the dashboard on https://www.shinyapps.io. alternatively one could also implement the dashboard in a cloud-based solution, e.g. https://aws.amazon.com/blogs/big-data/running-r-on-aws/. each approach has its own advantages and disadvantages, for instance, depending on a third party solution (like the previous mentioned) implies some cost to be paid to or dependency on the provider but will certainly eliminate some of the complexity and special attention one must take when using its own server. on the other hand, a self-deployed server will allow you for full control, in principle cost-effective or cost-controled expense and full integration with the end application. in our case, we opted for a self-controlled and configured server as mentioned above. moreover, it is quite a common practice to deploy (multiple) web services via vms or "containers". the vm for our web server runs on centos 7 and has installed r version 4.0 from sources and compiled on the vm. after that we proceeded to install the shiny server from sources, i.e. https://github.com/rstudio/ shiny-server/wiki/building-shiny-server-from-source. after the installation of the shiny-server is completed, we proceed by creating a new user in the vm from where the server is going to be run. for security reasons, we recommend to avoid running the server as root. in general, the shiny server can use a user named "shiny". hence a local account is created for this user, and then logged as this user, one can proceed with the installation of the required r packages in a local library for this user. all the neeeded packages for running the dashboard and the covid19.analytics package need to be installed. lst. 21 shows the commands used for creating the shiny user and finalizing the configuration and details of the log files. # place a shortcut to the shiny -server executable in / usr / bin sudo ln -s / usr / local / shiny -server / bin / shiny -server / usr / bin / shiny -server # create shiny user sudo useradd -r -m shiny # create log , config , and application directories sudo mkdir -p / var / log / shiny -server sudo mkdir -p / srv / shiny -server sudo mkdir -p / var / lib / shiny -server sudo chown shiny / var / log / shiny -server sudo mkdir -p / etc / shiny -server listing 21: list of commands used on the vm to finalize the setup of the shiny user and server. source: https: //github.com/rstudio/shiny-server. for dealing with the apache configuration on port 80, we added the file /etc/httpd/conf.d/rewrite.conf as shown in lst. 22. rewritecond %{ request _ scheme } = http rewriterule^https : / / %{ server _ name }%{ request _ uri } [ qsa , r = permanent ] listing 22: modifications to the apache configurations, specified in the file rewrite.conf. these three lines rewrite any incoming request from http to https. for handling the apache configuration on port 443, we added this file /etc/httpd/conf.d/shiny.conf, as shown in lst.23. this virtualhost receives the https requests from the internet on port 443, establishes the secure connection, and redirects all input to port 3838 using plain http. all requests to "/" are redirected to "http://0.0.0.0:3838/app1/", where app1 in this case is a subdirectory where a particular shiny app is located. there is an additional configuration file, /etc/httpd/conf.d/ssl.conf, which contains the configuration for establishing secure connections such as protocols, certificate paths, ciphers, etc. the main tool we use in order to communicate updates between the different elements we use in the development and mantainance of the covid19.analytics package and dashboard web interface is orchestrated via git repositories. in this way, we have in place version control systems but also offer decentralized with multiple replicas. fig. 11 shows an schematic of how our network of repositories and service is connected. the central hub for our package, is located at the github repo htttps: //github.com/mponce0/covid19.analytics; we then have (and users can too) our own clones of local copies of this repo -we usually use this for development and testing-. when a stable and substantial contribution to the package is reached, we submit this to the cran repository. similarly, when an update is done on the dashboard we can synchronize the vm via git pulls and deploy the updates on the server side. in this paper we have presented and discussed the r covid19.analytics package, which is an open source tool to obtain, analyze and visualize data of the covid19 pandemic. the package also incorporates a dashboard to facilitate the access to its functionalities to less experienced users. as today, there are a few dozen other packages also in the cran repository that allow users to gain access to different datasets of the covid19 pandemic. in some cases, some packages just provide access to data from specific geographical locations or the approach to the data structure in which the data is presented is different from the one presented here. nevertheless, having a variety of packages from which users can try and probably combine, is an important and crucial element in data analysis. moreover it has been reported different cases of data misuse/misinterpretation due to different issues, such as, erroneous metadata or data formats [51] and in some cases ending in articles' retractions [52] . therefore providing additional functionalities to check the integrity and consistency of the data, as our the covid19.analytics package github repo -central repository https://github.com/mponce0/covid19.analytics shiny server, running on vm https://covid19analytics.scinet.utoronto.ca local copies cran repo https://cran.r-project.org/package=covid19.analytics local copies local copies github io -web rendering https://mponce0.github.io/covid19.analytics/ private instances figure 11 : schematic of the different repositories and systems employed by the covid19.analytics package and dashboard interface. does is paramount. this is specially true in a situation where the unfolding of events and data availability is flowing so fast that sometimes is even hard to keep track of all the changes. moreover, the covid19.analytics package offers a modular and versatile approach to the data, by allowing users to input their own data for which most of the package functions can be applied when the data is structured using a time series format as described in this manuscript. the covid19.analytics is also capable of retrieving genomics data, and it does that by incorporating a novel, more reliable and robust way of accessing and designing different pathways to the data sources. another unique feature of this package is the ability of incorporating models to estimate the disease spread by using the actual data. although a simple model, it has shown some interesting results in agreement for certain cases. of course there are more sophisticated approaches to shred light in analyzing this pandemic; in particular novel "community" approaches have been catalyzed by this too [53] . however all of these approaches face new challenges as well [54] , and on that regards counting with a variety, in particular of open source tools and direct access to the data might help on this front. r: a language and environment for statistical computing, r foundation for statistical computing r: a language for data analysis and graphics covid19.analytics: load and analyze live data from the covid-19 pandemic the biggest mystery: what it will take to trace the coronavirus source animal source of the coronavirus continues to elude scientists a pneumonia outbreak associated with a new coronavirus of probable bat origin the proximal origin of sars-cov-2 bat-borne virus diversity, spillover and emergence extrapulmonary manifestations of covid-19 opensafely: factors associated with covid-19 death in 17 million patients considering how biological sex impacts immune responses and covid-19 outcomes coronavirus blood-clot mystery intensifies using influenza surveillance networks to estimate state-specific prevalence of sars-cov-2 in the united states consolidation in a crisis: patterns of international collaboration in early covid-19 research critiqued coronavirus simulation gets thumbs up from code-checking efforts timing social distancing to avert unmanageable covid-19 hospital surges special report: the simulations driving the world's response to covid-19 covid-19 vaccine design: the janus face of immune enhancement covidep: a web-based platform for real-time reporting of vaccine target recommendations for sars-cov-2 social network-based distancing strategies to flatten the covid-19 curve in a post-lockdown world asymptotic estimates of sarscov-2 infection counts and their sensitivity to stochastic perturbation evolutionary origins of the sars-cov-2 sarbecovirus lineage responsible for the covid-19 pandemic an interactive web-based dashboard to track covid-19 in real time pandemic publishing poses a new covid-19 challenge will the pandemic permanently alter scientific publishing? how swamped preprint servers are blocking bad coronavirus research project, trainees, faculty, advancing scientific knowledge in times of pandemics covid-19 risk factors: literature database & meta-analysis coronawhy: building a distributed, credible and scalable research and data infrastructure for open science, scinlp: natural language processing and data mining for scientific text the comprehensive r archive network covid-19 data repository by the center for systems science and engineering covid-19: status of cases in toronto database resources of the national center for biotechnology information ape 5.0: an environment for modern phylogenetics and evolutionary analyses in r rentrez: an r package for the ncbi eutils api a contribution to the mathematical theory of epidemics the sir model for spread of disease: the differential equation model, loci.(originally convergence exact analytical solutions of the susceptible-infected-recovered (sir) epidemic model and of the sir model with equal death and birth rates devtools: tools to make developing r packages easier shiny: web application framework for r shinydashboard: create dashboards with 'shiny', r package version 0 shinycssloaders: add css loading animations to 'shiny' outputs interactive web-based data visualization with r, plotly, and shiny, chapman and hall/crc, 2020 dt: a wrapper of the javascript library 'datatables', r package version 0 dplyr: a grammar of data manipulation estimated personal protective equipment (ppe) needed for healthcare facilities personal protective equipment (ppe) burn rate calculator high-profile coronavirus retractions raise concerns about data oversight covid-19 pandemic reveals the peril of ignoring metadata standards artificial intelligence cooperation to support the global response to covid-19 the challenges of deploying artificial intelligence models in a rapidly evolving pandemic the r script containing the shiny app to be run should be placed in /etc/shiny-server and confiurations details about the shiny interface are adjusted in the /etc/shiny-server/shiny-server.conf file.permissions for the application file has to match the identity of the user launching the server, in this case the shiny user.at this point if the installation was sucessful and all the pieces were placed properly, when the shiny-server command is executed, a shiny hosted app will be accessible from localhost:3838.since the shiny server listens on port 3838 in plain http, it is necessary to setup an apache web server to act as a reverse proxy to receive the connection requests from the internet on ports 80 and 443, the regular http and https ports, and redirect them to port 3838 on the same host (localhost). mp wants to thank all his colleagues at scinet, especially daniel gruner for his continous and unconditional support, and marco saldarriaga who helped us setting up the vm for installing the shiny server. key: cord-031378-iy67xnec authors: atif, iqra; cawood, frederick thomas; mahboob, muhammad ahsan title: the role of digital technologies that could be applied for prescreening in the mining industry during the covid-19 pandemic date: 2020-09-03 journal: trans indian natl doi: 10.1007/s41403-020-00164-0 sha: doc_id: 31378 cord_uid: iy67xnec the novel covid-19 (coronavirus disease of 2019) pandemic has caused global havoc and impacted almost every aspect of human life and the global economy. the mining industry is not immune to such impacts. the pandemic has accelerated the need for digital transformation in the mining industry and in the era of the fourth industrial revolution (4ir), there is further application of digital technologies in the early detection and prescreening of emerging infectious and viral diseases to keep mining areas and communities safer and less vulnerable. this paper aims to explore the application of smart digital technologies that could be applied for detection, prescreening and prevention of covid-19 in the mining industry. the study will contribute, firstly, to demonstrate the utility and applications of digital technologies in the mining industry and, secondly, the development of a body of knowledge that can be consulted to prevent the spread of the disease in the mining industry. the novel covid-19 (severe acute respiratory syndrome coronavirus 2-coronavirus disease of 2019) pandemic has caused global havoc and impacted almost every aspect of human life and the economy. the effect of this viral disease on human health is evident from its easy and rapid spread from person to person resulting in infection and sometimes death (worldometers 2020 ) and on the global economy. to date, more than 500,000 people have died from covid-19, while the mckinsey institute describes the pace of decline in economic activity to be the steepest since world war ii (craven et al. 2020 ). this effect is more prominent in resource-rich countries which are already struggling with their economies and where people have to physically work for their livelihoods. the current pandemic also has serious consequences on the short-, medium-and long-term future of the global mining industry, particularly where there is limited application of digital and automation technologies. an executive briefing by craven et al. (2020) highlighting the implications of covid-19 for business showed that the mining, oil and gas industry has the highest financial risk compared to all other industries in the usa (fig. 1) . the situation will not be different in south africa because the extractive industries are considered essential for the economic stability of the country, despite being severely affected by the covid-19 pandemic. there are several challenges that the mining industry is currently facing under this pandemic, including a mandatory shutdown, lower demand for extractive products and slowdowns when managing the risk; these cause loss of production, income and growth. the production of the south african mining industry has also shown a sharp decline during these uncertain times of covid-19. mining production fell by 18% when the country's lockdown started in march 2020 and reached 47.3% in april 2020 due to covid-19, as shown in fig. 2 . in south africa, the mines are expected to have covid-19 infection rates of between 7 and 10% under normal mining conditions. this rate can increase sharply when mine workers use public transport for commuting from different regions because of the migrant labor system in mining. the biggest challenge is re-starting operational activities after lockdowns, followed by the implementation of safety measures to curb the spread of covid-19 when production resumes (viljoen 2020) . as of 02 july 2020, there has been a total of 2573 positive cases in the south african mining industry with 835 in gold, 1395 in platinum and 2573 in other mines. this pandemic has raised attention towards a much needed and necessarily required digital transformation in the mining industry-not only for its sustainability but also for a more stable economic performance of any country in times of crises. there can be a potential application of digital technologies in the early detection and prescreening of covid-19 affectees to keep the mining areas and communities safe and ultimately stop the spread of the disease. the guidelines for a mandatory code of practice on the mitigation and management of covid-19 outbreak, developed jointly by the department of mineral resources and energy and the minerals council south africa, highlights the minimum requirements for the reduction and controlling of virus outbreak amongst mine employees returning to work (msiza 2020) . besides that, the mining companies have developed action plans to manage the impact of the coronavirus in their communities. smart, digital and appropriate personal protective equipment (ppe) further help prepare the mining industry for the covid-19. an adequate production and supply of ppe is important during this pandemic. to overcome this issue, three-dimensional (3d) printing, a novel and innovative technology, can be used to fabricate complex architectures and biomaterials using computeraided design (cad) system. the objective of this article is to explore the application of smart digital technologies that could be applied for detection, prescreening and prevention of covid-19 in the mining industry. this study is of interest to mineworkers, the mining industry, government and mine medical staff. this study will contribute, firstly, to demonstrate the utility and applications of digital technologies in the mining industry and, secondly, to the development of a pool of knowledge that can be consulted to prevent the covid-19 pandemic for the mining industry. potential digital technologies that could be applied to tackle various problems related to covid-19 pandemic are artificial intelligence (ai), data analytics, internet of medical things (iomt), smart biosensors and sanitizing equipment. ebel et al. (2020) at mckinsey institute have proposed five steps for managing the overall risk, namely to build "always on" response systems, strengthen detection mechanisms, integrate current efforts, develop better health-care systems and accelerate research and development. this paper does not cover the range of options to government and industry to prevent the spread of infectious diseases like covid-19, but rather focuses on one tiny aspect of the risk management process, which is to reduce the risk of the individual by wearing new-generation ppe to prevent the spread of the disease in the mining workplace. what follows is a discussion on several digital technologies which can be potentially used to overcome the covid-19 negative impacts in the mining industry. one of the most effective and commonly used method for prescreening of individuals for covid-19 is the sensing of body temperatures. however, the traditional body temperature measurements using glass mercury, ear or forehead thermometers are not only time-consuming and labor-intensive, but also has the threat of close contact, which can cause the risk of contamination. besides that, the other disadvantage of conventional body temperature measurements is the lack of data collection for analysis, which is useful for further interpretation and evaluation. artificial intelligence-based cameras are a hybrid of thermal, infrared and visible imaging, which can predict and provide near real-time updates of miner's body temperature and automatically send an alert to mine management in case of temperature anomalies. real-time video analytics have already been used to monitor the health and safety parameters in both underground and surface mining environments (dufour 2012; zhang et al. 2019) . chun (2020) reported an intelligent video system that was installed at public transport stations in china to scan large crowd body's temperature. the cameras were placed at prominent positions with appropriate angles for good quality video capturing and body scanning. this type of scanning can be done at different stages at multiple locations in the mining environment (e.g., mine entrance, lamp room, waiting areas, workstations). thermal camera scanning will probably not be an adequate approach in an underground mine because of the harsh environment. in addition, worker's ppe can alter the results and cause difficulty to differentiate temperatures coming from the worker's body, ppe and immediate surroundings (carroll 2020) . scanning the inner tear duct and forehead give the most reliable results, so it should be done at the accessing locations of mines without covering eyes or head with any ppe. dickson (2020) has described that thermal cameras produced by chinese baiduis firm can scan 200 people a minute and pinpoint the individuals with body temperature higher than 37.3 °c. the thermal infrared cameras were also placed at different hospital entrances around the world to identify any individuals (including visitors) with fever at the first point of entry. the system has proved to be very efficient in identification of potential covid-19 patients in a large crowded space (kung et al. 2020) . artificial intelligence-enabled cameras can be installed at a point of mine entry to ensure that workers obey covid-19 protocols and wear proper ppe (seo et al. 2015 ). an intelligent video system can also be used to assure proper self-quarantine of individuals (if necessarily required) as chun (2020) reported that china had used ai-based camera system for citizens to ensure their self-quarantine. such system has also been implemented in countries like the usa, uk and israel for intelligent decision making and controlling of the covid-19 spread (dobrea and dobrea 2020; naik et al. 2020). the other significant application of an ai-based video analytics system is to detect the abnormal respiratory patterns among individuals (jiang et al. 2020; wang et al. 2020b ) which can also be implemented in the mining environment for prescreening of covid-19 (fig. 3) . machine learning-based ai models can be trained on the characteristics of actual respiratory signals of mineworkers under different scenarios (with and without ppe, public places, sleep hours, office environment, underground mine with the harsh environment and family time). the capability of the trained models will be to detect unusual and unexpected patterns of breathing for identification of the covid-19 affectees. in the research conducted by koyama et al. (2019) , the authors had developed a system using respiratory monitoring algorithms based on the minute-ventilation sensor to predict heart failure. the developed system can monitor and investigate the changes in breathing patterns that could eventually help to control heart failures. another research conducted by wang et al. (2020a) proposed portable and ai (deep learning architecture)-based intelligent health screening dual-mode camera (visible and thermal) that can be used for the detection of respiratory infection disease like covid-19. the model identified the health status regarding respiration with the accuracy of 83.7%. therefore, such a system is also recommended for the mining industry to detect workers with abnormal respiratory behavior. the major benefit of using the intelligent video system is obtaining a contactless screening of individuals for covid-19 and other viral infections and then to separate them from other workers by not allowing access to the mine. by doing this, it will not compromise the health of, first, the person taking the measurements and, second, fellow mine workers inside the mine. several studies have indicated that face masks can reduce the transmissibility of the virus by minimizing the spread of infected droplets in both closed and open environments (eikenberry et al. 2020; esposito et al. 2020) . low or no transmissibility could significantly reduce the death toll and economic impacts as a low-cost solution. the research conducted by bae et al. (2020) showed that the different types of face masks have a different impact on curbing the covid-19 pandemic. surgical and respirator masks like n95 should be worn in public and workplaces as recommended by the world health organization (who) to minimize the spread. however, surgical face masks are less effective where the work needs to be done in harsh and confined environments such as mines and factories (bailar et al. 2006; steinle et al. 2018 ). the face masks in mining 4.0 should also be digitally smart, sensor based and equipped with an early warning system. 3d printed smart masks with biosensors can monitor the body's temperature, heart rate, blood oxygen levels and respiratory rate by placing sensors near the wearer's earlobes, nose and mouth (fig. 4) . these vital signs can be transferred in near real time to a mobile or desktop application to individuals, mine health care and management authorities for decision making. an ai health hackathon organized in february 2020 brought together students, research scientists and innovators from multiple disciplines to improve patient care by harnessing artificial intelligence and machine learning. the team vitalmask used biosensors technology to make a smart respiratory mask that prevents the spread of airborne diseases while monitoring the wearer's vital signs (kelley 2020). there is an extensive research and development required to test the suitability of the material that can be used to make the smart masks for harsh mining environment, but in all cases the material should be 100% pvc free and temperature resilient. the smart mask will not only help medical staff to prioritize patients, but also reduce the cost as it is a washable and reusable alternative to standard disposable masks. if adopted, it is recommended that companies should provide proper instructions or training to workers on how to wear, maintain and clean their face coverings to ensure the safety of individuals. face shield is another important ppe to minimize the spreading and associated negative impacts of viral and other diseases such as covid-19. chu et al. (2020) conducted a review of 172 observational studies, and they concluded that face shields have proven to be a good and inexpensive ppe in the reduction of covid-19, middle eastern respiratory syndrome coronavirus (mers-cov) or severe acute respiratory syndrome-related coronavirus (sars-cov) infections among the individuals. usually, several types of face shields are available; however, all provide a transparent plastic blockade that covers the face. for ideal protection, the shield should be extended below the chin, to the ears sideways, with no gap between the forehead and the shield's headpiece, as shown in fig. 5 . for the mining industry, the standard face shield design requires adjustment (cawley and homce 2007), to accommodate the standard miner's helmet and cap lamp as shown in fig. 6 . the producers of mine safety equipment should design an arc-rated face shield adjustable with hats to overcome the spread of covid-19 as per the mining industry and other national standards. if the mine workers use simple face shields that are not adjustable with the hard hats, then it should be used in addition to other ppe such as face masks and safety goggles. roberge (2016) reviewed face shields for infection control and concluded that it should not be used as solitary face/eye protection, but rather as adjunctive to other ppe like face masks, due to lack of a good facial seal peripherally that can allow for aerosol penetration. several mining companies have already acquired the face shields as a basic ppe to protect their workers and staff from the covid-19 pandemic. sibanye-stillwater, a leading international precious metals mining company based in south africa, has also started a project in collaboration with sibanye-stillwater digital mining laboratory (digimine) at the wits mining institute (wmi) for the production of 300 face shields per day for the company's staff and workers. also, the surplus face shields can be distributed to mining communities, government bodies and other health-care service providers in the region (mahboob 2020). on the other hand, researchers at the crop science division developed digital smart face shields that can track and monitor the vital health signs of health-care professionals. the face shields use iots technology to track temperature, atmospheric humidity, respiratory pattern, heart rate and blood oxygen level, alerting health-care workers through an attached led, if they need to stop and check for symptoms (das 2020) . smart bio-sensor-based face shields can also be used in the mining industry, not only for protection purposes, but also as display screens to highlight any critical information related to the miner's health and safety. the suggested face shield design with an adjustable cap lamp and ear protection is shown in fig. 7 . face shields provide several advantages, e.g., they can be reused for a long period and are washable with household cleaners or other common sanitizers. other advantages are that people can easily communicate with each other while smart boots is another digital technology that can be useful to prevent infectious viruses like covid-19 by providing the worker contact tracing and ensure social distancing (fig. 8) . the contact tracing can also be possible with the use of smartphones, when combined with physical distancing. the usage of smartphones has already been proven as a powerful asset in controlling the spread of covid-19 worldwide. however, according to the data from the mining industry, not more than 15% of the miners have their own smartphones. also, in the mining area, the miners have limited access to their mobile phones and usually are not allowed to bring on site due to health and safety issues. therefore, relying only on mobile phone technology means more than 80% of the population (miners and mining area community) could slip through the cracks. hence, the principle of smart boots is to attach a sensing device to the boots which alerts the person through a vibrating signal when the individual is in close contact with another person (minimum 2 m distance). when the mine worker gets this signal, he/she can either put a face cover or move away from other nearby worker(s). this will reduce wearable time because research conducted by bauchner et al. (2020) concluded that wearing a face shield or mask is challenging for a whole day or a shift. however, the addition of smart boots in ppe can ensure that workers keep a safe distance during the shift (from access to exit). another advantage of smart boots is that it can monitor the miner's activities like location, while collecting other data of the environment. the boots can also assist with extending the underground communications network, communicating alerts by beeping or flashing in high-risk areas, and sending emergency signals to the control room for possible assistance-along with the location of the (missing) person. the internet of medical things (iomt), also known as the health-care iot-based wearable health devices, are playing an important role in real-time monitoring of health conditions of individuals (qureshi and krishnan 2018) . during the current covid-19 pandemic, several innovators, medical authorities, and government entities are looking for potential usage of iomt technology to lessen the load on the health-care systems. these devices have already been applied in covid-19 conditions, not only to gather digital health data, but also to ensure that people obey certain lockdown and quarantine regulations. the research conducted by rahman et al. (2020) revealed that real-time data collected with iot-based health devices were used to predict the covid-19 outbreak with a confidence level of more than 80%. also, the study conducted by tripathy et al. (2020) fig. 7 digital face shield for the mining industry to manage and control the impacts of covid-19, source: das (2020) fig. 8 smart boots to prevent infectious viruses like covid-19 by contact tracing, geo-fencing and social distancing alerts, source: camas (2020) concluded that smart easy band health device could be used effectively to control the growth of new positive cases of covid-19 with auto-contact tracing and by ensuring critical social distancing. similarly, an iot-q-band system is another low-cost, smart health-care wearable used during the covid-19 pandemic-illustrated in fig. 9 . wearable bands are energized with a lightweight battery (for comfortable wear) and can be worn on the hand, arm, or leg and wirelessly connected to the communication point via a bluetooth link. the processing unit continuously sends the data to: 1. check the status of whether the wearable band is working or tampered; 2. check if people maintain their social distance of 2 m from others; and 3. monitor duration per activity during the shift. a designated person or mine hospital doctor can also monitor workers via a web interface, where the alerts can be generated using data analytics technology. besides the health bands, the usage of telemedicine services can also be explored to facilitate the remote location communities. however, in case of the mining industry, it is mandatory for each mine to have its own independent small-to mediumscale hospital not only for workers, but also for the nearby communities. usually, the workers have access to the community hospital and its associated facilities where medical staff can easily access the data as received from the health bands of the workers. smart disinfection tunnels or walkthrough sanitization gates can be installed at the entry and exit points of mines to sterilize the clothing and body of mineworkers. usually, these tunnels spray the disinfectant chemicals through nozzles arranged in a way to shower the complete body. the ideal disinfectant chemical to be used in these gates or tunnels should be non-volatile, non-toxic, odorless, colorless, quick spray, harmless to skin and other body parts in compliance with all health and safety regulations (biswal et al. 2020) . walkthrough gates or tunnels should be automatically activated using a passive infrared sensor to detect movement and measure a person's body temperature (fig. 10) . proving popular since the outbreak of covid-19 in south africa, indoor turbines, which atomize and distribute disinfectant using powerful fans and high-pressure nozzles, have been successfully used in warehouses and factories to make disinfecting liquid airborne and sanitizing vast areas for up to 18 h. however, there is not enough clinical evidence on the efficiency of these walkthrough gates or disinfection tunnels to prevent covid-19 (mallhi et al. 2020) . the national academies of sciences, engineering and medicine reported that ultraviolet (uv) light-based walkthrough gates possibly could eradicate the coronavirus that contains the deadly fig. 9 iot-q-band system for real-time monitoring of the health condition of individual and ensure social distancing to prevent the spread of covid-19 virus, source: singh et al. (2020) mers-cov and sars-cov. however, the who has advised that people should not use uv lamps to disinfect their hands or other areas of skin, as uv radiation can cause skin irritation and can damage eyes (leung and ko 2020). nonetheless, disinfection tunnels without uv radiations and with harmless sanitizers has application in crowded working environments such as mines to disinfect the people and control the novel covid-19 pandemic. dashboard is a significant technology for the management and visualization of various real-time digital datasets. tracking of covid-19 with the help of interactive dashboards makes it possible to forecast the effects of a pandemic on the industry and to assess several economic and health consequences related to it under different scenarios. there are several international dashboards for mapping of covid-19, e.g., johns hopkins university center for systems science and engineering dashboard, the who coronavirus disease (covid-19) dashboard shown in fig. 11 (dong et al. 2020 the purpose of all these dashboards is to track the spread of covid-19 and to evaluate different case scenarios to understand the spread and to determine future impacts. mining companies can develop their own dashboards to monitor the spread of the virus in the mines and surrounding regions, which can also be linked with other national and international dashboards for public awareness and information dissemination. dashboards for the mining industry can bring together location and timedependent events in association with the disease spread, providing travel and movement alerts for their employees. similarly, the dashboards can assist in the allocation of resources as per their need and urgency in the mining environment. finally, by preparing the data for dashboard analysis it becomes information for effective sharing and informing workers on risks, while management can further analyze data through (numeric) modeling and integration with, e.g., mine ventilation information to better understand the behavior of covid-19 in the mining environment. the graphical and tabular summary of all the potential digital technologies discussed in this paper is given in fig. 12 and table 1 , respectively. this is further proof that digital technologies can make mining both safer and more profitable. many governments have implemented national lockdown and social distancing strategies to mitigate the spread of covid-19 and to give their health-care systems and the economy time to prepare for the disease. in addition, there are non-pharmaceutical interventions that reduce human contact within the population and therefore constrains the spread of covid-19. digital technologies provide a newgeneration solution that allows governments and companies to collect, transfer, store, analyze, monitor, predict and visualize the covid-19 related data for better decision making. this research discussed the various digital technologies that provide innovative methods for monitoring and management of the covid-19 pandemic, in addition to ensuring the safety of the mineworkers. this paper provides a useful summary of currently available personal protective equipment for mine workers to prevent the spread of infectious and viral diseases in the mining workplace. reusability of facemasks during an influenza pandemic. institute of medicine of the national academies bauchner h, fontanarosa pb, livingston eh (2020) conserving supply of personal protective equipment-a call for ideas disinfection tunnels: potentially counterproductive in the context of a prolonged pandemic of covid-19 solepower: the "smartboots" that run on your footsteps vis syst design cawley jc, homce gt (2007) protecting miners from electrical arcing injury physical distancing, face masks, and eye protection to prevent person-to-person transmission of sars-cov-2 and covid-19: a systematic review and meta-analysis chinas investment in ai is paying off in a big way bayer smart face shield why ai might be the most effective weapon we have to fight covid-19. the next web, amsterdam dobrea d-m, dobrea m-c (2020) an autonomous uav system for video monitoring of the quarantine zones an interactive web-based dashboard to track covid-19 in real time strengthening health care's supply chain: a five-step plan trading econ. https ://tradi ngeco nomic s.com/south -afric a/minin g-produ ction . accessed 30 to mask or not to mask: modeling the potential for face mask use by the general public to curtail the covid-19 pandemic universal use of face masks for success against covid-19: evidence and implications for prevention policies combining visible light and infrared imaging for efficient detection of respiratory infections such as covid-19 on portable device an application of pacemaker respiratory monitoring system for the prediction of heart failure ko tcs (2020) improper use of germicidal range ultraviolet lamp for household disinfection leading to phototoxicity in covid-19 suspects walkthrough sanitization gates for covid-19: a preventive measure or public health concern? guidelines for a mandatory code of practice on the mitigation and management of covid-19 outbreak. the minerals council south africa contactless vital signs measurement system using rgbthermal image sensors and its clinical screening test on patients with seasonal influenza wearable hardware design for the internet of medical things (iomt) ab hamid sh (2020) defending against the novel coronavirus (covid-19) outbreak: how can the internet of things (iot) help to save the world? face shields for infection control: a review sanitizing tunnel/mobile disinfection chamber computer vision techniques for construction safety and health monitoring iot-q-band: a low cost internet of things based wearable band to detect and track absconding covid-19 quarantine subjects the effectiveness of respiratory protection worn by communities to protect from volcanic ash inhalation. part ii: total inward leakage tests easyband: a wearable for safety-aware mobility during pandemic outbreak coronavirus company news summary-anglo american platinum updates on production-peru mines restart-zambia sees 30% drop in mining revenue unobtrusive and automatic classification of multiple people's abnormal respiratory patterns in real time using deep neural network and depth camera abnormal respiratory patterns classifier may contribute to large-scale screening of people infected with covid-19 in an accurate and unobtrusive manner. mach learn who (2020) who coronavirus disease (covid-19) dashboard. world health organization covid-19 coronavirus pandemic. worldometers edge video analytics for public safety: a review the work presented here was conducted as part of the postdoctoral fellowship at the wits mining institute (wmi), university of the witwatersrand, johannesburg, south africa. the authors would like to thank and acknowledge the financial support provided by the sibanye-stillwater digital mining laboratory (digimine), wmi. the authors declare that they have no conflicts of interest or competing interests. key: cord-011413-yv4x8viu authors: shekar, kiran; badulak, jenelle; peek, giles; boeken, udo; dalton, heidi j.; arora, lovkesh; zakhary, bishoy; ramanathan, kollengode; starr, joanne; akkanti, bindu; antonini, m. velia; ogino, mark t.; raman, lakshmi; barret, nicholas; brodie, daniel; combes, alain; lorusso, roberto; maclaren, graeme; müller, thomas; paden, matthew; pellegrino, vincent title: extracorporeal life support organization coronavirus disease 2019 interim guidelines: a consensus document from an international group of interdisciplinary extracorporeal membrane oxygenation providers date: 2020-05-12 journal: asaio j doi: 10.1097/mat.0000000000001193 sha: doc_id: 11413 cord_uid: yv4x8viu the extracorporeal life support organization (elso) coronavirus disease 2019 (covid-19) guidelines have been developed to assist existing extracorporeal membrane oxygenation (ecmo) centers to prepare and plan provision of ecmo during the ongoing pandemic. the recommendations have been put together by a team of interdisciplinary ecmo providers from around the world. recommendations are based on available evidence, existing best practice guidelines, ethical principles, and expert opinion. this is a living document and will be regularly updated when new information becomes available. elso is not liable for the accuracy or completeness of the information in this document. these guidelines are not meant to replace sound clinical judgment or specialist consultation but rather to strengthen provision and clinical management of ecmo specifically, in the context of the covid-19 pandemic. the tulip bulbs i planted last fall are now blooming red and yellow, and the cherry trees are covered with blossoms. i am elated for mother nature's annual gift, yet i know that this season is already unlike any others. the emergence of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) and the disruption in our routines and expectations have made it spring, interrupted. still, as history teaches us during times of great challenge, we find our heroes. the frontline hospital team members and hospital support staff are performing heroically as the medical community struggles to understand and manage a new illness. despite the many variables and unknowns related to coronavirus disease 2019 (covid19) , extracorporeal membrane oxygenation (ecmo) professionals have faced the challenge of treating the most seriously ill patients with ingenuity and dedication. this guideline exemplifies the priorities of the global ecmo community to share the knowledge gained through our experiences of success and-just as importantly-failure. i am grateful to the extracorporeal life support organization (elso) covid-19 working group, a collaboration of 60 interdisciplinary ecmo providers from around the world, and the elso staff for their hard work. i also thank the reviewers for lending their time and expertise while leading the fight in some of the most severely affected parts of the world. our hearts go out to the families affected by this unprecedented pandemic. the team of experts who authored the guideline is resolute in defining "best practices" to fulfill our responsibilities to our fellow clinicians, our patients, and their families. in the months and years to come, we will be proud of our response to the call to serve. the resilience of the human spirit will prevail. spring will continue to thrill us. society will adapt and endure. mark t. ogino, md president, elso the world health organization declared the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) outbreak a pandemic on march 11, 2020. 1 patients infected with the novel virus develop coronavirus disease 2019 (covid19) leading to a significant increase in hospital and intensive care unit (icu) admissions globally. 2 a vast majority of intensive care admissions are due to hypoxaemic respiratory failure with up to 88% of patients (n = 1,591) requiring invasive mechanical ventilation in the italian cohort. 3 invasive ventilation rates of 30-71% have been reported in other settings. 4 -8 a small proportion of these patients fail maximal conventional therapies and may require extracorporeal membrane oxygenation (ecmo) support. as the pandemic has evolved, there has been a steady increase in ecmo use. 9, 10 at the time of writing this guideline, there were 858 covid-19 patients supported with ecmo. 9 ,10 (mean age 52 years, 95% vv ecmo, 5% va ecmo and other configurations). the pandemic of a novel and highly transmissible respiratory virus is placing significant stress on health care systems around the world. icus are forced to rapidly increase capacity to accommodate a large number of critically ill patients requiring organ support, most notably mechanical ventilation. in this setting, provision of ecmo may be challenging from both resource and ethical points of view. 11 the interim recommendations presented here balance the need to provide high-quality ecmo care to those who may benefit most while being cognizant of available resources and maintaining an environment of patient and staff safety (figure 1) . although there is paucity of high-quality evidence to guide ecmo practice in many areas, these recommendations are based on available evidence, [12] [13] [14] existing best practice guidelines, 15-24 experience from previous infectious disease outbreaks, [25] [26] [27] [28] [29] ethical principles, [30] [31] [32] [33] [34] [35] and consensus opinion from experts. in addition, the extracorporeal life support organization (elso) covid-19 working group members completed a survey on patient selection criteria for ecmo to build consensus. the guidelines fall into these three categories as follows: recommended: the technique/intervention is beneficial (strong recommendation) or the intervention is a best practice statement. not recommended: the technique/intervention is not beneficial or harmful. consider: the technique/intervention may be beneficial in selected patients (conditional recommendation) or exercise caution when considering this intervention. the guidelines provided here pertain to 10 key areas specific to covid-19 related cardiopulmonary failure and apply to neonatal, pediatric, and adult patient populations. we refer the readers to existing elso guidelines, 15 the elso red book, 17 published literature, 36 and reliable printed or online resources for additional information regarding the provision and practice of ecmo. the current work is a "living document" developed by the elso covid-19 working group. the group will remain active for the duration of the pandemic and during any future covid-19 outbreaks to revise the guidelines as new information and evidence become available. the most up-todate version of the guideline document and all previous iterations can be found on the elso website www.elso.org. we refer readers to published literature 36, 37 including existing guidelines 38 to assist with organization of ecmo programs outside the context of covid-19. • during the pandemic, covid-19 and non-covid19 patients should receive ecmo in established ecmo centers using available resources to maximize benefits. 11,39 • we do not recommend the commissioning of new ecmo centers for the purposes of treating covid-19 patients. • we recommend responsible ecmo use based on system capacity for ecmo. 40 when in crisis capacity (figure 2 ), health care services will be overwhelmed, making resource allocation more challenging and limiting ecmo utilization. resources are dynamic and ecmo centers may transition from conventional to crisis capacity rapidly. • centers should preferentially offer ecmo to patients in whom outcomes are favorable or ecmo runs are relatively short (e.g., meconium aspiration syndrome, near-fatal asthma, non-covid-19 myocarditis, massive pulmonary embolism, cardiotoxic medication overdose, etc.). • the international cooperation during the covid-19 pandemic has allowed for real-time communication of clinical experience, data, and outcomes in an unprecedented fashion. ecmo centers are encouraged to submit data to the elso registry to enable accurate reporting of realtime reporting of ecmo utilization during the pandemic 9 and enroll in ongoing studies such as the elso endorsed ecmo for 2019 novel coronavirus acute respiratory disease (ecmocard) study led by the asia-pacific elso 41 and the euro elso ecmo survey. 10 • elso chapters should regularly liaise with all relevant industry partners, regional distributors, and local manufacturers to maximize resources and maintain supply chains. • ecmo organization on a national level is encouraged to optimize resource utilization via coordination of government and private supply chains. centralization through existing public bodies such as the united kingdom national health service 42 and private entities such as japan's ecmo network (ecmonet) are crucial. ecmo provision based on system capacity. covid-19, coronavirus disease 2019; ecmo, extracorporeal membrane oxygenation; ecpr, extracorporeal cardiopulmonary resuscitation; icu, intensive care unit; va, venoarterial; vv, venovenous. • we recommend central coordination of ecmo services via regional networks while utilizing existing hub and spoke models of care and ecmo retrieval to service the ecmo needs of the region. 11 when individual institutions are overwhelmed or understaffed, it may be possible to enlist staff from areas with ongoing reserve. • we recommend similar selection criteria be utilized in regional networks to provide equitable care across the programs. • ecmo programs should keep a manifest of all team members who are trained to care for ecmo patients. • regular and frequent communication among ecmo directors and coordinators can help predict and prepare for ecmo needs with the possibility to centrally coordinate resources (personnel and equipment). • the ecmo director(s) should lead the team to ensure consistency in ecmo patient selection and daily patient management at an institutional level. • capacity can be increased by adapting equipment usage and staffing ratios. this will depend on the care model already in use at local hospitals. • coordination and communication between medical, nursing, and allied health staff is critical to quality ecmo outcomes. • ecmo has been mainly used for adult patients with covid-19 infection. in the event that adult ecmo programs exceed capacity, institutional, local, or regional pediatric ecmo programs can be valuable resources. • we recommend maintaining a 1:1 patient: nurse ratio when patients are on ecmo. when capacity is at conventional or contingency tier 1 levels, ecmo specialist ratio should follow institutional norms. • when capacity is at contingency tier 2 and crisis levels, transitioning to a patient: specialist 2:1 ratio with the ecmo specialist overseeing more than one circuit whilst maintaining a 1:1 bedside nursing ratio may be considered. this may be achieved by cohorting of ecmo patients where possible. • redeployment of perfusionists to bedside ecmo care and reintegration of former ecmo specialists can expand the personnel pool. • teams are encouraged to maintain a senior ecmo specialist without a patient assignment to act as a float for emergency contingency management. • simplification of the ecmo circuit may be used to increase circuit safety and reduce ecmo specialist workload in some settings. examples include omitting negative pressure side pigtails, to reduce the risk of air entrainment, or blood monitoring devices, to reduce the need for calibration samples. any such changes to standard circuitry should be communicated widely to staff. • redeployment of devices previously used in the hospital and familiar to staff can increase capacity. for instance, pumps being used as a paracorporeal ventricular assist device may also be used for ecmo when coupled with a membrane lung. the us food and drug administration has issued guidance to help expand the availability of devices (e.g., cardiopulmonary bypass devices, accessories, and components) used in ecmo therapy to address this public health emergency. 43 • fresh supplies of ecmo circuits and cannulas may be increasingly difficult to obtain. communication through elso with manufacturers may help to identify options for resupply. cardiac surgery and perfusion departments may be able to help with tubing and cannula supplies. • the shelf life of primed circuits may be extended to 60 days to conserve circuitry, provided as follows: 1) the circuit is constructed and primed using standard sterile techniques and 2) the prime is electrolyte solution-based, and no glucosecontaining solutions or albumin are used within the prime. 44 this may be more relevant to centers with smaller case volume. there is a clear indication of increased mortality with increasing age and comorbidities that should not be overlooked. 3, 8 specific considerations for patient selection will inherently be different during a pandemic due to a limited capacity to offer this resource-intensive mode of support, and thus the following should be taken into consideration. • as disease burden increases and systems move to escalating levels of surge capacity (contingency capacity tier 1 and beyond), we recommend that selection criteria become more stringent ( table 1) to use this resource for those most likely to benefit and return to an acceptable quality of life (figure 2 , refer to "ethics" section). • when decompression of an overwhelmed hospital within a region is needed, preferentially relocate suitable ecmo candidates (young, single organ failure, previously healthy) to available ecmo centers. indications for venovenous (vv) ecmo should not deviate from usual indications per elso 16 and other existing guidelines. 36 we recommend the following additional covid-19 pandemic considerations for vv ecmo: • we recommend against initiation of ecmo before maximizing traditional therapies for acute respiratory distress syndrome (ards), 45 in particular prone positioning (figure 3 ). • our understanding of ards in covid-19 is still evolving. there is considerable debate on the "atypical" nature of ards in this patient population 46,47 and on best mechanical ventilation strategy including adjuncts to be applied. although ventilation management before vv ecmo initiation may have a significant bearing on outcomes, 48 there is insufficient data to make any specific recommendations for mechanical ventilation strategies in context of covid-19 ards and as such they are beyond the scope of this work. • if mobile ecmo is unavailable, consider referring patients to ecmo centers "early," such as when partial pressure of oxygen (pao 2 ): fraction of inspired oxygen (fio 2 ) ≤ 100 mm hg. if the decision to transport is made too late, patients may be too unstable for transport. in patients with covid-19, the development of multiple direct and indirect cardiovascular complications including acute myocardial injury, myocarditis, arrhythmias, pericardial effusions, and venous thromboembolism have been reported in up to 22% of patients requiring icu care. [49] [50] [51] [52] elevation in high sensitivity troponin above the 99th percentile upper reference limit has been reported in 46% of nonsurvivors as opposed to 1% of survivors 53 and a continual rise in high sensitivity troponin has been associated with mortality. 53 covid-19 may also be associated with hypercoagulability, 54 increasing the risk of pulmonary thromboembolism. [55] [56] [57] • indications and patient selection criteria for venoarterial (va) ecmo should not deviate from per existing guidelines. 58 timely provision of va ecmo is recommended before development of multiple organ failure. • consider va ecmo in selected patients with refractory cardiogenic shock 59 (persistent tissue hypoperfusion, systolic blood pressure < 90 mm hg, cardiac index < 2.2 l/ min/m 2 , while receiving noradrenaline > 0.5 mcg/kg/min, dobutamine > 20 mcg/kg/min or equivalent). • the need for hybrid configuration such as veno-venous arterial (v-va) ecmo 60 (venous drainage with both venous and arterial returns) is relatively infrequent. it may be considered in experienced centers for patients with ards in addition to suspected acute stress/septic cardiomyopathy or massive pulmonary embolism with associated cardiogenic/obstructive shock failing medical therapies. • patients requiring va ecmo support who incidentally test positive for covid-19 but are not thought to be critically ill due to the virus should be considered for ecmo support in the usual fashion. • we recommend against provision of extracorporeal cardiopulmonary resuscitation (e-cpr) in less experienced centers or centers without an existing e-cpr program before the pandemic. e-cpr in patients with out-of-hospital cardiac arrest is not recommended when systems are experiencing surge situations (contingency capacity > tier 1). we recommend against the provision of prehospital e-cpr. • at experienced centers, e-cpr may be considered for highly selected non-covid-19 patients with in-hospital cardiac arrest depending on resource availability. however, in patients with covid-19, the potential for cross-contamination of staff and the use of personal protective equipment (ppe) by multiple practitioners when in short supply should be considered in the risk-to-benefit ratio of performing e-cpr. poor outcomes with conventional cpr have been reported in covid-19 patient population. 61 • emergency conversion from vv to va ecmo in patients who suffer cardiac arrest during cannulation for vv ecmo may increase risk to staff, is unlikely to result in a favorable outcome for the patient, and is thus not recommended. we recommend the following contraindications for ecmo in patients with cardiopulmonary failure due to covid-19 (table 1) in centers functioning under significant resource constraints, for example, contingency capacity ≥ tier 1. these recommendations are based on data available from conventionally managed critically ill covid-19 infected patients admitted to icu and existing ecmo risk prediction models derived from non-covid-19 patients. 3-8,62-64 data from covid-19 patients supported with ecmo should soon become available to further guide patient selection. • the cannulation consent process should explicitly involve discontinuation of ecmo care in the absence of recovery of lungs, heart, or both within an acceptable time frame as system capacity allows 11, 20 or if ecmo is actively harming the patient (e.g., severe bleeding or clotting). • consider performing ecmo cannulation within a designated covid-19 environment and avoid transfers to catheterization lab or operating rooms where possible. cannulation should be performed by trained cannulators. • a dedicated person should be allocated to medically manage the patient during the cannulation process. we recommend a maximum of five team members in the room/ bedspace during cannulation. cannulation team members should wear standard, contact, and airborne ppe. • awake cannulation is strongly discouraged. we recommend that the airway be secured before cannulation to avoid unplanned emergent intubations during the procedure that may pose an undue risk to staff present. appropriate use of sedation and neuromuscular blockade is recommended during cannulation. • centers should develop a checklist for cannulation and cannulation team members should ensure they take all necessary supplies with them before entering the room. we recommend preparing a cannulation covid-19 sprinter bag that contains all cannulae, guide wires, fluids, heparin, sterile sleeves for ultrasound probe, etc. • prepare a medication bag and resuscitation trolley outside the cannulation room. we recommend having a dedicated person in full ppe be stationed outside the cannulation room to bring additional supplies as needed. • placement of a mechanical chest compression device beforehand if the patient is expected to deteriorate before cannulation and offering va/v-va ecmo is considered appropriate in those circumstances. • we recommend the use of plain x-ray, vascular ultrasound, and echocardiography (transthoracic or transesophageal) or fluoroscopy over a blind cannulation. 65, 66 cannulation • we recommend 16 that large multistage, drainage cannula be used (e.g., 23 fr or greater for adults) where possible to minimize the need for insertion of an additional drainage cannula at later stage. we suggest a single stage, return cannula (19-23 fr for adults). • dual lumen cannulae should be avoided if possible as they take relatively longer time to insert, are associated with higher risk of thrombotic complications and malpositioning requiring repeat echocardiography with associated increased resource utilization and personnel exposure. • we recommend that either the femoro-femoral or femorointernal jugular configuration be used. the femoro-femoral approach allows for more rapid surgical field preparation, creates efficiency of movement around the bed, and keeps the operator away from the patient's airway. • we recommend a femoro-femoral configuration for va ecmo cannulation. a distal limb perfusion catheter is strongly recommended to reduce the risk of limb ischemia. • we suggest placement of three separate single lumen cannulae for the utilization of v-va ecmo and do not recommend the use of a double-lumen cannula for v-va ecmo. • we do not recommend the initiation of v-va ecmo as a preemptive strategy. if a patient requires vv ecmo but has no evidence of cardiac dysfunction or cardiac dysfunction is medically supportable with inotropes, placement of an arterial cannula is strongly discouraged. optimal supportive care on ecmo is critical to ensure positive outcomes. this should be guided by existing evidence and recommendations. 19 72 offer best practice guidance. ventilator dyssynchrony in setting of a high respiratory drive may lead to secondary lung injury and should be avoided. • centers should follow existing anticoagulation guidelines 73 and institutional protocols with appropriate monitoring and dose adjustments (figure 4 ). • since covid-19 patients may be associated with a hypercoagulable state, 57 consider targeting anticoagulation at the higher end of normal ecmo parameters. • caution should be exercised when using lower ecmo blood flow rates (< 2 l in adults) given the greater risk of circuit thrombosis in this patient population. • patients with a hypercoagulable status may benefit from antiplatelet agents (such as aspirin, clopidogrel, prasugrel, ticagrelor), but there is little data to recommend or refute. both thrombocytopenia as well as prothrombotic states have been reported in patients with covid-19. 57 • patients with covid-19 may have secondary hemophagocytic lymphohistiocytosis. 74 screening should be considered for this condition, and a hematology service should be consulted for appropriate therapies. • there is no evidence to guide the transfusion thresholds in patients with covid-19. • we recommend judicious use of blood products, due to anticipated blood product shortages during a pandemic. reasonable transfusion thresholds may include as follows: hemoglobin (hb) ≥ 7-8 gm/dl 75 ; platelet > 50,000 10 9 /l, and fibrinogen > 100 mg/dl. 73 if there is no clinically significant bleeding, lower platelet counts and fibrinogen concentrations may be tolerated. • routine use of antifibrinolytics is not recommended due to the risk of potential thrombosis in covid-19 patients, as there have been reports of a hypercoagulable state. • there are emerging reports of convalescent plasma transfusion 76 use in patients with covid-19. there is no current evidence for or against such plasma transfusion therapies in patients with covid-19 supported on ecmo. • we recommend early enteral nutrition (within 48 hours) commencing at low doses and advancing to target over 3-5 days. we recommend avoidance of prolonged nutrition deficit where it is anticipated the patient will recover. 77-79 • we recommend cautious use of prokinetics (metoclopramide) for delayed gastric emptying due to risk of prolonged qtc interval. • we recommend standard, contact, and airborne precautions if evaluating gastric residual volume, due to the unknown risk of exposure to sars-cov-2 via gastric secretions. • we recommend standard, contact, and airborne precautions while handling diarrheal stool or vomitus. there is a potential, but currently unknown, risk of sars-cov-2 transmission from stools or vomitus. a bowel management system may be used. • currently, there is not enough evidence to recommend for or against the use of covid-19 specific therapies (hydroxychloroquine, azithromycin, steroids, lopinavir/ ritonavir, remdesivir, or tocilizumab). decisions to utilize such therapies should be based on a case-by-case basis. 80 • there is not enough evidence to recommend routine steroids in covid-19-associated respiratory failure or ards. steroids may be used in the context of septic shock. 87, 88 role for cytokine hemadsorption devices • currently, we lack definite evidence to recommend for or against the use of extracorporeal cytokine hemadsorption devices in covid-19 patients who develop septic shock. 89 additionally, the effect of such devices on drug elimination or virus clearance is unknown. • early mobilization when safe and feasible may help improve recovery and maintain neuromuscular function. 90 however, in the setting of covid-19, early mobilization of patients during their ecmo course is unlikely to be feasible at most centers and is of unclear benefit and definite risks, which include as follows: hemodynamic instability, dislodgement of tubes/catheters, availability of resources to facilitate mobilization, and viral transmission. bedside nurses may be instructed on in-bed physical therapy maneuvers in an attempt to maintain standard of care while limiting personnel exposure and ppe use. • judicious decisions regarding the need and timing of procedures is important in covid-19 patients to avoid unnecessary staff-exposure. • we recommend bronchoscopy only if it can provide diagnostic or therapeutic benefit to the patient (with appropriate ppe required). patients can be made apneic during the procedure to minimize aerosol generation if tolerated. • percutaneous tracheostomy should be performed with caution after careful consideration of risk-to-benefit ratio in an individual patient. • based on current knowledge, existing weaning guidelines 16 • it is anticipated that most va ecmo runs in the context of covid-19 will bridge to recovery. we recommend the use of existing va ecmo weaning protocols. 58,94 • bridge to durable device or to transplant can be challenging in the setting of a pandemic. as such, we recommend that multidisciplinary teams discuss exit strategies before cannulation for va ecmo. family should be involved in the decision-making process along with ethics/palliative teams, if possible. • full ppe precautions should be observed. adequate care should be taken to prevent contact with bodily fluids. • careful assessment of bleeding and thrombotic risks is recommended before decannulation. cannulas placed by cut down should be surgically removed at the bedside, if possible. the risks of aerosol generation during electrocautery is unclear and optimal ppe should be used. • venous cannulae placed by percutaneous access can be removed at the bedside and bleeding controlled by topical pressure or sutures. smaller arterial cannulas (e.g., ≤ 15 fr) placed percutaneously may also be removed nonsurgically through close coordination with relevant surgical teams is recommended. • if adequate resources are available, centers with established mobile ecmo programs should offer ecmo transport to appropriately selected covid-19 patients. during the covid-19 pandemic, critically ill patients with cardiorespiratory failure can present at non-ecmo centers and exhaust local resources. societal recommendations include institution of ecmo or referral for ecmo in appropriately selected covid-19 patients. 11, 19 as such, programs with established mobile ecmo programs and with sufficient resources to maintain it, should continue to offer this highly specialized therapy to surrounding hospitals. commercial support for transport between sites also exists for areas where local transport is not available. • covid-19 specific criteria for ecmo cannulation should be extended for mobile ecmo candidates. ecmo application may also be considered to facilitate transport of unstable covid-19 patients being referred to external hospitals. patients with covid-19 may require transfer to other centers either for specialized procedures and consultation or due to local resource limitation and bed capacity. 11 although not immediately indicated for ecmo, if such patients are not stable for transport, ecmo deployment may facilitate safe transport. • if performed, ecmo cannulation at remote sites should be performed with full ppe. cannulation of patients at external sites carries a risk of exposure to the transport team and requires strict adherence to ppe precautions. 95 cannulation practices should follow the cannulation guidelines outlined in this document. • all transport team members, including ems personnel and driver or pilot, should have ppe training and wear ppe throughout the ecmo transport. the transport of infectious patients carries significant risk to transport personnel. accidental exposure and contamination, with subsequent quarantine, can lead to strain on already limited personnel and resources. 96 appropriate training has been shown to reduce self-contamination. 97 • minimize aerosol generating procedures (agps) during transport and consider the use of high-efficiency particulate air (hepa) filters on the expiratory limbs of mechanical ventilators. there is no evidence to support the routine use of a viral filter on the exhaust of the commonly used polymethylpentene based ecmo membrane lungs. • develop a plan to disinfect transport vehicles and to manage waste materials generated during transport in accordance with local regulations and in line with transport service providers. • intrahospital transport of covid-19 patients should be limited to vital diagnostic and therapeutic purposes and appropriate planning and protective precautions should be taken to prevent exposure to staff and other patients. • covid-19 is not a contraindication to ecmo in this patient population. • we recommend using existing indications and thresholds for consideration of ecmo as per currently published elso guidelines. 98-100 some of the covid-19 specific indications and contraindications are summarized in table 2 . • candidacy for ecmo should be preemptively made before reaching the stage of need for ecmo. this is based on the information that children with covid-19 admitted to pediatric intensive care unit (picu) are likely to have multiple comorbidities, and this may influence consideration of ecmo support. • e-cpr in pediatric covid-19 patients with severe ards is likely to have a poor prognosis, poses significant infection risks to staff due to aerosolization and is not recommended. however, ecmo centers may wish to define e-cpr candidacy for in-hospital cardiac arrest upon admission of a covid-19 positive patient to their unit. • the cannulation consent process should explicitly involve discontinuation of ecmo care in the absence of recovery of lungs, heart or both within an acceptable time frame 11, 20 or if ecmo is actively harming the patient (e.g., severe bleeding or clotting) • consent process should take into consideration the possibility that the parents/care providers may not be present for a face-to-face discussion. • the ecmo consent should involve the standard components: benefits, risks, and complications but should also refer to the current unavailability of published ecmo outcomes that would guide the length of ecmo run, particularly in the event of no lung recovery or irreversible multiple organ failure. we recommend following standard cannulation techniques. cannulation team members should wear standard, contact, and airborne ppe. • surgery (especially sternotomy and electrocautery) is an agp, and as such, the use of p2/n95 respirators (without valves) along with a smoke evacuation device and eye protection is recommended. powered air purifying respirators (paprs) are highly desirable in this setting. • surgical loupes are not a substitute for protective eyewear and may preclude the use of goggles or face shields. each program will need to determine if surgical cannulation techniques can be performed while maintaining ppe requirements. if not feasible, consideration for exclusive use of percutaneous cannulation should be discussed for patients with suspected and confirmed covid-19 infection. general supportive measures • management of ecmo in covid-19 patients is similar to standard ecmo patients. • anticoagulation guidelines as per institutional policy should be followed. higher than usual intensity of anticoagulation may be indicated. a case-by-case assessment of bleeding versus thrombotic risks is recommended pending further evidence. • the role of chest physiotherapy and bronchoscopy during ecmo should be determined on case-by-case basis. inline suction catheters are strongly recommended. • the covid-19 pandemic may result in a shortage of blood products. we recommend the development of a blood conservation plan which aligns with institutional and blood supply chain emergency/disaster blood supply guidelines. consider the following for your local plan: -restrictive transfusion thresholds, based hb concentration and physiologic metrics and biomarkers of oxygen delivery -reduced frequency of blood tests -a staged approach with phases for immediate introduction of blood conservation strategies and for when fresh product supplies are impacted. • therapeutic plasma exchange and ivig are currently not recommended for covid-19 patients unless part of a clinical trial. • use of medical therapies such as antivirals/hydroxychloroquine/azithromycin/zinc/vitamin c/steroids in pediatric patients should be individualized, based upon best available evidence at the time and is beyond the scope of this document. • refer to elso weaning guidelines 98-100 and ecmo weaning and decannulation in adult patients for covid-19 specific recommendations (refer to weaning and decannulation section). • although hospitals may be limiting or restricting visitation during the pandemic, neonatal and pediatric patients may benefit from parental presence at the bedside. we recommend one parent, with a maximum of two (depending on local institutional guidelines), be allowed to be present at the bedside. use of videoconferencing to connect with family members or support systems (religious personnel, etc.) may be beneficial. • resource availability and lack of improvement over time may necessitate reassessment of treatment goals and redirection of care. • parents and family members should be made aware of this plan during the consent process. • during a pandemic, pediatric hospitals associated with adult hospitals should reserve ecmo equipment for potential non-covid-19 neonatal and pediatric ecmo use, taking into special consideration, those diagnoses with historically excellent outcomes when supported with ecmo including but not limited to meconium aspiration syndrome and postcardiotomy support for lesions with good outcomes. for example, anomalous left coronary artery from the pulmonary artery (alcapa). the modes of transmission of sars-cov-2 are primarily through the respiratory tract and mucous membranes. there is a potential, but currently unknown, risk of sars-cov-2 transmission from stools or vomitus. all high-risk procedures on ecmo should be performed by experienced staff. key infection control and staff safety measures relevant to ecmo use in covid-19 infected patients are summarized in tables 3 and 4 . optimal ppe recommendations are subject to change as more data becomes available. patient selection and timing of discontinuation of ecmo support pose significant ethical and moral challenges in regular ecmo care, but especially so during a pandemic. 30, 31, 104 ecmo centers should develop predetermined "consensus criteria" encompassing all aspects of ecmo care in covid-19 patients. in addition, communication with local and regional ecmo and non-ecmo programs would be advantageous in caring for potential covid-19 patients that would benefit from ecmo support. reassessment of patient selection criteria and care should be continually assessed through the pandemic and may change as capacity status changes and more is learned about the disease. 35 • ecmo should only be considered in carefully selected covid-19 patients. (refer to patient selection section). ecmo should not be considered in patients who are unlikely to benefit and in those with significantly reduced life expectancy from preexisting disease. 32,33 • ecmo is a highly technical therapy and is resource intensive. although the distribution of this therapy should be as equitable as possible, during a pandemic such as covid-19, distribution should focus on optimal candidates for recovery. • we recommend involvement of supportive and palliative care teams, 34 before cannulation and throughout the ecmo course, in situations where centers are running at contingency or crisis capacity. virtual meetings with use of videoconferencing tools to limit need for exposure to covid-19 may be beneficial. • futility is a decision made at the bedside by the treatment team on a case-by-case basis. definitions of futility may change as we learn more about the trajectory of disease and recovery profiles in patients supported with ecmo. • ecmo should be discontinued if poor quality of survival is highly likely (severe neurologic insult, no heart or lung recovery with no possibility of a durable device implantation or transplant). • progressive multiple organ failure despite timely and optimal cardiopulmonary support indicates a poor prognosis, and we recommend that goals of care be reassessed and ecmo discontinued after discussion with family. • quality assurance and clinical governance frameworks must be maintained with ecmo quality reviews conducted frequently to measure overall outcomes, identify problems, and formulate plans for corrective actions. • we recommend that elso develop validated quality and process metrics specific to ecmo use during pandemics. • collection and sharing of data is important to ensure preparedness and patient care, especially in parts of the world yet to be affected. • the elso registry should continue to serve as useful resource during a pandemic and provide valuable real-time data to track global ecmo activity and to provide preliminary guidance on patient selection and outcomes. elso member centers are encouraged to enter minimum data prospectively at the initiation of the ecmo so that valuable real-time 9 preliminary guidance may be obtained from the elso registry. • centers that are providing ecmo and are not elso members are encouraged to join elso and enter covid-19 cases into the registry. membership fee is waived during this pandemic. • understandably, ecmo centers are likely to face an increase in research participation requests during the pandemic. we recommend that elso and global ecmo research networks such as the international ecmo network 105 develop a system of expedited endorsement of clinical studies during the pandemic. this is important to ensure that ecmo centers prioritize participation in global data collection, clinical trials, elso registry-based studies or other clinical studies that are most likely to yield meaningful results to guide ecmo practice. • we recommend ecmo centers participate in the elso and the ecmonet endorsed ecmocard study coordinated by the asia-pacific elso 41 and the euroelso ecmo survey. 10 • we recommend that elso develop a pandemic research plan with ready-to-go research proposals and preapproved ethics in place so that evidence-based guidance is generated in the quickest possible time to benefit most patients. adhere to local or institutional policies on ppe use for covid-19 patients ecmo initiation, and decannulation and bedside care should be performed with appropriate airborne plus contact precaution ppe including n95/ffp2 mask, gown, cap, eye protection (e.g., goggles or visor) ecmo initiation, decannulation, and all agps be performed with ppe and n95 masks or papr with full contact precautions although caring for covid-19 ecmo patients wear appropriate ppe including n95/ffp2 masks, gowns, cap, eye protectors (e.g., goggles, visor) and follow contact precautions for procedures in which splashing or aerosol generation is anticipated, a higher level of protection (e.g., gown at aami level 3 or equivalent) should be considered 18 labor-intensive procedures (e.g., mobilization, prone positioning, transport) carry significant risk of infection control breach to staff. we recommend that careful planning and team briefing be conducted beforehand while keeping the number of staff performing the procedure to the minimum simulation training on management of ecmo emergencies (e.g., cardiac arrest, pump failure) while wearing ppe or papr, since infection control breaches are more likely to occur in a stressful environment, should be scheduled. additionally, performing procedures in full ppe should also be considered in the event of ppe shortage 103 adhere to the local hospital policies use papr after appropriate training extending the use of n95/ffp2 masks could also be considered aami, association for the advancement of medical instrumentation; agp, aerosol generating procedure; covid-19, coronavirus disease 2019; ecmo, extracorporeal membrane oxygenation; ffp2, filtering facepiece 2; papr, powered air purifying respirators; ppe, personal protective equipment. adult intensive care services, the prince charles hospital jayesh dhanani (royal brisbane and women's hospital cincinnati children's papa giovanni xxiii hospital queensland children's hospital shands hospital for children great ormond street hospital for children nhs foundation trust cleveland clinic children's george's nhs foundation trusts brigham and women's hospital billings clinic hospital adult intensive care services, the prince charles hospital shekar raj (driscoll children's hospital fuwai hospital chinese association of medical science, beijing, people's republic of china) available at: www.who.int/dg/speeches/detail/who-directorgeneral-s-opening-remarks-at-the-media-briefing-on-covid critical care utilization for the covid-19 outbreak in lombardy, italy: early experience and forecast during an emergency response baseline characteristics and outcomes of 1591 patients infected with sars-cov-2 admitted to icus of the lombardy region characteristics and outcomes of 21 critically ill patients with covid-19 in washington state clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective, observational study clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china. jama 2020 clinical features of patients infected with 2019 novel coronavirus in wuhan available at: www.elso.org/registry/fullcovid19registry dashboard.aspx planning and provision of ecmo services for severe ards during the covid-19 pandemic and other outbreaks of emerging infectious diseases extracorporeal membrane oxygenation for severe acute respiratory distress syndrome extracorporeal membrane oxygenation for severe acute respiratory distress syndrome and posterior probability of mortality benefit in a post hoc bayesian analysis of a randomized clinical trial venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and metaanalysis available at: www.elso.org/portals/0/elso%20guidelines%20 for%20adult%20respiratory%20failure%201_4 surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (covid-19) initial elso guidance document: ecmo for covid-19 patients with severe cardiopulmonary failure 2_-guidance-for-cardiothoracic-transplant-and-vad-centers joint society of critical care medicine-extracorporeal life support organization task force position paper on the role of the intensivist in the initiation and management of extracorporeal membrane oxygenation extracorporeal membrane oxygenation (ecmo) in patients with h1n1 influenza infection: a systematic review and meta-analysis including 8 studies and 266 patients receiving ecmo extracorporeal membrane oxygenation in severe influenza infection with respiratory failure: a systematic review and meta-analysis extracorporeal membrane oxygenation for severe middle east respiratory syndrome coronavirus extracorporeal membrane oxygenation in severe ards secondary to middle east respiratory syndrome coronavirus university of pittsburgh medical center pandemic influenza task force's triage review board: ethics of triage in the event of an influenza pandemic task force for mass critical care; task force for mass critical care: triage: care of the critically ill and injured during pandemics and disasters: chest consensus statement international ecmo network (ecmonet): practice patterns and ethical considerations in the management of venovenous extracorporeal membrane oxygenation patients: an international survey ethical dilemmas encountered with the use of extracorporeal membrane oxygenation in adults understanding ethical decisions for patients on extracorporeal life support the round table conference: treatment limitations in the era of ecmo international ecmo network (ecmonet): position paper for the organization of extracorporeal membrane oxygenation programs for acute respiratory failure in adult patients international ecmo network (ecmonet) and the extracorporeal life support organization (elso): position paper for the organization of ecmo programs for cardiac failure in adults preparing for the most critically ill patients with covid-19: the potential role of extracorporeal membrane oxygenation refining surge capacity: conventional, contingency, and crisis capacity available at: www.england.nhs.uk/publication/extra-corporealmembrane-oxygenation-for-respiratory-failure-in-adults available at: www.fda.gov/regulatory-information/search-fdaguidance-documents/enforcement-policy-extracorporealmembrane-oxygenation-and-cardiopulmonary-bypass-devicesduring-the-coronavirus-disease-2019-(covid-19)-public-health-emergency extracorporeal life support for adults with respiratory failure and related indications: a review covid-19 does not lead to a "typical" acute respiratory distress syndrome mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome. an international multicenter prospective cohort coronavirus disease 2019 (covid-19) and cardiovascular disease the variety of cardiovascular presentations of covid-19. circulation cardiovascular considerations for patients, health care workers, and health systems during the covid-19 pandemic myocardial localization of coronavirus in covid-19 cardiogenic shock clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study coagulopathy and antiphospholipid antibodies in patients with covid-19 covid-19 complicated by acute pulmonary embolism acute pulmonary embolism and covid-19 pneumonia: a random association? incidence of thrombotic complications in critically ill icu patients with covid-19 management of refractory cardiogenic shock the elso maastricht treaty for ecls nomenclature: abbreviations for cannulation configuration in extracorporeal life support -a position paper of the extracorporeal life support organization in-hospital cardiac arrest outcomes among patients with covid-19 pneumonia in wuhan predicting survival after extracorporeal membrane oxygenation for severe acute respiratory failure. the respiratory extracorporeal membrane oxygenation survival prediction (resp) score predicting survival after ecmo for refractory cardiogenic shock: the survival after venoarterial-ecmo (save)-score the preserve mortality risk score and analysis of long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome available at: www.elso.org/portals/0/files/elso_ultrasoundguidance_ vvecmo_guidelines_may2015 the role of echocardiography in the management of patients supported by extracorporeal membrane oxygenation asian critical care clinical trials group: intensive care management of coronavirus disease 2019 (covid-19): challenges and recommendations preparing for covid-19: early experience from an intensive care unit in singapore critical care management of adults with community-acquired severe respiratory viral infection ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome mechanical ventilation for acute respiratory distress syndrome during extracorporeal life support. research and practice cesar trial collaboration: efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (cesar): a multicentre randomised controlled trial uk: covid-19: consider cytokine storm syndromes and immunosuppression blood conservation in extracorporeal membrane oxygenation for acute respiratory distress syndrome effectiveness of convalescent plasma therapy in severe covid-19 patients nutrition therapy in critical illness: a review of the literature for clinicians available at: www.nutritioncare.org/uploadedfiles/documents/ guidelines_and_clinical_resources/nutrition%20therapy %20covid-19_sccm-aspen.pdf hydroxychloroquine and azithromycin as a treatment of covid-19: results of an openlabel non-randomized clinical trial a trial of lopinavir-ritonavir in adults hospitalized with severe covid-19 using pk/pd to optimize antibiotic dosing for critically ill patients antimicrobial pharmacokinetic and pharmacodynamic issues in the critically ill with severe sepsis and septic shock pharmacokinetic changes in patients receiving extracorporeal membrane oxygenation sequestration of drugs in the circuit may lead to therapeutic failure during extracorporeal membrane oxygenation protein-bound drugs are prone to sequestration in the extracorporeal membrane oxygenation circuit: results from an ex vivo study risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in wuhan, china saudi critical care trial group: corticosteroid therapy for critically ill patients with middle east respiratory syndrome extracorporeal membrane oxygenation and cytokine adsorption early mobilization of patients receiving extracorporeal membrane oxygenation: a retrospective cohort study cannula and circuit management in peripheral extracorporeal membrane oxygenation: an international survey of 45 countries how i wean patients from veno-venous extra-corporeal membrane oxygenation weaning from veno-venous extracorporeal membrane oxygenation: how i do it predictors of successful extracorporeal membrane oxygenation (ecmo) weaning after assistance for refractory cardiogenic shock safe patient transport for covid-19 incidence of complications in intrahospital transport of critically ill patients-experience in an austrian university hospital improving the use of personal protective equipment: applying lessons learned available at: www.elso.org/portals/0/elsoguidelinesneonatal respiratoryfailurev1_4_1 initiation of a new infection control system for the covid-19 outbreak available at: unesdoc.unesco.org/ark:/48223/pf0000373115 available at: internationalecmonetwork.org we would like to thank dr. robert bartlett and dr. michael mcmullen from the executive committee for their invaluable comments for the guideline. our immense gratitude goes to the extracorporeal life support organization (elso) staff elaine cooley, peter rycus, and christine stead, who have worked tirelessly through these trying times to help get the guideline published on time. key: cord-256112-zg63v8hh authors: rowan, neil j.; laffey, john g. title: challenges and solutions for addressing critical shortage of supply chain for personal and protective equipment (ppe) arising from coronavirus disease (covid19) pandemic – case study from the republic of ireland date: 2020-07-10 journal: sci total environ doi: 10.1016/j.scitotenv.2020.138532 sha: doc_id: 256112 cord_uid: zg63v8hh coronavirus (covid-19) is highly infectious agent that causes fatal respiratory illnesses, which is of great global public health concern. currently, there is no effective vaccine for tackling this covid19 pandemic where disease countermeasures rely upon preventing or slowing person-to-person transmission. specifically, there is increasing efforts to prevent or reduce transmission to front-line healthcare workers (hcw). however, there is growing international concern regarding the shortage in supply chain of critical one-time-use personal and protective equipment (ppe). ppe are heat sensitive and are not, by their manufacturer's design, intended for reprocessing. most conventional sterilization technologies used in hospitals, or in terminal medical device sterilization providers, cannot effectively reprocess ppe due to the nature and severity of sterilization modalities. contingency planning for ppe stock shortage is important. solutions in the republic of ireland include use of smart communication channels to improve supply chain, bespoke production of ppe to meets gaps, along with least preferred option, use of sterilization or high-level disinfection for ppe reprocessing. reprocessing ppe must consider material composition, functionality post treatment, along with appropriate disinfection. following original manufacturer of ppe and regulatory guidance is important. technologies deployed in the us, and for deployment in the republic of ireland, are eco-friendly, namely vaporised hydrogen peroxide (vh2o2), such as for filtering facepiece respirators and uv irradiation and high-level liquid disinfection (actichlor+) is also been pursed in ireland. safeguarding supply chain of ppe will sustain vital healthcare provision and will help reduce mortality. • there is pressing need to find solutions for reprocessing of ppe for covid19 • reprocessing of ppe is challenging as made for one-time-use • most sterilization technologies are not suitable for ppe reprocessing • use of vaporised hydrogen peroxide and uv irradiation may prove effective for ppe a b s t r a c t a r t i c l e i n f o coronaviruses (covs) (order nidovirales, family coronaviridae, subfamily coronavirinae) are enveloped viruses with a positive sense, single-stranded rna genome (schoeman and fielding, 2019) . with genome sizes ranging from 26 to 32 kilobases (kb) in length, covs have the largest genomes for rna viruses. coronavirus is one of the major pathogens that primarily targets the human respiratory system (rothan and byrareddy, 2020) . previous outbreaks of coronaviruses (covs) include the severe acute respiratory syndrome (sars)-cov and the middle east respiratory syndrome (mers)-cov that are a great public health threat (carty and dinicolantonio, 2020) . a global pandemic status has been recently declared by the world health organization (who) for covid19. the first number of cases were identified in wuhan, a large city of 11 million people in central china in december 2019, which were linked to the huanan (southern china) seafood wholesale market (rothan and byrareddy, 2020) . these were identified by local hospitals using a surveillance mechanism for "pneumonia of unknown etiology", which was established in the wake of the 2003 severe acute respiratory syndrome (sars) outbreak with the aim of allowing timely identification of novel pathogens such as 2019-ncov (li et al., 2020) . globally, the number of confirmed cases as of this writing (3 april 2020) has reached 1,000,249 including 51,515 deaths (https://www.ecdc.europa.eu/en/geographical-distribution-2019ncov-cases) (fig. 1 ). covid19 is now globally distributed (fig. 2) , suggesting that universal solutions are required to prevent or slowdown its rapid spread until effective control measures are developed and deployed, such as vaccine (fig. 3) . covid19 is much more lethal than the typical flu, where former has a mortality rate of about 2.92% (carty and dinicolantonio, 2020) . the annual flu has a mortality rate of just 0.05 to 0.1%, inferring that covid-19 is around 30 to 60 times more lethal (carty and dinicolantonio, 2020) . covid19 causes an inflammatory storm in the lungs and it is this inflammatory storm that leads to acute respiratory distress, organ failure, and death. swaminathan et al. (2007) previously considered that while a new influenza pandemic may appear inevitable, critical parameters of transmissibility and attack rate are uncertain. these authors reported that estimates based on extrapolations from the 3 influenza pandemics of the 20th century suggest that healthcare facilities in the united states alone may be required to cope with 314,000-734,000 additional hospitalizations and 18-42 million outpatient visits (meltzer et al., 1999) . during the early containment phase of a pandemic, patients with suspected infection are likely to be referred to hospitals for isolation, diagnosis, and treatment until the transmissibility and virulence of the pandemic strain are known. although social distancing and school closures may reduce risk in the wider community, healthcare workers (hcws) are likely to encounter repeated close exposures. swaminathan et al. (2007) suggested that if hospitals are to continue to function adequately, reliable access to effective personal protective equipment (ppe; gowns, n95 masks, gloves, and eye protection) and antiviral drug therapy will be necessary for an unpredictable period. with awareness of the recent severe acute respiratory syndrome (sars) outbreak and with growing concern about human deaths from avian influenza (h5n1), governments worldwide have begun to stockpile ppe and antiviral medication. key strategies to control the speed and extent of viral spread within healthcare settings have been advocated by national government guidelines and the who (swaminathan et al. (2007) . these include rigorous infection control practices, prescriptive instructions for the use of ppe, and dissemination of antiviral medication. these authors reported that information regarding the required quantity and rate of use of these valuable resources in an outbreak situation is lacking, thereby limiting valid assessments of the adequacy of current stockpiles. this was corroborated by a previous simulation study conducted by mitchell et al. (2012) , where a patient with suspected avian or pandemic influenza (api) sought treatment at 9 australian hospital emergency departments where patient-staff interactions during the first 6 h of hospitalization were observed. based on world health organization definitions and guidelines, the mean number of "close contacts" of the patient was 12.3 (range 6-17; 85% hcws); mean "exposures" were 19.3 (range 15-26). overall, 20-25 ppe sets were required per patient, with variable hcw compliance for wearing these items (93% n95 masks, 77% gowns, 83% gloves, and 73% eye protection). these data indicate that many current national stockpiles of ppe and antiviral medication are likely inadequate for a pandemic. at this time of writing, in the republic of ireland, there is a national lockdown imposed by the irish government where citizens are requested to remain at home to prevent the spread of covid-19 infection. where new positive covid19 cases arise, the role of contact tracing and data analytics are important. social distancing and cocooning of the elderly and vulnerable groups has been adapted. only essential services, such as agriculture and fisheries, manufacturing and healthcare, have been granted permission to travel. there is a concerted effort to slow the rate of infection so as align with capacity of healthcare to meet fig. 1 . distribution of covid19 worldwide, as of 3 april, 2020. (source https://www.ecdc.europa.eu/en/geographical-distribution-2019-ncov-cases) number of cases, thus avoiding a mismatch in early peak in infections (fig. 3) . given need for react quickly, solutions (where appropriate) are based upon adaptation, blending and re-purposing of existing products, processes, technologies and infrastructures. solutions and challenges to address shortage of ppe in a regional irish hospital are described. use of smart software and networking with various distribution channels to meet shortfall in ppe and infection prevention and control (ipc) methods. a new team of experts was formed (designated rea-ppe) to deploy effective solutions in a short time frame, which included those from across academia, healthcare, enterprise ireland-funded technology gateways, science-foundation-ireland (sfi)-funded research centres (curam for medical device, command for software) and industry. rea_ppe team also links with the crisis management team in the regional hospital where solutions is to implemented by manager of the hospital sterile services department (hssd). this rea_ppe team comprises experts representative of anaesthesia and intensive care, medical device technology, infection control, hospital disinfection and sterilization, minimal processing; microbiology, toxicology, virology, material science, software engineering, and social marketing priority initially focused on delineating effective communication channels in order to inform stocks within healthcare from several routes that include use of dedicated webpage [https: //covidmedsupply.org/] established by researchers from nui galway and university of limerick (ireland) that collects donations of ppe from regional industries and academic institutions. given volatility in the global supply chain for ppe, ireland's health service executive (hse) actively purse ppe orders from china and other sources to meet specific requirements that are quality checked on arrival. upon arrival, ppe are distributed to primary healthcare, stepback healthcare facilities or nursing homes. hcw arededicated to one site to avoid risk of cross-infection. aer lingus (ireland's main national airline), made no-stop flights with a team of volunteer rotating pilots to china in order to collect vital ppe stock, where this process was repeated several times in the same week. covid19 pandemic caused uncertainty to the established norm that is addressed by teamwork, learning, adaptation and adjustment. stock usage will also be tracked through a new ppe mobile phone app that uses (1) backend database to save all information on ppe stock and distribution running on a cloud, such as aws, (2) webserver as a gateway between the mobile app and the database, such as aws, and (3) two functions for updating the database with latest ppe status along with querying the same database. provision has been made for use of smart blockchain system to replace the database, if the system becomes too complicated for mobile phone usage, such as data immutability, where possible, where there was identified shortages in ppe, bespoke production occurred to make these items using medical grade materials, such as continuous positive airway pressure (cpap) helmets for use in intensive care. cpap provides the maximal amount of mean airway pressure without intubation and promotes a more lungprotective ventilation pattern. various other bespoke manufacturing initiatives have commenced in ireland linked to international collaborators that included use of crowdfunding by group of researchers and scientists who raised €134,000 in order to develop an easy-to-build and inexpensive ventilator for covid-19 patients with first prototype now in place (https://www.thejournal.ie/emergency-ventilators-irishresearchers-crowdfund-5061521-mar2020/). other irish researchers in university college dublin and it sligo made easy-to-assemble ventilators using 3d printers and off-the-shelf components that will be validated by ireland's hse (https://www.irishtimes.com/business/ health-pharma/irish-project-for-easy-to-assemble-covid-19-ventilatorsbears-fruit-1.4205999). facial visors were also made using 3-d printers for use in regional hospitals and nursing homes. at the time of writing, it is uncertain as to what if not all bespoke manufactured ppe in ireland that will be inspected by hse before deployment and usage by frontline healthcare workers. the trend by many medical device manufacturers and academic institutions to redeploy expertise and resources to make ppe to address covid19 crisis is also emerging in other international countries (https://www.cam.ac.uk/business-and-enterprise/help-ustackle-covid-19). at this time of writing, there is a dearth in published literature on efficacy of innovations for reprocessing ppe. this is due to fact that ppe are manufactured for single use. threfore, there is reliance on information generated by medical device manufacturers and related sterilization industries to help understand how best to address this shortage of ppe and the need for reprocessing in a pandemic. traditionally, limited knowledge sharing occurs in the medical technology sector due to the need to protect ipr, which is is understandable given nature of commerce and competitiveness. however, there is an increasing trend by leading industries to publish findings that also assists in shaping iso standards, guidelines and regulations with a focus on future-proofing, greater resource utilization and sustainability (mcevoy and rowan, 2019; chen et al., 2019) . original equipment manufacturers (oems) of one-time-use ppe have recently provided new information on possible methods for reprocessing these items given the universal need to consider contingency plans arising from shortages during this pandemic (such as 3m science of life, 2020). ppe used in healthcare includes gloves, aprons, long sleeved gowns, goggles, fluid-repellent surgical masks, eye, nose and mouth protection, face visors and respirator masks. healthcare workers should wear protective clothing when there is a risk of contact with blood, body fluids, secretions and excretions. hcw should select the appropriate ppe based on a risk assessment of the task to be carried out (table 1) . there is particular focus airborne droplets (splatter) liberated through breathing or expelled through sneezing of infected covid19 patients may travel several meters and remain suspended for ca 30 min and survive on surfaces for potentially several days. surface, or contact surface, disinfection or sterilization of ppe will suffice, as coronavirus does not penetrate materials. however, greatest challenge to reprocessing on one-time-use ppe relates to ensuring material functionality post effective treatments. if one considers medical equipment designed for pre-processing, such as endoscope, there is pre-cleaning stage to reduce bioburden in advance of sterilization processes to ensure efficacy. this is relevant as unlike therapeutics (such as vaccines and antibiotics) that rely on a specific mechanistic target for model of action, sterilization modalities are non-specific with reliance upon ensuring that processes run full cycles for achieving sterility assurance level (sal) of products (mcevoy and rowan, 2019). for example, the presence of organic matter may affect the oxidative nature of the gas sterilization process, vaporised hydrogen peroxide (vh2o2). pre-cleaning presents an issue in hospitals as there is commensurate need to decontaminate equipment used in this process for covid19. onsideration was given to use of actichlor plus as a wash/disinfection phase. to prevent the spread of health-care-associated infections, all heat-sensitive endoscopes (e.g., gastrointestinal endoscopes, bronchoscopes, nasopharygoscopes) must be properly cleaned and, at a minimum, subjected to high-level disinfection after each use. high-level disinfection can be expected to destroy all microorganisms, although when high numbers of bacterial spores are present, a few spores might survive (cdc, 2008) . the medical device industry replies upon significant lethality of predetermined populations of a biological indicator (bi) that is typically a recalcitrant bacterial endospore (such as geobacillus stearothermophilus or bacillus atrophaeus). these bis are carefully selected for this purpose as they are more resistant to that of pathogenic microorganisms including covid19, which are typically orders of magnitude more sensitive to same applied lethal stress (fig. 4) . these are a highly validated and controlled sterilization processes. however, sal for these sterilization are endpoint-determination processes that rely upon 12 log reduction in bis that is excessive duration of treatment for reprocessing single-use ppe (fig. 5 ) (mcevoy and rowan, 2019) . there has been no reported cases of patient illness arising from a terminal sterilization of medical devices. furthermore, sterilization technologies are validated for full treatment regimes. there is an absence of publish knowledge as to the efficacy of operating same sterilization modalities under reduced exposure or cycle conditions, such as for the treatment of ppe. therefore, use of penetration technologies such as gamma, electron-beam and x-ray will not be appropriate as likely to affect material and functionality of ppe post treatments. gas-plasma generated hydrogen peroxide vapour will also be unsuitable as the plasma-process affects materials during treatment. steris ast have commenced studies on the combined use of real-time flow cytometry with conventional culture-based enumeration methods that will elucidate this gap, which includes frontier microbial inactivation kinetic modelling. kinetic modelling is important for informing changes in technologies, even for potential disruption potential in emerging innovations, such as in adjacent food industry . this pandemic situation will also present emerging minimal treatment opportunities for materials and treatments in medtech and sterilization industries, which will require greater flexibility in approach, such as for in situ 3d printing of medical devices in healthcare. future reduction in sterilization modality usage would also improve resource utilization and facilitate greater sustainability of the industries. this would also have significant knock-on influence for treated products, with quicker turn-around supply time to clients. however, it is essential that future reductions in sterilization processes are informed by best evidence and do not compromise on product safety, which require validation and regulatory approval before usage. it is appreciated that under pandemic situations, there is a need to do things differently, along with urgency. however, this must be measured, appropriate and best informed by critical information such as that supplied by original manufacturers of single-use devices (such as 3m announcement, 2020), along with international standards and regulators, such as aami and the fda. there is a gap in knowledge on extensive studies relating to reprocessing by this source too. 3m™ stated that "filtering facepiece respirators (ffrs), such as n95, ffp2, kn95, and similar are commonly used to help provide respiratory protection in a variety of workplaces, including healthcare settings. 3m™ reiterated that a common infection prevention practice employed by healthcare organizations is to utilize ffrs as one-time-use items when worn in the presence of infected patients. in the face of a global pandemic, associated ffr shortage, and based on currently available data, 3m™ does not recommend or support attempts to sanitize, disinfect, or sterilize 3m™ ffrs" (3m announcement, 2020). 3m™ reiterated the importance that such reprocessing methods do not compromise the respirator's filtration performance or the ability of the respirator to seal to the wearer's face as intended. albeit conducting additional research, 3m did not recommend or support any specific ffr disinfection method at this time (3m science of life, 2020). however, 3m™ noted that the u.s. centers for disease control and prevention (cdc) has published guidance on managing respirators during pandemics including the reuse and extended use of respirators at: https://www.cdc.gov/ niosh/topics/hcwcontrols/recommendedguidanceextuse.html what potential options are available for reprocessing of ppe to address shortage of supply chain arising from this coronavirus disease (covid19) pandemic? the contingency approach to be adapted by rea_ppe team in ireland will make provision for the deployment of vaporised hydrogen peroxide, such as for ffrs, on site at or near the hospital. this approach is to align with columbus-based battelle process, where it has been reported that up to10,000 n95 masks will be sterilized by vh2o2 in the united states, which has been authorised by the food and drug administration (fda, 2020a; fda, 2020b). final report for the bioquell hydrogen peroxide vapour decontamination for reuse of n95 respirators is available at fda (2020a). the fda (2020b) also released details on enforcement policy for face-masks and respirators during the coronavirus disease (covid19) public health emergency (revised april 2020)guidelines for industry and food and drug administration staff. these are important documents to inform reprocessing of ppe. this battelle approach involves filling a room or enclosed environment (up to 200m 3 ) with vh2o2 for the treatment of ppe. vh2o2 is an emerging technology for the medical device sterilization industry where its application, opportunities and discussed limitations by mcevoy and rowan (2019). vh2o2 technology is operative in united states now at steris ast. however, there is also a pressing need for rapid turn-around for reprocessed ppe on site in the hospitals, such as for critical support in icu. vhp has potentially additional benefits over use of eto (which currently sterilizes ca. 50% of medical devices globally) as it is safer and environmentally acceptable from a future sustainability perspective. use of gamma irradiation and eto constitutes ca. 95% of the terminal sterilization market (mcevoy and rowan, 2019). vh2o2 has great promise, but exhibits limitations such as against cellulose-based medical materials whereas eto has broad material compatability (mcevoy and rowan, 2019) . there is still uncertainty as to ensuring safe distribution of contaminated ppe for external contract vh2o2 sterilization services for treatment that negates reprocessing of ppe at plant level. the rappe team have placed an order for bq50 hpv system, similar to what is been deployed in the us. strict procurement rules on purchasing of assets over €25 k were relaxed to enable rapid uptake of technologies during this pandemic. recent studies supports that rna viruses, including coronavirus, are highly susceptible to hydrogen peroxide exposure where significant lethality is achieved with 0.5% hydrogen peroxide (a fraction to what is used in standard contact lens disinfection) in b1 min on glass. studies recently reported from china have also revealed that introducing hydrogen peroxide inhalation may improve covid19 patient outcomes (http://www.adledlight.com/news_show34.html). reappe contingency plan also includes provision for deploying uv-c at 254 nm (nanoclave cabinet, ireland) and broad-spectrum pulsed light (claranor, france) technologies for high-level disinfection of ppe. uv-c technology is a very effective technology for disinfection and used extensively by adjacent food and water industries. given that coronavirus (cov) and other respiratory viruses are significantly less resistant to that of bis used in sterilization modalities, the use of high to moderate-level disinfection is conceivable sufficient to meet needs for reprocessing of ppe (fig. 3) . these are also turnkey commercial technologies for ease of operation and integration within hospitals that also considers usage by existing decontamination staff and by the manager of hssd. efficacy of uv-irradiation technology is governed by the applied uv dose or fluence (w/m 2 ) and is affected by shading where it only inactivates what it irradiatesthus, ppe will need to be turned during treatments (rowan, 2019) . nanoclave chamber has 32 × 30 w and 16 × 25 w sylvania uvgi lamps that delivers a uv-c dose of 52 w/m 2 for 60s. nanoclave cabinet was shown to disinfect 3-log viral unit of adenovirus in 3 min at fixed wavelength of 254 nn that targets vital genetic material, such as rna (moore et al., 2012) . high intensity, pulsed uv technology (puv) uses broad spectrum pulsed light that is delivered at ca. 50,000 times the intensity of sunlight at contact surface where treatment time is exceptionally short duration, mere seconds (farrell et al., 2011; barrett et al., 2016) . previous researchers have demonstrated efficacy for extensive range of pathogens, but puv also affected by shading rowan, 2019) . puv is currently been used for high-throughput food packaging disinfection commercially (rowan, 2019) . puv has also been shown to be more effective and environmentally-friendly as a surface disinfection system compared with other minimal processing technologies tested, such as pulsedplasma gas-discharge that produced short-lived oxidising biocidal water (hayes et al., 2013; garvey et al., 2015) . there has been limited studies on use of uv-disinfection technology for ppe treatment. 3m™ recently referred to a previously published study by bergman et al. (2010) where these authors evaluated a multiple (3-cycle) decontamination processing for filtering facepiece respirators (ffrs) (3m science of life, 2020). the uv-germincidal-irradiation (uvgi) method described was operated for 30 min at 254 nm (15-min per side) for 3m™ 1860 and 1870 ffrs where straps on 1870 lost elasticity with a strong burning odour, and the nosefoam compressed on 1860 ffr model. this study did not assess the efficiency of disinfection method to inactivate microorganisms where it would be relevant to report on uv dose over treatment regime. prolonged and excessive exposure using low-pressure uv light source can produce significant thermal effects along with material damage over repeated use. bergman et al. (2010) also reported on the use various other unknown ffr makes and models and reported no observable physical change using same (1) uvgi for 15 min at 254 nm using one side of ffr facing lamp with strap removed, (2) ethylene oxide for 1 h in 100% eto sterilizer, and (3) vhp treatment for 15 min dewell, 125 min total cycle at 8 g/m 3 concentration. however, it is also unclear as to what specific ffr models were used and functionality post treatments. fisher and shaffer (2011) reported on the development of a method to assess modelspecific parameters for ultraviolet-c (uv-c, 254 nm) decontamination of filtering facepiece respirators (ffrs). uv-c transmittance was quantified for the distinct composite layers of six n95 ffr models and used to calculate model-specific α-values, the percentage of the surface uv-c irradiance available for the internal filtering medium (ifm). circular coupons, excised from the ffrs, were exposed to aerosolized particles containing ms2 coliphage and treated with ifm-specific uv-c doses ranging from 38 to 4707 j/m 2 . models exposed to a minimum ifm dose of 1000 j/m 2 demonstrated at least a 3 log reduction in viable ms2. model-specific exposure times to achieve this ifm dose ranged from 2 to 266 min. overall, fisher and shaffer (2011) found uv-c transmits into and through ffr materials. log reduction of ms2 was a function of model-specific ifm uv-c doses. the supply of national institute for occupational safety and health (niosh)-certified n95 filtering facepiece respirators (ffrs) may become limited during an influenza pandemic [institute of medicine (u.s.) committee on the development of reusable facemasks for use during an influenza (cited in fisher and shaffer, 2011) . extending the lifetime of ffrs for multiple uses (e.g. multiple donnings) may help to alleviate the supply demand (viscusi et al., 2007 (viscusi et al., , 2009a (viscusi et al., , 2009b . fisher and shaffer (2011) also advocated that an option that may permit ffr reuse is the decontamination or removal of the infectious material from the ffr through one or more physical or chemical treatments. for this option to be practical, the decontamination treatment must maintain ffr fit and filtration performance and not leave hazardous residues. other desired attributes for a decontamination method for ffr reuse would be low cost, high throughput and ease of use (viscusi et al., 2009b) . uvgi technology has been suggested as a viable option for ffr reprocessing application where nine ffr models were evaluated for changes in physical appearance, odour and laboratory performance (filter aerosol penetration and filter airflow resistance) following simulated decontamination using five different methods, including uvgi (viscusi et al., 2009b) . in latter study, uv-c treatment did not affect the filter aerosol penetration, filter airflow resistance or physical appearance of the ffrs. uv-c, as a decontamination method, is affected by several parameters, including the topography of the contaminated surface and the location of the microorganisms within the substrate. the use of uv-c for surfaces is mainly for hard, nonporous substrates (fisher and shaffer, 2011) . therefore, at this time of writing, while uvgi and puv methods appear promising, no validated decontamination methods for ffrs exist. lessons can also be gleamed from best-published information and hurdles arising from minimal processing technologies that have been exploited by the food industry for commercial applications (deng et al., 2019) . these technologies rely upon reduced severity of nonthermal treatments that equate to moderate of high-level decontamination gerard et al., 2019) . however, review of bestpublished approaches suggest that these technologies, in their current configurations, would not be suited for ppe reprocessing. these unsuitable technologies include high hydrostatic pressure, pulsed electric fields, pulsed-plasma gas-discharge, ultrsound and so forth (deng et al., 2019) . also, the majority of chemical biocides deployed in the food industry as liquid decontaminants for surface-treatments would not be effective for ppe as these cannot be easily used in the hospital setting. however, kampf et al. (2020) recently reported that coronaviruses persist on inanimate surfaces, such as glass, plastic and metal for up to 9 days, but they are efficiently inactivated on these surfaces with use of 62-72% alcohol, 0.5% hydrogen peroxide, or 0.1% sodium hypochlorite within 1 min exposure. use of high level disinfection with actichlor-plus served as both a detergent and biocide for reprocessing starmed hoods used by covid19 patients in icu. testing of starmed hoods in heated washer at 90°c caused damage to the pvc component. high level disinfection was applied in advance of lead-time for vhp and uv technologies arriving to hssd and as use of sodium hypochlorite was suggested as possible approach to cleaning and disinfecting 3m™ powered air purifying respirators following potential exposure to coronaviruses (https://multimedia.3m.com/mws/media/1793956o/ cleaning-and-disinfecting-3m-paprs-following-potential-exposure-tocoronaviruses.pdf). there is potential for use of combined hepa filtration with uv light disinfection for air disinfection in critical areas that will reduce aerobiology or airborne bioburden. however, consideration would need to be given to efficacy of reduction of covid19 or similar respiratory viruses. perceived benefits and future directions for the control of covid19 with a focus on addressing shortages in supply chain. the perceived indicative benefits of deploying solutions for reprocessing ppe to address front-line shortage have listed in terms of making potentially significant qualitative and quantitative difference are listed in table 2 . the world, as we know it, will be a changed place post covid19, where there will be greater focus on mitigation planning for managing pandemics nationally and transnationally with either increased provision and/or less reliance on one-time-use medical devices and ppe. future provision in hospitals and healthcare will also consider duality of sterilization treatments with reduced processing capability for to deliver if required, high or moderate level of disinfection. there will be increased emphasis on convergence of technologies and knowledge from adjacent disciplines, such as the food industry, to improve our understanding of minimal processing linked to sterilization. this will be framed upon increased demand for evidence-based research and shared publications so to inform validation and new regulations using potentially new smart innovations and services or adapting existing modalities. it is envisaged that there will be a commensurate push to promote more eco-innovations, along with review of exiting sterilization processes, for sustainability of resources and to meet existing needs arising and emerging from this covid19 pandemic. this pandemic also highlights the value of converging areas of expertise that will inform education and workforce training processes. this pandemic also highlights that despite staggering advancements in innovation, society is still very vulnerable to global treats to our health from what is a microscopic virus. commensurately, our collective creativity and ingenuity will enables us to countermeasure these challenges. in summary, providing solutions for the shortages in supply chain for one-time-use ppe is extremely complex. preference would always be for usage of single-use items as described by the manufacturers as ensuring the safety of our healthcare workers is paramount. logical first step solutions would be to improve communication lines for better stock management of ppe that exploits webpage and mobile phone app development along with dual bespoke production of ppe using medical grade materials where gaps are identified, such as ventilators. however, a pandemic foists untold and unexpected demands on society that includes provision or contingency planning for reprocessing ppe. under such situations, it is imperative to follow closely advice from original manufacturer of ppe on material composition and design features with view to making reprocessed ppe (where possible), fit for purpose. this also includes adhering to close advice provided by regulators, such as fda. the majority of existing in house hospital, external terminal sterilization and adjacent minimal processing technologies (as used in food industry) will not be effective for reprocessing ppe. however, review of best evidence suggest that preferred candidate methods for meeting this gap appears to be use of vaporised hydrogen peroxide (vhp) and uv irradiation technologies, which are likely be deployed in the republic of ireland. science foundation ireland -rapid covid19 fund grant with curam edical device centre. nr and jgl conceptualised the manuscript. nr drafted the manuscript. both authors read, edited, and approved the final manuscript. not applicable. the authors declare that they have no competing or conflict of interests. disinfection of filtering facepiece respirators detection, fate and inactivation of pathogenic norovirus employing settlement and uv treatment in wastewater treatment facilities evaluation of multiple (3-cycle) decontamination processing for filtering facepiece respirators nutraceuticals have potential for boosting the type 1 interferon response to rna viruses including influenza and coronavirus 3d printed polymers are less stable than injected moulded counterparts when exposed to terminal sterilization processing using novel vaporized hydrogen peroxide and electron beam processes emerging chemical and physical disinfection technologies of fruits and vegetables: a comprehensive review studies on the relationship between pulsed uv light irradiation and the simultaneous occurrence of molecular and cellular damage in clinically-relevant candida albicans final report for the bioquell hydrogen peroxide vapor (hpv) decontamination for reuse of n95 respirators enforcement policy for face masks and respirators during the cornovirus disease (covid19) public health emergency (revised) a method to determine the available uv-c dose for the decontamination of filtering facepiece respirators inactivation of parasite transmission stages -efficacy of treatments on food of animal origin ecotoxicological assessment of pulsed ultraviolet light-treated water containing microbial species and cryptosporidium parvum using a microbiotest battery inactivation of parasite transmission stages -efficacy of treatments on foods of non-animal origin disinfection and toxicological assessment of pulsed uv and pulsed-plasma gas-discharge treated water containing the waterborne protozoan enteroparasite cryptosporidium parvum persistence of coronavirus on inanimate surfaces and their inactivation with biocidal agents early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia terminal sterilization of medical devices using vaporized hydrogen peroxide: a review of current methods and emerging opportunities the economic impact of pandemic influenza in the united states: priorities for intervention impact of the 2009 influenza a (h1n1) pandemic on canadian health care workers: a survey on vaccination, illness, absenteeism, and personal protective equipment use of uvc radiation for disinfecting non-critical patient care items -a laboratory assessment of the nanoclave cabinet the epidemiology and pathogenesis of coronavirus disease (covid-19) outbreak pulsed light as an emerging technology to cause disruption for food and adjacent industries -quo vadis? a review of quantitative methods to describe efficacy of pulsed light generated inactivation data that embraces the occurrence of viable but non culturable state microorganisms coronavirus envelope protein -current knowledge personal and protective equipment and antiviral drug use during hospitalization for suspected avian or pandemic influenza disinfection of healthcare equipment -guideline for disinfection and sterilization in healthcare facilities effect of decontamination on the filtration efficiency of two filtering facepiece respirator models evaluation of the filtration performance of 21 n95 filtering face piece respirators after prolonged storage evaluation of five decontamination methods for filtering facepiece respirators decontamination, disinfection, and sterilisation the authors would like to thank dr. emma murphy for assisting with graphics editing of figures. key: cord-258504-pnd46ipd authors: bleasdale, susan c.; sikka, monica k.; moritz, donna c.; fritzen-pedicini, charissa; stiehl, emily; brosseau, lisa m.; jones, rachael m. title: experience of chicagoland acute care hospitals in preparing for ebola virus disease, 2014–2015 date: 2019-07-08 journal: j occup environ hyg doi: 10.1080/15459624.2019.1628966 sha: doc_id: 258504 cord_uid: pnd46ipd during the 2014–2015 ebola virus disease (evd) outbreak, hospitals in the united states selected personal protective equipment (ppe) and trained healthcare personnel (hcp) in anticipation of receiving evd patients. to improve future preparations for high-consequence infectious diseases, it was important to understand factors that affected ppe selection and training in the context of the evd outbreak. semistructured interviews were conducted with hcp involved with decision-making during evd preparations at acute care hospitals in the chicago, il area to gather information about the ppe selection and training process. hcp who received training were surveyed about elements of training and their perceived impact and overall experience by email invitation. a total of 28 hcp from 15 hospitals were interviewed, and 55 hcp completed the survey. factors affecting ppe selection included: changing guidance, vendor supply, performance evaluations, and perceived risk and comfort for hcp. cost did not affect selection. ppe acquisition challenges were mitigated by: sharing within hospital networks, reusing ppe during training, and improvising with existing ppe stock. selected ppe ensembles were similar across sites. training included hands-on activities with trained observers, instructional videos, and simulations/drills, which were felt to increase hcp confidence. many felt refresher training would be helpful. hands-on training was perceived to be effective, but there is a need to establish the appropriate frequency of refresher training frequency to maintain competence. lacking confidence in the cdc guidance, interviewed trainers described turning to other sources of information and developing independent ppe evaluation and selection. response to emerging and/or high consequence infectious diseases would be enhanced by transparent, risk-based guidance for ppe selection and training that addresses protection level, ease of use, ensembles, and availability. though the last major threat of ebola virus disease (evd) in the united states occurred in 2014-2015, acute care hospitals must remain prepared to respond to outbreaks of high-consequence infections. although classified as low global risk, the current evd outbreak in the democratic republic of congo (congo), combined with the recurring emergence of high-consequence infections (e.g., severe acute respiratory syndrome [sar] , middle east respiratory syndrome, 2009 h1n1 influenza), highlights the need for ongoing preparations. [1] healthcare personnel (hcp) are particularly vulnerable to occupationally-acquired infection during outbreaks of emerging infectious diseases, including evd and sars owing, perhaps, to uncertainty about the route of transmission and necessary personal protective equipment. [2, 3] after the infection of two hcp with evd, for example, the centers for disease control and prevention (cdc) revised their recommendation for personal protective equipment (ppe) to eliminate skin exposure, though ppe guidance continued to be updated through 2016. [4, 5] the purpose of this study was to understand how acute care hospitals in the chicago, illinois area prepared for the 2014-2015 evd outbreak, focusing on issues related to occupational health. more specifically, questions included: 1) how ppe ensembles were selected, 2) considerations for ppe acquisition and use, and 3) how training in the use of ppe ensembles and evd patient care was developed and delivered. while there is a growing body of literature describing preparations for the 2014-2015 evd outbreak, this study is unique because it allows comparison of experiences across different types of acute care hospitals (with different roles in the regional evd plan), and between hcp who planned and received training. [6] [7] [8] [9] the study objectives were achieved using semistructured interviews with hcp involved with evd preparations, and surveying hcp who participated in training for the use of enhanced ppe ensembles for evd. twenty-six of the 71 acute care hospitals in the chicago area were selected for recruitment using a purposeful sampling strategy (table 1) . hospitals were classified into categories based on their role in the regional evd response plan (ebola treatment center [etc] or ebola assessment center [eac] and non-etc/eac), type, location, and size (small with < 250 beds, medium with 250-500 beds, and large with > 500 beds). in each category, if there were 4 hospitals, all hospitals were selected for recruitment; otherwise, four hospitals were randomly selected. two hospitals were excluded from analysis because members of our research team were involved in evd preparations at these hospitals. individuals were eligible for participation if they were employed at a chicago area acute care hospital and participated in decision-making about ppe and/or contributed to the design or delivery of training during the 2014-2015 evd outbreak. participation in the interview was incentivized by a $30 gift card. attempts were made to contact up to eight individuals (up to three phone calls and three e-mails each) at each hospital, starting with individuals in infection prevention or emergency management. one to three individuals were interviewed at each hospital between september 2016 and february 2017. when more than one individual participated from a hospital, attempts were made to identify people with different disciplinary training and/or role in evd preparations. a semistructured interview guide was prepared. [10, 11] questions and follow-up probes were organized into four domains: participant characteristics, institution organization and culture, training experiences, and experience with personal protective equipment. the interview guide is available in the online supplemental materials. interviews were performed over the telephone, digitally recorded and transcribed. interviews were periodically reviewed to evaluate saturation of question or topic and identify the need for further probes for clarity. [12] a codebook for the interview transcripts was developed iteratively and validated by application to selected interviews by five investigators with tabulation of inter-rater reliability. [13] the final codebook is included in the online supplemental materials. final coding was performed on each interview transcript by two people, with a third adjudicated conflicting codes to select the five most relevant codes or subcodes for each response. the focused conversation method was used for group analysis of coded text: two analysis meetings were conducted focused on the objectives related to ppe and training, respectively. [14] the focused conversation method involves the group addressing a series of objective, reflective, interpretative, and decisional questions. more details are provided elsewhere, and the conversation guides are included in the online supplemental materials. [15] observations and themes identified in the focused conversation were further explored by identifying text that supported and challenged the findings, including identification of illustrative quotes. quantitative data from interviewed trainers is described at the hospital level by the percentages of hospitals interviewed. referral sampling was used to recruit survey respondents. an online survey using qualtrics xm (seattle, wa) was distributed by the interviewed trainers to colleagues and through the state of illinois rapid electronic notification system from october 2016 to june 2017. eligible respondents had received training in the use of ppe in the context of the 2014-2015 evd outbreak. survey respondents (trainees) were a different population than interviewees (trainers). the survey included 142 questions organized around six themes: 1) trainee characteristics, 2) ppe donning and doffing training received, 3) perceived impact of training, 4) training received regarding performing care activities while wearing ppe, 5) experience with specific types of ppe, and 6) experience with caring for suspected or confirmed evd patients. multiple choice answers were used to describe characteristics of the trainees and the training. likert scales were used for perceived impact and experience. the survey was piloted by trainers and trainees within our research institution and iteratively adapted to the final version. the survey is available in online supplemental materials. participation was incentivized by a $10 gift card. the study was approved by the university of illinois at chicago institutional review board, protocol # 2015-0900. recruitment of trainers occurred from september 2016 to february 2017 and resulted in 28 interviewed trainers from 15 of the 26 (58%) hospitals identified for recruitment (table 1) . trainers from additional hospitals were not recruited because preliminary review of transcripts suggested that saturation was achieved on most questions. trainers broadly fell into the following categories: infection prevention (n ¼ 12), emergency management (n ¼ 8), education (n ¼ 3), executive leadership (n ¼ 2), biosafety (n ¼ 1), and risk management (n ¼ 1). a total of 55 trainees completed the online survey between october 2016 and june 2017. thirty-four (62%) surveyed trainees identified that they worked at academic or tertiary care centers, while the remaining surveyed trainees were from nonacademic urban/suburban hospitals (33%), va hospitals 4%), and the fire department (2%). surveyed trainees identified as nurses (n ¼ 30), physicians (n ¼ 7), other clinical personnel (n ¼ 9), or nonclinical personnel (n ¼ 9). the majority worked in an emergency department (44%), followed by interfacility transportation (13%). interviewed trainers from 14 hospitals identified the cdc as a source of information about ppe for use with evd patients. cdc recommendations, however, were used with other resources including: biocontainment centers, expert consultants, in-house experts, and colleagues at other hospitals in the same healthcare network; occupational health agencies were rarely mentioned. multiple resources were used in part owing to concern that initial cdc recommendations to use standard and contact precautions were "inadequate" or "unreliable." [16] the evolution in cdc recommendations had significant implications: hospitals had to evolve with the recommendations, the changes decreased credibility of the personnel selecting ppe and delivering training and influenced hcp attitudes toward possible care of an evd patient. one interviewed trainer explained that the changes from cdc "messed with our credibility." another trainer described that changes from cdc resulted in training hcp on the use of three different ppe ensembles, which meant that "the caregivers weren't particularly happy." the overall delay in clear recommendations from cdc was felt to add "unneeded anxiety." interviewed trainers from all hospitals indicated that inadequate ppe supply affected preparations when the cdc recommendations moved to the use of enhanced ppe ensembles. [5] the common theme was that trainers used what "we could get our hands on." some hospitals initiated training with available equipment while waiting for preferred equipment, like powered air purifying respirators (paprs) and fluid-impermeable coveralls, to become available; others adapted or "cannibalized" equipment from specialty units (e.g., orthopedic surgery), such as surgical helmets with shrouds and longer gloves. interviewed trainers from one hospital described the plan to use suits designed for hazardous materials (hazmat) response as a "last resort option" if they ran out of other ppe supplies. these strategies, however, could not overcome limitations in available ppe sizes, a challenge expressed by many interviewed trainers. limited supply of paprs was specifically identified by interviewed trainers from several hospitals, though the majority of interviewed trainers described training with paprs. some hospitals substituted shrouded surgical helmets for paprs because the helmets provided the same cooling effect as the airflow in paprs but included n95 respirators in the ensemble because the helmet does not provide respiratory protection. one interviewed trainer described that the hospital (non-etc/eac) did not have paprs and did not initially seek to acquire the highest levels of recommended ppe, including paprs, because they did not anticipate receiving an evd patient. this was the only interviewed trainer that described the use of this type of risk-based decision making for ppe selection and training. some interviewed trainers from smaller hospitals felt that their hospitals were at a disadvantage relative to larger hospitals with respect to acquiring ppe. one interviewed trainer described, "we didn't have a lot of the resources that some of the bigger facilities did. [ … ] we can't really compete with the big dogs if you will." supply shortages were minimized among smaller hospitals that were part of a healthcare network, as interviewed trainers from networked hospitals described plans for just-in-time delivery of ppe and centralized patient care, which decreased the need for ppe stockpiling and training at the smaller hospitals. interviewed trainers did not describe the cost of ppe as a limiting factor in preparations, and many cited worker safety as sole criteria for ppe selection. the resources were described in a carte blanche fashion: "we're buying the best for our employees," "the cadillac of everything," and "i don't care what the price is we just have to do this." interviewed trainers postulated reasons for the extent of financial support in both positive and negative terms. positive expressions about the availability of financial resources centered on the organization's commitment to safety, "there was no hedging on the commitment of the organization for the safety of all of our employees across the board." negative expressions centered on the organization's fear of failure, "i think they just got the money because no hospital wanted to be caught not doing anything about it." interviewed trainers from 47% of hospitals described evaluating and modifying ppe ensembles in ways characterized here as improvisation, and these activities were often described as involving the hcp who would provide care to evd patients. the impermeability of body coverings, including at junctions between pieces of ppe, was a common concern. some interviewed trainers described finding it difficult to identify or evaluate fluid-impermeability ratings, describing a body covering as being made of "an impermeable-like type of material but, there's no signage or anything." interviewed trainers from two hospitals described independently evaluating the permeability of ppe or the connections of ppe ensembles with surrogates for blood with water or kool-aid. an interviewed trainer described evaluating an ensemble to figure out, "how do we do this so that it doesn't leak around the edge of the tyvek suit?" and, that after identifying a potential ensemble through a trialand-error approach, the interviewed trainer said that staff answered the questions, "what do you think? can you get in? can you get out? how should we modify it? does this work?" concerns extended to breaching ppe and contributed to decisions to use hooded paprs or shrouded surgical helmets in an attempt to prevent hcp from touching their face. while interviewed trainers from 50% of the non-etc/ eac hospitals felt they did not serve a population at risk for evd, interviewed trainers from all hospitals described fear as common emotion among hcp. as one interviewed trainer described, " … [hcp] kept thinking about the nurse that was in texas that seemed to have had all the protection that she needed but she still got exposed somehow." fear led to decisions about ppe that some interviewed trainers characterized as "irrational." as one participant described, "[hcp] were not paying attention to the different risks between a wet and a dry patient. they heard ebola, ebola wet, highly contagious, everybody dies, and they wanted to be encased like a mummy." another participant described specific requests from hcp who "said that they would refuse to take care of anybody unless they were provided with this absurd amount of protection [ … ] not levels of ppe required or requested by the cdc … ." comfort and ease of use interviewed trainers described heat as the main factor affecting comfort during use of the enhanced ppe ensembles. heat management motivated the use of paprs and shrouded surgical helmets, which move cool air over the head of the wearer. these devices also have less impact on the visual field of the wearer than goggles or face shields. interviewed trainers at a couple of hospitals indicated that suits for hazmat response were not preferred because they are hot and heavy and would be reserved for emergencies. the final ppe ensembles selected at the different hospitals were quite similar, and were described by interviewed trainers as involving head-to-toe coverage consistent with the cdc recommendations for "no skin exposure". [5] the use of paprs and tyvek coveralls or fluid-impermeable gowns were identified by interviewed trainers at 10 and 12 hospitals, respectively, including all etcs. head coverings (e.g., shrouds or hoods) were described by interviewed trainers at 4 of the 5 hospitals that did not use paprs. interviewed trainers at 4 hospitals (2 etcs), described the use of surgical helmets. interviewed trainers at 4 hospitals described training the majority of hcp at the hospital in ppe donning/ doffing, regardless of whether they were expected to care for evd patients. more commonly, interviewed trainers indicated that ppe donning/doffing training was limited to hcp anticipated to be in the patient care workflow. hcp in the emergency department were most frequently identified by interviewed trainers as recipients of ppe donning/doffing training (n ¼ 14 hospitals interviewed), followed by environmental service workers (n ¼ 9) and intensive care or isolation room workers (n ¼ 5). other hcp groups described by interviewed trainers as included in training were: laboratory, radiology, respiratory therapy, security, transportation, and emergency medical technicians. training about donning/doffing ppe was described by interviewed trainers from all 15 hospitals. while a variety of training methods for ppe donning/doffing were described, interviewed trainers at the majority of hospitals interviewed indicated use of hands-on practice. this is consistent with surveyed trainees, 93% of whom reported receiving hands-on training in ppe donning and doffing in a group setting. instructional videos about ppe donning and doffing were also identified frequently by interviewed trainers, and by 49% of surveyed trainees. interviewed trainers from the majority of hospitals interviewed identified that existing staff participated in delivery of training about ppe donning/doffing. the staff most frequently identified included: infectious diseases clinicians and infection control personnel (53%), clinical educators (47%), and clinical staff (16%). forty-percent of hospitals interviewed specifically described using a train-the-trainer model to distribute training. all hospitals interviewed indicated that the ability of hcp to don/doff ppe was evaluated using observation, including return demonstration. interviewed trainers at some hospitals described using check lists to aid observation or markers (glow germ or chocolate syrup) to evaluate self-contamination during ppe doffing. the vast majority of surveyed trainees (98%) received instructions on a specific order for donning/ doffing ppe. of the 52 surveyed trainees who indicated their ability to don/doff ppe was evaluated during training, 85% reported demonstration for trainer and 15% reported demonstration for a fellow trainee. no surveyed trainees reported taking a written quiz. training in the care of evd patients was described at 47% of hospitals interviewed, including the etcs and eac, while training in logistical protocols (intake procedures, communication protocols, etc.) were described at 73%. surveyed trainees most frequently indicated that they received training in: cleaning patient care areas or spills (56%), transporting patients (55%), transportation of body fluids (36%), blood draw (22%), and emergency medical procedures (16%). one surveyed trainee wrote in that s/he was trained to not provide resuscitation to evd patients. five surveyed trainees indicated receiving training in the use of electronic devices, including: a bluetooth stethoscope, telemedicine equipment, and/or ipads/tablets. simulations and/or drills of care activities and logistical protocols were described by interviewed trainers from the vast majority of hospitals and identified as opportunities to: increase the speed of response, increase the comfort and ease of hcp to use ppe (e.g., learning the "physical boundaries" imposed by the ppe), identify gaps in preparations, increase hcp confidence, and revise operating procedures. that is, the simulations were part of a continuous improvement process, rather than a summative assessment of hcp competency. hcp were viewed "as active learners and trainers because of their contributions [to the care process] and what they had to say." changes described as arising from simulations and drills included: installation of phones in patient rooms to improve communication, changes in staffing requirements, creation of a "all call" page of hcp who would respond to an evd patient, and adoption of a risk tiered approach to ppe. two interviewed trainers from different hospitals described negative consequences of unannounced simulations involving mock patients. specifically, fear among hcp during the simulation affected how they performed their work and/or resulted in emotional distress. in a hospital where the interviewed trainer noted the first drill was "incredibly stressful," the trainer described that a staff member in the patient room "panicked and tried to come out [ … ] tried to take off his ppe and get out" during a drill. interviewed trainers described that fears were assuaged through "town hall" education and information sessions and through training. one interviewed trainer said town halls were used " … to keep people updated on what we learned through cdc [ … ] because there was all sorts of [ … ] misinformation going on." the impact of training, particularly simulation, reduced fear and led to revisions of the ppe ensembles. for example, an interviewed trainer from a hospital where hcp "wanted to be encased [in ppe] like a mummy" noted that preferences "started to change after like the 4th or 5th simulation where people were like, '[m]an, [i] can't work like this.'" when asked to identify the three training modalities that had the greatest positive impact on their confidence to care for an ebola patient, surveyed trainees most frequently identified: hands-on activities in group (n ¼ 39) or individual settings (n ¼ 28), trained observers (n ¼ 21), instructional videos (n ¼ 11), training in a simulated care area with (n ¼ 10) or without task trainers (n ¼ 8), and using markers for evaluation of self-contamination during ppe doffing (n ¼ 8) ( table 2 ). the majority of surveyed trainees were very (52%) or moderately (31%) confident in their ability to don ppe and to doff ppe as instructed; and the majority (67%) reported that the presence of an observer would increase their confidence in doffing ppe as instructed. the majority of surveyed trainees were very (33%) or moderately (41%) confident in their ability to work as an individual or in a group to care for an evd patient. interviewed trainers from the etcs and two other hospitals reported that their hospital has performed some skill maintenance training since the outbreak ended (interview period september 2016 to february 2017). the value of skill maintenance was linked with the need to be "always prepared for things like ebola" and/or a trend toward improved emergency management and business continuity planning. barriers to skill maintenance training identified by interviewed trainers at etcs included debate about who should be trained, and how frequently hcp should be trained. interviewed trainers from non-etc hospitals identified staff turnover as a barrier. the majority of surveyed trainees (58%) perceived a need for refresher training, but the perceived need for training differed with time since last training (v 2 p < 0.001). among surveyed trainees who indicated a need for refresher training about patient care activities 48% wanted the training twice per year or more frequently, and 42% wanted the training annually. thirteen of the interviewed hospitals described some historical education on ppe, however many interviewed trainers described how evd preparations made them aware of deficiencies in routine training and use of ppe. deficiencies included needed "clarification on how to don and doff", lack of experience with elements of the ensemble, limited training to only a subset of providers, lack of hands-on training, and lack of retraining after hire. despite these identified gaps, interviewed trainers from only two hospitals indicated a change in routine training, specifically, new employee orientation was changed to include hands-on training in ppe donning/doffing. hospitals in the chicagoland area were resourceful in their occupational health preparations for the 2014-2015 evd outbreak were able to select ppe ensembles they judged appropriate for the hospital's role in the regional evd plan and trained hcp in the use of enhanced ppe ensembles and/or evd patient care. interviewed trainers at all hospitals interviewed indicated that at least some training involved enhanced ppe ensembles. this is consistent with the response that half of the non-etc/eac interviewed hospitals had some expectation of receiving an evd patient, and with the federal policy recommending that all hospitals be able to provide care for an evd patient for up to 24 hr. [17, 18] fortunately, only suspected evd patients were treated in chicagoland hospitals, so the ability of preparations to protect hcp from occupationally-acquired evd was not tested. our results, however, do not suggest that substantial changes in routine practices have occurred outside of etcs that would ease preparations for the next outbreak of an emerging or high-consequence infectious disease of a similar scale, as limited refresher training is ongoing, and only two hospitals interviewed have modified routine training in the use of ppe. interviewed trainers expressed the perception that the immediacy of the threat of a high-consequence infectious disease has decreased, which is likely a driver to decreased institutional commitment to preparedness activities, and failure to institutionalize changes resulting from lessons learned in the evd preparations. in addition, with the 2018-2019 evd outbreak in congo at a low global risk, there has not been a response to initiate refresher training at non-etcs. interviewed trainers were frequently critical of cdc guidance for ppe ensembles for care of evd patients. the initial recommendations from the cdc for standard and contact precautions were perceived as inadequate, and repeated revisions created challenges for hospitals to acquire equipment and maintain trust with hcp. lacking confidence in the cdc guidance, interviewed trainers described turning to other sources of information, particularly the biocontainment units and individuals perceived to be experts (in-house and external). few interviewed trainers mentioned referencing occupational health agencies, such as the national institute for occupational safety and health and the occupational safety and health administration. this is disappointing as occupational health experts can contribute substantially to the prevention of infection among patients and hcp, and since the 2014-2015 evd outbreak there has been movement to increase the availability of information about ppe from these and other federal occupational health agencies. [19] [20] [21] [22] there remains, however, a need to provide further guidance on how to evaluate ensembles, not just individual pieces of ppe, for their level of protection against infectious diseases and for their comfort and usability. in the face of ppe shortages and changing ppe guidance, most hospitals utilized multiple sources of information and improvised to select ppe ensembles that met their needs. this approach is consistent with the spirit of standard precautions. standard precautions require hcp to perform specific behaviors (e.g., hand hygiene), select ppe and use work practices that are appropriate to the nature of anticipated contact with body fluids. [23] application of standard precautions to the care of a symptomatic evd patient leads to the enhanced ppe ensemble ultimately recommended by the cdc. more specifically, given the large volumes of body fluid emitted in late-stage evd and the large number of sites where ebola virus may initiate infection, it is necessary to protect the dermis, facial mucous membranes and (controversially) the respiratory tract from contact with patients' bodily fluids. [24] [25] [26] [27] furthermore, the high evd mortality rate observed in africa requires a precautionary approach to worker protection. [28] in this context, standard precautions would identify the need for fluid-impermeable ppe to protect the entirety of the dermis, the mucous membranes, and the respiratory tract. the lower rates of evd mortality observed in the united states and europe and improved understanding of virus shedding in the early stages of evd could allow a change in the ppe ensemble under the standard precautions framework, such as the two-tier, symptom-based, ppe recommendations. [29, 30] the reliance on ppe to protect hcp from occupationally-acquired infectious diseases is unfortunate, as ppe is the lowest strategy in the hierarchy of controls. research objectives for this study were focused on topics related to ppe, so other types of control strategies employed were not explore with interviewed trainers, but a few surveyed trainees described receiving training in electronic devices to reduce patient contact, such as telemedicine equipment or bluetooth tm stethoscopes. since the 2014-2015 evd outbreak, there has been evaluation of the environment and how it contributes to risk and can be optimized for protection of hcp. [31] there should be increased efforts to identify engineering and administrative controls to reduce pathogen emission and limit pathogen transport through the environment. until that time, however, it is critical that hcp have access to and correctly use ensembles of ppe that effectively interrupt disease transmission. hands-on practice was the most common modality for training in ppe donning/doffing and evd patient care activities described in our sample and was valued by trainees. others have found that workers desire hands-on training about ppe donning and doffing, and this type of training is consistent with principles of adult education because it actively engages the worker in a realistic, relevant activity. [32] [33] [34] hands-on training also offers opportunity for evaluation, which is particularly important when self-perceived proficiency is not correlated with performance, such as has been observed for doffing of ppe ensembles. [35] hands-on training can provide real-time feedback to correct behaviors in the moment with observer interventions or surrogates for contamination. [36, 37] in this sample, skills maintenance training was limited and primarily occurred at etcs. a barrier identified was debate over the appropriate frequency of training, though surveyed trainees who wanted refresher training, wanted it to occur 1-2 times annually. the annual interval for many occupational health trainings is driven by logistical concerns rather than evidence of skill retention. training in complex activities like ppe donning/doffing may need to occur more frequently than annually. this study is subject to a number of limitations. while this study used a stratified random sampling scheme to identify hospitals for recruitment of interviewed trainers to help ensure that varied experiences were represented, individuals declined to participate or were not responsive to recruitment efforts. some individuals specifically cited negative experiences during the evd preparations as a reason to not participate, which may have led to a bias in our sample towards individuals with positive experiences. however, all interviewed trainers described the period of the 2014-2015 evd outbreak as extremely stressful, and some described negative experiences. amongst our sample of interviewed trainers, however, there was consistency among responses, suggesting that saturation was reached for many of our questions, despite the modest sample size. the trainee survey was distributed through referral sampling, and received a small number of responses, but there is no reason to believe that interviewed trainers distributed the survey to a specific subset of potentially eligible colleagues. given the limited sample size, inferences from the survey were limited, but findings were consistent with interviewed trainers. this mixed methods approachan effort to triangulate the true experience of hcp involved in evd preparationsis the strength of the research approach. by design, the study captured the experience in the chicagoland area and was conducted after the conclusion of the 2014-2015 evd outbreak. thus, experiences described herein may be specific to chicago and subject to recall bias. a strength of our approach to this qualitative research was the use of multiple coders applying a codebook to interview transcripts and the focused conversation method for data analysis and interpretation. these methods ensured that the data were reviewed by multiple people from the research team through different disciplinary perspectives. themes emerging from the focused conversation were verified by reviewing the interview text to identify supporting and challenging quotes and, to the extent feasible, tabulating quantitative information. though hospitals in the chicagoland area were able to select ppe ensembles and train hcp to use these ppe ensembles while providing care to evd patients, it is not clear that the preparations have resulted in lasting changes that will ease preparations for the next high-consequence infection outside of etcs. refresher training is essential for maintaining preparedness, and there is a need to determine, through research, a training interval that maintains skills while minimizing cost and administrative burden. hospitals were able to improvise and identify other sources of information to guide ppe selection in the face of dissatisfaction with initial cdc recommendations, using an approach consistent with the philosophy of standard precautions. occupational health agencies could and should fill the need for guidance for ppe selection and evaluation that is relevant to diverse infectious diseases, and acknowledge the need to consider: protection level, ease of use, ensembles, and availability. such guidance could result from revisiting ppe selection in the context of standard precautions and/ or the development of a tool to guide decision making. world health organization: ebola virus disease -democratic republic of congo ebola virus disease cluster in the united states occupational deaths among healthcare workers cdc: infection prevention and control recommendations for hospitalized patients under investigation (puis) for ebola virus disease (evd) healthcare workers on personal protective equipment for ebola. cdc online newsroom addressing infection prevention and control in the first u.s. community hospital to care for patients with ebola virus disease: context for national recommendations and future strategies preparing the health system to respond to ebola virus disease rapid development and deployment of ebola readiness training across an academic health system: the critical role of simulation education, consulting and systems integration chicago ebola response network (cern): a citywide crosshospital collaborative for infectious disease preparedness rigour and qualitative research qualitative research in health care -analyzing qualitative data (reprinted from qualitative research in health care) saturation in qualitative research: exploring its conceptualization and operationalization the place of inter-rater reliability in qualitative research: an empirical study the art of focused conversation utilizing the focused conversation method in qualitative research: a team-based approach to data analysis and interpretation guidelines for isolation precautions: preventing transmission of infectious agents in healthcare settings the emergency medical treatment and active labor act (emtala): what it is and what it means for physicians hospital preparedness for patients under investigation (puis) or with confirmed ebola virus disease (evd): a framework for a tiered approach j ebola hemorrhagic fever j cdc national institute for occupational safety and health: niosh personal protective equipment information (ppe-info) personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff (review) isolation gowns in health care settings: laboratory studies, regulations and standards, and potential barriers of gown selection and use osha: fact sheet: ppe selection matrix for occupational exposure to ebola virus guideline for isolation precautions in hospitals part ii. recommendations for isolation precautions in hospitals assessment of the risk of ebola virus transmission from bodily fluids and fomites protecting health workers from airborne mers-cov -learning from sars uncertainty, risk analysis and change for ebola personal protective equipment guidelines epidemiology of ebola virus disease (evd) and occupational evd in health care workers in sub-saharan africa: need for strengthened public health preparedness successful delivery of rrt in ebola virus disease guidance on personal protective equipment (ppe) to be used by healthcare workers during management of patients with confirmed ebola or persons under investigation (puis) for ebola who are clinically unstable or have bleeding, vomiting, or diarrhea in u.s. hospitals, including procedures for donning and doffing ppe j ebola hemorrhagic fever making the invisible visible: why does design matter for safe doffing of personal protection equipment? cdc safety training course for ebola virus disease healthcare workers acceptability and necessity of training for optimal personal protective equipment use use of remote video auditing to validate ebola level ii personal protective equipment competency the association between self-perceived proficiency of personal protective equipment and objective performance: an observation study during a bioterrorism simulation drill violet': a fluorescence-based simulation exercise for training healthcare workers in the use of personal protective equipment assessing viral transfer during doffing of ebola-level personal protective equipment in a biocontainment unit we would like to acknowledge isabel farrar with the uic survey research laboratory for assistance and advice with the interview and survey instruments, agnes kalat for programming our survey, and yu-kai huang for analyzing the survey responses. the data generated by the interviews in this study are not publicly available because it is not possible to effectively de-identify these data, which were sampled from a small geographic region. extended and additional quotes are available in the supplementary materials, and survey data will be available within 12 mo of publication at uic indigo, indigo.uic.edu. the authors have no conflict of interest to disclose related to this manuscript. key: cord-016223-nk8xwa0t authors: andersen, bjørg marit title: strict isolation date: 2018-09-25 journal: prevention and control of infections in hospitals doi: 10.1007/978-3-319-99921-0_19 sha: doc_id: 16223 cord_uid: nk8xwa0t strict isolation: suspected highly infectious and transmissible virulent and pathogenic microbes, highly resistant bacterial strains and agents that are not accepted in any form of distribution in the society or in the environment. examples are completely resistant mycobacterium tuberculosis, viral haemorrhagic fevers like ebola and lassa, pandemic severe influenza and coronavirus like sars, mers, etc. in most countries, strict isolation is a rarely used isolation regime but should be a part of the national preparedness plan. for instance, in norway, strict isolation has not been used for the last 50–60 years, except for one case of imported ebola infection in 2014. patients in need of strict isolation should be placed in a separate isolation ward or building. infection spread by contact, droplet and airborne infection, aerosols, re-aerosols, airborne microbe-carrying particles, skin cells, dust, droplets and droplet nuclei. at the same time, it is always contact transmission (contaminated environment, equipment, textiles and waste). the source of infection is usually a patient but may also be a symptomless carrier or a zoonotic disease. to prevent transmission from an infectious patient to other patients, personnel, visitors and the environment and to protect patients with impaired immune defence against infection [1] [2] [3] [4] [5] [6] [7] [8] . • all patients having contagious disease that can easily be transferred directly or indirectly via contact, blood and body fluids, air/droplets or via equipment, textiles and surfaces. • all patients with significant reduced infection defence or otherwise infection vulnerable and who should be protected against infection. hospital management should ensure necessary capacity and type of isolating units: contact-and air-droplet isolates and protective isolates. updated isolation routines, adequate protective equipment-including ppe-routines for disinfection of rooms and surfaces and disinfectants and hand hygiene facilities should be available. department management should implement isolation procedures, train the use of ppe, control the use of routines and provide sufficient stock and capacity of ppe and means for disinfection and hand hygiene. the staff should follow current guidelines for treatment of patients with infections and for patients that should be extra protected against infections. the isolation unit is usually located in a separate isolation ward or building and has defined as negative air pressure systems (in pascal), separate ventilation with disinfection of air extraction, a properly interlock function and also direct access from the outside. the waste water is decontaminated (autoclave). the patient room has sluice systems and bathroom with through-put decontaminator or autoclave with direct entrance from the patient room. personnel involved in treating high-risk infections should be specialized in isolation work and be healthy, not immunosuppressed, and if possible should be vaccinated, if vaccine is available. the staff should be bound to the ward/unit while isolation treatment takes place. fewest possible should participate in the isolation work. the staff should come and go directly to the high-risk unit and should not stay, work or visit other wards during the isolation period. the infection ward should have restricted admission with registering (name, address, date, time, etc.) and follow-up of all staff and visitors that attended the department. [1, 7, [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] see chap. 21. isolation units for airborne infections should be safe enough for high-risk cases, if used properly [1, 9, [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] . there should be no offices, laboratories, other patient wards or other regular human activities under, over or around this isolation unit. the unit should be located in a separate ward, preferably in a separate building with direct access via an external sluice and internal access through a negative air pressure sluice with sufficient areal for donning and doffing and for a safe treatment of infectious equipment and waste. • each isolate should be 35-40 m 2 , including sluice (6 m 2 ), decontamination room/bathroom (5-6 m 2 ) and patient room (20-25 m 2 ). there should be a minimum of 2-m free zone around the patient's bed on both long sides and at the foot end. • there must be direct access from the patient room to the decontamination room/ bathroom. • interlocked doors must be included in the sluice system. opening of the doors should be in direction from negative pressure to the positive pressure room to avoid air leaks. if the negative pressure increases in the room, the door will close even tighter. • no through-put cabinet from the disinfection room/bathroom, because it can create imbalances in the air pressure. • through-put autoclave/decontaminator from disinfection room to the sluice may be recommended if secured and controlled against air leakage. • graduated negative air pressure is quality ensured by measurements, pressure manometer and control of ventilation. • exhaust from the isolation unit must be disinfected in a satisfactory manner so that it does not expose personnel, patients or passers-by to infection. exhaust is usually sent out from the disinfection room, via a separate disinfection unit where the used air is treated with uv-irradiated hepafilters, and sent out over the roof (see below). • waste water, sewage and other waste should be disinfected/autoclaved before it is discharged outside the isolation area. if the isolate is not a unit for collecting and treating infectious waste/liquid, the faeces, urine and other body fluids are treated locally with 5% chloramine in 1 h before being discharged to the public sewage system. [1, 9, [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] there should be written guidelines for air pressure and air flow. negative pressure should be defined in relation to adjacent rooms and to outside pressure. pressure conditions are checked outside of the patient unit, before entering the unit. there should be an increasing negative pressure from the sluice through the patient room to the disinfection room. the following negative pressure in pascal is recommended in the unit: the negative air pressure must withstand fluctuations in the pressure outside the building, for example, during high winds with increased pressure against the building. it should not be related to pressure fluctuations within buildings. the unit must be tight to prevent air leakage and pressure variations. • no air leaks. all ventilation ducts must be completely sealed without any air leaks (e.g., all-welded steel pipe) and with a separate (over roof) air input and outlet for each isolation unit. disinfection systems for air extraction/exhaust should be placed as close as possible to each isolation unit so that contaminated air does not go far in the piping on the way out. exhaust air must be sterile after the disinfection process. externally placed pipes for air inlet and outlets from isolates must be protected from strong winds that can create unfavourable pressure conditions. the air inlet/outlet to other parts of the hospital must also be protected against contamination from the isolates. therefore, separate isolate buildings are the best solutions. • air change. minimum of six changes of fresh air per hour in the patient room. this involves the replacement of all air in approximately 70 min. avoid short circuit of the air currents. • clean inlet air-hepa-filtered and backlash secured-is introduced from the ceiling or top of the wall of the patient room in such a way that the least possible turbulence occurs during normal use. • exhaust air is contaminated and should be disinfected and hepa-filtered closest possible to the isolation unit. all air from the isolation unit goes out via the separate exhaust system; from the patient's room through grates on lower end of the door to the disinfection room. the exhaust air is disinfected close to-or in the isolate to avoid contaminated air in the piping. exhaust air is never drawn directly out from the patient room or from the sluice because of risk of unfavourable air currents and increased infection burden on personnel. exhaust air must be sterile after treatment and sent out via pipe over roof. • gassing of ventilation pipes with disinfecting gases (formaldehyde, chlorine dioxide, hydrogen peroxide, etc.) must be implemented in a regular manner. assuming the ventilation duct is completely closed and separately for each unit, various types of gas could be used. if leakages are suspected, it may be difficult to use formaldehyde gas (allergy) and chlorine dioxide gas if other part of the building is to be used. the type of gas used must be chosen according to documented effect of the infectious agent, for instance, ebola infection. chlorine gas and hydrogen peroxide dry gas are among the safest gases used today. there is currently no gas which disinfects tubercle bacilli. • continuous electricity supply must be ensured in the isolation unit and the ventilation and negative pressure system. all fixtures and equipment must be disinfected with strong disinfectants, including disinfecting gases, and must be cleaned easily and satisfactorily. note! disinfectant gas can affect instruments and equipment. there should not be wood, tile or other building materials that are easily chipped or cracked, with storage niches for infectious agents. there should be handwashing and suspension of automatic dispensers of disinfectants and paper towels in the sluice, patient room and disinfection room, to avoid unnecessary contamination of doorknobs, etc. thermal disinfection/autoclaving of waste water from the unit should be done the closest possible to the unit to prevent other wards/departments be charged with infectious agents. the container, tank and piping must be absolutely tight and robust for heat/cold/corrosive agents and for ground movements. the drainage system must be shutdown, if needed. air systems connected to the drain/sewer/water must be connected to isolation unit's exhaust system for full inactivation of infectious materials and must be completely sealed. in isolation units with collection of infectious waste water in tank for further disinfection/autoclaving, it is particularly important to ensure safe and risk-free isolation conditions. this means that infected air, liquid and waste should not be spread to nearby areas, even under accidents in the decontamination process. all supply pipes to collection tanks must be sealed, controllable and withstand disinfectants. the sluicing function to such special areas for collecting and decontamination must be ensured in accordance with regulations for the airborne infection isolation units. in case of technical accidents in the collection and treatment rooms, the air should be disinfected with gases before technical personnel enters. technical staff, handling medical equipment, including collection tanks and autoclaves, shall be specially trained in infection control and must be able to use a sluice function with the use of ppe, when entering these disinfection areas. the sluices should be roomy with plenty of space for larger equipment, handwashing/hand disinfectant, through-put disinfection machine/autoclave, etc. there should be a separate out sluice for doffing (undressing), bags for contaminated waste/equipment and opportunities to disinfect/autoclave used ppe-or parts of it-and other equipment. room for a separate shower in the out sluice system should be considered and a room for disinfection of equipment to be reused (e.g. goggles, shoes, etc. that can be disinfected in chloramine 5% in 1 h or autoclaved). the sluice system should be adapted for separate gas disinfection via sealed and tight pipes and interlocked system that can be implemented systematically daily or as needed, without affecting the patient in the isolation room. inter-locking. one of the doors in the sluice/anteroom must always be kept closed. preferably use controlled closures for all doors. [1, 9, [16] [17] [18] [19] [20] [21] [22] • a quarantine unit should include some large patient rooms where it is a place for intensive treatment, acute surgery, dialysis and other invasive treatments, x-ray, microscopy of infectious materials, some important biochemical analyses, etc. [1, 9, [16] [17] [18] [19] [20] [21] [22] • waste, reusable equipment, etc. from the patient or disinfection room should be autoclaved in the through-put autoclave (or disinfection machine) from the disinfection room or patient room to a clean sluice where it can be taken out and treated as noninfectious. all equipment from patient unit must be autoclaved or disinfected in an appropriate manner. equipment can be decontaminated at high temperature (>90° c) in an instrument washing/decontamination machine or submerged in a bath of chloramine 5% 1 h (or peracetic acid or household bleach 10%), depending on the agent in question. s. • in-sluicing and donning (dressing) is done in a clean sluice before entering the unit, with clean, new clothes and clean, new ppe every time. reuse of disposal ppe is not recommended. • out sluicing needs plenty of space for washbasin and suitable hand disinfectant, for doffing (undressing) and for the use of at least three waste bags (disposal, textiles and reusable equipment). ppe must be removed carefully, following guidelines, and placed in a waste bag which is then placed directly in through-put autoclave. reusable equipment (goggles, shoes, etc.) that can be decontaminated/autoclaved are placed in separate containers for reuse. then shower with, for instance, chlorhexidine (hibiscrub) disinfectant in disposable packages, optionally soap in disposable packages. the shower head is set low and with weak force to avoid aerosols against the face. after the shower is finished, the entire cabinet interior, including the floor, is treated with hot water (>75 °c). self-disinfecting shower unit (after use) is advantageous (gas or disinfectant liquid). used towels are put in the textile bag. new, clean clothes are taken on in a clean wardrobe. only the hospital's clothing and shoes are used. [1, 9, [16] [17] [18] [19] [20] • gown-disposable, with tight-fitting cuffs and discarded after each use. it should have long sleeves, be tight around the neck, long and liquid tight. the opening should be on the back; it should be tied back, never on front. option: disposable coveralls with hood or full and tight costume. • cap/hood-surgical-covering all the hair and ears. keeps the hair in place and covers the ears. respiratory protection is set on the outside of the cap. • respiratory mask, p3-level, check leakage with leak test (to be learned). in special cases, a turbo equipment (papr, powered air-purifying respirators) or fresh air/compressed air system is used. remember that battery and reusable parts should be disinfected between each use. • "phantom hood" (surgical large disposable hood) is placed gently over the head and covers the neck and cheeks. • face protection. tight-fitting goggles if high risk. face shield with danger of splatter of infectious material. • gloves with long "cuff", double gloves to make work in isolation easier. latex gloves are denser than vinyl gloves. • shoe covers/room-bound shoes that may be autoclaved after use or boots that are submerged in chloramine bath or other disinfectant after each use. • special leg covering up to the knee at high risk, serious infection. for out sluicing: [1, 9, [16] [17] [18] [19] [20] follow the hospital's procedure that must be learned, trained and supervised. check if waste bags and equipment for undressing are available in the sluice out. all work in the sluice out, like assistance with undressing, takes place only with full dressed ppe. as a rule, there are two people when undressing; a person who can advise and provide assistance, double pack infection bags and take care of equipment to be autoclaved. the assistant uses full, clean ppe. gloves and hand disinfectant must be used before any handling of the equipment. all undressing must occur very carefully and quiet to minimal re-aerosols of microbes from the ppe. remove the individual infection equipment in such a way that you do not contaminate yourself or the environment. carried out in this order: 1. hand disinfection while the gloves are on. 2. room-bound shoes/boots are tilted off and put foot straight into clean shoes. reusable shoes or boots are put in a separate container for autoclaving or disinfection. shoe covers-if used-are carefully removed one after another and placed gently in the waste bag. rinse the shoes on chloramine inserted diaper lying on the floor. 3. hand disinfection while the gloves are on. 4. gloves-double gloves are removed simultaneously-learn the method. grab the left glove at the wrist (not higher up) and gently turn inside out when doffing. the inside of this glove is usually clean and can be used as a "cloth" placed on the right hand to grab through to remove (roll off) the other glove. learn the technique. for left-handed do the opposite. place gently in the waste bag. 5. hand disinfection. 6. put on clean gloves for further undressing-not over the cuff. 7. gown-learn the method, open closure on the back (neck first). pull the cuffs over gloves and roll the gown gently along from the side and from above downwards without touching the outer side. place gently in the waste bag. 8. hand disinfection while the gloves are on. 9. goggles: take back and bend the body forwards to avoid contact with the skin, hair and cloths while taking off the goggles carefully. place in container for autoclaving of reuse. 10. face shield/visor-loosen from behind as mask and take off bending forward. 11. gloves-learn the method to take off without recontamination (see above). placed gently in the waste bag. 12. hand disinfection. 13. "phantom hood"; take back on the lower part of the hood that has been covered by the gown, and with both hands tear it up along the seam behind while bending the body forwards to avoid contact with the skin, hair and cloths; take off the hood slowly, and put it in the waste bag. 14. hand disinfection. 15. respiratory protection mask-grasp the elastic back on the head; bend the body forwards to avoid contact with the skin, hair and cloths; take off carefully, and place the mask in the waste bag. 16. hand disinfection. 17. the surgical cap/hood-which was under masks and phantom hood; take off from behind, bend the body forwards to avoid contact with the skin, hair and cloths and place the cap in the waste bag. 18. hand disinfection. 19 . showers and dressing of new clothes as described above. autoclaved or heat disinfected (85-90 °c for 10 min) or submerged in disinfectants (chloramine 5%, household bleach 10% or peracetic acid) before normal processing. option: all textiles are treated as infected and put in a container for used textiles. contaminated/wet fabrics are packed in plastic before placing in waterproof textile bag. the outside of the bag is decontaminated and washed with 5% chloramine before double packed with a new clean bag in the sluice. the outside will then be clean during transport for further treatment. the type of the infectious agent and local possibility determine further treatment of textiles (heat washing, chemicals, autoclaving, burning). excess equipment should be removed before the patient arrives. used equipment should be autoclaved in a through-put autoclave before the normal treatment. option: disinfected in the isolation unit's disinfection room. equipment that can withstand heat is heat disinfected in decontaminator or instrument washing machine. heat-sensitive components like thermometers are disinfected in 5% chloramine or other disinfectants for 1 h. used equipment should be autoclaved in a through-put autoclave before normal treatment. option: decontaminated in the isolation unit's disinfection room (85-90 °c) or double packed and brought to the decontamination room in the ward for decontamination-and then processed as usual. disposable equipment is treated as infectious waste. infectious waste is autoclaved in through-put autoclave, before processing as ordinary waste. option: all waste is double packed and treated as special infectious waste. the outside of the bag is decontaminated and washed with 5% chloramine before double packed with a new clean bag in the sluice. the outside will then be clean during transport for further transport and treatment. infectious waste is brought directly to incineration without intermediate storage. follow general guidelines. the boxes may be autoclaved in through-put autoclave, before processing as ordinary waste. option: boxes are double packed and treated as special infectious waste. the box must not be filled more than about ¾ full. see labelling for filling level. the outside of the bag is decontaminated and washed with 5% chloramine before double packed with a new clean bag in the sluice. the outside will then be clean during transport for further special transport and destruction. infectious waste is brought directly to incineration without intermediate storage. in most cases it is not recommended to bring the patient out of isolation during the period of active infection. special solutions should be made for these. if transport out of the isolate is necessary, everything must be planned carefully in advance. death bodies are wrapped in body bag, double packed in the sluice and sent directly to the pathologist or burial. remember information in advance! follow general guidelines and contact serving microbiological laboratory or the national institute of public health before transport of sampled biological materials form the patient! sampling/preparation for transfer of infectious sample material should be provided in the patient room or its disinfection room. sample vials and outside of the package must be clean before transport. blood samples from patients with blood-carrying infection are packaged in special cases (sleeves) before transport. the outer package is put on in the sluice. nb! a good cleaning and disinfection of the workplace! note on the outer bag suspected high-risk agent with red ink! special transportation! contact receiver in advance, and ask how to bring the samples to the laboratory. send no samples as post in pneumatic tube! only essential transport is allowed, depending on infectious agents. patient, cloth and stretcher/bed should be clean during transport. bandages must be clean, and drains, etc. must be covered and free of leaks. staff transporting and receiving the patient must be informed about the infection in advance and guided on individual infection prevention and the use of ppe. patients with respiratory infection should wear surgical mask or respiratory mask (p1-p3 level) outside the isolate. the transport should not go through wards or crowded areas and avoid the use of a lift. internal transport in hospitals is not recommended in certain highly infectious and severe illnesses. in agreement with the patient library, the patient can borrow books that can be discarded. the books are kept in isolation. all books are treated as infectious waste by termination of the isolation. restricted admittance and use the same guidelines and ppe (donning and doffing) as for the staff. handwashing is required when the sluice is left. limit visits to a minimum, especially with highly infectious diseases such as sars. the cleaning and disinfection is performed by trained personnel with required attire and use of ppe. regular detergent, water and clean equipment are used if no other routine is ordered. bucket and squeegee are disinfected in the decontaminator of the isolation unit; shaft is disinfected chemically in 5% chloramine (or household bleach) in 1 h and kept in the unit during the entire treatment. use only disposable mops and cloths placed in yellow plastic bag in yellow infectious waste bag and autoclaved in the isolation unit. discard as infectious waste after appointment. option if not autoclave/decontaminator in the isolation unit: infectious waste bag is treated exterior with 5% chloramine and double packed in new yellow thick plastic bag in the sluice. special infectious waste is brought directly for burning/autoclaving. in case of spills, the nursing staff should immediately remove the spill and disinfect the area with 5% chloramine 1 h (covered by plastic) before cleaning. before regular disinfection of the isolation unit after terminated isolation, it is recommended to treat the unit with hydrogen peroxide dry gas, three cycles, using a spore control. only trained personnel are participating in the work with disinfection, and they use mandatory infection control equipment. the nurse, in cooperation with infection control personnel, is responsible for informing the staff about what should be disinfected and how. bedding, curtains, drapes, etc. should be autoclaved, if possible, before sending it to laundry or to incineration. floors, walls, ceilings, all horizontal surfaces, ceiling suspension, lighting in ceilings, etc., handles, dial string (changed), levers, buttons, switches, bed, waterproof mattresses, bedside tables and other fixtures and equipment (tv, telephone, computer, etc.) are disinfected with 5% chloramine (or household bleach 10%) for 1 h. textiles, reusable equipment and waste: follow described above recommendations. unused disposal equipment that has been inside the isolation unit is disposed of as infectious waste. after manual disinfection, all rooms and ventilation systems are gassed once more. this is done in collaboration between the ward, housekeeping/technical and infection control personnel. to treat with gas disinfection before and after manual disinfection is recommended to reduce the infectious airborne agent (aerosols and re-aerosols) in the unit. after the recommended effect period of the disinfectant, the rooms are cleaned with ordinary detergent, water and clean equipment. there are many discussions concerning the degree of airborne transmissions and how to protect personnel, especially against dangerous infections; see the background information [1, 9, [16] [17] [18] [19] [20] (fig. 19.1) . isolation regimens should not prevent treatment but be included in the diagnosis and treatment. nb! good hand hygiene is important! it prevents the spread of infection! handbook of hygiene and infection control in hospitals. part 1 microbiology and infection control no. 55 of protection against infectious diseases regulations in infection control in health facilities -hospital infections, established by the health and social affairs action plan for infection control in norwegian hospitals, health directorate's guidance series 2-92. directorate of health use of isolation to prevent spread of infection in hospitals. health directorate's guidance series: directorate of health on the protection of workers from the risks related to exposure to biological agents at work cdc draft guideline for isolation precautions in hospital in: handbook of hygiene and infection control in hospitals. oslo: ullevål university hospital cdc draft guideline for isolation precautions in hospital guideline for isolation precautions in hospitals cdc draft guideline for preventing the transmission of mycobacterium tuberculosis in health care facilities the use of adult isolation facilities in a uk infectious disease unit guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. cdc isolation of dangerous infections. in: handbook of hygiene and infection control in hospitals. oslo: ullevål university hospital scenario pandemic influenza and pandemic avian influenza. in: handbook of hygiene and infection control in hospitals. part 1 microbiology and infection control avian influenza with pandemic potential handbook of hygiene and infection control in hospitals. part 1 microbiology and infection control handbook of hygiene and infection control in hospitals. part 1 microbiology and infection control the design of isolation rooms hospital and community acquired infection and the built environment-design and testing of infection control rooms door-opening motion can potentially lead to a transient breakdown in negative-pressure isolation conditions: the importance of vorticity and buoyancy airflows isolation rooms for highly infectious diseases: an inventory of capabilities in european countries patient care in a biological safety level 4 (bsl-4) environment evidence-based design of health care facilities: opportunities for research and practice in infection prevention the role of facility design in preventing the transmission of healthcare-associated infections: background and conceptual framework the role of the hospital environment in preventing healthcare-associated infections caused by pathogens transmitted through the air the airborne transmission of infection in hospital buildings: fact or fiction? role of ventilation in airborne transmission of infectious agents in the built environment-a multi-disiplinary systematic review virus diffusion in isolation rooms review of aerosol transmission of influenza a virus detection of bordetella pertussis and respiratory syncytial virus in air samples from hospital rooms aerial dispersal of methicillin-resistant staphylococcus aureus in hospital rooms by infected and colonised patients air and surface contamination patterns of methicillinresistant staphylococcus aureus on eight acute hospital wards air contamination around patients colonized with multidrug-resistant organisms international infection control guidelines may not protect against ebola. hospital health care infection control guidelines that did not work against ebola in 2014 textbook of hygiene. oslo: fabritius & sønner forlag violent expiratory events: on coughing and sneezing the potential for airborne dispersal of clostridium difficile from symptomatic patients virus associated with skin rash and children's diseases. in: handbook of hygiene and infection control in hospitals. part 1 microbiology and infection control bordetella pertussis -whooping cough. in: handbook of hygiene and infection control in hospitals. part 1 microbiology and infection control aiborne dispersal as a novel transmission route of coagulase-negative staphylococci, interaction between coagulase-negative staphylococci and rhinovirus infection possible role of aerosol transmission in a hospital outbreak of influenza protecting staff against airborne viral particles: in vivo efficiency of laser masks droplet fate in indoor environments, or can we prevent the spread of infection pneumonic plague outbreak multi drug-resistant tuberculosis outbreak in gaming centres health care response to cchf in us soldier and nosocomial transmission to health care providers key: cord-271925-85bixn27 authors: rao us, v.; arakeri, g.; subash, a.; thankur, s. title: droplet nuclei aerosol and covid 19 a risk to healthcare staff date: 2020-05-03 journal: br j oral maxillofac surg doi: 10.1016/j.bjoms.2020.04.036 sha: doc_id: 271925 cord_uid: 85bixn27 nan we read with great interest the editorial by herron jbt et al 1 on the personal protective equipment (ppe) and coronavirus disease 2019 . the authors need to be complimented for a well-timed paper that addresses the current issue of exposure of health care workers to covid 19. authors mentioned that flügge droplets travel up to 4.5 m, representing a risk to healthcare staff that is not directly involved in patient care. 1, 2 it is also noteworthy that the aerosols and droplets produced through speech has also been linked in person-to-person virus transmission. 3 large droplets fall on to the ground, small droplets can dehydrate and remain as "droplet nuclei" in the air and behave like an aerosol. 3, 4 with the day-time temperature soaring, high-speed ceiling fans are being used in hospital wards. this can expand the spatial extent to which the emitted infectious particles can travel. health care workers and employers who are not directly involved in patient care are also at risk of virus transmission due to this and need to take adequate precautions. furthermore, given the rising number of covid 19 cases in india, different cadres of healthcare personnel are being inducted for screening and treatment delivery. communitybased health workers are being deployed as the "interface between the community and the public health system". 5 as they deal with suspected cases, they are also prone to droplet nuclei aerosol exposure. hence it is advised to educate them about the droplet nuclei aerosol risk and the use of n95 or ffp2 masks. as rightly mentioned by the authors, the health care staff and the employee must receive adequate training to use personal protective equipment. there is a high chance that newly recruited or mobilised health care staff lack thorough knowledge of ppe usage. after gowning up, healthcare workers may get a sense of protection. this could be disastrous, as there is always a possibility that the health care staff may become a victim of human error making them vulnerable. this is a common scenario during the removal and disposing of ppe safely. once the purpose is served, the users must take the utmost caution while disrobing and disposing of the ppe. those at the forefront are busy and stressed with long shifts in sub-optimal conditions and fatigue is bound to set in. the staff may overlook the strict protocol of removal and disposal of ppe, thus defeating the entire purpose of wearing ppe. lastly, the availability of adequate ppe has been a key concern globally. in india, the certified kits should be made from 70 ± 5 gsm material, adhere to south india textile research association (sitra) guidelines, seam stitches and be hydrophobic. avaricious elements have been manufacturing these at a premium without adhering to safety regulations. adequate training and education about droplet nuclei aerosol is very important for the safety of health care professionals and reducing risk of virus exposure. the training should be simple yet easy to reciprocate so that it can percolate across the spectrum of healthcare workers. none. not applicable. personal protective equipment and covid 19-a risk to healthcare staff? the impact of high-flow nasal cannula (hfnc) on coughing distance: implications on its use during the novel coronavirus disease outbreak visualizing speech-generated oral fluid droplets with laser light scattering mechanistic insights into the effect of humidity on airborne influenza virus survival published by elsevier ltd on behalf of the british association of oral and maxillofacial surgeons. transmission and incidence time to bring some hope to asha workers fighting coronavirus at frontline key: cord-027880-1apexs6o authors: hankenson, f. claire; mauntel, mark; willard, jamie; pittsley, leslie; degg, william; burnell, niko; vierling, alan; griffis, stanley title: vaporized hydrogen peroxide decontamination of n95 respirators in a dedicated animal research facility for reuse during a novel coronavirus pandemic date: 2020-06-24 journal: appl biosaf doi: 10.1177/1535676020936381 sha: doc_id: 27880 cord_uid: 1apexs6o introduction: during the covid-19 pandemic, health care systems and safety providers have faced an unprecedented challenge of limited access to personal protective equipment (ppe) to conduct patient and public care. in federal emergencies, reuse of ppe after disinfection can occur by processes, like vaporized hydrogen peroxide (vhp), recommended by the centers for disease and control and prevention. we identified a vacant animal holding facility at our institution to repurpose into a regional vhp decontamination center. methods: the facility is a multiroom, 20 000 ft(2) building with control of hvac to adjust to vhp conditional requirements. h(2)o(2) was delivered to rooms using robotic halofoggers, dispersing h(2)o(2) vapor and increasingly concentrated microdroplets as a fog for a timed period based on cubic footage of rooms. results: fogging cycles eliminated 6-log geobacillus stearothermophilus up to 7 days postcycle. functional efficacy of treated n95s was confirmed by fit tests of institutional personnel. signage, process flow mapping, and training materials facilitated ease of workflow and adherence to safety expectations within the building. discussion and conclusion: our study determined that a variety of n95 respirator types and sizes were able to be cleared of potential bacterial and viral agents using vhp in a controlled fog/dwell/exhaust cycle. this repurposed animal facility has the capacity to decontaminate up to 6700 respirators daily, which will address the predicted surge of covid-19 cases in the state, and ultimately allow each respirator to be reused multiple times. there is no other public site in the region with our capacity to offset the continued supply chain issues for ppe needs. an urgent need exists for access to personal protective equipment (ppe), specifically n95 (also referred to as ffr, filtering face piece respirators) respirators, for health care providers, first-line responders, and police, fire, and safety officials in response to the covid-19 pandemic. news media stories continue to highlight the extreme difficulty in procurement of ppe, the seizure of ppe shipments prior to distribution, and the practice of extending use of single n95s for multiple shifts, if not days, by health workers. to contribute to the decontamination effort for ppe needed in health sites in proximity to our institution, we repurposed a vacant animal research housing facility to establish a center for application of vaporized hydrogen peroxide (vhp) to disinfect critical medical materials for their return into service. the project was designed using an interdisciplinary approach between veterinary and medical experts, hospital partners (health systems a & b), and environmental safety, microbiology, and supply chain experts. numerous studies conducted with vhp have evaluated its use in veterinary and research facilities, high-containment laboratories, and hospital sites. [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] building on the foundation of useful vhp data 2, [14] [15] [16] and subsequent approvals by the food and drug administration since march 2020, the leadership at the state and institutional levels sought options for vhp decontamination locally. our h 2 o 2 decontamination process was founded on the fda emergency use authorization (eua) granted to battelle memorial institute 14 and duke university 3,16 as well as statements and publications from other sites and agencies. 15, [17] [18] [19] [20] [21] at our institution, campus animal resources (car) oversees the biomedical animal research operation and has used vhp in routine practice for many years. vhp exposures within the program have disinfected animal housing rooms between species and project cohorts and also decontaminated laboratory spaces with equipment like computers, incubators, texts, and lab notebooks without damaging effects. 22 building on our decontamination efforts to date, the vhp process for human medical equipment was assessed internally with the intent to return disinfected n95 respirators to their original owners at our hospital partner sites and assist safety groups (police and fire departments) with equipment disinfection across the state of michigan. this study describes the intensive developmental process that was necessary to convert a multiroom animal housing facility into a regional vhp decontamination center in response to the impact of the coronavirus pandemic in the united states. our vhp process uses the halo disinfection system, dispensed by the halofogger, and includes confirmation of vhp exposure within the area using chemical indicator h 2 o 2 strip tests (halosil, distributed by quip laboratories, inc; wilmington, de). the halofogger disperses macrodroplets of 5% hydrogen peroxide solution, halomist fluid, in a uniform fashion for a timed period based on cubic footage of the room size, which then dictates the amount of ppe that can be decontaminated ( the selected animal housing facility (bldg j) is a 10-room, 20 000-ft 2 environmentally controlled stand-alone building. the facility accommodates housing and contains a 3-room animal surgery suite, restrooms, and break-room area; there is no public access, wet lab space, or connection to other facilities. the building hvac is manually controlled and can be adjusted to meet vhp operation conditional requirements (temperature <70 f, humidity <50%). animal housing rooms are temperature (68-72 f) and humidity (30-70%) controlled; within bldg j in march/april, rooms are 68 f and *35% to 40% humidity. due to the supply air needing to be cut off completely for the vhp cycles to function, temperatures are currently below that for which animal housing would be acceptable. the animal care program and affiliated animal housing buildings are accredited by aaalac. facilities are inspected semiannually by the institutional animal care and use committee, registered to the us department of agriculture (usda), and are included in the public health service assurance for research use; importantly, this facility will not be used for animal housing during its conversion to a vhp disinfection center. repurposing adjacent housing rooms (n ¼ 9) allows for fogging of n95s in each space using 1 fogger per room; health teams enter through the converted surgical suite to don ppe (disposable gown, face protection, double gloves), and contaminated materials are delivered into the building through a separate entry that was formerly used as an emergency exit ( figure 1 ). animal operations staff are to assess foggers and refill fluid reservoirs as needed, place chemical and biological indicators for each new cycle, stock ppe stations, and arrange for removal of full cardboard barrels for incineration, along with standard facility cleaning, as needed. safety of personnel working within the facility was paramount; therefore, process flow maps were created using microsoft visio ( figure 2 ) to predict routes intended to limit crossover of labor, maximize social distancing, and separate the 2-person team from the soiled medical materials. the goal of the logistics effort was to ensure design of specific procedures so that the facility remains (1) pathogen-free for all persons and (2) capable of safely processing medical items from regional hospitals for decontamination and return. instructional signage was created to indicate personnel versus material entry, ppe vhp cycle parameters were tested repeatedly to ensure bacterial spore kill for all bis. in brief, individual bis are removed from packages by pulling open the edges of the pouch and laying the bi, without directly contacting the disk, into the bottom half of a plastic petri dish, with the domed side of the bi touching the dish. petri dishes with bis are placed at up to 10 distinct locations across storage racks, on high and low shelves, and at corners of the room most distant from the halofogger. following completed vhp cycle (fog/dwell/exhaust) phases, petri dish bottoms are covered with corresponding tops, taped closed, and transported to an adjacent building for culture procedures. sterile collection of bis is critical to avoid crosscontamination; it is recommended to harvest bis from petri dishes within a biosafety cabinet, using sterile forceps to place disks into media vials. vials are to be sealed tightly and incubated (convection style incubator, precision scientific, set to 60 c) upright in test tube racks at 55 c to 60 c for up to 7 days. each culture run should include a fresh bi that was not exposed to vhp, instead taken directly from its package and placed in media (control þ). an unopened media vial (control -) is included with each culture. training documents and standard operating procedures were an essential component of the institutional fda eua application and captured each step of the process. in brief, health care/ safety staff (in teams of two) inspect used n95 respirators for holes, tears, obvious damage, or significant visible soiling (including makeup, blood) and should discard these respirators to remove them from circulation at the originating site. to ensure "chain of custody," health care employees are instructed to label names on their used respirators with permanent marker and then place within individual paper bags before collection for decontamination. the batch of ppe destined for transfer to our institution is placed in biohazard containers (red bag style) that are closed and secured into plastic tote bins that are closed with a firm lid seal. car is contacted directly to schedule availability for vhp decontamination of n95s. health partner sites are asked to identify teams to serve as the dedicated n95 transporters/collectors, typically comprised of administrators and supply chain and surgery technicians with experience in donning/doffing ppe, sterile technique, and clean-to-dirty practices. health teams are given a personal tour at the time of arrival prior to unloading any used materials within animal rooms. health teams are instructed how to lay out n95s on storage racks in rooms, placing them with domed surface facing ceiling, and situate respirators to avoid overlap on storage rack shelving (figure 3 ). disposable items (respirators with makeup or stains, paper bags, packing materials, biohazard transport bags) are collected within the room into a cardboard fiber barrel lined with plastic for later incineration through institutional waste stream protocols. prior to exit from rooms, health teams are to remove their outer layer of gloves, press the start button on the halofogger within the room, and exit to the hallway within 90 seconds before the initiation of fogging. room doors are shut and frames sealed using 2-inch masking tape. to facilitate communication between health teams and car staff, the start time of the fogger and word cycle is to be written on a whiteboard placed on the outside of the room. staff exit the building through a pass-through room, distinct from where they and their materials entered, allowing for a different location to doff ppe per cdc guidelines and wash hands in portable sinks (borrowed from the institutional athletic department). sanitizer in hands-free dispenser is provided in the pass-through area as an additional safety measure for use before departure. once the appropriate fog/dwell phases are complete, animal operations staff enter the facility through the personnel pathway and verify that the chemical indicator placed on the interior of the room viewing window turned to the color black, confirming vhp exposure. (note: in the rare circumstance when a viewing window indicator remains white, it will be assumed that the room has not been exposed; the vhp equipment will be assessed, and the fogger cycle will be run again.) next, keeping the room door closed, the exhaust vent within the room is opened by using an exterior pull string that was positioned prior to vhp cycle startup. following the exhaust phase, facility staff remove masking tape from room door frame and stand at open doorway to check vhp levels (drager x-am 5100 single gas h 2 o 2 monitor, handheld). to deem room safe for personnel entry, the h 2 o 2 levels must be <1.0 ppm. if the room reading is higher than 1.0 ppm, the door should be closed, and more time should be allowed to evacuate vapor through the building exhaust system until the sensor reads below 1.0 ppm. bis are collected, as described previously, without disturbing any of the arranged ppe. next, car staff leave room, close door, and update whiteboard signage to read test with date and time to indicate that bis are undergoing assessment. facility staff exit building through the pass-through and deliver room bis and positive control bi to laboratory (see "bi collection and culture procedures"). media tubes are assessed daily for up to 7 days, and health team personnel are contacted to arrange for ppe retrieval once bacterial kill is confirmed. similar to entry practices when bringing used materials to the building, health staff repeat these steps and maintain social distancing as the 2 team members don ppe and walk to their assigned room marked test. the health team enters the room and closes the door, then proceeds to gather ppe into clear plastic bagging (brought by the team) to clearly reveal name of original wearer. each respirator is to have a hashmark placed with permanent marker along the respirator edge to verify 1 vhp exposure has occurred. up to 20 vhp cycles are permitted for a single respirator, per recommendations from the fda as part of the institutional eua application. items are placed within the transport containers that were left within the room to also be disinfected; the outer container is closed and sealed before leaving room. health staff write "empty" on the room door whiteboard, take the transport container with cleaned items to place outside the w door, and exit through the pass-through room. the transport container is retrieved, and the health team alerts the car team that the collection is complete. this final confirmatory communication allows the animal operations group to proceed to set up the housing rooms for a fresh vhp cycle in a timely manner. the hospital testing sites, as our partners in the design of this vhp decontamination project, return respirators to original wearers and conduct osha fit testing with their own employee health staff, including nurses, at their sites. per osha announcements, vhp is a recognized method to decontaminate n95s for emergency use, in support of cdc directives on this method, with a number of caveats that are to be followed for wearing decontaminated respirators. 19, 20, 23 once an employee (regardless of whether from a health site or from the institution) is properly fit tested, the type and size of the n95 respirator is noted in a record that is kept in employee health/online training systems. each respirator is to be inspected after the decontamination cycle, and respirators that are soiled, distorted, or perforated are discarded. each health staff member will perform a self-seal test on their decontaminated respirator before use. if the respirator fails the self-seal test, it is discarded. respirators for which the wearer has already been fit tested will be returned to the wearer and put through additional fit testing procedures (sitedependent). hospital partners will use qualitative methods with either bitrex (moldex) or saccharine/bitter (3m) for fit testing. pilot tests of commonly used n95s exposed to consecutive cycles of vhp and then fit tested on employees were successful; no failed fit tests, no reported chemical odor, and no concerns about seals, elastic, and nose pieces were reported. pilot tests to verify vhp cycles were conducted without ppe (n ¼ 8) and with used ppe (n ¼ 5). of those vhp trials conducted without ppe, the first 3 trials (data not shown) had more than 1 positive bi within 24 hours of culture; therefore, conditions continued to be optimized in consultation with quip laboratories. of the next 5 trials (table 2) , only 1 had a positive bi when the disc was placed in closest proximity to the exhaust vent for the room. all other samples in those optimized trials without ppe had complete bi kill in media tubes incubated for up to 7 consecutive days. once confidence in culture technique was solidified, contaminated ppe was brought to our facility by health care system partners (n ¼ 3) and by safety responders involving police and fire departments (n ¼ 2); all cultured bis were successfully killed for these cycles, and materials were returned to their owners. training documents created throughout the project included: instructions for health care facilities for vhp decontamination, instructions for health care personnel for vhp decontamination, health care provider fact sheet (fda eua format), instructions for facility operation of vhp decontamination equipment, and a standard operating procedure and data recording sheet on the placement and collection of bi in validating the vhp cycle. dedicated data sheets recorded individual vhp cycle parameters and bi culture results for each pilot test; completed sheets were scanned and saved to a shared departmental server. the ability to repurpose a secure vacant animal facility into a regional vhp decontamination center offered an unprecedented opportunity for veterinary, animal care, and medical professionals and administrators to cooperatively and creatively respond to the covid-19 crisis. every step in our protocol was tested by animal operations staff as well as logistics experts, medical professionals, and administrators at health systems a and b. health system a contains 5 hospitals serving seven counties, and health system b has 5 acute care hospitals and 2 psychiatric hospitals, overall serving >15 counties in the state. between these 2 major hospital systems, more than 18 000 clinicians and support staff are providing care and services to patients suspect for and confirmed with covid-19. although both hospital systems have supply chain leaders and purchasing staff working tirelessly to obtain requisite ppe, on any given day, the supplies for isolation gowns, face shields, and n95 s are dire. the estimated "burn rate" considering the single use of respirators ranges from 2300 to 3200 per day. they estimate the burn rate for isolation gowns ranges from 13 000 to 18 000 per day. our regional decontamination site is intended to serve as a stopgap measure to offset the discard of single-use ppe until such time that suppliers are secured to restore ready access to ppe at these health centers. important to the covid-19 response, virucidal activity of vhp is paramount, and the ability to kill geobacillus spores serves as a proxy to ensure that environmentally hardy organisms are eliminated by the cycle time described for the halofogger with halomist. 24 we did not have access to confirmed covid-19 samples to test eradication of coronavirus by the hydrogen peroxide fogging system; however, the epa data for this chemical confirm virucidal activity. one of the major advantages of hydrogen peroxide is its safety profile; it readily breaks down into water and oxygen with no toxic by-products or residues. our cycle design includes a dwell phase that is double the length of the manufacturer recommended time, and after a 90-minute exhaust phase (during which the room air changes per hour are minimally 10-15 per hour), there has not been detection of h 2 o 2 levels above 1.00 ppm remaining in the room at the time of bi collection. importantly, safety of personnel working within the facility is paramount, and process flow mapping has been executed to ensure limited crossover of labor, social distancing, and appropriate donning and doffing of protective gear for these needs. the shared partnership between health care and facility staff eliminates concerns about labor fatigue for any group working on this process. because of the repurposing of an animal facility for this request and given the number of higher education/biomedical universities that have similar animal facilities at their locations, this project is readily adaptable for similar innovation at multiple institutions throughout the united states, a great many of which already have access to and ownership of portable h 2 o 2 fogging devices. institutions with aaalac-accredited animal research areas, all of which comply with regulated environmental controls, will be able to use our protocols, specific vhp cycle times, and bi exposure and collection instructions to deliver vhp decontamination of used medical materials for their regions as well. our institution is actively seeking fda eua approval because this regional site has the ability to influence multiple areas throughout the state, in particular to sterilize n95 respirators for reuse by the original wearer and disinfect other medical items (face shields, eyewear, and isolation gowns) that may potentially become challenging to procure in the weeks and months ahead. we believe that the use of this dedicated facility for h 2 o 2 decontamination will support multiple larger clinical and smaller safety units and their essential employees for all first-responders to rely confidently on the security and efficacy of their ppe while they give care to patients and the public. hydrogen peroxide vapour decontamination of surfaces artificially contaminated with norovirus surrogate feline calicivirus evaluating the virucidal efficacy of hydrogen peroxide vapour webinar: solutions for ppe shortages -covid-19 decontamination strategies and in-house production options facility-wide eradication of corynebacterium bovis by using pcr-validated vaporized hydrogen peroxide pcr prevalence of murine opportunistic microbes and their mitigation by using vaporized hydrogen peroxide staphylococcus xylosus pcr-validated decontamination of murine individually ventilated cage racks and air handling units by using 'active-closed' exposure to vaporized hydrogen peroxide disinfectants used for environmental disinfection and new room decontamination technology efficacy of vaporized hydrogen peroxide for repeated sterilization of a single-use single-incision laparoscopic surgery port gaseous decontamination methods in high-containment laboratories area fumigation with hydrogen peroxide vapor vaporized hydrogen peroxide-based biodecontamination of a high-containment laboratory under negative pressure gaseous and air decontamination technologies for clostridium difficile in the healthcare environment biodecontamination of animal rooms and heat-sensitive equipment with vaporized hydrogen peroxide final report for the bioquell hydrogen peroxide vapor (hpv) decontamination for reuse of n95 respirators hydrogen peroxide vapor sterilization of n95 respirators for reuse decontamination and reuse of n95 respirators wtih hydrogen peroxide vapor to address worldwide personal protective equipment shortages during the sars-cov-2 (covid-19) pandemic evaluation of five decontamination methods for filtering facepiece respirators assessment of n95 respirator decontamination and re-use for sars-cov-2. preprint occupational safety and health administration. enforcement guidance on decontamination of filtering facepiece respirators in healthcare during the coronavirus disease 2019 (covid-19) pandemic national institutes of health. nih study validates decontamination methods for re-use of n95 respirators decontamination assessment of bacillus anthracis, bacillus subtilis, and geobacillus stearothermophilus spores on indoor surfaces using a hydrogen peroxide gas generator n95 respirator decontamination: osha weighs in. ehs daily advisor virucidal activity of disinfectants against parvoviruses and reference viruses we are grateful for the input of institutional colleagues, including norman beauchamp, kristen burt, becky ceru, chris colvin, michelle cooper, jeff dwyer, kevin eisenbeis, preston fishnick, larry gremel, jr haywood, kelly jimenez, janet lillie, brian smith, and vedat verter. we appreciate additional contributions from our health team partners, including jon baker, shelley hagan, brian mccardel, annette philips, and bob seidel. timothy hiddell and donna monroe provided their expertise on biological indicator parameters and halosil equipment and products. the authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. not applicable to this study. the authors received no financial support for the research, authorship, and/or publication of this article. not applicable to this study. not applicable to this study. key: cord-302902-34vftqt9 authors: law, brenda hiu yan; cheung, po-yin; aziz, khalid; schmölzer, georg m. title: effect of covid-19 precautions on neonatal resuscitation practice: a balance between healthcare provider safety, infection control, and effective neonatal care date: 2020-08-18 journal: front pediatr doi: 10.3389/fped.2020.00478 sha: doc_id: 302902 cord_uid: 34vftqt9 adaptations have been proposed for resuscitation of infants born to women with covid-19, to protect health care providers, maintain infection control, and limit post-natal transmission. changes especially impact respiratory procedures, personal protective equipment (ppe) use, resuscitation environments, teamwork, and family involvement. adding viral filters to ventilation devices and modifications to intubation procedures might hinder effective ventilation. ppe could delay resuscitation, hinder task performance, and degrade communication. changes to resuscitation locations and team composition alter workflow and teamwork. physical distancing measures and ppe impede family-integrated care. these disruptions need to be considered given the uncertainty of vertical transmission of sars-cov-2. covid-19 is an evolving pandemic caused by the novel betacoronavirus sars-cov-2 (1). while mortality is associated with advanced age and co-morbidities, pregnant women can be affected (2) . it is unclear how much maternal covid-19 infection contributes to fetal distress, preterm labor, or indications for early delivery (3) . suspected vertical transmission has been reported (4) but the risk appears low (5) . current neonatal resuscitation guidelines include recommendations on equipment, procedures, team composition, and teamwork (6) . adaptations have been proposed for resuscitation of infants born to women with suspected or confirmed covid-19, to protect health care providers (hcps), limit post-natal transmission, and maintain infection control (7) . neonatal resuscitation may be especially impacted by changes in (i) respiratory support, (ii) personal protective equipment (ppe), (iii) resuscitation environment, (iv) team-based activities, and (v) family involvement ( table 1) . in this article, we explore these potential disruptions and propose strategies to evaluate and minimize their impact. mask ventilation and endotracheal intubation are aerosol generating procedures (agp) critical to neonatal resuscitation (6) . the risk of transmitting sars-cov-2 to hcps during agps is estimated from observational studies in other viral infections (8) . modifications to ventilation practices during neonatal resuscitation have been proposed to protect hcps during agps, based on limited evidence on vertical transmission and aerosolization of sars-cov-2 (7, 9) . general covid-19 resuscitation guidelines recommend the use of viral filters on mask ventilation devices to decrease risks to hcps (9) . the effectiveness of viral filters depend on mask seal, filter, and device type (e.g., self-inflating bag, flowinflating bag, and t-piece resuscitators), flow rate, filter integrity, and patient factors (10) . experience with filters come from ventilated patients in intensive care or anesthetic environments (11) filters increase airway resistance, dead space and co 2 retention, and obstruct the ventilation circuit if soiled (10, 11) . filter complications may be exaggerated in neonates due to their lower tidal volume, minute ventilation, and functional reserve (11) . smallest filters are only rated for infants weighing 3 kg and above. manufacturers have warned against fitting of viral filters to their devices, as these configurations are untested (12) . further testing is needed to determine how filters affect mask ventilation in neonates. another strategy to reduce aerosolization during mask ventilation is to minimize mask leak. two-person mask application reduces mask leak but increases hcp exposure; respiratory function monitoring detects mask leak but requires additional training and equipment (13) . endotracheal intubation is a confirmed risk factor for hcp infection in the previous sars (severe acute respiratory syndrome) outbreak (14) . given the low likelihood of vertical transmission with the sars-cov-2, the need for covid-19 intubation precautions during neonatal resuscitation in the delivery room is likely low. pre-emptive intubation to avoid mask ventilation (as suggested in adult settings) may lead to excess intubations and intubation attempts in neonates. the use of videolaryngoscopes and cuffed endotracheal tubes further minimize risk during neonatal resuscitation, but are significant practice changes for many centers. at our center, we have not altered the indications, timing, or procedure for intubation during neonatal resuscitation of covid-19 exposed infants. nonetheless, concerns with this procedure may cause deviations from established practice. changes to respiratory equipment or indications for their use may affect hcp workload, introduce equipment uncommon in neonatal care, or lead to neonates receiving supports or interventions unsuited to their needs. examples include: using low flow nasal canula (lfnc) instead of nasal cpap (constant positive airway pressure) to avoid agps, intubating with cuffed endotracheal tubes, or inserting viral filters in respiratory circuits. the impact of these approaches may be unpredictable. if vertical transmission is unlikely (5), the potential harms of these variations may outweigh potential benefits, particularly if hcps don ppe. hcp roles and tasks are variably impacted by personal protective equipment (ppe) (15) . although opinions vary with respect to use of respirator (n95) vs. surgical masks for neonatal resuscitation (7, 16) , both may impact hcp performance. guidelines support use of ppe in suspected or confirm covid-19 settings, even if initial resuscitation is delayed (9) . donning ppe introduce delays when neonatal resuscitation is not anticipated, and may be done incorrectly if hcps are rushed. when the likelihood of resuscitation is low, hcp exposure, and ppe use may be minimized by limiting the resuscitation team to 1 or 2 members. this approach acknowledges that advanced resuscitation (e.g., umbilical venous line insertion, epinephrine), if required, may be delayed. some advocate that possible delays to emergency c-sections should be discussed with pregnant women under covid-19 isolation (17) . similar discussions for neonatal resuscitation may be needed. donning and doffing ppe take practice, time, and care for full effect. when pressed for time, hcps may don and doff incorrectly (18) . additional staff may be engaged to "spot" breaches and prevent self-contamination during doffing. ppe itself may further impact individual performance (19) . the effect of masks and eye-protection on performance of neonatal resuscitation tasks is unknown. eye-protection or fogging may hinder vision, interfering with clinical assessments and procedures such as intubation. respirator masks create resistance to breathing and can cause anxiety and discomfort. finally, ppe might disrupt interpersonal communication. face coverings can obscure both verbal and non-verbal communication. masks can decrease speech intelligibility (20) , particularly in a noisy resuscitation environment. speech can be further distorted through devices (e.g., speaker phones) used to communicate with hcps outside of the resuscitation room. simulation training can help ensure safe use and familiarity with ppe, but practice with ppe can be limited by the need to conserve supplies. in addition to ppe, hcps experience modifications to the physical resuscitation environment. specific labor and operating rooms may be designated for women requiring covid-19 precautions (7). negative pressure isolation rooms are preferred for ongoing care, if available. not uncommonly, designated rooms are remote from the neonatal unit, not designed for isolation, and previously reserved for cases not needing neonatal equipment or team involvement. room changes can increase travel time for the neonatal team and may delay responses due to unfamiliarity with room location and layout. for covid-19 cases, there are conflicting opinions on whether neonatal resuscitation should occur directly in the delivery room (dr) (7, 16) . remaining in the dr reduces the extent of contamination. on the other hand, resuscitation in a space separate from the mother (i) limits exposure of obstetrical hcps to neonatal agp, (ii) removes the neonate and the neonatal team from exposure to maternal infection, and (iii) allows for a dedicated resuscitation space. some centers have rooms adjacent to dr and operating rooms for neonatal resuscitation and stabilization, ergonomically organized with equipment, and sterile supplies. these areas are infrequently designed for isolation or decontamination. resuscitation in the dr changes the access to such organized equipment and alters workflow. accessibility to equipment may be improved using modular, portable emergency packs that contain basic neonatal resuscitation equipment. non-urgent interventions (e.g., line insertion), may be deferred in favor of transport to the neonatal intensive care unit (nicu) for procedures. subsequent downstream disruptions include increased nicu workload and potential delays in procedures which would have previously occurred before transfer to the nicu. conversely, for units used to resuscitations in the dr, resuscitating in a separate room can also be disruptive. when transporting a potentially infected neonate to the neonatal unit, avoidance of environmental contamination and bystander exposure are priorities (21) . transporting a neonate in an enclosed incubator with a clean transport team in ppe may minimize contamination but requires additional personnel, ppe consumption, and choreographing of patient movement. enclosed incubators are not airtight and may emit generated aerosols, contaminating hospital corridors, and putting bystanders at risk. additional precautions include placing viral filters on ventilators to filter expired gases. the need for careful neonatal transport may (i) increase hcp workload, (ii) delay further interventions (e.g., venous access and intubation for surfactant), and (iii) increase the risk for hypothermia in small infants. possible solutions include dedicated or escorted routes through the facility that are free of visitors and non-essential staff. drills or briefings that clarify the physical environment, equipment, and transfer route will mitigate some of these risks. neonatal resuscitation team size and composition vary. for hospitals used to larger teams for complex resuscitations, decreasing team size to limit hcp exposure may disrupt team function. some potential changes include: (i) team leader performing procedures such as airway management, (ii) recorder staying outside the resuscitation room, and (iii) additional hcps and trainees waiting outside the room. during in-situ simulations, we encountered communication breakdowns between those inside and outside the resuscitation room causing inaccuracies in timing chest compressions, incomplete resuscitation records, and delays in activating additional personnel. communication failures can further cause errors through failures in shared situational awareness and team coordination. neonatal, obstetrical, and anesthetic teams need to share covid-19-related information during briefings and timeouts, and in real-time. this should help the neonatal team prepare for covid-19 precautions, as well as minimize personnel in the operating room if a mother is being intubated and extubated. by alerting when agp are performed, neonatal hcps can give obstetrical team members the opportunity to take suitable precautions. these communication practices will need training and reinforcement to ensure that they occur consistently. finally, hcp trainees may be excluded from resuscitations of infants born to women under covid-19 isolation. in canada, pediatric residents report a low level of confidence in their neonatal clinical skills and may only have limited exposure to neonatal resuscitation in their training (22) . if covid-19 or other similar communicable diseases become prevalent, this approach will negatively impact our ability to train hcps. strategies are needed that facilitate the training of both established team members and trainees in the "new normal" of this and future pandemics. policies for increased physical distancing and isolation are highly disruptive to family-integrated care. for example, while telehealth can facilitate physical distancing for antenatal consultations, effective electronic communication can be challenging for sensitive conversations surrounding resuscitation and goals of care. limiting family presence during active neonatal resuscitation can further impact communication, availability of emotional support, and shared decision-making. infection control practices, such as face masks or isolation, are barriers to mother-infant interaction and bonding. opinions on mother-infant contact post-partum differ with a balance of benefits (e.g. bonding, establishing breastfeeding, and aiding postnatal transition) against concerns for postnatal covid-19 transmission (7, 9, 16) . involvement of parent advocates in policy development can help sustain efforts to provide safe and compassionate care during this pandemic. together, these potential impacts are illustrated in figure 1 . probably the most effective path to maximizing patient and hcp safety during neonatal resuscitation is via efficiently identifying pregnant women with suspected covid-19 prior to delivery. over-or under-identification represent risk to the woman, the baby and/or the clinical team. clear rationales for practice changes as well as staff familiarity with procedure and equipment modifications will ensure that both risks and disruptions are minimized. tabletop exercises, insitu walkthroughs, and real-time simulations can help achieve these goals, aiding protocol development, testing, and knowledge dissemination (23) . simulations can involve just the neonatal team, or include obstetrical and anesthetic members. local infection prevention and control (ipc) involvement ensures ipc standards are met. frequent communication between protocol development and resuscitation teams keep frontline hcps up to date; hcps have identified clear communication, training, and support from managers as facilitators to following ipc guidelines (24) . ideally, frontline hcps are involved from the planning stages to detect and mitigate impact on workflow. continuous evaluation ensures that plans live up to the challenge of reality. at our center, teams are encouraged to provide feedback with each covid-19 encounter. during initial stages, medical and ipc leads were notified of each covid-19 encounter and actively solicited post-hoc feedback from frontline hcps. successes and challenges were shared, and protocols amended or clarified as needed. multidisciplinary representation in our local covid-19 response team and a dedicated neonatal resuscitation team nurse coordinator provided multiple mechanisms for hcp to provide feedback. as our frontline hcps gained confidence and comfort in our protocols, daily in-person team huddles, and email communication facilitated ongoing feedback, communication, and support. successful communication strategies will vary depending on unit culture, size, and acuity. information sharing between nicus in our region helped further refine protocols as successful strategies and solutions were rapidly disseminated. as we learn more about perinatal transmission of covid-19, protocols should be amended to minimize disruptions. future redesign of neonatal resuscitation equipment, spaces, training, and teams could better address infection control and protection. technologies such as smart glasses can provide real-time visualaudio links between team members in different rooms to help maintain team communication. when resuscitating infants born to women with suspected or confirmed covid-19 infection, adaptations to current guidelines are considered to protect hcps and maintain infection control. adaptations involve changes to ventilation procedures and equipment, use of ppe, decreasing team size, and physical distancing measures. these adaptations are assisted by early identification of maternal covid-19 status, real-time simulations, continuous protocol evaluation, and team communication strategies. although safety for all involved remains a priority, these changes can be disruptive and should be re-evaluated as more information emerges around the perinatal transmission of this sars-cov-2. the original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s. world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19) clinical characteristics and intrauterine vertical transmission potential of covid-19 infection in nine pregnant women: a retrospective review of medical records coronavirus in pregnancy and delivery: rapid review probable congenital sars-cov-2 infection in a neonate born to a woman with active sars-cov-2 infection an analysis of 38 pregnant women with covid-19, their newborn infants, and maternal-fetal transmission of sars-cov-2: maternal coronavirus infections and pregnancy outcomes american heart association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care neonatal resuscitation and postresuscitation care of infants born to mothers with suspected or confirmed sars-cov-2 infection aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed covid-19: from the emergency cardiovascular care committee and get with the guidelines[(r)]-resuscitation adult and pediatric task forces of the american heart association in collaboration with the heat and moisture exchangers and breathing system filters: their use in anaesthesia and intensive care. part 2 -practical use, including problems, and their use with pediatric patients the use of filters with small infants covid-19 resource center mask leak in one-person mask ventilation compared to two-person in newborn infant manikin study transmission of severe acute respiratory syndrome during intubation and mechanical ventilation understanding workflow and personal protective equipment challenges across different healthcare personnel roles delivery room considerations for infants born to mothers with suspected or proven covid-19 covid-19) infection in pregnancy: information for healthcare professionals. royal college of obstetricians and gynecologists (uk) frequent and unexpected deviations from personal protective equipment guidelines increase contamination risks the effects of wearing respirators on human fine motor, visual, and cognitive performance diminished speech intelligibility associated with certain types of respirators worn by healthcare workers air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) from a symptomatic patient exploring pediatric residents' perceptions of competency in neonatal intensive care world health organization. who simulation exercise manual barriers and facilitators to healthcare workers' adherence with infection prevention and control (ipc) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis we would like to thank the public for donating money to our funding agencies: gs is a recipient of the heart and stroke foundation/university of alberta professorship of neonatal resuscitation, a national new investigator of the heart and stroke foundation canada and an alberta new investigator of the heart and stroke foundation alberta. the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © 2020 law, cheung, aziz and schmölzer. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-267996-5l9shks8 authors: tysiąc-miśta, monika; dziedzic, arkadiusz title: the attitudes and professional approaches of dental practitioners during the covid-19 outbreak in poland: a cross-sectional survey date: 2020-06-30 journal: int j environ res public health doi: 10.3390/ijerph17134703 sha: doc_id: 267996 cord_uid: 5l9shks8 the coronavirus infectious disease 2019 (covid-19) pandemic has put enormous pressure on health care systems around the world. dentistry has had to adjust to the new epidemic situation to not only bring relief to suffering patients but also to avoid becoming a source of sars-cov-2 transmission. methods: a comprehensive, cross-sectional survey was conducted between april 6 and 16, 2020 among 875 polish dental practitioners. the aim of the research was to assess dentists’ attitudes and professional approaches resulting from the covid-19 pandemic. results: 71.2% of dentists who responded to the questionnaire decided to suspend their clinical practice during that particular time. the main factors for this fact were the shortage of personal protective equipment (ppe), the respondents’ subjective perceptions of the risk of covid-19 contraction and a general feeling of anxiety and uncertainty regarding the covid-19 situation. the authors observed a significant decrease in the number of patients admitted weekly in april 2020 (12.06; sd, 11.55) in comparison to that in the time before the state of pandemic was declared on march 11, 2020 (49.21; sd, 24.97). conclusions: due to the unpreparedness of the dental sector, both in national health and private settings, most of the polish dentists decided to voluntarily suspend their clinical practice in order to mitigate the spread of the disease. the covid-19 outbreak has revealed numerous shortcomings in the dental care system, especially regarding the insufficient coordination of health services related to the pandemic and lack of advanced ppe. this has led to an overwhelming feeling of fear, confusion and anxiety among dental professionals in poland and a sudden decrease in the number of performed dental procedures. hopefully enriched with the recent experience and due to the implementation of proper strategic and long-term measures, dental practitioners will be better prepared and adapted to global health care disruptions in the future. from december 8, 2019, a series of pneumonia cases in wuhan, hubei province, china began to emerge [1] . according to data released by the world health organization (who) up to june 18, 2020, coronavirus disease 2019 has affected close to 200 countries, with a total of 8,223,454 confirmed cases and 444,813 deaths worldwide [2] . on the same day, the overall number of confirmed cases in poland reached 30, 195 [3] . on 3 june 2020, the polish ministry of health (pmh) announced that since the beginning of the pandemic, 1659 nurses, 660 doctors and 85 midwives had been infected with sars-cov-2 [4] . variables, such as a lack of access to adequate, enhanced ppe; individuals' covid-19 contraction risk assessments; self-reported feelings of anxiety regarding the disease; gender; the acknowledgement of national guidance on how to treat patients during the recent health care crisis; and other factors such as age, years of clinical experience, marital status, having children, place of residence, risk group for coronavirus infection due to comorbidities and, finally, dentists' acknowledgement of the professional recommendations launched by the pda and pmh. our secondary aim was to assess the decrease in the number of dental patients admitted in april 2020 in comparison with that in the time before the beginning of the pandemic in poland in march 2020. the cross-sectional survey was conducted between the 6th and 16th of april 2020 among polish dental practitioners. the tool utilized for data collection was a specifically designed online google forms questionnaire. a representative sample group of dentists was gathered through four major facebook groups dedicated to polish dentists: "dentyści", "dentyści ogłaszają", "dentyści przypadki, kursy i dyskusje" and "lekarze dentyści nfz". the polish dental association and twenty-four polish district chambers of physicians and dentists were contacted via e-mail and asked to share information about the study with their members, encouraging them to participate. a total of 875 polish dentists responded to the questionnaire. the data were collected anonymously to ensure the reliability of all of the information and compliance with eu personal data protection legislation. ethical approval from the bioethical committee of the medical university of silesia in katowice poland was obtained. the quantitative statistical analysis included the chi-square test for 2 × 2 tables. in justified cases, it was supported by the determination of the odds ratio, together with a 95% confidence interval and verification using the mantel-haenszel test. in addition, in several cases where groups had insignificant numbers, fisher's exact test for 2 × 2 tables was used. additionally, the non-parametric mann-whitney test was implemented, and finally, the non-parametric kruskal-wallis test, supplemented by post-hoc tests in the variant proposed by conover, was utilized. the test results were considered significant when p < 0.05. a group of 875 dentists submitted completed questionnaires. according to the supreme medical council of the chamber of physicians and dentists (smccpd) on may 4, 2020, there were 37,845 professionally active dentists in poland [21] . the age of the participants of the survey ranged from 24 to 75 years (mean of 39.1; sd, 11 years). the respondents' demographic characteristics are presented in table 1 [21] . dental practitioners were asked whether they were continuing their clinical work during the covid-19 pandemic, following the implementation of special epidemic measures in march 2020. a total of 71.2% of the respondents decided to entirely suspend their dental practice. only 28.8% of the participants declared that they had carried on with their clinical duties. the fractional distribution of the various reasons for both choices is presented in the table 2 . more than one answer could have been chosen. the quantitative statistical analysis included the factors that might have had influence on dentists' decisions as to whether to work during the pandemic. a total of 75.3% of respondents said that they did not have sufficient access to ppe, while 24.7% declared the opposite. among those who decided to work, only 46% had adequate ppe supplies; 54% stated the opposite. in the group of dentists who suspended their clinical work, 83.9% of the respondents said that they did not have sufficient access to ppe, while 16.1% were satisfied with it. the results indicated a high significance of the relationship between the decision to work during the covid-19 pandemic and access to ppe (p < 0.001, chi-square test) and (p < 0.001, mantel-haenszel test). the odds ratio (or = 4.46) indicated that dentists who continued clinical work were four and a half times more likely to have access to ppe than those who suspended their work. an average value of sensitivity (0.460) and remarkably high specificity (0.840) for the tests were obtained (figure 1 ). other. 59 (9.5%) the quantitative statistical analysis included the factors that might have had influence on dentists' decisions as to whether to work during the pandemic. a total of 75.3% of respondents said that they did not have sufficient access to ppe, while 24.7% declared the opposite. among those who decided to work, only 46% had adequate ppe supplies; 54% stated the opposite. in the group of dentists who suspended their clinical work, 83.9% of the respondents said that they did not have sufficient access to ppe, while 16.1% were satisfied with it. the results indicated a high significance of the relationship between the decision to work during the covid-19 pandemic and access to ppe (p < 0.001, chi-square test) and (p < 0.001, mantel-haenszel test). the odds ratio (or = 4.46) indicated that dentists who continued clinical work were four and a half times more likely to have access to ppe than those who suspended their work. an average value of sensitivity (0.460) and remarkably high specificity (0.840) for the tests were obtained (figure 1 ). dentists were also asked about the most important necessities regarding dental practice during the covid-19 pandemic. more than one answer could have been chosen. the answers were grouped into five major categories, listed below in table 3 . table 3 . main demands in dental practices during the peak of the covid-19 pandemic. dentists were also asked about the most important necessities regarding dental practice during the covid-19 pandemic. more than one answer could have been chosen. the answers were grouped into five major categories, listed below in table 3 . procedures (no update on disinfection and work safety protocols, lack of goodwill from management to adjust the dental office to the new procedures) dentists assessed covid-19's occupational contraction risk as 4.77 (sd, 0.59) on a 5-point scale. based on the mann-whitney test (p < 0.001), we found that those who did not work rated the risk significantly more highly than dentists who continued their clinical practice ( figure 2 ). a total of 74.8% of those who suspended their work estimated the threat as 5, whereas only 25.2% of those who continued their work rated it as high. overall, 82.9% of all the respondents assessed the risk as 5. adapted dental offices (separate rooms for doffing and donning of ppe, efficient ventilation systems) 63 (11.07%) procedures (no update on disinfection and work safety protocols, lack of goodwill from management to adjust the dental office to the new procedures) 53 (9.31%) dentists assessed covid-19's occupational contraction risk as 4.77 (sd, 0.59) on a 5-point scale. based on the mann-whitney test (p < 0.001), we found that those who did not work rated the risk significantly more highly than dentists who continued their clinical practice ( figure 2 ). a total of 74.8% of those who suspended their work estimated the threat as 5, whereas only 25.2% of those who continued their work rated it as high. overall, 82.9% of all the respondents assessed the risk as 5. the respondents rated their feelings of anxiety regarding the covid-19 pandemic as 3.61 (sd, 1.01) on a 5-point scale ( figure 3 ). dentists who suspended their clinical work rated their anxiety more highly than dentists who continued their practice (p < 0.001, mann-whitney test). the respondents rated their feelings of anxiety regarding the covid-19 pandemic as 3.61 (sd, 1.01) on a 5-point scale ( figure 3 ). dentists who suspended their clinical work rated their anxiety more highly than dentists who continued their practice (p < 0.001, mann-whitney test). the chi-square test showed that the groups differed in terms of gender (χ 2 = 13.129; p < 0.001). an additional analysis was conducted by calculating the value of the odds ratio (or) and subjecting it to verification using the mantel-haenszel test (χ 2 = 13.11; p < 0.001). the result of this test indicates that the or value is 1.9, which means that the chance there will be a man in the group of dentists who continued clinical work during the covid-19 pandemic was almost twice as high as that in the group of dentists who did not continue their work. an average value of sensitivity (0.250) and remarkably the chi-square test showed that the groups differed in terms of gender (χ 2 = 13.129; p < 0.001). an additional analysis was conducted by calculating the value of the odds ratio (or) and subjecting it to verification using the mantel-haenszel test (χ 2 = 13.11; p < 0.001). the result of this test indicates that the or value is 1.9, which means that the chance there will be a man in the group of dentists who continued clinical work during the covid-19 pandemic was almost twice as high as that in the group of dentists who did not continue their work. an average value of sensitivity (0.250) and remarkably high specificity (0.860) for the tests were obtained (figure 4 ). < 0.001, mann-whitney test). the chi-square test showed that the groups differed in terms of gender (χ 2 = 13.129; p < 0.001). an additional analysis was conducted by calculating the value of the odds ratio (or) and subjecting it to verification using the mantel-haenszel test (χ 2 = 13.11; p < 0.001). the result of this test indicates that the or value is 1.9, which means that the chance there will be a man in the group of dentists who continued clinical work during the covid-19 pandemic was almost twice as high as that in the group of dentists who did not continue their work. an average value of sensitivity (0.250) and remarkably high specificity (0.860) for the tests were obtained (figure 4) . female dentists showed a significantly higher level of self-reported anxiety ( figure 5 , p <0.001). the kruskal-wallis test confirmed (kw = 32.32; p < 0.001) significant differences among four groups of dentists: non-working females, working females, working males and non-working males ( figure 6 ). the kruskal-wallis test confirmed (kw = 32.32; p < 0.001) significant differences among four groups of dentists: non-working females, working females, working males and non-working males ( figure 6 ). the kruskal-wallis test confirmed (kw = 32.32; p < 0.001) significant differences among four groups of dentists: non-working females, working females, working males and non-working males ( figure 6 ). the conover post-hoc test showed that the biggest difference in the self-reported feeling of anxiety occurred between the group of non-working female dentists and the group of working male dentists (p < 0.01) ( table 4 ). the conover post-hoc test showed that the biggest difference in the self-reported feeling of anxiety occurred between the group of non-working female dentists and the group of working male dentists (p < 0.01) ( table 4 ). table 4 . self-reported feeling of anxiety level vs. gender: continuity of clinical work. conover post-hoc, significant results in bold. we analyzed the significance of the relationship between dentists' decision whether to continue clinical work and acknowledgement of the pda (figure 7 ) and the pmh (figure 8 ) guidelines. when assessing the pda recommendations, the chi-square test indicated statistical significance (χ 2 = 4.436; p = 0.035). the same situation occurred with that of the pmh guidelines (χ 2 = 4.443; p = 0.035). the or for the acknowledgement of the pda recommendations reached an average of 4.8 and for that of the pmh recommendations, 2.05. it means that dentists who continued to practice were almost five times more often acquainted with the pda guidelines and two times more often acquainted with the pmh guidelines compared to dentists who suspended their work. we noticed exceedingly high sensitivity (0.992) in detecting people who acknowledged the pda recommendations in the group of professionally active dentists (specificity, 0.037). the values of sensitivity and specificity calculated for the acknowledgement of the pmh recommendations in the subgroups of dentists who worked clinically and those who did not were 0.952 and 0.093, respectively. we analyzed the significance of the relationship between dentists' decision whether to continue clinical work and acknowledgement of the pda (figure 7 ) and the pmh (figure 8 ) guidelines. when assessing the pda recommendations, the chi-square test indicated statistical significance (χ 2 = 4.436; p = 0.035). the same situation occurred with that of the pmh guidelines (χ 2 =4.443; p = 0.035). the or for the acknowledgement of the pda recommendations reached an average of 4.8 and for that of the pmh recommendations, 2.05. it means that dentists who continued to practice were almost five times more often acquainted with the pda guidelines and two times more often acquainted with the pmh guidelines compared to dentists who suspended their work. we noticed exceedingly high sensitivity (0.992) in detecting people who acknowledged the pda recommendations in the group of professionally active dentists (specificity, 0.037). the values of sensitivity and specificity calculated for the acknowledgement of the pmh recommendations in the subgroups of dentists who worked clinically and those who did not were 0.952 and 0.093, respectively. we asked our respondents how they rated the assistance of the pda and pmh recommendations on a scale of 1 to 5. the pda guidelines were rated as 3.33 (sd, 1.00), and the pmh guidelines, as 3.0 (sd 1.00). dentists graded the work of the polish chamber of physicians and dentists as 2.29 (sd, 1.11) on a 5-point scale. we asked our respondents how they rated the assistance of the pda and pmh recommendations on a scale of 1 to 5. the pda guidelines were rated as 3.33 (sd, 1.00), and the pmh guidelines, as 3.0 (sd 1.00). dentists graded the work of the polish chamber of physicians and dentists as 2.29 (sd, 1.11) on a 5-point scale. a significant decrease in the number of patients admitted weekly by polish dentists before and during the covid-19 pandemic (figure 9 ) was observed (p < 0.0001, wilcoxon tests). we defined the period before the pandemic as the time before march 11, 2020, the day when the director-general of the who officially declared the present outbreak of coronavirus disease (covid-19) a pandemic. the period during the pandemic refers to the time frame of the conducted survey; that is, the time between april 6 and 16, 2020. the number of patients decreased from 49.21 (sd, 24.97) to 12.06 (sd, 11.55). these calculations only considered the number of patients treated by dentists who continued their clinical practice during the outbreak. in the entire group of examined dentists, the number of patients dropped from 47.13 (sd, 24.93) to 3.60 (sd, 8.31). a significant decrease in the number of patients admitted weekly by polish dentists before and during the covid-19 pandemic (figure 9 ) was observed (p < 0.0001, wilcoxon tests). we defined the period before the pandemic as the time before march 11, 2020, the day when the director-general of the who officially declared the present outbreak of coronavirus disease (covid-19) a pandemic. the period during the pandemic refers to the time frame of the conducted survey; that is, the time between april 6 and 16, 2020. the number of patients decreased from 49.21 (sd, 24.97) to 12.06 (sd, 11.55). these calculations only considered the number of patients treated by dentists who continued their clinical practice during the outbreak. in the entire group of examined dentists, the number of patients dropped from 47.13 (sd, 24.93) to 3.60 (sd, 8.31). we also investigated factors such as age, years of clinical practice (table 4) , marital status, having children, place of residence, belonging to the risk group for coronavirus infection due to comorbidities, and dentists' opinions on the lasting impact of covid-19 on dental procedures (table 5 ) in relation to the decision to continue dental practice or not. no statistical significance was observed. statistical characteristic mann-whitney test figure 9 . number of patients admitted by one dentist per week, and clinical performance before and during a peak of the covid-19 outbreak (p < 0.0001, wilcoxon test). we also investigated factors such as age, years of clinical practice (table 5) , marital status, having children, place of residence, belonging to the risk group for coronavirus infection due to comorbidities, and dentists' opinions on the lasting impact of covid-19 on dental procedures (table 6 ) in relation to the decision to continue dental practice or not. no statistical significance was observed. our research provided an insight into reasons and factors that influenced the attitudes of polish dentists during the covid-19 pandemic in poland. in our sample, women were predominant due to the fact that the number of female dentists in poland (77%) is higher than the number of male dentists (23%) [21] . the age and place of residence distributions are slightly less representative, evidencing a sort of selection bias, probably due to the social network dissemination of the questionnaire. on april 6, 2020, when we started to conduct the survey, there were 4201 people who had tested positive for covid-19 in poland; 99 of them were novel cases. up to that day, 98 polish citizens had died due to coronavirus infection, and 162 had recovered [22] . at the end of survey on april 16, 2020, there were 7771 confirmed cases; 189 of them were novel. two hundred and ninety-two poles had died and 774 had recovered up to that day. the number of cases had not reached its peak [23] . in this period, 71.2% of the respondents decided not to practice dentistry. in comparison to in other european countries, this situation was exceptional, because everywhere else, if any restrictions were imposed on the oral health care sector, they were implemented and executed by the authorities. our findings are similar to the results of a study conducted by ahmed and jouhar et al. in a group of 650 dentists from 30 countries (only one from poland), which found that 66% of respondents decided to suspend their dental practices until the number of covid-19 cases started to decline [24] . among the dentists who continued their clinical work during the pandemic, the main reason for their decision was the altruistic need to provide emergency and urgent dental procedures. this essential duty of medical/dental care is a fundamental principle of the dental profession. in a study conducted among 711 first year dental students from 14 countries, 36.3% declared that they decided to become a dentist to help poor and underprivileged people to improve their oral health [25] . on the contrary, the two main reasons for dentists to discontinue their clinical activities during the covid-19 pandemic were fear for their own wellbeing and, equally, the wellbeing of their close relatives/families. studies on earlier outbreaks of coronavirus infectious diseases such as sars [26] and mers [27] revealed many factors leading to psychological distress, including the fear of becoming infected while treating a patient or passing the infection on to family. in a previously mentioned study by ahmed and jouhar et al., 92% of dentists declared that they were afraid of carrying the covid-19 infection from their dental practice to their families [24] . additionally, in the study by duruck at el., facing covid-19 contraction threat, 90% of dentists were concerned about their families and about themselves [10] . according to the research conducted by maunder et al., many hospital staff members during the sars pandemic expressed conflict between their roles as health care providers and parents, feeling, on the one hand, a duty of care and, on the other hand, fear and guilt about potentially exposing their families to infection [28] . the second reason for dentists' decisions to suspend their clinical work was the fact that many of the respondents thought that the dental surgeries were not adequately equipped, and they believed that during a pandemic, there should be special emergency dental clinics assigned by the pmh. unfortunately, such clinics were not designated by the polish authorities. instead, the pda launched a campaign-"i do not panic. i treat responsibly"-to reassure dentists that with the implementation of enhanced infection control protocols, dental treatment could be resumed [29] . the pda also published a list of dental offices that volunteered to help patients with dental emergencies during the covid-19 pandemic [30] . the subject of ppe is discussed in almost every piece of survey-based research regarding dentists during the covid-19 pandemic. the necessity of having substantial knowledge and awareness regarding enhanced ppe utilization is emphasized. in the study conducted by ahmed and jouhar et al., 90% of respondents reported not wearing an n-95 mask while treating a patient. the research by duruk et al. [10] also showed that only 12% wore an n-95 mask. cagetti et al. reported that 55% of respondents used an fpp2 or fpp3 mask. based on this research, we do not know if it is a result of shortages in ppe supplies or a lack of willingness to implement adequate procedures [24] . in more recent studies from italy, it has been revealed that dentists' attitudes regarding ppe could be improved [31] . our research emphasizes the fact that during the time between april 6 and 16, 2020, access to ppe in poland was extremely limited. all the ppe resources were targeted to hospitals. the authorities did not take the oral health care sector, either public or private, into consideration. according to our research, access to ppe was a particularly important decisive factor for polish dentists as to whether to continue or suspend their clinical practice during the pandemic. in march 2020, the world health organization (who) released a press report highlighting the severe shortage of personal protective equipment (ppe) affecting health care workers worldwide during the covid-19 pandemic [32] . there was a myriad of reports about the lack of personal protective equipment (ppe) all over the world [33] [34] [35] , the royal college of surgeons of england conducted a survey on ppe between april 6 and 9, 2020, which revealed that more than half (57%) of doctors had described shortages of ppe in the past 30 days discussions around ppe were increasingly politicized and sensitive [36] , causing overwhelming anxiety both in health care professionals and patients [37] . due to the shortages, research on refreshing face masks for extended wear and reusing them after a cleaning process emerged [38] . the covid-19 outbreak had a large impact on health care providers all over the world. until may 12, 2020, the official number of infected health workers in italy amounted to 21,981. the number of deceased physicians reached 160, of whom 16 were dentists [39] . this reinforces the concept that close contact with positive patients, whether symptomatic or not, exposes health care workers to a higher risk of infection. sars-cov-2 has been demonstrated to remain aerosolized for 3 h after contamination and on plastics and stainless steel for up to 72 h. it has a half-life in aerosols that is relatively long and lasts approximately 1.1 to 1.2 hours [40] . in research by de stefani et al., italian dentists evaluated covid-19 danger as 8/10 and their worries about being at risk of contagion at work as 7.3/10 [41] . in another study from italy, 65% of responders evaluated the dentists' infection risk as very likely [39] . these results are coherent with our findings. most jordanian dentists participating in a survey on covid-19 perceived the risk as moderate, and almost one-third believed that it was not a serious public health issue; however, we have to be aware that there were no "local" cases in jordan at the time of this data collection [42] . anxiety, insomnia, depression, obsessive-compulsive symptoms and somatization are all well-known psychological hazards for health care workers during a pandemic [43] . duruk et al. [10] noticed that 95% of female and 88% of male dentists were concerned about being infected with covid-19 due to high occupational risk. according to our study, dentists who stayed at home during the outbreak also had a significantly higher level of self-reported anxiety. our findings are consistent with a study, which showed that front-line nurses had significantly lower vicarious traumatization scores than non-front-line nurses [44] . we believe that dentists who decided to work showed better coping mechanisms, which helped them to overcome their anxieties and to provide oral health care. we also found that men were two times more likely to work during the pandemic than their female counterparts. this may be due to the fact that some women declared in the questionnaire that they were pregnant or that they had to stay at home with their children, because kindergartens and schools in poland were closed because of the pandemic. however, we also noticed that women were more likely to suspend their clinical practice due to a self-reported feeling of anxiety. the highest level of anxiety was observed in the group of non-working women, and the lowest, in the group of working men. in the research by choy at el., female dentists had higher mean scores for patient-related, job-related, staff-related and technical-related stressors than male dentists in everyday dental practice [45] . on the contrary, in the research by shacham et al. [3] on factors related to the psychological distress caused by the covid-19 pandemic among israeli dentists and dental hygienists, gender did not have a significant impact. in order for dentistry to do its part in mitigating the spread of covid-19, new protocols for admitting dental patients were introduced. our research shows a great need for pda and pmh guidance and the notable impact of these authorities on the making of an informed decision on whether to provide dental treatment or not. the need for leadership and the feeling that one is not alone in a health care crisis of this magnitude was also emphasized by mauder [28] . in our study, we observed a vast decrease in the number of treated patients. this is consistent with an analysis conducted in china in the period february 1-10, 2020, when the number of dental patients declined by 38%. the conclusions of that finding were that the covid-19 situation significantly influenced people's dental care-seeking behavior and that they were not willing to go to dental institutions for non-urgent work. another important conclusion was that people's need for dental services might grow explosively when the threat of covid-19 is over [46] . this situation was the consequence of the pda and pmh recommendations, which suspended elective dental procedures and encouraged teleconsultations and e-prescriptions, in order to minimize the number of dental patients reporting to outpatient clinics to seek treatment. the second factor was the implementation of new, necessary infection control procedures. according to new guidelines, one patient per hour should be appointed. patient flux should be organized in such a way that only one patient in the waiting room is present [47] . dental practices established pre-check triages to measure and record the temperature of every staff member and patient with a contact-free forehead thermometer as a routine procedure. dental staff were required to ask patients questions about their health status regarding possible covid-19 symptoms, and patients' contacts needed to be provided with medical masks and hand disinfection agents once they entered the dental office [48] . if aerosol-generating procedures were impossible to avoid, dental dams, high-volume suction, and swabbing or disinfection of the teeth prior to the commencement of tooth preparation should have also been included [49] . after the procedure, all the disposable protections had to be removed, and high-level disinfection of the whole operating room with sodium hypochlorite 0.1% or 70% isopropyl alcohol performed. after each patient, an air change of at least five minutes was advised [50] . the first report on how to organize dental procedures under the premise of adequate protection measures during the covid-19 pandemic came from the school and hospital of stomatology of wuhan university, where the number of admitted patients was also reduced [6] . the covid-19 pandemic has introduced several new problems regarding oral health care in poland. due to shortages in the access to ppe, their prices have rapidly increased. in may 2020, the owners of public dental offices signed a petition to the nhf with a request to revise the evaluation of dental procedures [51] . on june 2, 2020, the nfh published a draft of a new decree regarding dentistry funding. though needs such as the increase in the funding of endodontic procedures have been recognized, the proposal was negatively assessed by the supreme medical council (smc) on june 8, 2020. according to the smc, the proposed changes will only slightly increase the valuation of the scheduled visits [52] . on the other hand, the inevitable increase in the prices of dental treatment in the private sector has encountered many unfavorable opinions from the news media and patients in poland [53] . it is predicted that the coronavirus pandemic will also have a negative financial impact on the dental sector as a whole, and many practitioners might not be able to restart their practice because of the new disease prevention protocols, which require investment. this will further reduce access to primary and specialist dental care [54] . on april 22, 2020, an association of polish dental employers was established, its main goals being to represent the social and economic interests of union members and initiate activities aimed at increasing the competitiveness of union members and the quality of dental services [55] . the authors suggest that a fund, which would provide financial support to its members in moments of crisis like this, should be established. shanafelt et al. identified that health care professionals tended to have five types of requests to their organization during the covid-19 pandemic: 'hear me, protect me, prepare me, support me and care for me'. it is critical that leaders understand the sources of distress, assure health care professionals that their concerns are recognized, and work to develop approaches that will help to minimize these concerns to the extent that they are able [56] . only by re-organizing health care systems in this manner, based on empathy and the understanding of employees' needs, would we be able to continue to have devoted and caring medical personnel. despite these difficulties, in june 2020, the majority of dentists in poland returned to work, implementing additional, strict infection control protocols. finally, as rosenberg argued, epidemics put pressure on the societies they strike, and as a result, they provide a sampling device for social analysis. they clearly demonstrate what really matters to a population and what they truly value. the history of epidemics offers considerable advice but only if people know the history and respond with wisdom [57] . hopefully, our research will add insight into how to reorganize dental care when future pandemics emerge. it is important to stress the limitations related to sampling error in this research, including the relatively moderate sample group. this could have been caused by the short period of data collection, leading to mainly dentists who were active on social media during the short period of data collection participating in the study. due to the lack of preparedness of the dentistry sector, both public and private, a substantial majority of polish dentists decided to voluntarily suspend their clinical practice. the covid-19 outbreak has revealed numerous shortcomings in the dental care system, especially regarding the insufficient coordination of services related to the pandemic globally and general deficit of advanced ppe. the direct result of the overwhelming fear, confusion and anxiety among dental staff, which was amplified by the high perception of covid-19 contraction risk, was a significant reduction in dental clinical practice in poland. a sudden decrease in the number of performed dental procedures and implementation of new infection control protocols has caused financial problems for many dental practices. it is expected that dentists, enriched with the experience acquired during the recent outbreak, will be able to efficiently redefine their scope of practice and adjust to the new circumstances. epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study who coronavirus disease (covid-19) dashboard. available online coronavirus disease (covid-19) dashboard. available online ministerstwożongluje danymi o liczbie zakażonych pielęgniarek-portal pielęgniarek i położnych covid-19: present and future challenges for dental practice covid-19): emerging and future challenges for dental and oral medicine dental care and oral health under the clouds of covid-19 airborne transmission of sars-cov-2: the world should face the reality severe acute respiratory syndrome and dentistry|elsevier enhanced reader investigation of turkish dentists' clinical attitudes and behaviors towards the covid-19 pandemic: a survey study public health interventions to mitigate early spread of sars-cov-2 in poland covid-19 a praca lekarza dentysty: wytyczne pts uaktualnione. polskie towarzystwo stomatologiczne. 2020. available online what dentists need to know about covid-19 coronavirus disease (covid-19) dashboard. available online coronavirus disease (covid-19) dashboard. available online ciągu doby wykonano ponad 4,7 tys. testów na #koronawirus testów na #koronawirus fear and practice modifications among dentists to combat novel coronavirus disease (covid-19) outbreak dental students' motivations for their career choice: an international investigative report facing sars: psychological impacts on sars team nurses and psychiatric services in a taiwan general hospital middle east respiratory syndrome coronavirus (mers-cov) outbreak perceptions of risk and stress evaluation in nurses the immediate psychological and occupational impact of the 2003 sars outbreak in a teaching hospital polskie towarzystwo stomatologiczne mapa pracujących gabinetów stomatologicznych. polskie towarzystwo stomatologiczne. 2020. available online epidemiological aspects and psychological reactions to covid-19 of dental practitioners in the northern italy districts of modena and reggio emilia shortage of personal protective equipment endangering health workers worldwide ethical rationing of personal protective equipment to minimize moral residue during the covid-19 pandemic in pursuit of ppe covid-19: third of surgeons do not have adequate ppe, royal college warns|the bmj ppe guidance for covid-19: be honest about resource shortages mitigating the psychological impact of covid-19 on healthcare workers: a digital learning package opinion to address a potential personal protective equipment shortage in the global community during the covid-19 outbreak covid-19 outbreak in north italy: an overview on dentistry. a questionnaire survey aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 covid-19 outbreak perception in italian dentists dentists' awareness, perception, and attitude regarding covid-19 and infection control: cross-sectional study among jordanian dentists general hospital staff worries, perceived sufficiency of information and associated psychological distress during the a/h1n1 influenza pandemic vicarious traumatization in the general public, members, and non-members of medical teams aiding occupational stress and burnout among hong kong dentists the impact of the covid-19 epidemic on the utilization of emergency dental services covid-19 and professional dental practice. the polish dental association working group recommendations for procedures in dental office during an increased epidemiological risk transmission routes of 2019-ncov and controls in dental practice novel coronavirus (covid-19) and dentistry-a comprehensive review of literature the severe acute respiratory syndrome coronavirus-2 (sars cov-2) in dentistry. management of biological risk in dental practice niemiłe zaskoczenie u dentystów the financial impact of covid-19 on our practice understanding and addressing sources of anxiety among health care professionals during the covid-19 pandemic the twitter pandemic: the critical role of twitter in the dissemination of medical information and misinformation during the covid-19 pandemic funding: this research received no external funding. the authors declare no conflict of interest. key: cord-258965-g47n531n authors: ekpenyong, bernadine; obinwanne, chukwuemeka j.; ovenseri-ogbomo, godwin; ahaiwe, kelechukwu; lewis, okonokhua o.; echendu, damian c.; osuagwu, uchechukwu l. title: assessment of knowledge, practice and guidelines towards the novel covid-19 among eye care practitioners in nigeria–a survey-based study date: 2020-07-16 journal: int j environ res public health doi: 10.3390/ijerph17145141 sha: doc_id: 258965 cord_uid: g47n531n the aim of this study was to explore knowledge, practice of risk and guidelines of the novel corona virus disease (covid-19) infection among the eye care practitioners and the potential associated factors. a cross-sectional self-administered online survey was distributed via emails and social media networks between 2nd and 18th may 2020 corresponding to the week of the lockdown in nigeria to eye care practitioners (ecps). data for 823 respondents were analyzed. knowledge and risk practice were categorized as binary outcome and univariate and multivariate linear regression were used to examine the associated factors. the mean score for covid-19-related knowledge of public health guidelines was high and varied across the ecps. ophthalmic nurses, ophthalmologists and optometrists showed higher covid-19-related knowledge than other ecps (p < 0.001), particularly those working in the private sector. more than 50% of ecps stated they provided essential services during the covid-19 lockdown via physical consultation, particularly the ophthalmologists. most respondents reported that the guidelines provided by their association were useful but expressed their lack of confidence in attending to patients during and after the covid-19 lockdown. compared to other ecps in nigeria, more ophthalmic nurses received training in the use of personal protective equipment (ppe). this survey is the first to assess knowledge, attitudes and practice in response to the covid-19 pandemic in nigeria. ecps in nigeria displayed good knowledge about covid-19 and provided eye care services during the covid-19 lockdown in nigeria, despite the majority not receiving any training on the use of ppes with concerns over attending to patients. there is need for the government to strengthen health systems by improving and extending training on standard infection prevention and control measures to ecps for effective control of the pandemic and in the future as essential health workers. the emergence of the novel coronavirus disease in 2019 in december 2019 in the city of wuhan, the chinese province of hubei city, halted the ever-busy human society and threatened every nation [1] . a completely different type of acute pneumonia [2] which had close resemblance to the previous middle east respiratory syndrome (mers) and severe acute respiratory syndrome (sars) viruses but appeared to be much more lethal than the two was reported [3] . the infection soon became a cause of concern with the world health organization, declaring the rapid spread of cases of covid-19 a pandemic on 11th march, 2020 and recommended that a globally coordinated effort was needed to fight the pandemic [4] . while there is currently no vaccine for covid-19 [5] , the symptoms can include fever, flu-like symptoms such as a cough, sore throat and fatigue and/or shortness of breath, diarrhea, nausea and vomiting [6] . the risk of death in covid-19-infected individuals increases with older age, presence of hypertension, diabetes and coronary heart diseases [7] . there are also reports of conjunctivitis and transmission of the virus by aerosol contact with conjunctiva [8] with some uncertainty as to whether the virus is evident in human tears [1] . on the 28th of january 2020, sub-saharan africa's first confirmed case of covid-19 was announced in nigeria. this led to the activation of the country's national coronavirus emergency operation centre by the government. during to the ebola outbreak of 2014, of the 15,000 confirmed cases, there were over 9000 suspected cases in west africa, but this was controlled in just 92 days [9] . currently, the control of covid-19 is becoming challenging for the nigerian government despite the mobilization of resources and manpower by the nigeria centre for disease control ncdc [9, 10] . there are about 16,658 confirmed cases of covid-19 and 424 lost lives of humans from the infection (16 june 2020). the majority of the cases are in the former capital city of lagos (7319 cases, 82 deaths), federal capital city of abuja (1264 cases, 26 deaths) and kano (1158 cases, 50 deaths) [10] . as the country continues to experience steady increase in the number of confirmed cases [10] , the different levels of government have taken proactive steps to curtail the spread of coronavirus throughout the country. movements were restricted within and between states, and the society observed a partial lockdown in response to the pandemic. current evidence suggests that the implementation of outbreak response strategies for covid-19 can limit the disease. however, these situational responses affect businesses including their interactions with relevant regulators/professional bodies causing the government to respond through the nigerian national assembly's emergency stimulus bill, the central bank of nigeria's policy measure which dedicated its credit facility to develop the healthcare sector [11] . unlike some businesses and occupations considered as essential services, eye care professions (ecp) discontinued operations during the lockdown denying many patients-particularly those in need of emergency care or receiving routine injections for management of blinding eye diseases such as diabetes macular edema-access to eye care. ecps may be susceptible to infection due to close patient proximity during examination such as slit lamp examination, applanation tonometry and the potential contamination of instruments [12] ; however, medical visits related to systemic and ocular disease or injury where there is significant risk of permanent vision loss because of any postponement of care, as determined by the treating ecp, are considered essential visits [13] . other conditions considered by ecps as essential services have been summarized in table 1 . additionally, the same groups burdened by covid-19 complications could also suffer more vision problems including individuals with hypertension, respiratory conditions, and heart disease and the elderly [14] . patients who have lost or broken their glasses or contact lenses with consideration given to prescription needs and level of disability without correction are considered as essential services [13] . there are also concerns existing around the pandemic with various reports from news outlets and social media reporting how best to limit the chance of infection, with significant amounts of misinformation and speculation [5] which many patients may request clarification from their ecps to keep them safe through this period. the aim of this study was to assess knowledge and practice of covid-19 exposure risk among ecps as well as understand their confidence in current federal ministry of health (fmoh) guidelines for identifying possible covid-19 cases, knowledge of personal protective equipment (ppe) recommendations and training in its usage when managing such cases. the impact of covid-19 lockdown among practitioners was also assessed. this survey is among the first to assess knowledge level, practice of risk and awareness of the guidelines for consulting patients at risk or confirmed cases of covid-19 in nigeria incorporating responses from all tiers of ecps in nigeria. the findings will also provide first evidence on ecps' knowledge of covid-19 in nigeria. this will help to reduce their risk, and that of their family, of contracting the virus, reduce morbidity and mortality associated with being infected. evidence from the study can also be used to implement emergency policies to counter the spread and impact of a similar outbreak in future. the study will provide clarity on the essential nature of ecps services to help policy making in future outbreaks. this study on the knowledge, practice, impact and guideline on covid-19 was conducted among eye care practitioners in nigeria. according to the world bank group (2019), nigeria has an estimated population of 195,874,740 people. majority of eye care service practitioners are located in the cities [15] . nigeria is home to 7000 registered optometrists [16] , about 300 ophthalmologists [17] , 2000 ophthalmic nurses [18] and 941 dispensing opticians [16] . all eye care practitioners practicing in nigeria have overlapping roles without distinct borders. ophthalmologists undergo a minimum of four (4) years postgraduate training after a medical degree and provide surgical as well as medical eye care [19] . optometry is a licensed professional program completed in a minimum of six (6) years leading to the award of doctor in optometry (od) which empowers optometrists to provide general eye care including treating eye diseases, refractive errors, low vision and contact lenses [16] . an ophthalmic nurse has a one-year post-basic nursing training in eye care and work with other ecps to engage in blindness prevention activities and care for patients for ocular surgeries. dispensing opticians obtain a three-year national diploma and work in optical laboratories to interpret and dispense optical prescriptions [20] . a self-administered questionnaire developed and used previously for ecps [21] was modified and pre-tested to ensure that it was suitable for use in nigeria. the initial survey was piloted among 10 optometrists who were not part of the study team and did not participate in the final survey to ensure clarity and understanding as well as to determine the duration for completing the questionnaire prior to disseminating them. the study adhered to the principles of the 1967 helsinki declaration (wma, 2013) and the protocol was approved by the human research ethics committee of the cross river state ministry of health, nigeria (ref #: crsmoh/rp/rec/2020/116). participation was anonymous and voluntary. informed consent was obtained from all participants prior to commencement of the study and after the study protocol has been explained. participants consented to voluntarily participate in this study by answering either a 'yes' or 'no' to the question inquiring whether they voluntarily agree to participate in the survey. a 'no' response meant that the participants could not progress to answering the survey questions and were excluded from the study. the required sample size for this study was determined using a single population proportion formula given as: in the absence of similar studies in nigeria, the study assumed a proportion of 50% of the population and used a desired precision of 4% and 95% confidence level for a two-sided test. to make up for non-response rate of 25%, the sample size was determined to be 800 persons, which was adequate to detect statistical differences in the analysis of online cross-sectional study on covid-19 among ecps in nigeria. respondents were proportionately determined across the 4 categories of ecps. a self-administered anonymous online survey was administered using convenience sampling technique, on a first-come bases until the required number was obtained within the one-month duration of the survey. a total of 823 questionnaires were fully completed and retrieved in the estimated proportions for the different categories of ecps except for ophthalmic nurses where we got less than the required sample (ophthalmologists [n = 66], optometrists [n = 598], ophthalmic nurses [n = 48] and dispensing opticians [n = 111] ). the survey was created in survey monkey and disseminated to registered ecps in nigeria including optometrists, ophthalmologists, opticians, ophthalmic nurses, and ophthalmic technicians between 2nd and 18th may 2020. distribution was through the administrative heads of the various professional bodies including the ophthalmological society of nigeria (osn), nigerian optometric association (noa), nigeria ophthalmic nurses association (nona) and association of nigerian dispensing opticians (ando) and individually. a link to the online survey was disseminated via the emails and social media platforms (facebook and whatsapp) of the different professional organizations. survey link remained active from 2 may to 18 may 2020, within which time participants completed the survey. the practitioners did not receive incentives for participating in the study and were not under any obligation to complete the survey. participants included ecps who were currently registered to provide clinical services at different levels of eye care within nigeria at the time of the study. responses from non-ecps, non-nigerians, ecps practicing outside nigeria, and non-practicing practitioners were excluded from the analysis. the survey tool was shown in table s1 and consisted of 36 items divided into five sections (demographic characteristics, knowledge, practice of risk of contracting the infection, impact and guidance) utilizing closed-ended questions and a four point 'likert-type scale' to score participants' responses. the responses ranged from 'yes' (score '1 ) to 'no' (score '-1 ). a 'not sure' response was scored as 'zero'. for responses utilizing likert scale, the scores ranged from '3 for 'extremely confident' to '1 for confident and '-1 was scored for 'not-confident' the impact of covid-19 pandemic on practitioners, their family members and practices, including questions on their confidence in the current fmoh guidelines for identifying possible covid-19 cases, their knowledge of personal protective equipment (ppe) recommendations, and training in its usage during consultation were assessed. the explanatory (independent) variable included basic characteristics and explanatory factors including gender, age in categories, region of practice, level of education, marital, employment and religion status, type of ecp, practice setting and practice years. the dependent variables in the regression analysis was knowledge relating to covid-19. the total score ranged from 1 to 9. the scores were derived from questions inquiring on 'whether the participants knew the occupation classified as 'essential work' by the ministry of health during the covid-19 lockdown', if ecps could correctly identify from a list of nine items, the recommended ppes by the ncdc in preventing covid-19 transmission, during consultation of confirmed/suspected cases for health care workers? descriptive statistics and multivariable analysis were performed to demonstrate the outline of the findings of this study and sample characteristics. the responses were presented descriptively in tables. first, the entire cohort-men and women-was analyzed -to determine the knowledge towards covid-19. then, chi-square tests were used to examine the variability in responses by gender, for the different ecps, concerning the knowledge, practice and understanding of the guidelines of the fmoh. the variability in responses between ecps from the different specialties concerning their understanding of guidelines was also assessed. univariate linear regression analysis was calculated in order to assess the unadjusted coefficient. all confounding variables with a p value < 0.20 were retained and used to build a multivariable linear regression model. a manual stepwise backwards model was used to estimate the adjusted estimate for independent variables and to determine factors associated with kap scores towards covid-19. a p-value ≤ 0.05 was considered statistically significant and we checked homogeneity of variance and multicollinearity using variance inflation factors (vif). all statistical analyses were carried out using the statistical program for social sciences, version 25.0 (spss inc, chicago, illinois, usa). a total of 823 respondents (males, n = 374, 45.4%, females n = 449, 54.6%) aged 21-72 years (mean age ± sd, 38 ± 10 years) completed the online questionnaire. about 84.3% were aged less than 50 years and male respondents were significantly older than the females (39 ± 10 years, 95% ci 38-39.7 versus 37 ± 10 years, 95% ci 36.3-38.2; p = 0.033). table 2 presents the demographic characteristics of the respondents including their employment status and years of practice. the total knowledge score relating to covid-19 ranged from 1 to 9 with a mean score of 6.98 ± 2.00. figure 1 shows the mean knowledge score for each eye care profession in the survey. there was a significant difference in the mean knowledge score between the professions (one way analysis of variance, p < 0.0001) with post hoc analysis revealing that the differences was only when ophthalmic nurses (7.71 ± 1.81), optometrists, ophthalmologists (7.10 ± 1.85 and 7.39 ± 2.08, respectively) were compared with the opticians (5.77 ± 2.34, p < 0.0001) who had the least knowledge of covid-19 transmission. no other multiple comparison showed significant difference. in the multivariable analysis, we found that, after adjusting for all cofounders in the final model, eye care profession (job title) was the only factor associated with knowledge of risk towards covid-19 (adjusted coefficient, −0.182, 95% confidence interval −0.601, −0.22; p < 0.0001) ( table 3 ). in the multivariable analysis, we found that, after adjusting for all cofounders in the final model, eye care profession (job title) was the only factor associated with knowledge of risk towards covid-19 (adjusted coefficient, -0.182, 95% confidence interval -0.601, -0.22; p < 0.0001) ( table 3) . table 4 shows the opinion of ecps with respect to covid-19 during the lockdown. over 70% of the subjects reported lack of confidence in the guideline of the federal ministry of health did not consider eye care workers as "essential workers" during the lockdown. notwithstanding, 43.2% were either not so confident or not at all confident attending to any patient during the lockdown while 54.6% also reported they were not so confident or not all confident attending to covid-19 patient or those at risk of covid-19. when questioned about their level of confident attending to patients after the lockdown, 26.3% of eye care professionals reported lack of confident attending to patients even after the lockdown is over and for majority of the practitioners (90%), covid-19 will change the way the deliver eye care service in their practice. the results also revealed that a high proportion of eye care professionals provided eye care services to patients during the lockdown (figure 2 ) with more ophthalmologists and an equal proportion of optometrists and ophthalmic nurses providing services. of the various means of consultation during the lockdown (figure 2) , it can be seen that many ophthalmologists (73%), optometrist and ophthalmic nurses (65% and 62%, respectively) did so via physical consultations in the clinic. more optometrist than ophthalmologist (10.4% vs. 6.1%) utilized videoconferencing to provide this much-needed service during the lockdown while consultation over the phone, social media were also utilized by ecps during the lockdown (figure 2 ). compared to other practitioners, a significant higher percentage of optometrists reported that their professional association provided information on guidelines during covid-19 ( figure 3) . for over 80% of the respondents from each eye care profession, the guidelines were useful and regarding the use of personal protective equipment (ppe), less than 40% of each eye care professionals received training on the use of ppe in the control of covid-19. slightly more ophthalmic nurses (28.9%) received training on ppe compared to the ophthalmologists (14.0%) but this was at borderline significance (p = 0.056) (figure 3 ). 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% compared to other practitioners, a significant higher percentage of optometrists reported that their professional association provided information on guidelines during covid-19 ( figure 3 ). for over 80% of the respondents from each eye care profession, the guidelines were useful and regarding the use of personal protective equipment (ppe), less than 40% of each eye care professionals received training on the use of ppe in the control of covid-19. slightly more ophthalmic nurses (28.9%) received training on ppe compared to the ophthalmologists (14.0%) but this was at borderline significance (p = 0.056) (figure 3 ). compared to other practitioners, a significant higher percentage of optometrists reported that their professional association provided information on guidelines during covid-19 ( figure 3 ). for over 80% of the respondents from each eye care profession, the guidelines were useful and regarding the use of personal protective equipment (ppe), less than 40% of each eye care professionals received training on the use of ppe in the control of covid-19. slightly more ophthalmic nurses (28.9%) received training on ppe compared to the ophthalmologists (14.0%) but this was at borderline significance (p = 0.056) (figure 3) . this is the first study to assess the knowledge, attitude and guidelines of all tiers of ecps regarding the public health initiatives for the novel coronavirus in nigeria. the study found that knowledge about covid-19 preventive guidelines was high among ecps and ophthalmic nurses, ophthalmologists and optometrists were significantly more knowledgeable compared to opticians. the majority of the ecps did not receive training on the proper use of ppes despite a significant proportion stating that they attended to patients during the lockdown period. although the majority of the ecps felt that their professional association provided some useful information on guidelines during the pandemic, this was considered grossly inadequate for many of the ophthalmologists and ophthalmic nurses. more than half of the ecps expressed lack of confidence in caring for patients at risk of covid-19 and, for more than a quarter of them, this will continue even after the lockdown is over. similarly high covid-19-related knowledge was reported in the general nigerian population [22] , and that of the chinese population [23] as well as those of the health care practitioners [14] but an earlier survey found a lack of understanding of the public health guidelines related to covid-19 among ecps in the uk. the study included 100 ecps (ophthalmologists, optometrists, ophthalmic nurses and healthcare assistants) [21] . compared to the uk study, the present study found high knowledge scores among respondents and this difference may be related to timing of both studies as the time lag may have allowed for the respondents in the present study to learn more about covid-19 and, as such, demonstrated higher knowledge scores. at the time of the uk study, the coronavirus outbreak had just been designated a pandemic by the who [4] , although the first confirmed case was reported in the uk on 29 january 2020. the significant association found between covid-19-related knowledge and the category of ecp may be attributed to the ophthalmic nurses having more training on ppes than other ecps, which may have translated to the higher knowledge scores. although the nigerian federal ministry of health do not consider ecps as essential workers, a large proportion of the respondents disagreed with this and more than half confirmed that they provided emergency eye care services via physical examination of patients during the lockdown. this finding suggests the need to consider the inclusion of ecps as part of the essential healthcare team since ocular emergencies can occur at any time and viral conjunctivitis may be a symptom of covid-19 [16, 24] . several guidelines to limit the risk of infection and help ecps safely provide eye care services have been published by the ophthalmic associations, societies and researchers during the pandemic [10, 12, 16, [25] [26] [27] [28] [29] [30] . this is vital as several procedures involve the practitioner to be in close proximity to patients and as such proper use of ppe is essential. a survey of optometrists and opticians conducted in austria, germany and switzerland reported that over 50% of the ecps planned to wear masks during refraction, contact lens fitting and practiced hand washing and disinfection before performing procedures [31] . however, training in the use of ppe is important to avoid the ecp being infected. the finding that majority of ecps did not receive any training on proper use of ppes, was concerning and potentially dangerous, as it puts the practitioner at high risk of contracting covid-19 [32, 33] . an interesting finding of this study was the increased use of telemedicine for delivering eye care services during the covid-19 pandemic, although only a few utilized this service. there is need for education on the methods of delivering this service and the associated benefits for ecps in nigeria. in addition, the fact that majority of the participants in this study were optometrist may be a reflection of the higher number of registered optometrists compared to ophthalmologists and the fact that most of them are practicing in urban centers [34] . this study has some limitations. firstly, the majority of the respondents were practicing in urban areas and their responses may not represent that of ecps practicing in rural areas. secondly, the low number of responses from ophthalmic nurses was lower than estimated from their registry, and this may affect the responses obtained from the group. future studies should consider other ways of reaching this subgroup as their knowledge and practice as front-line workers is important. in addition, further studies are needed to investigate the knowledge and preparedness of ecps in rural settings to provide service during the covid-19 pandemic in nigeria. despite these limitations, this study is strengthened by the larger sample size compared to a previous study [21] . another strength of this study was the representation of the opinions of all tiers of ecps who are involved in the delivery of eye care services during the lockdown in nigeria. in addition, the study was the first to provide evidence on knowledge, practice and guidelines of african ecps during a pandemic. it identified major gaps in the ability of the ecps to continue providing care during and after the pandemic which, if not addressed, might put the ecps and their patients at risk of contracting the virus infection during consultation. addressing these gaps is important to build confidence among ecps and their patients during a pandemic and, more so, as most african countries prepare for a possible second wave of the virus. this study demonstrated that ecps in nigeria were knowledgeable about covid-19 and readily explored several avenues to serve the nigerian population during the covid-19 lockdown. however, the ecps reported lack of confidence on the non-inclusion of eye care workers as essential in the government guidelines for the control of this pandemic, which places them at increased risk. therefore, to ensure that ecps continue to provide the needed services during the pandemic or similar events, there is need for training on the proper use of ppe and recognition as essential worker; this will, in turn, boost their confidence when attending to patients even after the lockdown. the nigerian government need to strengthen health systems by improving and extending training on standard infection prevention and control measures for effective control of the pandemic. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/14/5141/s1, table s1 : survey tool used in this study. funding: this research did not receive any funding. deadliest enemy: our war against killer germs world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19) clinical and ct features in pediatric patients with covid-19 infection: different points from adults who declares covid-19 a pandemic the covid-19 pandemic: important considerations for contact lens practitioners coronavirus disease 2019: coronaviruses and blood safety clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study sars-cov-2 may be related to conjunctivitis but not necessarily spread through the conjunctiva sars-cov-2 and conjunctiva nigeria responds to covid-19; first case detected in sub-saharan africa covid-19 nigeria. nigeria centre for disease control briefings: nigerian emergency economic stimulus bill: all you need to know; brooks and knights legal consultants novel coronavirus disease 2019 (covid-19): the importance of recognising possible early ocular manifestation and using protective eyewear policy institute's response to covid-19: doctors of optometry essential care guidelines for covid-19 pandemic knowledge, attitude, and practice regarding covid-19 among healthcare workers in henan strengths, challenges and opportunities of implementing primary eye care in nigeria odorbn. legislation lagos: optometrists and dispensing opticians registration board of nigeria (odorbn). 2020. available online international council of ophthalmology nigerian nurses decry lack of suitable eyecare facilities ophthalmology training in nigeria: the trainee ophthalmologists' perspective. niger dispensing opticianry calabar: college of health technology survey of ophthalmology practitioners in a&e on current covid-19 guidance at three major uk eye hospitals survey data of covid-19-related knowledge, risk perceptions and precautionary behavior among nigerians. data brief 2020, 30, 105685 knowledge, attitudes, and practices towards covid-19 among chinese residents during the rapid rise period of the covid-19 outbreak: a quick online cross-sectional survey assessing viral shedding and infectivity of tears in coronavirus disease 2019 (covid-19) patients protecting yourself and your patients from covid-19 in eye care protective equipment (ppe) for coronavirus disease (covid-19): interim guidance precautionary measures needed for ophthalmologists during pandemic of the coronavirus disease 2019 (covid-19) guidance for risk assessment and public health management of healthcare personnel with potential exposure in a healthcare setting to patients with coronavirus disease (covid-19) preparing for a covid-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore. can ophthalmology practice during the covid-19 pandemic pandemic: survey of future use of personal protective equipment in optometric practice acceptability and necessity of training for optimal personal protective equipment use perception of job-related risk, training, and use of personal protective equipment (ppe) among latino immigrant hog cafo workers in missouri: a pilot study estimated number of ophthalmologists worldwide (international council of ophthalmology update): will we meet the needs acknowledgments: the authors are grateful to the nigerian optometric association for their financial contribution for data collection. the authors declare no conflict of interest. key: cord-271048-tq1sk01g authors: ellis, r.; hay-david, a.g.c.; brennan, p.a. title: operating during the covid-19 pandemic: how to reduce medical error date: 2020-04-13 journal: br j oral maxillofac surg doi: 10.1016/j.bjoms.2020.04.002 sha: doc_id: 271048 cord_uid: tq1sk01g our professional and private lives changed on march 11 2020 when the coronavirus disease 2019 (covid-19) was declared a pandemic by the who. by march 16, surgical training was suspended, mrcs and frcs examinations cancelled and all courses postponed. in theory, essential cancer surgery, emergency and trauma operating will continue. all elective, non-essential cases are currently cancelled. while we adapt to our new ways of working, we remind ourselves that surgeons are flexible, resilient and, ultimately, we are doctors in the first instance. we present a short article on operating during the covid-19 pandemic. the covid-19 pandemic is likely to be the biggest public health crisis that we will encounter in our lifetimes. the scale of viral spread worldwide, coupled with the subsequent burden on healthcare systems, makes tackling the virus a monumental task. governments around the world are employing strategies to minimise loss of life while trying to maintain functioning economies. the changes in healthcare in the united kingdom, seen over the last few weeks, are unprecedented. intensive care capacity has been increased exponentially, resources including personal protection equipment (ppe) and ventilators are being manufactured at an impressive rate, and, the workforce is being mobilised or redeployed. it is estimated that 2, 660 doctors are among the 12,000 retired nhs staff returning to clinical practice. 1 med* corresponding author. ical and nursing students are volunteering their services. final year medical students will have their graduation date brought forward in order to join the workforce. since its launch on march 24 2020, 405,000 people applied to be a nhs volunteer responder within the first 24 hours. this number now stands at 700,000. 2 the response from the general public is mixed: one of fear and frustration. initially manifested as panic-buying from supermarkets (soap, antibacterial hand gel, and toilet rolls), there is now a gradual acceptance that social distancing and self-isolation will stop the spread of covid-19 and thereby reduce the strain on the nhs. at time of writing 203 countries / areas are affected with 754,948 confirmed cases and 36,571 confirmed deaths. 3 updates from the four royal surgical colleges have been delivered on a regular basis, providing support by keeping dialogue open (emails and webinars) and by providing educational material. it is unsurprising that some clinicians find this an unfamiliar and unnerving time with loss of routine and a rota that changes weekly (if not daily). a reminder by dame clare marx, gmc chair, that we must be flexible: to stick to basic principles; to adhere to gmc guidance; work intelligently; and, minimise risks to our own health. 4 with the cancellation of elective operating and clinics, clinicians are being redistributed throughout hospitals to assist colleagues in other specialties. these may include roles outside our comfort zones / normal remit. many surgical colleagues are being trained in managing unwell patients suffering with coronavirus on the wards, others have been supporting emergency departments and intensive care units. despite covering an increasing number of patients admitted with covid-19, surgeons will still be dealing with emergency surgical admissions and will continue to operate on emergency cases. many of these patients will be covid-19 positive when tested and some may be acutely unwell as a result of the infection. emergency operating during the covid-19 crisis can be challenging for a wide variety of reasons. additionally, we have started to see patients presenting late to hospital with advanced surgical pathology often due to a fear of hospital admission during this pandemic or due to a reduction in outpatient activity. in light of these new and unfamiliar challenges, there are resources available to help surgeons revise their knowledge of acute medicine and receive updates on covid-19 via webinars 5, 6 ; critical care websites with up to date guidelines and handbooks (such as the intensive care society: www.ics.ac.uk/ics/handbooks.aspx); systemic training in acute illness recognition and treatment for surgery (start) course, that includes a human factors presentation, on the rcs website; non-technical skills for surgeons course (notss) presentations are available on the rcs edinburgh website (www.rcsed.ac.uk) to both members and non-members. a greater understanding and appreciation for human factors (hf) can have a significant impact in the reduction of surgical error in such challenging circumstances. 7 surgeons will find themselves operating in different theatres to normal and with unfamiliar (or different) equipment. theatre teams may be unfamiliar with a particular specialty and we may find ourselves operating out of hours more frequently on acutely unwell patients. never has there been a more important time to utilise our non-technical skills to reduce the risk of surgical error. we must take care to introduce ourselves and our role to all new team members during the briefing, to outline the proposed operation and its steps and to ensure all of the required equipment has been sourced before proceeding. clarify any expected or potential concerns from a surgical and an anaesthetic perspective and ask the team if they have any questions. in some situations, surgical options may be limited by the patient's general health or other factors, it is therefore important that these are considered before the planned procedure begins. the patient's covid-19 status must also be identified to ensure the appropriate ppe is used in line with the trust's and public health england (phe) advice. at time of writing, phe advise full ppe (ffp3 mask, visor or safety glasses, gown and gloves) for aerosol generating procedures (agps) for patients with known or symptomatic covid-19. there is currently variation in practise between trusts as to whether all patients should be treated as having covid-19. masks require training to ensure correct fit. some trusts use the n95 mask that you must "pass" the test in order to use safely. if you are able to taste the aerosolised bitter solution sprayed you have "failed" the test and it is ineffective in providing protection. training is also required in the donning and doffing process to ensure this is done correctly and minimises your own risk of exposure. operating can be challenging: uncomfortable and unfamiliar. full ppe can be distracting when first worn, therefore where possible operate with other senior team members to reduce the risk of error. furthermore, as we have experienced, ffp3 masks can make some procedures such as operating down a microscope more challenging as it can affect the usual comfortable eye positions (fig. 1) . wearing face masks and hoods can also significantly reduce the clarity of verbal communication between theatre staff. additionally, it may be more difficult than usual to read non-verbal cues. therefore, care must be taken to ensure open, focussed channels of communication are established between all team members throughout the entire procedure. we must use names to address individual team members and ask people to repeat our requests back to us to ensure a shared understanding. situational awareness may be impaired given the circumstances; therefore care should be taken to ensure all team members are aware of our expectations for the procedure including volume of blood loss and duration. consider allooperating in full ppe can also be exhausting, when performing long procedures, breaks may be required to prevent fatigue. dehydration and hunger are also linked to an increased risk of surgical error; therefore it is imperative that we look after ourselves at work. 8 lack of sleep has been attributed to slower cognitive processing and decision making, increasing the risk of error. 9 despite increasing workloads during this pandemic it is essential that clinicians take care of their own health to optimise their ability to care for others. burn out amongst clinicians may become more common in such a demanding environment. it is important that we look out for this in ourselves and our colleagues, recognising and dealing with this early before it can lead to suboptimal performance. 10 many clinicians are away from families in order to avoid risk to loved ones. there are also more widespread concerns causing stress and anxiety: covid-19 testing (patients and healthcare workers); distrust of governmental decisions; unnecessary "fake" news and scaremongering; concern over inconsistent policies by different trusts in the uk on ppe use (who standards versus phe advice); concern for an overstretched health service that cannot deliver care; and, normal concerns for their own heath and that of their families. trusts have access to support for healthcare workers suffering from burn out which should be utilised at the earliest opportunity. we have entered a period of unease and uncertainty due to the covid-19 pandemic and are seeing unprecedented changes in healthcare: junior members of staff training their seniors on how to complete ward jobs and other administrative tasks; intensive care nurses supervising non-intensive care unit doctors looking after patients in over-flow icu spaces; surgeons working alongside physicians; and, senior team members taking bloods and cannulating patients. overall, this public health crisis has united us in our pursuit of a common goal -flattening the work hierarchy and provoking a considerable change in the way we work in the uk. 11 when we emerge from this crisis, we hope that we will continue to work together as valued team members. concerns over death-in-service benefits keeping doctors from nhs frontline. the guardian world health organisation. coronavirus disease (covid-19) outbreak situation our message to the profession available here: www.rcsed.ac.uk/professional-support-developmentresources/learning-resources/webinars/covid-19/coronavirus-covid-19-essential-knowledge-for-surgeons-undertaking-acute-medical-care european centre for disease prevention and control. webinars on covid19 leading article: what can we do to improve individual and team situational awareness to benefit patient safety? impact of hydration and nutrition on personal performance in the clinical workplace sleep: its importance and theeffects of deprivation on surgeons and other healthcare professionals the impact and effect of emotional resilience on performance: an overview for surgeons and other healthcare professionals challenging hierarchy in healthcare teams -ways to flatten gradients to improve teamwork and patient care we have no conflicts of interest. not applicable. key: cord-264614-2x7cdul3 authors: díaz-guio, diego andrés; díaz-guio, yimmy; pinzón-rodas, valentina; díaz-gomez, ana sofía; guarín-medina, jorge andrés; chaparro-zúñiga, yesid; ricardo-zapata, alejandra; rodriguez-morales, alfonso j. title: covid-19: biosafety in the intensive care unit date: 2020-08-27 journal: curr trop med rep doi: 10.1007/s40475-020-00208-z sha: doc_id: 264614 cord_uid: 2x7cdul3 purpose of review: covid-19 is a new, highly transmissible disease to which healthcare workers (hcws) are exposed, especially in the intensive care unit (icu). information related to protection mechanisms is heterogeneous, and the infected hcws’ number is increasing. this review intends to summarize the current knowledge and practices to protect icu personnel during the patient management process in the context of the current pandemic. recent findings: the transmission mechanisms of sars-cov-2 are mainly respiratory droplets, aerosols, and contact. the virus can last for a few hours suspended in the air and be viable on surfaces for several days. some procedures carried out in the icu can generate aerosols. the shortage of respirators, such as the n95, has generated an increase in the demand for other protective equipment in critical care settings. summary: the probability of transmission depends on the characteristics of the pathogen, the availability of quality personal protective equipment, and the human factors associated with the performance of health workers. it is necessary to have knowledge of the virus and availability of the best possible personal protection equipment, develop skills for handling equipment, and develop non-technical skills during all intensive care process; this can be achieved through structured training. coronaviruses belong to the family coronaviridae, which comprise a great number of viruses common in humans and other animals [1] . the severe acute respiratory syndrome coronavirus 2 (sars-cov-2), a new betacoronavirus, is the etiological agent of the coronavirus disease [2, 3] . sars-cov-2 is an rna virus, the seventh in a coronavirus family this article is part of the topical collection on emerging tropical diseases able to infect humans. it is 40-140 nm in diameter (0.04-0.14 μm) and has a lipid envelop. its target is angiotensinconverting enzyme 2 (ace2) [2, 3] . this new coronavirus has a high infecting capacity; its basic reproduction number (r0) is variable, possibly between 2 and 3 [4] , twice the r0 of swine flu (h1n1) [5] , and similar to the 1918 pandemic influenza (spanish flu) [6] . it has a global distribution; it is also a highly transmissible agent with potentially fatal outcomes. to date, july 12, 2020, it has infected nearly 12.5 million people and caused the death of more than 560,000 patients, including health personnel [7] . for a safe work environment, joint work between workers and employers is required. in the case of health services in the covid-19 pandemic, this premise is also pertinent. employers must guarantee resources for the protection of healthcare workers (hcws), and they must make judicious and rational use of the biosecurity elements available [8] . covid-19 is a very transmissible disease; its transmission mechanisms are mainly respiratory droplets, aerosolized particles, and contact. however, in the intensive care unit (icu), some procedures are associated with aerosol production [9] . most patients present mild symptoms, and 10-30% need hospitalization in the icu [10, 11] , which has exceeded the available resources, even in countries with robust healthcare systems [12] . in low-income countries, the situation could become even worse [13] . health systems must optimize their resources, prepare their icus, and guarantee the protection of those who face the pandemic on the front line [14] . this article aims to show the different strategies to prevent the widespread of the disease to critical care healthcare workers based on the review of the recent literature and the author's experience with the personal protective equipment (ppe) in the care of patients with covid-19 and work on human factors in crisis management. covid-19 can be transmitted person to person through droplets emitted by infected patients when they speak, cough, sneeze, or when a person comes into contact with contaminated surfaces [15] . most of the procedures that can generate aerosols are executed in the icu (orotracheal intubation, tracheostomy, cpr, among others), which exposes the personnel to a high risk of contagion [9] . it is necessary to define some concepts of the dynamics of respiratory droplets (> 5 μm) and aerosols (< 5 μm) produced by the airways of patients with respiratory disease, and the interaction of these particles with the intensive care unit hospitalization environment. the flow acceleration achieved when coughing can be between 2 and 50 m/s, and when sneezing can reach up to 100 m/s [16] . the emitted gas forms a turbulent, multiphase cloud, which can go up to 8 m [17] ; the aerosolized virus may remain suspended for several hours and be active on surfaces for many days [18, 19] . in china, 3.8% of those infected correspond to health personnel [20] ; in italy, 10-20% [21, 22] . in colombia, as of july 12, 2020, 2,633 covid-19 infected healthcare workers have been reported, which corresponds to 2% of the total number of infected in the country; 75.3% were associated with patient care. most infections have occurred in nursing assistants (34%), physicians (18.5%), nurses (13.5%), administrative staff (9.3%), and clean and disinfection workers (5%). 0.83% of infected health personnel have died [23] . intensive care personnel is more habituated to biosafety protocols. nonetheless, in this pandemic, several limitations in adherence to infection control guidelines have been evidenced, including the shortage of ppe, poor quality of ppe, unavailability of rooms with antechamber, bathroom, negative pressure and air exchange, shortcomings in training in ppe donning and doffing, frequent changes on management guidelines, and ambiguity of the recommendations [24] [25] [26] . the patient may disperse particles that have infectious contents. these particles experience changes with the dynamics of airflow in the room, which can be influenced by the high traffic in the place, the presence of air conditioning, negative pressure, door opening, among others. the droplets are heavy and usually fall on the patient and in his environment. despite that, they can be dried by air currents leaving the droplet nuclei exposed and able to persist suspended in the air. viral dose, exposure time, mucosal exposure, and tidal volume are determining factors in the possibility of contamination and hcws possible infection [16, 27] . the infectious particles can be on the patient, in their environment (fomites), and possibly in the patient's room air. the virus can reach its target site through the eyes conjunctive, nose, and mouth mucosae. the fecal-oral route may be involved, but this has not been proven so far [28] . if we understand these data, we may have an opportunity to prevent the spread of the disease to healthcare workers with specific physical barriers known as personal protective equipment (ppe) [29, 30] . eye protection can be done by wearing goggles, facial shields, or full-face elastomeric respirators. mouth and nasal protection are conferred by n95/kn95/ffp2 (filtering face piece) or higher respirators. in the event of a shortage of disposable respirators, half-face or full-face elastomeric respirators with n95 or more top filters can be used. the inspiratory and expiratory seal verification is essential in all respirators before use (fig. 1 ). the protection offered by masks and respirators against particles larger than 0.3 μm is a surgical mask: 80%, ffp2: 94%, n95: 95%, ffp3: 99.9%, n100: 99.9%. it is strongly recommended to verify the national institute for occupational safety and health (niosh) quality certification, it must be written on the front of the device. the who recommendations indicate the use of a surgical mask when health personnel is not exposed to aerosolgenerating procedures (agps) and n95 when performed [28] . however, the european cdc in high-risk environments recommends the use of ffp2 or equivalent respirators, and for agps recommends ffp3 or equivalent [8, 29] , we are aligned with the european recommendations. nonetheless, to date, there is no robust evidence that medical masks are inferior to n95/ffp2 respirators for protecting healthcare workers against laboratory-confirmed covid-19 during patients care and non-agps [31] . the elastomeric respirator is a valid and increasingly used option due to the shortage of n95/ffp2 respirators [32] . this device can be found in half-face and full-face versions. it is reusable and has different types of filters, although n95 or higher is recommended. it has been shown that short time is required to learn how to use them [33] . in table 1 , we describe the ppe with its use considerations. while personal protective equipment is an essential part of safety to prevent sars-cov-2 transmission, it must be employed appropriately, together with frequent hand hygiene, and mastering specific techniques and non-technical skills like awareness, closed-loop communication, leadership, team working, appropriate resource management, and cognitive aids [14, 34] . below, we feature some safety recommendations from patient's admission to the icu until discharge. critically ill patients should be hospitalized in the intensive care unit after a triage process. the referring service (emergency room, operating room, general room, among others) must report the arrival [35] . the hospital should have specific routes for infected patients' transfer [36] . it is recommended that patients be hospitalized in individual rooms with antechamber, bathroom, and negative pressure systems with high-efficiency filters (hepa) and 12 air changes per hour. non-intubated patients must wear a surgical mask [37, 38] . the number of healthcare workers that meet the patient should be the minimum necessary, and all must use ppe appropriately, with donning and doffing assisted by an external verifier guided by a checklist (table 2 ) [30] . the most frequent covid-19 clinical manifestations are respiratory. most critically ill patients have respiratory distress and oxygenation disorder [10] ; therefore, they need airway management and mechanical ventilatory support in the icu. airway management is considered a high-risk activity for aerosol production; this includes positive pressure mask ventilation, supraglottic device insertion, orotracheal intubation, open airway aspiration, bronchoscopy supported procedures, tracheostomy, and tracheal extubation [9, 38] . for tracheal intubation of the patient with suspected or confirmed covid-19, full and verified ppe must be available. that includes n95/ffp2, ffp3, or equivalent respirators or paprs [29, 30] , in addition to observing the following recommendations: for intubation and even for planned extubation, in places where negative pressure is not available, acrylic boxes and plastic devices have been used [39, 40] . they can protect against splashes, possibly aerosols, but this is not clear. these devices can make intubation complex; therefore, the hcws must be trained in their use. before the pandemic, tracheostomies were performed between the 7th and 14th days of endotracheal intubation. however, the median time from intubation to death of covid-19 patients has been reported to be on the 7th day [41] . due to the high risk of aerosol production during the tracheostomy, and hcws' risk of contagion, it seems reasonable to wait for establishing a life prognosis, which could avoid futile procedures if the tracheostomy were performed too early, thus, protecting healthcare personnel [42] . all hcws participating in the procedure must wear full ppe, which includes paprs, n99, or ffp3 respirators [43] . the patient should be sedated and relaxed. regarding the technique, there is no apparent difference between open and percutaneous tracheostomy. if the percutaneous method is chosen, the one-step dilation technique is preferred [42] . the consideration of thoracic compressions as an aerosolgenerating procedure has been controversial, due to the united kingdom's national healthcare system (nhs) not considering them agps [44] ; however, the who and scientific societies put on inner gloves, "second skin". 3. gown / coverall gown: secure both ties at the back of the gown. coverall: fasten hat and arms of the suit to avoid contact with the ground. hold the cup with your hand, first raise the lower band, leave below the ears, then the upper band and leave it above the ears. fit the coupling plate over the nose dorsum and perform a fit check (forced exhalation -forced inspiration). put on your cap: no skin exposed. adapt the adjustable base to the size of the head in case of face shield. goggles or face shield must be worn over prescription glasses. 6. outer gloves put on the gloves making sure the suit cuffs are covered by the gloves. hand hygiene or alcohol gel application. remove one glove and squeeze it with the opposite hand, then remove the other glove from the inside and wrap the one that was initially removed. hand hygiene or alcohol gel application. remove the goggles by holding them from the temples. if it is a face shield, hold it from the posterior side of the adjustable base. 6. gown / coverall remove the gown by folding it and pulling it away from the body only by touching the inner part (disinfected side). include over shoes. hand hygiene or alcohol gel application. consider that they are [28, 37] ; we agree with the latter. therefore, it is necessary to have all the aerosols precautions in addition to the following recommendations [45, 46] : & define if the patient is a resuscitation candidate. & minimize the number of resuscitation personnel. & avoid the maneuver "listening and feeling" to determine to breathe. & perform early intubation along with a high-efficiency filter. & employ commercial chest compression systems. the mortality of patients admitted to the icu is elevated, even more so in those requiring mechanical ventilation [11, 41] . there is no direct evidence on the risk of contagion of healthcare workers who have had contact with the bodies of covid-19 deceased persons. in a study related to the severe acute respiratory syndrome (sars) epidemic, there was a reported contagion of 27% of hcws that came into contact with corpses [47] . it is recommended that icu healthcare workers who manage corpses use full ppe following the same recommendations that were described for performing icu procedures. tubes and venous and arterial lines should be removed; puncture sites should be disinfected. corpses should be packed in a double leak-proof bag; the exterior cover, surfaces, and environment must be adequately disinfected. it is also recommended to avoid direct contact with bodily fluids, contaminated surfaces, transporting stretchers, and make a timely transfer of corpses to the morgue or designated areas. for a recent systematic review on the management of bodies, we refer the reader to yaacoub et al. [48] . one of the transmission mechanisms is the contact of hcws with contaminated surfaces; the presence of sars-cov-2 at different sites in the patient's room has been documented [28] . the stability of the pathogen depends on several factors: inoculum size, viral resilience, surface ph, temperature, and humidity of the environment. persistence has been shown for up to 3 days, depending on the material, being higher in plastic and steel [18] . it is susceptible to heat and standard disinfection methods. the surface disinfection process should start with cleaning with soap and water or neutral detergents associated with mechanical measures, to remove dirt and reduce the load of pathogens. second, the use of disinfectants, the who recommends hydrogen peroxide, chlorine-based solutions, and alcohol. efficiency will depend on concentration and exposure time [49, 50] . ethanol 70-90% requires 30 s-1 min to be effective, chlorine-based products (e.g., hypochlorite) at 0.1% (1000 ppm) for general environmental disinfection or 0.5% (5000 ppm) for blood and large body fluid spills require 1 min, and hydrogen peroxide > 0.5% at least 1 min. cleaning and disinfection should start from the least contaminated to the most contaminated; the cleaning material must be labeled and frequently changed due to the risk of contamination. in general, it is recommended in the work areas with patients to clean two to three times a day; objects of everyday use (door handles, keyboards, tables, among others) must be cleaned with higher frequency. sanitation and disinfection workers are essential in this pandemic and should receive the best protection available against sars-cov-2 and the substances for disinfection use. it is not recommended to spray people or use disinfection chambers for personnel [50] . at present, most of the people around world are at home protecting themselves with social distancing. meanwhile, the hcws must take care of the patients. anxiety, insomnia, depression, and cognitive overload have been reported in healthcare personnel. they are afraid of contagion, infecting their families, failing, and dying [51] . the use of personal protective equipment, although it is an excellent measure of protection, also presents difficulties that can generate stress and discomfort. putting them on and removing them is not easy and time-consuming [52] . in this crisis, performing procedures has become more difficult [53] ; initially, a feeling of awkwardness is generated; the goggles become foggy; breathing with disposable or elastomeric respirators requires more effort; skin injuries occur; thirst, heat, dizziness, and headaches are felt. other difficulties are that most hcws dress similarly, which limits mutual recognition, added to that respirators significantly limit communication; this has increased the complexity of an already complex disease; the cognitive load of health personnel is already high. higher cognitive load increases the probability of failure [54] , of becoming contaminated and infected. briefing and debriefing are strongly recommended on each shift and after each severe incident. possibly, the most efficient way to decrease cognitive load and improve performance is through training techniques and tasks such as donning and doffing, as well as human factors or non-technical skills such as leadership, communication, and situational awareness. an excellent way to do this is through structured clinical simulation; this includes clear learning objectives, plausibility between the simulated and real context, intentional reflection, usage of metacognitive strategies, and evaluation of learning results [55, 56] . in low-and intermediate-income countries, the availability of adequate resources for the protection of hcws is possibly insufficient, which has led health care personnel to improvise their ppe, which puts their safety at risk; therefore, government and administrative levels must guarantee the workers of the icu the adequate resources. covid-19 is a highly contagious disease, and icu healthcare workers are very exposed. the main transmission mechanisms are droplets and contact. however, some procedures can generate aerosols. the virus enters the body through the mouth, eyes, and nose. therefore, biosafety should focus on aerosol precautions and the correct use of full personal protective equipment, surface decontamination, and frequent hand hygiene. the availability of full personal protective equipment does not indicate absolute safety; there are factors related to the pressure of critically ill care and human factors that are involved with non-safe performance, and that can be improved through training and teamwork. conflict of interest the authors declare that they have no conflict of interest. human and animal rights and informed consent not applicable. the species severe acute respiratory syndrome-related coronavirus: classifying 2019-ncov and naming it sars-cov-2 a novel coronavirus from patients with pneumonia in china a new coronavirus associated with human respiratory disease in china the reproductive number of covid-19 is higher compared to sars coronavirus modeling influenza epidemics and pandemics: insights into the future of swine flu (h1n1) transmissibility of 1918 pandemic influenza who. coronavirus disease 2019 -situation report -174 european centre for disease prevention and control. safe use of personal protective equipment in the treatment of infectious diseases of high consequence: a tutorial for trainers in healthcare settings staff safety during emergency airway management for covid-19 in hong kong clinical, laboratory and imaging features of covid-19: a systematic review and meta-analysis at the epicenter of the covid-19 pandemic and humanitarian crises in italy: changing perspectives on preparation and mitigation. nejm catal innov care deliv will colombian intensive care units collapse due to the covid-19 pandemic the italian covid-19 outbreak: experiences and recommendations from clinical practice 2019 novel coronavirus: where we are and what we know airborne spread of infectious agents in the indoor environment turbulent gas clouds and respiratory pathogen emissions: potential implications for reducing transmission of covid-19 aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 it is time to address airborne transmission of covid-19 characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72314 cases from the chinese center for disease control and prevention coronavirus disease 2019 (covid-19) in italy covid-19 and italy: what next? covid-19 colombia | reporte 17-06-2020 barriers and facilitators to healtcare workers' adherence with prevention and control (ipc) guidelines for respiratory infectious diseases : a rapid qualitative evidence synthesis ( review ) healthcare workers' and students' knowledge regarding the transmission, epidemiology and symptoms of covid-19 in 41 cities of bolivia and colombia covid-19: a crisis that requires urgent training measures airborne transmission of severe acute respiratory syndrome coronavirus-2 to healthcare workers: a narrative review who. transmission of sars-cov-2: implications for infection prevention precautions. scientific briefing personal protective equipment (ppe) needs in healthcare settings for the care of patients with suspected or confirmed novel coronavirus (2019-ncov) personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff medical masks vs n95 respirators for preventing covid-19 in healthcare workers: a systematic review and meta-analysis of randomized trials. influenza other respir viruses storage and availability of elastomeric respirators in health care training and fit testing of health care personnel for reusable elastomeric half-mask respirators compared with disposable n95 respirators non-technical skills in the intensive care unit icu admission, discharge, and triage guidelines: a framework to enhance clinical operations, development of institutional policies, and further research preparing your intensive care unit for the covid-19 pandemic: practical considerations and strategies surviving sepsis campaign: guidelines on the management of critically ill adults intensive care medicine consensus guidelines for managing the airway in patients with covid-19: guidelines from the difficult airway society, the association of anaesthetists the intensive care society, the faculty of intensive care medicine and the royal college of anaesthetist clear plastic drapes may be effective at limiting aerosolization and droplet spray during extubation: implications for covid-19 barrier enclosure during endotracheal intubation baseline characteristics and outcomes of 1591 patients infected with sars-cov-2 admitted to icus of the lombardy region recommendation of a practical guideline for safe tracheostomy during the covid-19 pandemic personal protective equipment (ppe) for surgeons during covid-19 pandemic: a systematic review of availability, usage, and rationing covid-19: infection prevention and control guidance covid-19 in cardiac arrest and infection risk to rescuers: a systematic review covid-19 practical guidance for implementation risk factors for sars infection among hospital healthcare workers in beijing: a case control study safe management of bodies of deceased persons with suspected or confirmed covid-19 : a rapid systematic review protection and disinfection policies cleaning and disinfection of environmental surfaces in the context of covid-19: interim guidance prevalence of depression, anxiety, and insomnia among healthcare workers during the covid-19 pandemic: a systematic review and meta-analysis human factors risk analyses of a doffing protocol for ebola-level personal protective equipment: mapping errors to contamination difficult airway in the critically ill patient: much more than technical skills evaluation of cognitive load and emotional states during multidisciplinary critical care simulation sessions relationship among mental models , theories of change , and metacognition : structured clinical simulation cognitive load and performance of health care professionals in donning and doffing ppe before and after a simulation key: cord-258498-0mvxwo3w authors: shah, saleha title: covid-19 and paediatric dentistrytraversing the challenges. a narrative review date: 2020-08-21 journal: ann med surg (lond) doi: 10.1016/j.amsu.2020.08.007 sha: doc_id: 258498 cord_uid: 0mvxwo3w the coronavirus disease (covid-19) pandemic has become a major global public health emergency with a focus on preventing the spread of this virus for controlling this crisis. a dental setting is at a high risk of cross infection amid patients and dental practitioner's owing to the spread of infection via droplets suspended in the air by infected symptomatic or asymptomatic subjects. this review article informs about measures which reduce facility risk, manage symptomatic patients and protect personal health care and management with reference to paediatric dentistry. the routine aerosol generating procedures are not designed to offer protection against transmission of pathogens and the standard protective measures do not offer adequate effectiveness against patients generating aerosol in the incubation period, are unaware of the infection or conceal information regarding their infection. 5, 6 dental healthcare personnel (dhcp) are all paid and unpaid persons serving in dental healthcare settings with a potential for direct or indirect exposure to patients or infectious materials (body substance, contaminated medical supplies, devices, equipment, environmental surfaces, air). a dhcp is placed in the very high exposure risk category by osha via high potential for exposure to known or suspected viral sources for covid-19 during specific dental procedures. 5, 6, 7 the risk of sars-cov-2 transmission via aerosols generated during dental procedures cannot be eliminated when practicing in the absence of airborne precautions (airborne infection isolation rooms or single-patient rooms, respiratory protection program, n95 respirators). it is vital to reduce the risk of infections in a dental setting by infection control measures since unrecognized asymptomatic and presymptomatic infections have a likelihood of transmission in healthcare settings. sars-cov2 is sensitive to heat and ultra-violet rays. it is inactivated at 56°c for 30 minutes and by lipid solvents ethanol, 75% ether, disinfectants containing peracetic acid, chloroform and chlorine but not by chlorhexidine 7, 8 this is essential in the reliable and effective protection of dhcp from exposure to pathogens. it includes engineering controls, administrative controls and personal protective equipment (ppe). the optimal way to prevent airborne transmission is via a combination of interventions from the hierarchy of controls including elimination (physical removal of hazard), substitution (replacing hazard), engineering controls, administrative controls and ppe (least effective control owing to a high level of worker involvement and dependence on proper fit and correct use). source control entails coverage of the mouth and nose by a cloth face or a facemask to aid the reduction of risk of transmission of sars cov-2 from both symptomatic and asymptomatic people via respiratory secretions. 7,8, paediatric dental practice aims to maintain the well-being and safety of children during this pandemic by redesigning, reconsidering and reflecting on the dental care practices and staying up to date with the current evidence based guidance and recommendations for child oral health care. hence a risk assessment of the practice should be carried out to identify the measures required to minimize the risk of covid-19 transmission. administrative controls and work practices: these work practices and policies reduce or prevent hazardous exposures. the practice should be cleaned thoroughly and clutter removed to facilitate frequent cleaning and disinfection. toys, magazines and other frequently touched objects in the waiting area which cannot be cleaned or disinfected regularly are removed from the waiting area. devise a protocol for receiving mails and deliveries. the number of dental setting/hospital/outpatient patients is limited and screened for respiratory illness prior to healthcare. triage by telemedicine (telephones, video-call applications on cell phones, video monitoring or tablets) and manages patients suspected of covid-19 without a face to face visit. if the signs and symptoms are present then the appointment is rescheduled. clinical care is limited to one patient at a time. the essential personnel should only be allowed to enter a patient care area. limit dhcp during a procedure to those essential for procedure support and patient care. this avoids multiple room entry and bundling. entry of known or suspected covid-19 should be restricted by the dhcp or allowed to enter with ppe. dhcp at higher risk for severe illness from covid-19 (old age, chronic medical conditions, pregnant) should be excluded from caring for confirmed or suspected covid-19. dhcp recovered from covid-19 (protective immunity) care for covid-19 patient. 9, 10, 11, 12, 13, 14, 15, 30, 31, 32, 33, 34 dhcp should be monitored and managed with application of flexible sick leaves. hcp should monitor themselves regularly for fever and covid-19 symptoms. they should stay at home if they feel unwell and cover their faces or leave the workplace if they start feeling unwell at work. every hcp should be screened for fever and symptoms consistent with covid-19 (fever >100.0of, cough, shortness of breath, and sore throat) when their shift commences. testing should also be done if temperature is <100.0 o f or with other symptoms consistent with covid-19. if covid-19 is ruled out based on time and test and the dhcp has an alternate diagnosis (tested positive for influenza); the criteria for return to work should be based on that diagnosis. they should continue wearing a mask subsequent to returning to work, self-monitor for symptoms and reevaluate with a medical facility. 24, 27, 28, 29 a dhcp should be trained on the use of n95 respirators (putting on, removal, limitations, maintenance, check seal, repair, replace) when caring for patients in aerosol generating procedures. they should undergo medical clearance and fit testing. a qualitative fit test is a pass/fail test relying on individual sensory detection whereas a quantitative fit test is a numerical measure of the effectiveness. cohorting confirmed patients of covid-19 in one area to confine their care prevents patient contact and minimizes the use of respirators. just-in-time fit testing is the ability of a healthcare facility for larger scale evaluation, training and fit testing of hcp prior to receiving patients during a pandemic. an annual fit may be temporarily suspended during expected shortages. 9, 10, 11, 12, 13, 14, 15, 30, 31, 32, 33, 34 the set up should include clean or sterile accessible supplies and instruments for specific dental procedure only. instruments should be stored in covered storage (drawers and cabinets) to maintain decontamination. they should be supplied when needed and disposed when the dental procedure concludes. safety and quality assurance checks on radiographic equipment should be performed. aed should be tested as well. all the emergency drug kits should be checked for expiry. ensure that the rechargeable items are fully charged and operational. check the drinking water dispenser for staff use and recommission by manufacturer's instructions. the computer updates should be checked and installed. minimally invasive/atraumatic restorative techniques (hand instruments) should be prioritized, aerosol-generating procedures via dental handpiece and air/water syringe should be avoided and ultrasonic scalers discontinued. when aerosol-generating procedures are necessary use four-handed dentistry to droplet spatter and aerosols may be minimized via a high evacuation suction and dental dam. preprocedural mouth rinses (pmrs) with an antibacterial product (chlorhexidine gluconate, essential oils, povidone-iodine or cetylpyridinium chloride) may reduce the level of oral microorganisms in aerosols and spatter generated during dental procedures however (ppmr) do not have evidence regarding their clinical effectiveness to reduce sars-cov-2 viral loads or to prevent transmission. 9, 10, 11, 12, 13, 14, 15, 30, 31, 32, 33, 34 engineering controls: barriers (glass/plastic windows/curtains) in reception areas where patients report on arrival (intake desk, triage station, information booth, pharmacy and drop-off/pick-up windows are placed to reduce the risk of exposure between the potentially infectious patients and dhcp. aerosol-generating procedures for patients confirmed or suspected of covid-19 should take place in an airborne infection isolation room (aiir). air should be exhausted directly outside or filtered directly via a high-efficiency particulate air (hepa) filter before recirculating. the expedient patient isolation room method involves high-ventilation-rate, negative pressure, inner isolation zone within a "clean" larger ventilated zone by a portable fan device with high-efficiency particulate air (hepa) filtration. it increases effective air changes per hour of clean air to the room thereby reducing the risk to persons entering without respiratory protection. twelve air changes per hour are recommended for a renovation or new construction. the ventilated headboard is a special inlet system to provide an improved air intake for a corresponding high-efficiency particulate air (hepa) fan/filter unit ventilation system with proper engineering controls (filtration, exchange rate) should be installed and maintained to provide movement of airflow in a direction from a clean (dhcp workstation or area) to a contaminated area (sick patient/clinical patient) (appropriate filtration, exchange rate) should be installed and maintained. air supply in the receptionist area with return air louvers positioned in the waiting area achieves this effect. a heating, ventilation and air conditioning (hvac) professional can increase the filtration efficiency to the highest level without deviation from designed airflow as well as increase the percentage of outdoor air supply. demand controlled ventilation (temperature setpoint and/or occupancy controls) should be limited during occupied hours and up to 2 hours post occupancy to ensure that ventilation remains unchanged. bathroom exhaust fans should run continuously during work hours. a portable hepa air filtration unit may be considered during and following an aerosol procedure. these units reduce particle count (droplets) and turn over time in the room rather than just relying on the building hvac system capacity. a hepa unit should be placed within the vicinity (chair) of a patient but not behind dhcp and the dhcp should not be positioned between the unit and the patient's mouth. the position of a unit ensures that the air is not pulled into or past the breathing zone of the dhcp. an upper-room ultraviolet germicidal irradiation (uvgi) is used as an adjunct to higher ventilation and air cleaning rates. follow environmental cleaning and disinfection procedure with hospital-grade disinfectant 9, 10, 11, 12, 13, 31, 32, 33, 34, 35, 36 patient placement dental treatment should ideally be provided in an individual patient room when possible. in open floor plan dental facilities with open floor plans the spread of pathogens man be prevented by a distance of at least 6 feet between patient chair, easy-to-clean floor-to-ceiling barriers to enhance the effectiveness of a portable hepa air filtration systems without interfering with the fire sprinkler systems and physical barriers between chairs for patients. the dental operatory should be parallel to the direction of airflow where feasible. in vestibule-type office layouts consider patient orientation by placing the head near the return air vents, away from pedestrian corridors, and towards the rear wall. the maximum number of patients who can receive care at the same time in the dental facility safely is determined by the layout of the facility, number of rooms and the time needed to clean and disinfect the operatories. it is advised that dhcp should wait at least 15 minutes after the conclusion of dental treatment and exit of the patient to commence the room cleaning and disinfection process. this allows droplets to sufficiently fall from the air after a dental procedure. 3, 24 personal protective equipment: respiratory protection (ppe) standard precautions assume that each person is potentially infected or colonized with pathogens which may be transmitted in a healthcare setting. standard precautions entail a n95 (standard and surgical medical respirators) or facemask, eye protection (goggles, protective eye wear with solid waste shields, or a full face shield), and a gown or protective clothing during procedures which produce splash, spatter of blood or body fluid and known/suspected covid-19 patients. a respirator is a ppe device worn on the face, covering least the nose and mouth to reduce the risk of inhaling hazardous airborne particles (dust and infectious agents), gases, or vapors. respirators are certified by cdc/national institute for occupational safety and health (niosh). surgical respirators are indicated for respiratory protection in airborne pathogens (tuberculosis, measles, varicella) and fluid hazard (high-velocity splashes, sprays, splatters of blood or body fluid) hence preferred over a facemask. an effective face seal of a respirator requires qualitative or quantitative measurement. the highest level of surgical mask should be used. a faceshieid is worn over a standard n95 when a surgical n95 is unavailable. n95 masks need to be conserved during the crisis period. conventional capacity provides patient care sans any alteration in existing daily practices. contingency capacity practices may be used provisionally during expected periods of n95 respirator shortages without significant impact on patient care. 9, 10, 11, 12, 13, 16, 17, 18, 19, 20, 21, 22, 23 alternatives to n95 masks include filtering facepiece respirators n99, n100, p95, p99, p100, r95, r99, and r100, elastomeric half-mask (replace filter cartridges) and full facepiece air purifying respirators, powered air purifying respirators (loose fitting hoods or helmets) reusable (paprs). all of these provide equivalent or higher protection than n95 respirators when worn properly. filtering facepieces with an exhalation valve are not used in a sterile surgical setting since the unfiltered exhaled air compromises a sterile field. n95 may be retained, reserved and used beyond the shelf life during shortage in the pandemic. they may be re-used by one hcp for multiple encounters with different patients but removed (doffing) after each encounter. the time in between re-use should not exceed the 72 hours expected survival time for sars-cov2. n95 contaminated with gross blood, respiratory or nasal secretions and/or other bodily fluids should be discarded. contamination may be reduced/ prevented by wearing a facemask over it. 9, 10, 11, 12, 13, 16, 17, 18, 19, 20, 21, 22, 23 a facemask block respiratory secretions produced by the dhcp from contaminating other persons and surfaces (source control) when worn with instructions in symptomatic patients suspected of covid-19 or other respiratory infection (fever, cough) but not n95. dhcp should wear a facemask at all times while they are in the dental setting as a part of universal source control. they should be instructed to not touch or adjust their mask or cloth face cover and perform hand hygiene immediately before and after. cloth face covering should not substitute a respirator or facemask. dhcp whose job does not require ppe (clerical) may wear cloth face covering. dhcp (dentists, hygienists, assistants) may wear cloth face covering when not engaged in direct patient care and switch to a respirator or a surgical mask when ppe is required. dhcp when leaving the facility at the end of their shift should remove their respirator or surgical mask and wear cloth face covering. self-contamination is prevented by changing or laundering a cloth face covering saturated with respiratory secretions, soiled, dampened or posing difficulty for breathing. hand hygiene must be performed before and after touch/adjustment of face cloth or face mask.n95 and face mask should be used according to the type of activity. a dhcp at a distance greater than 6 feet from a symptomatic patient does not need a face mask or n95. facemask may be used in a dhcp within 6 feet of an asymptomatic patient for provision of direct patient care. in other countries respirators for occupational use are approved according to country-specific standards. manufacturers sans niosh approval should only include products approved by and received from china. if the remaining supply of n95 is absent consider hepa with facemasks. extended use of facemasks and respirators should is undertaken only when the facility is at contingency or crisis capacity and has implemented all likely applicable engineering and administrative controls. 9, 10, 11, 12, 13, 16, 17, 18, 19, 20, 21, 22, 23, 37, 38 hand hygiene: hand hygiene is indicated after all patient contact, contact with infectious material and prior to wearing and removing ppe (gloves) to remove any possible pathogen transfer to bare hands. abhr with 60-95% alcohol or washing hands with soap and water for at least 20 seconds is advisable. for visibly soiled hands use soap and water before abhr. hand hygiene supplies should be available for the dhcp in every care location. 9, 10, 11, 12, 13, 16, 17, 18, 19, 20, 21, 22, 23 use eye protection (goggles, disposable face shield) and remove them prior to leaving the operatory. reusable eye protection (goggles) must be cleaned and disinfected according to manufacturer's instructions. the disposable eye protection should be discarded after use. personal eyeglasses and contact lenses are inadequate. 24, 25, 26, 27 gloves: clean and non-sterile gloves should be worn upon entering the patient care area. they should be removed and discarded followed by immediate hand hygiene. if they are torn or heavily contaminated they should be changed. they should be educated about the signs and symptoms and diagnoses of skin reactions associated with glove use 24, 25, 26, 27 gown: a clean isolation gown is worn upon entry; changed if soiled and removed to be discarded in a waste or linen container before leaving. cloth gowns are laundered post use. gown shortage should be prioritized for aerosol generating procedures, splashes and sprays where high-contact patient care activities favor transfer of pathogens to the hands and clothing of dhcp. 24, 25, 26, 27 sequences recommended for donning and doffing ppe: j o u r n a l p r e -p r o o f before entering a patient care area perform hand hygiene and don a clean protective clothing or gown that covers skin and personal clothing likely to be soiled by potentially infectious material like blood, saliva, or other materials. if a gown and protective clothing become soiled they should be changed. a surgical mask or respirator is worn and the mask ties are secured on the crown of the head (top tie) and base of the neck (bottom tie). if loops are present hook the mask around ears. respirator straps should be placed on the crown of the head and base of the neck and checked for a user seal check each time. eye protection should not include personal eyeglasses and contact lenses. hand hygiene is followed by putting on clean non-sterile gloves. they should be changed when torn or heavily contaminated prior to entering the room. 24 after completion of dental care gloves are removed and the gown or protective clothes are discarded in a dedicated container for waste or linen. disposable gowns are discarded after each use and protective clothes are laundered after each use. exit the patient care area and perform hand hygiene, remove eye protection carefully by grabbing the strap and pulling upwards and away from head without touching the front of the eye protection. clean and disinfect reusable eye protection prior to reuse by the manufacturer's reprocessing instructions but discard disposable eye protection after use. remove and discard surgical mask or respirator without touching the front. for a surgical mask untie (or unhook from the ears) and pull it away from the face carefully without touching the front. for a respirator remove the bottom strap by touching the strap only and bring it over the head carefully. for the top strap; grasp it and bring it over the head to pull the respirator away from the face without touching the front. finally perform hand hygiene to follow standard precautions. 24 before arrival: appoint each group of patients one personnel from the dental clinic who can be reachable 24/7 in case of an emergency in order to asses and determine the need to be seen. when scheduling appointments (elective) provide instructions to the patient to call ahead of the visit and discuss the need to defer/reschedule their appointment if they experience fever or symptoms of covid-19 on the day of their appointment/visit. impart advice about their own cloth face covering, irrespective of their symptoms before entering the dental facility. schedule an appointment for possible covid-19 patients by triage to determine the need for appointment versus management at home. if the patient has to attend an appointment they must call beforehand to inform triage personnel about their symptoms of covid-19 as well as follow appropriate preventive actions throughout the visit to contain the respiratory secretions. if a face cloth is difficult to tolerate hold a tissue instead). if a patient is arriving via transport by emergency medical services (ems) allow the healthcare facility to prepare for receiving the patient. 24 upon arrival and during the visit: monitor and limit the points of entry to the dental facility as well as post visual alert posters, signs in appropriate language for instructions on respiratory hygiene, hand hygiene, cough etiquette, facemask or face cover. provide 60-95% alcohol-based hand rub, tissues and no-touch receptacles for disposal at the entrances, waiting rooms, check-in, elevators and cafeterias. minimize overlap in dental appointments and ask the patients and attending visitors to wear a face covering or mask prior to entry irrespective of symptoms of fever and covid-19. set up physical barriers (plastic or glass windows) to limit close contact between triage dhcp and potentially infectious patients. establish an outdoor triage station to screen individuals prior to entering the facility. the triage dhcp must wear a respirator/mask, eye protection and gloves for taking vitals and assessing patients for care until covid-19 is considered unlikely. 24 prioritize triage of suspected symptomatic covid-19 patients. dhcp should inquire about the presence of fever, symptoms of covid-19, or contact with patients with possible covid-19 from every patient at the time of patient check-in. covid-19 symptomatic patient should be isolated in an examination room with door closed and waiting space separated by 6 feet or more with easy access to respiratory hygiene supplies. they should not be allowed to wait among other patients. if they opt to wait in a personal vehicle or outside the facility they may be contacted by mobile phone when their turn arrives. in an afebrile patient (temperature < 100.4˚f) and otherwise without symptoms consistent with covid-19 may be provided dental care using appropriate engineering and administrative controls, work practices, and infection control considerations. the patient should be asked to wear a face cover at the completion of dental care prior to leaving the treatment area. all new fevers and symptoms consistent with covid-19 should be monitored. inadvertent treatment of a patient confirmed to have covid-19 later may occur even when dhcp screen patients for respiratory infections. the patient should be therefore be requested to inform the dental clinic if they become symptomatic or are diagnosed with covid-19 within 14 days following the dental appointment. in a patient with fever strongly associated with a dental diagnosis (pulpal and periapical dental pain and intraoral swelling) but no other symptoms consistent with covid-19; care can be provided with appropriate protocols. 24 additional strategies to minimize chances for exposure: this depends on factors like level of sars-cov-2 community transmission, number of covid-19 being cared for at a facility, healthcare-associated transmission and anticipated ppe or staffing shortages. the potential for patient harm if care is deferred needs to be determined. it is better to modify or cancel inperson group healthcare activities and implement virtual methods or schedule smaller in-person group sessions with a face cover and a distance of 6 feet apart. postpone all the dental elective procedures, surgeries and non-urgent outpatients. if a patient with a dental emergency is highly likely to cause harm by deferring treatment it is advisable to provide care without delay in facilities less heavily affected by covid-19; provide care without delay in your facility as opposed to transferring them or provide care without delay while resuming regular care practices. 24, 25, 26 facility considerations: dental equipment considerations: the manufacturer's instructions should be reviewed for instructions for use (ifu) on dental equipment for office closure, period of non-use and reopening for all equipment and devices. it may require maintenance and/or repair after a non-use period. test the quality of water for duwl prior to dental care to ensure that the standards for safe drinking water are met (< 500 cfu/ml). assess the need to shock duwl of any devices and products that deliver water used for dental procedures. the standard maintenance and monitoring of duwl should be continued according to the ifus of the dental operatory unit and the duwl treatment products. in the presence of dampness or mold (musky smell), determine the source of water entry, clean it up and remediate. indoor temperature and humidity must be maintained within recommended ranges. 30, 31, 32, 33 the autoclaves and instrument cleaning equipment should be cleaned routinely and maintained in accordance with the manufacturer's schedule. sterilizers should be checked with a biological indicator and matching control after a period of non-use prior to reopening. maintenance air compressor, vacuum and suction lines, radiography equipment, high-tech equipment, amalgam separators and other dental equipment according to manufacturer's instructions. 30, 31, 32, 33, 34 semicritical items in contact with mucous membranes or non-intact skin have a lower risk of transmission. they are heat-tolerant hence sterilized by using heat. a semicritical heat-sensitive item is processed with high-level disinfection. noncritical care items have the least risk of transmission via intact skin hence cleaned only but if an article is visibly soiled it is cleaned following disinfection with an epa-registered hospital disinfectant. in case of visible contaminated with blood or opim use epa-registered tubercocidal hospital disinfectant. blood spill can be managed by an epa-registered hospital disinfectant effective against hbv and hiv, epa-registered hospital disinfectant with a tuberculocidal claim (intermediate-level disinfectant) or an epa-registered sodium hypochlorite product. the central processing area should be divided into sections for receiving, cleaning, and decontamination; preparation and packaging; sterilization and storage. 34 the handpeice should be run to run to discharge water, air, or a combination for a minimum of 20-30 seconds after each patient to physically flush out material that may enter the turbine and air and waterlines heat methods can sterilize dental hand pieces and other intraoral devices attached to air or waterlines. manufacturer instructions should be followed for cleaning, lubrication, and sterilization should be followed to ensure their effectiveness and longevity of hand pieces. handles or dental unit attachments of saliva ejectors, high-speed air evacuators, and air/water syringes should be covered with impervious barriers which are refreshed after each use. visible contamination requires cleaning with an intermediate disinfectant prior to replacing the barriers. 30, 31, 32, 33, 34 radiograph cross-contaminate equipment and environmental surfaces with blood or saliva hence use an aseptic technique, wear gloves when taking radiographs and handling contaminated film packets, wear additional ppe (mask, eyewear, gown) for blood or other body fluid spatter. heat-tolerant intraoral radiograph accessories may be heat sterilized for semicritical items like film-holding and positioning devices before patient use digital radiography sensors and other high-technology instruments (intraoral camera, electronic periodontal probe, occlusal analyzers, lasers) are semicritical devices which may be cleaned, heat-sterilized or high level disinfected. 30, 31, 32, 33, 34 reprocess heat-sensitive critical and semi-critical instruments by using sterilant/high-level disinfectants or low temperature sterilization method (ethylene oxide). single-use devices are usually heat-intolerant cannot be reliably cleaned. syringe needles, prophylaxis cups and brushes, and plastic orthodontic brackets, prophylaxis angles, saliva ejectors, high-volume evacuator tips and air/water syringe tips, cotton rolls, gauze, irrigating syringes should be disposed after each use. endodontic burs, files, broaches, diamond and carbide burs should be considered single use. laboratory items (burs, polishing points, rag wheels, laboratory knives) should be heat-sterilized, disinfected or discarded. heat-tolerant items used in the mouth (metal impression tray, face bow fork) should be heat-sterilized. articulators, case pans and lathe should be cleaned and disinfected. semicritical instruments needed for immediate use or use within a short time may be sterilized unwrapped on a tray or a container system. critical instruments for immediate reuse can be sterilized unwrapped if the instruments are transported in a sterile covered container during removal from the sterilizer and transport to the point of use however critical items should not be stored unwrapped. 30, 31, 32, 33, 34 personnel subject to occupational exposure should receive training for infection-control in combination with standard precautions, engineering, work practice, and administrative controls to reduce occupational exposures to blood to prevent transmission of hbv, hcv, and hiv. dhcp are at a significant risk for acquiring or transmitting hepatitis b, influenza, measles, mumps, rubella and varicella which are vaccine-preventable. they should be vaccinated for hepatitis b vaccine however routine immunization for tb is not recommended. the vaccine for hepatitis c vaccine is still unavailable and the risk of hiv transmission in dental settings is extremely low. hbsag-positive persons should be counseled about hbv transmission prevention and for medical evaluation. 39 environmental infection control: environmental cleaning and disinfection procedures should be followed correctly and consistently. water should be run through pipes and taps in surgeries, kitchen, bathrooms and showers. a liquid chemical sterilant/high-level disinfectant should not be used as a holding solution or an environmental surface disinfectant. after working on a patient without suspected or confirmed covid-19; wait 15 minutes after completion of clinical care and exit of each patient to begin to clean and disinfect room surfaces of the dental operatory. this allows droplets to fall from the air after a dental procedure to perform sufficient disinfection. entrance in the operatory is delayed until time elapsed allows air changes to remove potentially infectious particles. cleaning and disinfection procedures include cleaning of frequently touched surfaces or objects and aerosol generating areas with cleaners and water followed by application of environmental protection agency-registered, hospital-grade disinfectant based on contact times shown on the product's label. alternative methods for disinfection which can be instituted include ultrasonic waves, high intensity uv radiation, and led blue light however their efficacy against covid-19 virus is unknown. sanitizing tunnels are not recommended for use by cdc. 39, 40, 41, 42, 43 the purpose of laundry is to protect the worker from exposure to potentially infectious materials throughout the stages of collecting, management and arranging of contaminated materials via ppe, work practice, containing, labels, ergonomics and hazard communication. hot water washing is recommended at 160°f (71°c) at least for a minimum of 25 minutes. chlorine residual of 50-150 ppm is attained during the bleach cycle and chlorine bleach is activated at 135°f-145°f (57.2°c-62.7°c) water temperature. rinse cycles add a mild acid (sour) to neutralize the alkalinity in water soap, or detergent. dry cleaning is an alternative cleaning process utilizing organic solvents (perchloroethylene) for removal of soil from fabrics that may have been damaged in conventional laundering. waste should be handled with ppe and wastewater treatment facilities include oxidation with hypochlorite (chlorine bleach) and peracetic acid and inactivation via uv irradiation. puncture-and chemical-resistant/heavy duty utility gloves should be worn for instrument cleaning and decontamination procedures. ppe should be worn during cleaning when splashing or spraying is anticipated. food service utensils should be managed in accordance with the infection control policy. 39, 40, 41, 42, 43 extracted teeth are potentially infectious hence disposed in medical waste bins. extracted teeth sent to a dental laboratory for shade or size comparisons should be cleaned, surface-disinfected with an eparegistered hospital disinfectant with intermediate-level activity (tuberculocidal). extracted teeth containing dental amalgam should not be placed in a medical waste container that uses incineration for final disposal since they may be given to recycling company. they may be returned to the patient on request hence standard maintenance does not apply. dental prostheses, appliances, and items used in fabrication (impressions, occlusal rims, bite registrations) must be managed by optimum communication and coordination between the laboratory and dental practice with appropriate cleaning and disinfection with an epa-registered hospital tuberculocidal disinfectant. parenteral medication should be administered with an aseptic technique. a single syringe should not be used for multiple patients even if the needle has been changed perform surgical hand antisepsis by an antimicrobial soap and water, or soap and water followed by alcohol-based hand scrub prior to wearing sterile surgeon's gloves. 39, 40, 41, 42, 43 risk assessment and work restrictions for dhcp with potential exposure to covid-19: the close contact with vulnerable individuals in dental settings requires a conservative approach to monitoring and applying work restrictions to prevent transmission from potentially contagious dhcp to patients, other hcp/dhcp and visitors. the contact tracing of exposed dhcp and application of work restrictions depends upon the degree of sars-cov-2 community transmission (minimal-no, moderate) and their resources. high-risk exposures involve exposure of dhcp eyes, nose, or mouth to material potentially containing sars-cov-2 particularly from aerosol-generating procedure (prolonged exposure for 15 minutes or more). exposure not included as higher risk include body contact with the patient without ppe and hand hygiene and touching the eye, nose, or mouth with the same hands. exposures can occur from a suspected case of covid-19 or from a person under investigation (pui). a record should be maintained for a dhcp exposed to puis. if the test results are delayed over 72 hours or the patient is covid-19 positive then the work restrictions apply. a dhcp with prolonged close contact with a patient, visitor, or dhcp with confirmed covid-19 should be excluded from work for 14 days after last exposure, self-monitored for fever or symptoms consistent with covid-19 and contact their medical evaluation and testing facility if fever or symptoms consistent with covid-19 develop. 44 dhcp with risk exposures other than high exposure risk do not require work restrictions. they should follow infection prevention and control practices by wearing a facemask at work, self-monitoring for fever or symptoms consistent with covid-19, not reporting to work when ill and undergoing screening for fever or symptoms consistent with covid-196 when their shift commences. a dhcp who develops fever or symptoms consistent with covid-196 should immediately self-isolate and contact a medical evaluation and testing facility. dhcp with travel or community exposures should inform their health facility for guidance on need for work restrictions. for covid-19 confirmed symptomatic individuals consider the exposure window to be 2 days before symptom onset through the time period. for covid-19 confirmed asymptomatic individuals determining the infectious period can be challenging. they must be considered potentially infectious commencing 2 days post exposure until they fulfill the criteria for discontinuation of transmission-based precautions. if the date of exposure is undetermined, use a starting point of 2 days prior to the positive test through the time period when the individual fulfills the criteria for discontinuation of transmission-based precautions. when reopening a practice post covid-19 shutdown follow the dental practice reopening guidelines. 44 dental caries risk assessment: it is based on patient specific risk indicators including prior caries experience and longitudinal evaluation of caries progression. longitudinal evaluation at each visit considers cavitation of white spot lesion and increased dimension. progression in the existing white spot lesion is considered an increased risk status. other caries risk factors include a high frequency of fermentable carbohydrate, maternal caries and socioeconomic status of the family. surgical management of the enamel carious lesions is based on visual detection, shadowing under the enamel and radiographic enlargement of lesion. active surveillance of caries monitors initial carious lesion progression instead of definitive treatment. active surveillance strategies include preventive therapy with compliance and recall. 45 children are considered at a low caries risk if they have no caries, no new lesion in 1 year, no white spot lesions and belong to a high socioeconomic status. they receive a clinical examination at twelve months and a diagnostic radiograph at twenty four months. preventive therapy includes tooth brushing twice a day with a fluoride toothpaste twice a day and fissure sealants. restorative therapy is not indicated. 45 children considered at a medium risk of caries have or have had one or more lesions per year and belong to a middle socioeconomic status. they require a diagnostic examination at twelve months and a radiographic assessment between twelve to fourteen months. preventive regimen includes tooth brushing with fluoride toothpaste, a six monthly application of topical fluoride and provision of fissure sealants. restorative therapy entails active surveillance of carious white spot lesions and proximal enamel lesions. progressive and cavitated carious lesions maybe managed by restorative therapy or by an aerosol free topical application of silver diamine fluoride. 45 children are considered to be at a high risk if they have or have had one or more proximal lesion, have more than two lesions per year, have white spot lesions or enamel defects, active caries in a mother or caregiver, wear appliances, have a high sugar consumption and belong to low socioecenonmic status. they require a clinical examination at an interval of three months, a radiograph at an interval of six months and dietary analysis. preventive care includes tooth brushing with a fluoride toothpaste twice a day, systemic fluoride supplements, professional topical fluoride application every 3 months, fissure sealants and brushing with a high potency fluoride gel in a child over 6 years of age. restorative care includes surveillance of white spot lesions, restoration of proximal caries and restoration of progressing and cavitated lesions or treatment with topical application of silver diamine fluoride. 45 early childhood caries (ecc): early childhood caries (ecc) is defined as one or more decayed (non-cavitated or cavitated lesions), missing (due to caries) or filled tooth surfaces in any primary tooth in a child under 6years. severe early childhood caries (secc) is defined as any sign of smooth-surface caries in a child < 3 years of age, and from ages 3 through 5, one or more cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing, or filled score of greater than or equal to four (age 3), < than or = to five (age 4), or < than or = to six (age 5). 46 caries disease process initiates as early as the first year in the life of a child. this highly prevalent global chronic disease is cost intensive and impacts the quality of life of a child and their parents. cries management is child specific management of caries process via primary, secondary and tertiary prevention. ecc reduction approaches focus on inter-professional care to ensure access to oral health for infants/toddlers and raise awareness regarding the adverse sugar consumption effects. 47 primary prevention encompasses prenatal health care, avoidance of night time bottle feed with sugary drinks or milk, restricting sugar intake and frequency for children younger than 24 months, avoiding frequent/nocturnal breast or bottle feeding after 1 year, exposure to dietary fluoridate (water, milk, salt), use of an age appropriate amount of fluoride toothpaste containing at least 1000ppm fluoride for brushing at least twice a day, dental visit in the first year of life and regular applications of 5% fluoride. secondary prevention comprises of more frequent fluoride application with fissure sealing for arresting caries progression prior to cavity formation. tertiary prevention combines non-invasive and invasive management for cavitated lesions. topical application of silver diamine fluoride arrest and prevent noncavitated and progressive cavitated dentinal lesions in an aerosol free environment. 47 fluoride: fluoride is the cornerstone of caries prevention. it functions by arresting or inactivating carious lesions as a therapeutic agent in nrct (non-restorative caries treatment). addition of optimum fluoride level to community water supply (0.5 to 1.1 mg/l) helps reduce the caries prevalence safely and effectively. hence this stable public health practice benefits all the residents irrespective of their level of education, oral hygiene practices, socioeconomic background, employment status or access to oral health care. 48 brushing the teeth twice a day with a fluoridated toothpaste containing 1000ppm f at least and with an age appropriate amount on a tooth brush reduces caries effectively. the recommended use of fluoride toothpaste in a child upto first two years is 1000ppm f, twice a day with a grain sized amount of 0.125g. for a child between two to six years of age the recommended use of fluoride toothpaste is 1000ppm f, twice a day with a pea sized amount of 0.25g. in a child over six years of age the recommended use of fluoride toothpaste is 1450 ppmf, upto full length of brush amount of 0.5-1.0g. hence this is a convenient, widespread, inexpensive and culturally approved approach to caries prevention in a safe and effective manner. the amount of toothpaste used is important since children tend to swallow the toothpaste which poses a risk for fluorosis. the recommended use of fluoride toothpaste based on standard prevention in children less than 3 years is 1000 -1500ppm f. enhanced prevention for children over 3years includes 1350-1500 ppm f and for children over ten years includes 2800ppm f. 48 professional topical fluoride varnish application containing 5% f (22,600ppmf) or gel containing 1.23% f (12,300ppmf) may reduce caries in children. in a child over 6 years of age and at a high risk of caries 0.5% fluoride gels and pastes are recommended. fluoride supplements consisting of tablets/lozenges and drops may be considered in fluoridated water deficient area. their intake should not exceed 0.07mg/kg body weight daily and should be used with care to prevent oral topical effects. non-cavitated and cavitated dentinal lesions can be arrested or prevented successfully by the use of aerosol free sdf 38% silver diamine fluoride containing 5% fluoride (44,800ppmf). 48 minimally invasive dentistry: the current paradigm shift focuses on minimally invasive management strategies which arrest caries by assessing the caries risk, early detection of caries, implementing prevention measures, promoting enamel and dentine remineralization, instituting minimally invasive surgical interventions and repairing restorations conservatively as opposed to replacement. these techniques work well in conjunction with fluoride exposure and good oral hygiene for both non-cavitated and cavitated lesions. they allow the reversal of demineralized lesions (non cavitated) thereby arresting naturally. proximal non-cavitated lesions may be managed by a micro invasive infiltration method. cavitated lesions can be arrested by topical application of aerosol free 38% sdf (silver diamine fluoride). surgical intervention advocates a minimal cavity design, conservative caries removal from deep lesion and adhesive restorative material. 49 erosion: it is an irreversible tooth structure loss arising by chemical dissolution via intrinsic sources (gastric acid) or extrinsic sources (diet) but not bacterial acid. the thin and less mineralized enamel of primary dentition renders it more susceptible to erosion. bulimia erodes the lingual surface of upper incisors whereas gastrooesophageal reflux erodes the molars. dietary acid can erode any surface but it is avoidable by cutting down acidic food and beverage exposure. diagnosis necessitates the need for discerning the etiology if the diagnosis is by location and level of erosion. management includes regular monitoring and the use of a fluoride containing toothpaste or mouthwash containing stannous fluoride, addressing the etiology addressed and delaying the restorative intervention for monitoring. minimally invasive techniques may be applied for restoration of teeth which hurt. a medical referral is indicated for patients with dental erosion due to gerd and bulimia. 50 periodontal disease: periodontal assessment for primary teeth includes clinical and radiographic evaluation of the gingiva, periodontium, alveolar bone levels and tooth mobility. permanent dentition should be assessed subsequent to complete eruption. triaging helps evaluate conditions which may have four combinations. they may have healthy gingiva with healthy bone, healthy gingiva with diseased bone (eg hypophosphatasia), diseased gingiva with healthy bone (eg herpetic gingivostomatitis) and diseased gingiva with diseases bone (neutrophil defects). 51 generalized gingivitis continuing over 2 weeks is viral in origin due to an underlying systematic cause. they require periodontal culturing to rule out anaerobic bacteria triggering an aggressive immune j o u r n a l p r e -p r o o f response (papillon-lefevre syndrome or neutorpenias). a medical referral with regular follow up assists in ruling out chronic idiopathic neutropenia, cyclical neutropenia and leukemia. hypophosphatasia may be considered in a non-traumatic premature primary incisor loss before 4 years of age with a concomitant diagnosis of cementum pathology. langerhan's cell histiocytosis may be deliberated in premature eruption of primary molars in the neonatal period. diagnosis is confirmed upon presence of birbeck granule in specimen for gingival biopsy from the molar region. 51 effectiveness and compliance of medication for enhancing immune response in patients with systemic disease (gcf in cyclical neutropenia or insulin treatment in insulin-dependent diabetes) is ascertained by regular monitoring of gingival and periodontal health. stem cell transplant may be carried out to improve immunity for improved periodontal health in children in chronic granulomatous disease and leukocuyte adhesion deficiency disorder however it is very rare. 51 mih is a qualitative, enamel developmental defect which involves one or more posterior teeth with or without permanent anterior. they present as a demarcation, creamy/white to yellow to brown patches with or without post eruptive breakdown and sensitivity. it may range from mild to severe and impair tooth brushing. primary molars with hypomineralization predispose the permanent dentition to a higher risk of mih. early diagnosis concomitant with prevention and restorative care prevents subsequent progressive breakdown, hypersensitivity and pulpal inflammation. 51 the adhesive restorations should include sound enamel since bonding for sealants and composites is compromised. atypical amalgam restorations needing more retentive features may aggravate the tooth defect and result in a high failure. gic temporization despite a high failure rate can be utilized. aesthetics in mild incisors may be conservatively managed by combining etching, bleaching and sealing. severe cases may be managed by microabrasion or composite veneers and a full coronal coverage for the molars. restorations have a poor long term outcome in this dental anomaly. if one or more teeth are affected with severe mih and pain consider extracting the first permanent molars prior to the eruption of second permanent molars (8-9 y). the occlusion will determine the need for an orthodontic alignment. recall will prevent failure of restorations, recurrent caries and post eruptive breakdown. sensitivity may be managed by topical fluoride varnish application and arginine desensitization paste however hypersensitivity may require local anaesthesia for restorative management. 52 developing dentition: malocclusion in the developing dentition needs recognition, risk factor identification (environmental, etiologic, premature primary tooth loss), diagnosis and optimum treatment. this contributes to a stable, functional and aesthetic occlusion in the permanent dentition. the developing dentition is evaluated clinically (palpation), by radiographs and functional analysis for habits, airway, tooth size and shape, anomalies, anterior and posterior crossbite, skeletal discrepancy, periodontal health for achieving a diagnosis. breast feeding reduces non-nutritive habits which may otherwise require management appropriate for the child's development, comprehension, malocclusion and the ability to cope with treatment. space maintainers prevent space loss due to premature primary tooth loss. minor interceptive orthodontics can manage aesthetics in an increased overjet which predisposes the incisors to an increased risk of trauma. 53 special care dentistry: in special care dentistry basic advice and dental intervention have a high impact on pain management and clinical outcomes. during the pandemic triaging, ranking, conceding and making challenging choices have become a daily actuality. telecommunication can enhance communication and provide psychological counseling and advice for special needs patients however phobia, learning disabilities and attention deficit hyperactivity disorder (adhd) do not tolerate any form of local anaesthesia require sedation and general anaesthesia which is currently suspended. they can benefit from alternative techniques (gradual exposure, behavioral management, hypnotherapy, professional cognitive behavioral therapy (cbt), desensitization methods, virtual goggles for distraction) in a more adjustable dental service. there is a need to balance and weight the clinical decisions and review service capacity and patient's safety regularly. 54 dental emergency treatment: commonly presenting acute oral conditions/problems need a modified and consistent management approach. management of dental emergencies focuses on triage, relief from pain (analgesia) or infection (antimicrobial) and provision of care via remote consultation (videocall or telephone). referral is indicated in unmanageable severe or uncontrolled symptoms with adequate documentation. 55, 56 dental triage of usually presenting dental conditions categorizes patients into three types. the first type requires advice and self-help. they have mild -moderate symptoms which can be managed remotely by analgesics and antimicrobials. the second type requires urgent care. they have severe or uncontrolled symptoms which are unmanageable by a patient and require the patient to see a dentist in a designated urgent dental care center. the third type is emergency care for emergency conditions which require immediate attention. 55 acute apical abscess includes pain (localized to a single tooth); swelling of the gingiva, face or neck; fever, listlessness, lethargy and loss of appetite in children under 16 years of age. management by selfhelp includes analgesics and antibiotics (swelling/systemic infection) with a recall after 48-72 hours. urgent care by extraction or drainage is needed for spreading infection without airway compromise or continuing or recurrent symptoms. emergency care is indicated for spreading infection with an airway compromise or trismus. 55 acute periodontal abscess/perio-endo lesions include pain and tenderness of gingival tissue, increased tooth mobility, fever and swollen/enlarged regional lymph nodes, presence of swelling on gingiva and gingival suppuration. management by self-help includes analgesics and antibiotics (swelling/systemic infection) with a recall after 48-72 hours. urgent care is for spreading infection without airway compromise or continuing or recurrent symptoms. emergency care is indicated for spreading infection with an airway compromise or trismus. 55 acute pericoronitis includes pain around a partially erupted tooth, swelling of gingiva around the erupting tooth, discomfort on swallowing, limited mouth opening, halitosis (unpleasant mouth odour), fever, nausea and fatigue. advice and self help include analgesia, chlorhexidine mouthwash/gel or warm salt water mouthwash, gentle toothbrushing of the affected area with a small head toothbrush in combination with benzdyamine mouthwash, antibiotics (swelling/systemic infection) and recall after 48-72 hours. urgent care by extraction is for spreading infection without airway compromise or continuing or recurrent symptoms. emergency care is indicated for spreading infection with an airway compromise and/or severe trismus. 55 necrotizing ulcerative gingivitis/periodontitis include pain (localized/generalized), swelling, gingival bleeding, halitosis, gingival ulceration, fever and malaise. advice and self help include optimal analgesia, chlorhexidine or hydrogen peroxide mouthwash/gel, gentle toothbrushing of the affected area with a small head toothbrush in combination with benzdyamine mouthwash or spray and metronidazole as the antibiotic drug of choice. 55 reversible pulpitis includes intermittent or stimuli associated toothache with tenderness to percussion. advice and self help care recommend analgesia, repair of a missing filling with an emergency temporary repair kit from a pharmacy or online, avoidance of hot or cold food and to call back if the sypmtoms worsen. 55 irreversible pulpitis includes sharp and spontaneous pain which lasts for several hours and keeps the patient awake and pain which is difficult to localize to a single tooth, it may be dull or throbbing and worsened by heat and alleviated by cold. advice and self help recommend analgesia, cold water rinses and to call back if symptoms worsen. urgent care is needed when the severe and uncomfortable pain prevents sleeping or eating. management includes extraction at an urgent dental care centre. 55 dentine hypersensitivity includes sharp, sudden or short duration pain and exposed root surface secondary to gingival recession. advice and self help recommend application of desensitizing toothpaste to the affected area and avoidance of stimulus which include cold or acidic food and drinks. 55 dry socket includes pain which arises 24-48 hours after extraction in the vicinity of site of extraction. the socket is tender with an unpleasant taste or odour and occasional swelling. advice and self help include analgesis, warm salt water mouthwash and antibiotics in infection (spreading or systemic) or a patient who is immunocompromised. urgent care is required for dressing if the pain is severe, uncontrollable and prevents sleeping or eating. 55 post extraction haemorrhage entails bleeding which may be immediate, within a few hours secondary to inadequate initial hemostasis or within a few weeks due to possible infection. advice and self help include no spitting or rinsing, gentle rinses with warm but not hot salt water mouthwash to remove the excess blood, placing a rolled up piece of cotton or gauze moistened with saline or water on the socket and firmly biting on it to maintain a solid and continuous pressure for 20 minutrs prior to checking for bleeding. the patient is advised to avoid smoking, exercising, drinking alcohol or disturbing the clot after the bleeding has stopped. urgent care is required when the bleeding stops but is not brisk and persistent. emergency care is recommended when the bleeding fails to stop, is brisk and persistent. the patient should be asked about anticoagulant medication (warfarin, clopidogrel, aspirin). 55 oral ulceration include pain (lip and/or oral cavity), ulceration, inflammation, abnormal appearance and dehydration or listlessness or agitation if severe. advice and self help for ulcers less than three weeks include chlorhexidine mouthwash under 7y, analgesia or topical benzdyamine oromucosal spray, soft diet, keeping the dentures clean or use a repair kit for trauma from an adjacent tooth. if the ulcers are due to primary herpetic gingivostomatitis, herpes zoster infection or in an immunocompromised patient consider antiviral agents (acyclovir or penciclovir) in the early stages. urgent care is advised for ulcers persisting over three weeks. if the ulcers are due to an underlying medical condition then a medical practitioner should be consulted. emergency care is for oral ulceration with severe dehydration. 55 cracked, fractured, loose or displaced tooth fragments lead to pain (generalized or localized), tenderness to bite, sensitivity to hot cold and sweet food, open cavity, missing section of a tooth or filling, sharp edge on the tooth, mobile tooth or fragment, mobility or loss of restoration, soft tissue trauma (tongue, lip, cheek ), gingival inflammation or recurrent caries. emergency care is indicated for inhalation of a piece of tooth, filling or restoration. advice and self help for broken or fractured teeth and filling includes emergency temporart repair kit for sensitive teeth, analgesia and call back if pain persists. prosthesis (crown, bridge or veneer) may be repaired by an emergency repair kit with analgesics for pain relief. 55 ill fitting or loose dentures result in pain (general, localized), difficulty in speech and mastication. advice and self help include analgesia, removal of denture and routine dental care when the services have resumed. 55 trauma from a fractured or displaced orthodontic appliance causes pain and soft tissue injury. emergency care is required if the airway is compromised or the patient inhales or ingests pieces of a fractured appliance such as brackets. however brackets pass the bowel without incident. for advice and help the patient maybe referred to the orthodontic guidelines (british orthodontic society). 55 avulsed, displaced or fractured teeth encompass a fracture of tooth or loss of structure, increased tooth mobility or several teeth mobile as a unit, displacement or elongation or an empty socket. urgent care if a permanent tooth has been avulsed (knocked out) includes handling the tooth with care by the crown (white part) and avoid touching the root, washing the tooth briefly for ten seconds under cold running water if dirty, re-implant it in the socket and bite on it with a handkerchief gently to hold it in position. if it is not possible to re-implant the tooth, it may be transported in milk (not water) or in the mouth between molars and inside of the cheek. a permanent tooth which has moved out of its usual position to affect the bite should be referred to an urgent care center. a permanent tooth fracture involving pulp should also be referred to an urgent dental care center. a permanent tooth fracture of the enamel and dentine requires advice and self help for applying a desensitizing toothpaste, analgesia and soft diet. a primary tooth which has moved out of its position and interferes with the bite requires urgent care. if a primary tooth has displaced without affecting the bite advice and self help should include information about soft diet and analgesia. a primary tooth which has been avulsed (knocked out) requires advice and self help for analgesia and soft diet however it should not be re-implanted. 55 dento-alveolar injuries include pain, bleeding, swelling, teeth/dentures which do not meet together, mobility, praesthesia, other problems related specifically to bone fractures (nose bleed, diplopia, visual loss). emergency management is necessitated for severe bleeding which does not stop within 15-30 minutes, significant facial trauma, head injury or loss of consciousness and inhalation of a tooth or a tooth fragment. advice and self help for cases which do not have an emergency includes cleaning the affected area by gentle rinsing with a mild antiseptic, removing foreign objects from the mouth, applying ice pack to the soft tissue injury and swelling, applying pressure with a finger to stop bleeding and analgesia. antibiotics are not indicated for non-emergency situations. 55 hence successful outcomes depend on an optimum advice and timely emergency dental care. moderate dental pain can be managed in adults by paracetamol, 2 x 500mg tablets upto four times daily (4-6 hourly for 5 days or with ibuprofen, 2 x 200mg tablets upto four times a day (4-6 hourly) first after food. severe dental pain can be managed by increasing the dose of ibuprofen to 3 x 200mg tablets upto four times a day right after food or combining ibuprofen with paracetamol after food without exceeding the daily dose/frequency or by diclofenac, 1 x 50mg tablet upto three times a day in combination with paracetamol. maximum dose of drug in twenty four hours is 4 g paracetamol, 2.4 g ibuprofen and 150 mg diclofenac. contraindications for diclofenac and a high dose of ibuprofen (more than 1.6 g daily) include moderate or severe asthma, renal impairment or hypersensitivity to aspirin. the regimen for adult patient requiring a proton pump inhibitor include iansoprazole, 1 x 15 mg capsule daily for 5 days or omerprazole, 1 x 20mg capsule daily for 5 days. 56 analgesic doses for children: dental pain is managed in children by paracetamol suspension (120 mg/5 ml or 250 mg/5 ml) or tablet (500 mg). the age dependent dose can be given upto four times a day. the dose recommended for 6-12 month old is 120mg, 2-3 years is 180mg, 4-5 years is 240 mg, 6-7 years is 240-250 mg, 8-9 years is 360-375 mg, 10 -11 years is 480-500 mg, 12-15 years in 480 -750 mg and 16-17 years is 500mg -1g. the alternative drug is ibuprofen sugar free suspension (100 mg/5 ml) or tablet (200 mg). this age dependent drug is given upto three times a day. the recommended dose for 1-3 years is 100 mg, 4-6 years is 150 mg, 7-9 years is 200 mg and 10 -11 years is 300 mg. the doses for 6-11 months is 50 mg and x 400 mg tablet, three times a day. the dose of amoxicillin or phenoxymethylpenicillin may be doubled in severe infections (extra oral swelling, eye closing or trismus). 56 antimicrobials for children: dental infections in children can be managed by amoxicillin, phenoxymethylpenicillin or metronidazole. amoxicillin is administered as a sugar free oral suspension (125 mg/5 ml or 250 mg/5 ml) or capsule (250 mg). the age dependent dose can be given three times a day. the dose for 6-11 months is 125 mg, 1-4 years is 250 mg, 5-11 years is 500 mg and 12-17 years is 500 mg. the dose of amoxicillin for severe dental infections in children from 6 months to 11 years the may be increased upto 30 mg/kg (max 1g) for 3 times a day. for severe infection in children between 12-17 years the dose of amoxicillin maybe doubled. phenoxymethylpenicillin is available as a sugar free oral solution (125 mg/5 ml or 250mg/5 ml) or tablets (250 mg). the age dependent dose can be given upto 4 times a day. the dose for 6-11 months is 62.5 mg, 1-5 years is 125 mg, 6 -11 years is 250mg and 12 -17 years is 500 mg. for severe infections in children upto 11 years the dose of phenoxymethylpenicillin can be increased upto 12.5 gm/kg for four times a day. for severe infections in children aged 12-17 years the dose maybe increased upto 1g for four times a day. metronidazole is available as an oral suspension (200 mg/5 ml) or a tablet (200 mg). the dose dependent medicine can be administered upto three times a day unless indicated otherwise. the dose for 1-2 years is 50 mg, 7-9 years is 100mg and 10-17 years is 200 mg. the dose for 3-6 years is 100mg given twice a day as opposed to thrice a day. 56 first line of antimicrobials for dental infections: acute apical abscess, acute periodontal abscess/perioendo lesions are managed by a 5 day course of amoxicillin, phenoxymethyl penicillin or metronidazole whereas acute pericoronitis, necrotizing ulcerative gingivitis/ periodontitis can be managed by a 3 day course of metronidazole or amoxicillin. 56 it is necessary to check the patient's current use of analgesics before advising or prescribing analgesics. paracetamol in many over the counter preparations should be identified in all medications which have been ingested. an overdose is dangerous because it may cause fatal hepatic damage that is sometimes not apparent for 4-6 days. refer a patient for an emergency assessment if they ingest a therapeutic excess of more than the recommended daily dose [8 x 500 mg tablets for adults] and more than or equal to 75 mg/kg in any 24-hour period. paracetamol is the analgesic of choice for women who are breastfeeding. for a pre-term, or low birthweight infant seek advice from a gp. absorption, distribution, metabolism, or excretion of paracetamol may be affected by an underlying medical condition. paracetamol is a suitable analgesic option in most people with liver disease but dose reduction might be required for some patients with moderate or severe acute hepatitis. for people taking anticoagulants paracetamol is considered safer than aspirin or nsaids because it does not affect platelets or cause gastric bleeding. patients should have their usual inr check planned and inform their clinician if they have been using paracetamol regularly. use paracetamol and ibuprofen with caution in children (asthma). a gp should be contacted when uncertain about a patient's medical condition, current medication or suitable analgesia. 56 use nsaids with caution and if absolutely necessary use the lowest effective dose for the shortest time possible. patients already taking an nsaid (prescribed or not) regularly for a non-dental condition should not take an additional nsaid to control dental pain. ibuprofen should be prescribed with caution for patients taking low dose aspirin since the administration of additional nsaid may reduce the cardioprotective benefit of low dose aspirin and increases the risk of gi bleeds. in patients taking low dose aspirin, if an nsaid is necessary to control the pain, consider ibuprofen up to 1200 mg maximum daily with a ppi or contact the gmp for advice. elderly patients at increased risk of cardiovascular, renal, and serious adverse effects including gi bleeding and perforation, which may be fatal should be prescribed ibuprofen with caution not exceeding 1200 mg ibuprofen per day with a ppi. diclofenac is contraindicated. monitoring blood pressure, renal function, and features of heart failure may be required 1-2 weeks after starting or increasing the dose of an nsaid. avoid nsaid's in people with dehydration, due to risk of acute kidney injury. chronic alcoholism and alcohol dependence increases the gi risk is increased with nsaids hence avoid nsaids if possible or prescribe with a ppi. prescribe ibuprofen with caution to people with cerebrovascular disease, ischaemic heart disease, peripheral arterial disease, or risk factors for cardiovascular events like hypertension, hyperlipidaemia, diabetes mellitus and smoking. prescribe it with caution in cardiac impairment or mild to moderate heart failure (nsaids may impair renal function) but not in severe heart failure. prescribe up to 1200 mg per day as a first-line option (lower dose than the 4 x 400 mg per day regimen recommended in the bnf for dental pain). for higher doses liaise with the patient's gmp. monitor blood pressure, renal function, and features of heart failure may be required 1-2 weeks after starting or increasing the dose of an nsaid. liaise with the patient's gmp to discuss. if in doubt about the severity of the patient's heart failure or appropriate analgesics, consult with their gmp. prescribe nsaids with caution to people with inflammatory bowel disease (nsaids may increase the risk of developing or cause exacerbations of ulcerative colitis or crohn's disease). prescribe nsaids with caution to people with mild to moderate hepatic impairment (do not prescribe in severe hepatic impairment). dose reductions and monitoring of liver function may be necessary. prescribe nsaids with caution to people with severe renal impairment and avoid if possible since sodium and water retention may occur leading to deterioration in renal function and, possibly renal failure. if the patient cannot avoid using an nsaid and has impaired renal function, monitor renal function 1-2 weeks after starting or increasing the dose of an nsaid. avoid concomitant use of nsaids with anticoagulants (e.g. warfarin, dabigatran) if possible. all nsaids can cause gi irritation and reduce platelet aggregation, which can worsen any bleeding event. if concurrent use is necessary be aware of the potential risks of bleeding. consider giving gastroprotection. liaise with the patient's gmp if a ppi is required but is not currently prescribed. prescribe nsaids with caution for patients with bleeding disorders (e.g. haemophilia, von willebrand disease and clotting factor deficiencies). consult with the patient's gmp or haematologist. 56 discussion: the role of dental professionals in preventing the transmission of covid-19 is critically important since it has the most risk of spreading the virus than any profession in relation to covid-19. dentistry follows the principle of universal precautions for cross-infection control to safe guard the dental health care professionals and the patients. hence the strict cross infection control measures and the awareness of j o u r n a l p r e -p r o o f infectious diseases transmission are leading to a better level of infection prevention control and better personal protective measures in a dental setting. acute/chronic oral medicine issues are managed over the phone and medication regimens are continued as previously prescribed to avoid detrimental effects of sudden change in pharmacotherapy. organized urgent dental care delivered by dhcp in appropriate ppe (gowns, gloves, ffp3 masks and eye protection) with high-volume aspiration and other measures to reduce/avoid the production of droplets, splatter and aerosols by dental drills and saliva. the profound impact of the sars-cov2 pandemic on dentistry necessitates that a paediatric dentist stays up to date with the current resources and evidence based guidance on dental care for children. the revised consensus guidelines highlight revised infection control protocols, management of suspected and possible cases of covid-19 virus and risk based management of pediatric dental emergencies with medication or intervention. patients treated for covid-19 in icu will require care since they are at a high risk of deterioration of oral health. 57, 58 conclusion: covid-19 viral transmission concern necessitates the implementation of specific protocols to reduce the risk and spread of infection from patient to another person or medical tools and equipment. this narrative review article discusses and suggests the modification of patient management, clinical practice, introduction of devices and organizational practices during the covid-19 and the way forward with reference to paediatric dentistry. paracetamol is considered safer than aspirin or nsaids because it does not affect platelets or cause gastric bleeding. patients should have their usual inr check planned and inform their clinician if they have been using paracetamol regularly. use paracetamol and ibuprofen with caution in children (asthma). a gp should be contacted when uncertain about a patient's medical condition, current medication or suitable analgesia. 56 use nsaids with caution and if absolutely necessary use the lowest effective dose for the shortest time possible. patients already taking an nsaid (prescribed or not) regularly for a non-dental condition should not take an additional nsaid to control dental pain. ibuprofen should be prescribed with caution for patients taking low dose aspirin since the administration of additional nsaid may reduce the cardioprotective benefit of low dose aspirin and increases the risk of gi bleeds. in patients taking low dose aspirin, if an nsaid is necessary to control the pain, consider ibuprofen up to 1200 mg maximum daily with a ppi or contact the gmp for advice. elderly patients at increased risk of cardiovascular, renal, and serious adverse effects including gi bleeding and perforation, which may be fatal should be prescribed ibuprofen with caution not exceeding 1200 mg ibuprofen per day with a ppi. diclofenac is contraindicated. monitoring blood pressure, renal function, and features of heart failure may be required 1-2 weeks after starting or increasing the dose of an nsaid. avoid nsaid's in people with dehydration, due to risk of acute kidney injury. chronic alcoholism and alcohol dependence increases the gi risk is increased with nsaids hence avoid nsaids if possible or prescribe with a ppi. prescribe ibuprofen with caution to people with cerebrovascular disease, ischaemic heart disease, peripheral arterial disease, or risk factors for cardiovascular events like hypertension, hyperlipidaemia, diabetes mellitus and smoking. prescribe it with caution in cardiac impairment or mild to moderate heart failure (nsaids may impair renal function) but not in severe heart failure. prescribe up to 1200 mg per day as a first-line option (lower dose than the 4 x 400 mg per day regimen recommended in the bnf for dental pain). for higher doses liaise with the patient's gmp. monitor blood pressure, renal function, and features of heart failure may be required 1-2 weeks after starting or increasing the dose of an nsaid. liaise with the patient's gmp to discuss. if in doubt about the severity of the patient's heart failure or appropriate analgesics, consult with their gmp. prescribe nsaids with caution to people with inflammatory bowel disease (nsaids may increase the risk of developing or cause exacerbations of ulcerative colitis or crohn's disease). prescribe nsaids with caution to people with mild to moderate hepatic impairment (do not prescribe in severe hepatic impairment). dose reductions and monitoring of liver function may be necessary. prescribe nsaids with caution to people with severe renal impairment and avoid if possible since sodium and water retention may occur leading to deterioration in renal function and, possibly renal failure. if the patient cannot avoid using an nsaid and has impaired renal function, monitor renal function 1-2 weeks after starting or increasing the dose of an nsaid. avoid concomitant use of nsaids with anticoagulants (e.g. warfarin, dabigatran) if possible. all nsaids can cause gi irritation and reduce platelet aggregation, which can worsen any bleeding event. if concurrent use is necessary be aware of the potential risks of bleeding. consider giving gastroprotection. liaise with the patient's gmp if a ppi is required but is not currently prescribed. prescribe nsaids with caution for patients with bleeding disorders (e.g. haemophilia, von willebrand disease and clotting factor deficiencies). consult with the patient's gmp or haematologist. 56 transmission of covid-19 to health care personnel during exposures to a hospitalized patient covid-19 in a long-term care facility -king county presentation published at cdc/niosh topic page: aerosols, national institute for occupational safety and health cdc guidance for dental settings: interim infection prevention and control guidance for dental settings during the covid-19 response novel coronavirus-important information for clinicians guidelines for infection control in dental health-care settings-2003 who.int. 2020. coronavirus situation report-83 suggestions on the prevention of covid-19 for health care workers in department of otorhinolaryngology head and neck surgery refining surge capacity: conventional, contingency, and crisis capacity impact of multiple consecutive donnings on filtering facepiece respirator fit aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 simple respiratory mask simple respiratory protection-evaluation of the filtration performance of cloth masks and common fabric materials against 20-1000 nm size particles guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. last update filtering out confusion: frequently asked questions about respiratory protection, fit testing osha's respiratory protection standard niosh-approved n95 particulate filtering facepiece respirators updated air purifying respirators for use in health care settings during response to the covid-19 public health emergency approved respirator emergency use authorization (eua)external icon recommended guidance for extended use and limited reuse of n95 filtering facepiece respirators in healthcare settings considerations for recommending extended use and limited reuse of filtering facepiece respirators in healthcare settings engineering controls to reduce airborne, droplet and contact exposures during epidemic/pandemic response in-depth report: expedient methods for surge airborne isolation within healthcare settings during response to a natural or manmade epidemic. cincinnati, oh: u.s. department of health and human services framework for healthcare systems providing non-covid-19 clinical care during the covid-19 pandemic the impact of the covid-19 epidemic on the utilization of emergency dental services discontinuation of transmission-based precautions and disposition of patients with covid-19 in healthcare settings criteria for return to work for healthcare personnel with suspected or confirmed covid-19 disinfectants for use against sars-cov guidance for reopening buildings after prolonged shutdown or reduced operation niosh testing and remediation of dampness and mold contamination guidance for reopening buildings after prolonged shutdown or reduced operation environmental control for tuberculosis: basic upper-room ultraviolet germicidal irradiation guidelines for healthcare settings tlvs and beis: based on the documentation of the threshold limit values for chemical substances and physical agents & biological exposure indices guidelines for infection control in dental health-care settings-2003pdf icon epa list n: disinfectants for use against sars-cov-2 (covid-19 laundry and bedding: guidelines for environmental infection control in health-care facilities clinical questions about covid-19: questions and answers interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings guidance for risk assessment and work restrictions for healthcare personnel with potential exposure to covid-19 iapd foundational articles and consensus recommendations: caries risk assessment and care pathways american academy of paediatric dentistry. caries risk assessment and management for infants, children and adolescents. reference manual iapd foundational articles and consensus recommendations: management of early childhood caries iapd foundational articles and consensus recommendations: use of fluoride for caries prevention iapd foundational articles and consensus recommendations: minimal invasive dentistry iapd foundational articles and consensus recommendations: management of dental erosion iapd foundational articles and consensus recommendations: paediatric periodontal disease iapd foundational articles and consensus recommendations: management of molar incisor hypomineralization iapd foundational articles and consensus recommendations: management of the developing dentition dentistry and coronavirus (covid-19)-moral decision-making drugs for the management of dental problems during covid-19 pandemic the workers who face the greatest coronavirus risk. the new york times evaluating the protection afforded by surgical masks against influenza bioaerosols: gross protection of surgical masks compared to filtering facepiece respirators appoint each group of patients one personnel from the dental clinic who can be reachable 24/7 in case of an emergency in order to asses and determine the need to be seen water should be run through pipes and taps in surgeries, kitchen, bathrooms and showers when reopening a practice post covid-19 shutdown follow the dental practice reopening guidelines paracetamol in many over the counter preparations should be identified in all medications which have been ingested. an overdose is dangerous because it may cause fatal hepatic damage that is sometimes not apparent for 4-6 days. refer a patient for an emergency assessment if they ingest a therapeutic excess of more than the recommended daily dose [8 x 500 mg tablets for adults] and more than or equal to 75 mg/kg in any 24-hour period. paracetamol is the analgesic of choice for women who are breastfeeding. for a pre-term, or low birthweight infant seek advice from a gp. absorption, distribution, metabolism, or excretion of paracetamol may be affected by an underlying medical condition. paracetamol is a suitable analgesic option in most people with liver disease but dose reduction j o u r n a l p r e -p r o o f the following information is required for submission. please note that failure to respond to these questions/statements will mean your submission will be returned. if you have nothing to declare in any of these categories then this should be stated. all authors must disclose any financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work. examples of potential conflicts of interest include employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding. i do not have any financial or personal relationships with the other people or organizations which could inappropriately affect my work. all sources of funding should be declared as an acknowledgement at the 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others, who have contributed in other ways should be listed as contributors.saleha shah-sole author j o u r n a l p r e -p r o o f in accordance with the declaration of helsinki 2013, all research involving human participants has to be registered in a publicly accessible database. please enter the name of the registry and the unique identifying number (uin) of your study.you can register any type of research at http://www.researchregistry.com to obtain your uin if you have not already registered. this is mandatory for human studies only. trials and certain observational research can also be registered elsewhere such as: clinicaltrials.gov or isrctn or numerous other registries. name of the registry: unique identifying number or registration id: hyperlink to your specific registration (must be publicly accessible and will be checked): the guarantor is the one or more people who accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish hence a risk assessment of the practice should be carried out to identify the measures required to minimize the risk of covid-19 transmission.added to refine the manuscript:the practice should be cleaned thoroughly and clutter removed to facilitate frequent cleaning and disinfection.devise a protocol for receiving mails and deliveries.dhcp recovered from covid-19 (protective immunity) care for covid-19 patient. 9, 10, 11, 12, 13, 14, 15, 30, 31, 32, 33, 34 safety and quality assurance checks on radiographic equipment should be performed. aed should be tested as well. all the emergency drug kits should be checked for expiry. ensure that the rechargeable items are fully charged and operational. check the drinking water dispenser for staff use and recommission by manufacturer's instructions. the computer updates should be checked and installed. key: cord-259984-csdf1a69 authors: raffiq, azman; seng, liew boon; san, lim swee; zakaria, zaitun; yee, ang song; fitzrol, diana noma; hassan, wan mohd nazaruddin wan; idris, zamzuri; ghani, abdul rahman izaini; rosman, azmin kass; abdullah, jafri malin title: covid-19 pandemic and its impact on neurosurgery practice in malaysia: academic insights, clinical experience and protocols from march till august 2020 date: 2020-10-27 journal: malays j med sci doi: 10.21315/mjms2020.27.5.14 sha: doc_id: 259984 cord_uid: csdf1a69 the newly discovered coronavirus disease 2019 (covid-19) is an infectious disease introduced to humans for the first time. following the pandemic of covid-19, there is a major shift of practices among surgical departments in response to an unprecedented surge in reducing the transmission of disease. with pooling and outsourcing of more health care workers to emergency rooms, public health care services and medical services, further in-hospital resources are prioritised to those in need. it is imperative to balance the requirements of caring for covid-19 patients with imminent risk of delay to others who need care. as malaysia now approaches the recovery phase following the pandemic, the crisis impacted significantly on neurosurgical services throughout the country. various emergency measures taken at the height of the crisis may remain as the new normal in the provision of neurosurgical services and practices in malaysia. the crisis has certainly put a strain on the effective delivery of services and as we approach the recovery era, what may have been a strain may prove to be a silver lining in neurosurgical services in malaysia. the following details are various measures put in place as the new operational protocols for neurosurgical services in malaysia. the novel coronavirus, otherwise known as coronavirus disease 2019 (covid-19) pandemic in malaysia, is part of the worldwide ongoing pandemic which was first reported in wuhan china in december 2019. malaysia's first case was confirmed on 25 january 2020, detected among travellers from china entering malaysia via singapore. malaysia's response overseen by the national crisis preparedness and response centre (cprc) under the health ministry began as early as 6 january 2020 following world health organization (who) initial report of the disease in china. various hospital was designated specifically as covid-19 pandemic hospitals, gazettement of quarantine centres, reorganisation of health services, formulation of new operational protocols, stockpiling of essential equipment and redeployment of essential medical workforce and manpower to these centres; as well active detection, monitoring and treating covid-19 patients. these early response measures were escalated to a total lockdown of movement on 18 march 2020, intended to mitigate the spread of covid-19, following the declaration of a worldwide covid-19 pandemic by who on 11 march 2020. the movement control order (mco) in malaysia lasting for a period of 6 months, coupled by the intense proactive measures by the health ministry has successfully kept the number of cases relatively low comparatively, with a total recorded case of 8,556 with 121 deaths. malaysia's proactive and stringent measures have and continue to receive international praise and recognition in successfully mitigating the spread and containing covid-19 transmission. as malaysia now approaches the recovery phase following the pandemic, the crisis impacted significantly on neurosurgical services throughout the country. various emergency measures taken at the height of the crisis may remain as the new normal in the provision of neurosurgical services and practices in malaysia. the crisis has certainly put a strain on the effective delivery of services, and as we approach the recovery era, what may have been a strain may prove to be a silver lining in neurosurgical services in malaysia. the following details the various measures put in place as the new operational protocols for neurosurgical services in malaysia. role and importance of dedicated operating theatre, instruments and icu care all tertiary hospital should have a dedicated operating theatre (ot) for suspected covid-19 patients (1) . the ot requirements should be fully equipped with negative pressure ventilation (recommended). the maximal number of staff is six: i) one specialist; ii) one medical officer; iii) one anaesthetist; iv) one anaesthetist mo; v) one scrub nurse; and vi) one circulating nurse. for elective surgery, kindly refer to its section further below (2) . limiting ot staff to essential members will help preserve the surgical workforce. the types of neurosurgery cases done are either cranial surgery or spine surgery. endonasal surgery should be avoided during covid-19 pandemic (3) . table 1 shows tiers for neurosurgery cases (4) . a neurosurgical emergency includes cerebral haemorrhages (subarachnoid and intraparenchymal), acute hydrocephalus, tumours at risk of intracranial hypertension, spinal cord compressions with, or at risk of neurological deficit, and traumatic cranial and spinal trauma emergencies (5) . (table 2 ) (6) for green level, all elective cases proceed as scheduled. for yellow level, the ot schedule is capped for 3 weeks to 75% of capacity, yielding a 25% reduction in all elective and procedural cases. all outpatient procedures black level, significant state or federal resources are needed to fight the outbreak. all urgent scheduled surgical cases will be cancelled. this 'volume limiting approach' encourages maximal adaptability, in which the supply of hospital capability meets the demand for scheduling needs. should be designated to an off-site hospital where covid-19 patients are not expected to be admitted. there is a hard cap on the number of cases requiring post-operative admission; the 12-patient limit for all surgical cases (including non-neurosurgical cases). for red level, there is a 50% reduction in all elective case scheduling. for the team-based paired coverage will go into effect during red levels of covid-19. in this model, each hospital (columns) will have three groups of providers. there will be two teams that switch coverage on a 3-day cycle. each team will cover for 3 days, and then have 3 days off while the second team covers. the transition between teams will occur virtually, avoiding unnecessary team-to-team contact. a backup group substitutes for any team member who shows signs of illness. if a team becomes contaminated, the other team will take over and the alternates will fill the gap. contact between teams and alternate is prohibited. each team will only rotate at one hospital (no cross-covering) and will only have contact with members within their team. teams at the same site will not have any overlapping clinical time with each other. this system ensures adequate coverage, minimises hand-off issues, and, most importantly, minimises transmission risk across teams. due to the likelihood of infection among inpatient providers, there will be a designated 'alternate pool' of providers that will substitute for those who show covid-19 symptoms. activation of paired coverage system (pcm) (6) is triggered by a red level of surge. all residents are aware of their role in the pcm ahead of time. site-specific needs are addressed within the team. for example, teams at the main hospital are larger than teams at other satellite hospitals. the pcm is adaptable such that the number of team members can vary, along with the experience level of the team. the core function of the pcm (limiting healthcare worker transmission of the virus) remains. it is also important that neurosurgeons provide their anaesthesia colleagues, nursing staff and the ot with objective data about which cases should be expected to proceed during a covid-19 outbreak. neurosurgeons need to predict what cases should be classified as an emergency. a checklist that can be applied to neurosurgical cases during the covid-19 pandemic is as per figure 1 . the checklists help organise surgical staff during times of crisis, such as guiding action during 'red alerts' from neuromonitoring during spinal surgery. the checklist strategy organises surgical staff around the common goal of booking cases during the outbreak. distribution of the checklist to all surgical staff will facilitate effective communication and the ease with which appropriate neurosurgical cases can be scheduled. surgical workforce (7) the surgical workforce must be able to maintain emergency surgery capabilities including major trauma. it is important to protect and preserve the surgical workforce as well. these will include rotas where some members of the team do not come into work and act as a healthy reserve (refer to a 3-group setting [surgical team]). when not vital to the effort, keep surgical and anaesthetic staff out of hospital and self-isolating at home to preserve human resources. this will also allow personnel to rest before they return to clinical work. non-surgical solutions to be used to avoid surgery where possible. personal protective equipment (ppe) must be used correctly in line with national guidance. rest, recuperation and psychological support should be factored into all planning. (3, 8, 9) pre-operatively, the patient must be tested for covid-19 and proceed if negative. full powered air purifying respirators (paprs) for surgeons and all team members in the ot for any of these cases that do actually need to move forward, either for cases in which we cannot wait for test results or for cases that test positive but still need to proceed. for urgent cases (that should be done within 1 week), two covid-19 tests separated by 24 h with the patient quarantined in the interval between tests before the surgery, with the surgery proceeding only if the results are negative for both tests. if covid positive, papr for all ot staff may be necessary until further data is available. for emergent/unavoidable case for a known or undetermined covid-19 patient, the surgeon and all ot personnel in the surgical suite should use papr, which filter the air being breathed in addition to face shields and other standard ppe. it is also vital for a cessation of positive pressure ventilation in ot during the procedure until 20 min after the patient leaves (10). the patient should be isolated and medical personnel should wear full ppe when nursing post-operative patients until covid-19 status is known. (1, 3) regional anaesthesia (ra) is preferred than general anaesthesia (ga) to reduce aerosols. in ga, a negative pressure setting (risk of aerosol transmission) is required. the intubation and extubation are done with full ppe including papr or its equivalent. only essential staff should be present in the ot. postop management is done in the isolation room. thromboprophylaxis should be considered throughout the hospital stay. non-invasive ventilation should not be used. (1) proper droplet precautions or proper decontamination processes should be followed. there should be an escalation of standard of practice during airway management for all patients to reduce exposure to secretions. hand hygiene should be taken care of with frequent hand washing using alcohol-based hand wash gels, which should be available near every anaesthesia station. the number of staff members present for intubations/ extubations should be limited to reduce the risk of unnecessary exposure. it is also recommended to strongly consider prophylactic antiemetics to reduce the risk of vomiting and possible viral spread. (3, 9, 12) rapid sequence induction (rsi) and use a video laryngoscope (vl) with the goal of a high first pass success rate (fps) is recommended. iv sequence induction without bag mask ventilation is preferred to minimise exposure risks and aerosolisation. preoxygenation for a minimum of 5 min with 100% oxygen and perform a rsi to avoid manual ventilation of patient's lungs and potential aerosolisation of virus from airways (3) . rsi (ensure a skilled assistant is available to perform cricoid pressure) or a modified rsi should be performed as clinically indicated. if manual ventilation is required, apply small tidal volumes (3). placement of a high quality heat and moisture exchanging filter (hmef) rated to remove at least 99.97% of airborne particles 0.3 microns or greater in between the facemask and breathing circuit or in between facemask and reservoir bag is required. awake fibreoptic intubations are essentially contraindicated unless specifically indicated. ppe should be provided when performing an aerosol generating procedure. preoxygenation using a bag-valve-mask (bvm) that can be purposely modified for covid-19 patients with a viral filter, without squeezing the bag. the most experienced anaesthesia professional available should perform intubation if possible. a trainee should avoid intubations of sick patients during this time. the laryngoscope should be resheathed immediately post-intubation (double glove technique). used airway equipment should be sealed in a double zip-locked plastic bag and must then be removed for decontamination and disinfection. there should be no airway carts in the room. thus, appropriately sized equipment should be pre-packed for that patient. the use of deeper sedation extubation to prevent coughing is also preferable as long as the airway is safe. (3, 12, 13) all anaesthesia professionals should utilise ppe appropriate for aerosol-generating procedures for all patients when working near the airway. 'rescue like' crash intubations where ppe cannot be fully adhered to should be avoided. correct donning and doffing of ppe should be adhered to. properly fitted n95 masks or paprs should be used for all patient. at a minimum, n95 masks should be used for all patients. for those who are not n95 fit-tested, have facial hair or fail n95 fit-testing, paprs should be used if possible. issuance of n95 masks or availability of paprs for all clinical anaesthesia personnel should be a priority. extended use and/or limited reuse of n95 masks should follow the centres for disease control and prevention (cdc) and institutional guidelines. a papr provides superior protection and may be warranted for airway procedures in patients with known or suspected covid-19. for aerosol-generating procedures, this includes eye protection (goggles or a disposable face shield that covers the front and sides of the face), a gown and gloves, in addition to airway protection with n95 masks or paprs. effective hand hygiene before putting on and after removing ppe must be ensured. procedures for proper donning and doffing, disposal of contaminated ppe, and cleaning of contaminated reusable ppe and anaesthesia equipment should be established following cdc and institutional recommendations. the double gloving technique is used during intubation. the outer gloves are used to sheath the laryngoscope blade and change the inner gloves as soon as possible afterwards. after removing protective equipment, remember to avoid touching your hair or face before washing hands. during extubation, maintain strict hands hygiene, wear a mask with a face shield and carefully dispose of contaminated equipment. the use of two providers for ppe donning and doffing procedures should be encouraged, to allow one person to observe and coach the other through the steps of the routine. appropriate ppe and the procedures for donning and doffing ppe are available at the cdc webpage. approaches to conserve supplies (12, 13) the administration should minimise the number of individuals involved. where feasible, use alternatives to n95 masks (e.g. other classes of filtering facepiece masks, facepiece air purifying respirators and paprs). n95 masks should be allowed for extended use and/or limited reuse. the use of n95 masks should be prioritised for that personnel at highest risk of covid-19 exposure and/or those anaesthesia professionals in high risk categories (e.g. those with prior health conditions, older age). staff should receive training in the appropriate donning and doffing of ppe taught through simulation and videos without using precious resources. in resource-limited situations, extended use of n95 masks (continuous wearing while seeing multiple patients) is preferred to limit the reuse of n95 masks (doffing and redonning between patients). n95 mask life may be lengthened and surface contamination reduced by wearing a plastic face shield or a surgical mask over the n95 (cdc respirator guidance). use of chlorine or alcohol solution to sanitise n95 masks is not recommended as it damages mask integrity. heating n95 masks to 70 â°c (160 â°f) in a dry oven for 30 min seems a promising solution to disrupt viral particles and maintain mask integrity for reuse. further guidance from cdc and partners in health (pih) on reuse of n95 masks or best practices when no respirators are available (such as wearing two surgical masks) are available. in routine clinical care of covid-19 suspected or confirmed infections, surgical masks are acceptable ppe, except in the case of aerosol generating procedures (intubation, high flow nasal cannula, non-invasive ventilation, bronchoscopy, administration of nebulised medications, etc). facilities which do not have disposable surgical attire, theatre garb in the form of cloth scrub hats or bonnets should be washed between each use if possible and no less than daily. theatre gowns and drapes should be washed and sterilised between each patient as is currently expected. if theatre gowns are repurposed for isolation units, they should be washed after each prolonged care routine. if surgical ppe is not impermeable, consider wearing rubber aprons under linen gowns and always perform handwashing after doffing surgical ppe and before touching clean items or self. ot management and preparation during covid-19 (14, 15) surveillance on possible further transmission to patients and other personnel should be done. covid-19 in a patient receiving surgery is sporadically reported with a special focus of management technique. surgical infection usually focuses on patient but it is important to give attention to the practitioner who works in the operation room. an ot with a negative room pressure environment located at a corner of the operating complex, and with separate access, is designated for all confirmed (or suspected) covid-19 cases. the ot consists of five interconnected rooms, of which only the anteroom and anaesthesia induction rooms have negative atmospheric pressures. the ot proper, preparation and scrub rooms all have positive pressures. understanding the airflow within the ot is crucial to minimising the risk of infection. the same ot and the same anaesthesia machine will only be used for covid-19 cases for the duration of the epidemic. an additional heat and moisture exchanger (hme) filter are placed on the expiratory limb of the circuit. both hme filters and the soda lime are changed after each case. the anaesthetic drug trolley is kept in the induction room. no unnecessary items should be brought into the ot, including personal items such as mobile phones and pens. before the start of each operation, the anaesthesiologist puts all the drugs and equipment required for the procedure onto a tray to avoid handling of the drug trolley during the case. nevertheless, if there is a need for additional drugs, hand hygiene and glove changing are performed before entering the induction room and handling the drug trolley. a fully stocked airway trolley is also placed in the induction room, as far as possible, disposable airway equipment is used. if single-use plastic anaesthesia or surgical equipment (endotracheal tubes, ventilator circuit tubing, plastic suction tubing, electrocautery handpieces) must be reused, ensure that disinfection aiming for 'high-level disinfection' or 'sterility' is employed. this includes immersion in appropriate concentration glutaraldehyde, phenol, or hydrogen peroxide solution for the recommended duration. the airway should be secured using the method with the highest chance of first-time success to avoid repeated instrumentation of the airway, including using a video-laryngoscope. equipment in limited supply such as bispectral index monitors or infusion pumps may be requested but need to be thoroughly wiped down after use. hospital security is responsible for clearing the route from the ward or intensive care unit (icu) to the ot, including the elevators. traffic should be minimised, especially opening and closing of theatre doors. patients with known or suspected covid-19 infection should wear surgical masks when being transported through hospital spaces or in rooms without negative pressure isolation. the transfer from the ward to the ot will be done by the ward nurses in full ppe including a well-fitting n95 mask, goggles or face shield, splash-resistant gown and boot covers. for patients coming from the icu, a dedicated transport ventilator is used to avoid aerosolisation, the gas flow is turned off and the endotracheal tube clamped with forceps during the switching of ventilators. the icu personnel should wear full ppe with a papr for the transfer. in the induction room, a papr is worn during induction and reversal of anaesthesia for all personnel within 2 m of the patient. for operative airway procedures such as tracheostomy, all staff keep their papr on throughout the procedure. during the procedure, a runner is stationed outside the ot if additional drugs or equipment are needed. these are placed onto a trolley that will be left in the anteroom for the ot team to retrieve. this same process in reverse is used to send out specimens such as arterial blood gas samples and frozen section specimens. the runner wears ppe when entering the anteroom. personnel exiting the ot discard their used gowns and gloves in the anteroom and perform hand hygiene before leaving the anteroom. any papr will be removed outside the anteroom. patients who do not require icu care post-operatively are fully recovered in the ot itself. when the patient is ready for discharge, the route to the isolation ward or icu is again cleared by security (using an advance runner to clear the way). a minimum of 1 h is planned between cases to allow ot staff to send the patient back to the ward, conduct thorough decontamination of all surfaces, screens, keyboard, cables, monitors and anaesthesia machine. surfaces in the ot should be thoroughly cleaned between cases including pulse oximeter probes, thermometers, blood pressure cuffs and other reusable materials (70% alcohol solution or 0.5% chlorine solution). as part of minimising contamination in ot, in addition to surface cleaning, using clear plastic sheets (to be changed in between patients) to cover the anaesthesia machine, the monitors as well as the patient's face, especially during aerosol producing airway manoeuvres like intubation and extubation, is recommended. all unused items on the drug tray and airway trolley should be assumed to be contaminated and discarded. all staff must shower before resuming their regular duties. as an added precaution, after confirmed covid-19 cases, a hydrogen peroxide vaporiser will be used to decontaminate the ot. clear instructional posters for ppe donning/doffing should be prominently displayed. a taped off area just outside of the ot door should be clearly marked for donning and doffing activities. (16) few steps must be emphasised to reduce the risk of contracting covid-19 among hcps. some precaution that needs to be taken note are: staff who are more at risks such as older adults (e.g. those over 60 years), those with underlying medical conditions (e.g. heart disease, chronic respiratory diseases, cancer), those at risk due to an immunocompromised from a medical condition or treatment (e.g. chemotherapy) and pregnant staff should take care of the lower risk stream of non-covid-19. (16) ot is potentially a high exposure zones given manipulation of the airway and aerosolisation of respiratory particles, with anaesthesia providers at particularly high risk. it comes with the additional risk inherent in the presence of multiple staff members. the perioperative personnel are at an advantage given their familiarity with maintaining sterility. however, the ancillary staff such as ot cleaners, instrument reprocessing staff and laundry personnel may be at risk. hence, they should take appropriate precautions and wear ppe (goggles or face shield, surgical mask, heavy duty gloves, long sleeved gown, boots) to avoid exposure to contaminated materials. there are no special decontamination methods other than machine laundering with detergent are required for laundering linens; all surface areas should be disinfected with 0.5% chlorine or 70% alcohol solutions. immediate surgical plan during pandemic (13) a clear plan should be made to conduct essential operations. elective operations should be indefinitely postponed to preserve vital resources including hospital beds and ppe. exceptions are for cancer or highly symptomatic patients and as such the current guidance is not to postpone (table 1) . each hospital must make a plan based on the current availability of resources. to facilitate decision making and avoid conflicts between patients and providers, a triage algorithm for identification of nonemergent conditions can be used. surgical emergencies still require prioritisation. funding must be adequate to support the hospital and staff with critical surgical services that will continue to be required despite the pandemic response. using a checklist to ensure appropriate precautions are taken for operations with suspected or known covid-19 infection is also important. simulation has been also helpful in establishing new routines in the ot. aerosolgenerating procedures that can be provided using other mechanisms should be avoided if at all possible (e.g. metered-dose inhaler instead of nebuliser treatment). further planning for the repurposing of ots to support critical care whilst not precluding the ability to provide lifesaving operative care is needed. surgical services are already underfunded and poorly prioritised in many health systems, so the commandeering of ots for use as icu, which has been proposed in many high-resource settings, must be done with extreme caution. emergency surgery will still be necessary for obstetrics and to save life (neurotrauma) and limb, and these capacities should not be compromised by taking up all available ot space and ventilators with covid+ patients. as the average reported time spent on mechanical ventilation has been up to 13 days, critical resources and space will be occupied for many weeks and will be difficult to reclaim once repurposed. repurposing of staff for managing covid-19 cases should be taken into consideration as well. guidance and training should be provided to make the best use of the technical and clinical skills of all perioperative personnel while protecting them from exposure. hospitals, professional societies and ministries of health could also provide physician and nursing staff with basic icu and ventilator management refresher education to improve their capacity to care for covid-19 patients. up to date guidelines on covid-19 management should be provided as knowledge and evidence around best management evolves. it is also vital to maintain and support staff wellness. it is important to recognise that doctors, nurses, cleaners and other hospital support staff have significant fears and concerns (the fears of transmitting to family or becoming infected oneself, the increase in work hours and the need for childcare coverage) that must be acknowledged and managed. providers may also be understandably nervous about providing care outside of their normal scope of practice or working beyond their area of competence. leadership can help manage these by providing information in a transparent way, expressing gratitude for the commitment to patients and colleagues, and reassurances that the system will help protect them and support them and their family. national cprc mentioned that severity of the situation and the availability of resources may change on a daily basis. thus, communication is critical, and an effective communication plan both within and between facilities and health system planners, as well as between providers across the health system and even between countries, is essential and should be established immediately. the preparation of healthcare facilities at large for the safe triage, testing and management of patients with confirmed or suspected covid-19, and managing surge conditions are needed. ethical considerations in resource management are also very important. in many places, the number of ventilators available for persons requiring ventilatory support will be inadequate. in some settings, it is common to reallocate resources from terminal patients or patients with brain death or very low likelihood of recovery (e.g. severe traumatic brain injury) to those with a higher likelihood of recovery. in settings where resources are severely limited and must be rationed, consider creating a committee or utilising standardised risk assessments to determine allocation decisions in advance. this avoids placing the burden of decision making on the frontline health care workers, as these decisions should be not be made ad hoc by the bedside clinician but through careful deliberations by the institution. cultural and medicolegal context should be taken into account to determine the most appropriate allocation and potential protocols for rationing medical resources and care in advance. critical testing, ppe, icu beds, therapeutics, and vaccines should go first to front line health care workers and others who keep critical infrastructure functioning; these workers should be given priority not because they are more worthy but due to their instrumental value in the pandemic response and difficulty of replacing (instrumental value). should the surgical instrument be reused? (17). instruments and devices that have been used in procedures for patients with known or suspected covid-19 should be handled the same as other instruments. reprocessing should follow manufacturer's instructions for use (ifu) and be consistent with recommendations in the local infectious disease unit. covid-19 is an enveloped virus and is susceptible to the environmental protection agency (epa)registered disinfectants that are used in the health care setting (18) . there are no additional recommendations by cdc for disinfection and sterilisation of these items used for covid-19 patients. instruments should be cleaned, decontaminated, dried and stored in a manner that reduces the risk of exposing patients and personnel to potentially pathogenic microorganisms (19). high-level disinfect or sterilise them according to the manufacturer's written ifu. they should be packed and stored in individual packs that avoid contamination. (20) patients should perform second pcr + rapid test prior to icu admission. if rapid test positive, then to discuss with covid-19 hospital. if accepted, then to transfer to covid-19 hospital. if not accepted, then send to negative pressure isolation room icu using designated walkway (only suspected covid-19) while awaiting second pcr results. if require urgent resuscitation, to transfer to negative pressure isolation room icu using specific walkway (only suspected covid-19). if rapid test is negative, then to send to negative pressure isolation room icu using designated walkway (only suspected covid-19) while awaiting second pcr. if two negative pcr results, then it is considered a non-covid-19 patient and to be admitted normal icu cubicle. if pcr is not done on admission or only rapid test is done on admission, then a critically ill patient should have 2 pcr done 48 h apart to rule out disease. there is an exception for planned elective admission to icu after elective surgery. for this group of patients, a negative first pcr is adequate, and the patient is to be admitted to a non-isolation cubicle in icu. (21, 22) full ppe must be readily available in icu. prepacked full ppe sets including hazmat suit should be put into a bag, to ease donning in the case of emergency. two sets will be readily available in the emergency trolley with additional sets kept at specific storage area in the icu together with papr. two nurses to attend with full ppe first. one person to be exclusively in charge to help donning of ppe of medical staff to ensure that all are properly fitted, with hazmat suit and papr if required. papr and hazmat suit will be needed for procedures like intubation and bronchoscopy. donning and doffing of ppe instructions should be pasted on the wall. nurses and doctors to undergo training on where and how to don and doff in icu isolation room, as well as in other non-isolation cubicles. designated area to doff ppe in non-isolation icu cubicles/wards to be assigned. walkie talkie to be available in isolation room for outside communication (to get medications, additional materials). nurses outside will prepare required materials/medication and put on a trolley, leave it in the airlock to be collected by nurses in the isolation room. (13, 18, 20) glidescope and ultrasound must be fully covered with plastic when in a room. ultrasound transducer to be covered with transducer cover if in use. cleaning should be per biomedic advice. person cleaning equipment should be made aware of the infectious component and be protected with full ppe. outside nurse to be fully protected when removing equipment outside isolation room for cleaning. the same ventilator should be used for negative pressure isolation room icu and should not with ventilator in the other rooms. (23) the viral filter should be on both inspiratory and expiratory ends. once intubated, to clamp the ett, remove the viral filter for connection with ventilator tubing. etco 2 monitor i.e. capnograph and closed suction catheter to be connected to patient immediately upon intubation. disconnection of ventilator should be reduced. (23) nurses should be divided into covid-19 team and non-covid-19 team. the covid-19 team to take care of covid-19 suspect or covid-19 positive patients. the non-covid-19 team to take care of the non-covid-19 patients. the covid-19 team nurses should not be rotated to non-covid-19 patients. (e.g. patient a is managed by nurse x, y and z in three shifts. this team should take care of patient a until second pcr results are available) container for contaminated ppe for covid-19 suspect or positive should be clearly labelled for cleaners to take extra precautions. decontamination of the pathways and negative pressure isolation room icu used by these patients will be per hospital protocol. the whole icu need to be close and decontaminated in the presence of a covid-19 positive case in nonisolation icu cubicle with no other patients around. for the presence of a covid-19 positive case in non-isolation icu cubicle with existing non-covid-19 patients in icu, the whole icu must be closed and decontaminated plus to consider testing these patients (existing non-covid-19 patients) and transferring to other hospitals. potential covid-19 case in non-isolation room, to limit one visitor/patient. the covid-19 positive in non-isolation room, then no visitors allowed in icu. one staff member in front of icu is stationed to monitor visitor flow in and out of icu (get visitor's name and phone number in the case of contact tracing). in the event of a covid-19 positive case in non-isolation room in icu, contact tracing will include, (1) existing non-covid-19 patients in icu during that period, (2) all visitors who enter icu during that period, (3) all icu staff entering icu during that period, and (4) all doctors entering icu during that period. (27) triage may not be implemented by a facility without clear sanction from appropriate public health authorities. systems for sharing information about the number and severity of cases, equipment availability, and staffing shortages could be activated throughout hospital groups and regional networks. patients are assessed on medical/ clinical factors alone, regardless of their work role. the ontario health plan for an influenza pandemic (ohpip) protocol and the sequential organ failure assessment (sofa) score should be used. candidates for extubation during a pandemic would include patients with the highest probability of mortality. initial assessment using the sofa scoring system (points based on objective measures of function in six domains: lungs, liver, brain, kidneys, blood clotting, and blood pressure) with best score of 0 and worst score of 24. time trials assessment at intervals of 48 h and 120 h. those showing improvement would continue ventilator use until the next assessment, whereas those who no longer met the criteria would lose access to mechanical ventilation. chronic care facilities will have to provide more intensive care on-site as part of the general process of expanding care beyond standard locations. the proposed justification for such a strategy would be that more patients could ultimately survive if these ventilators were used by the previously healthy victims of a pandemic. setting aside the small number of ventilators in chronic care facilities for use by chronically ill people, who likely will have severely limited access to ventilators in acute care facilities. clinicians providing direct care will relay data to a supervising clinician serving as a triage officer, who will calculate the sofa score and make triage decisions but will not provide direct care. terminal weaning in response to patient preferences can include sedation so that the patient need not experience air hunger. patients who are extubated against their wishes should be offered appropriate palliative care based on their clinical conditions and preferences. because transparency is a crucial element of adherence to ethical standards, clinicians must document decisions regarding sedation with extubation. the guidelines do not support the use of manual ventilation devices for patients who do not meet criteria for ventilator access. daily retrospective review of all triage decisions should be made, to ensure consistency and justice. physicians will need to discuss altered standards of care in a disaster, especially for scarce resources such as ventilators. patients and families must be informed immediately that ventilator support represents a trial of therapy that may not improve the patient's condition sufficiently and that the ventilator will be removed if the patient does not meet specific criteria. elective surgeries and other elective procedures that could result in the use of mechanical ventilators should be cancelled (27) . ventilators, supplies, and personnel from ambulatory surgery centres and other facilities not being utilised for covid-19 patients or not experiencing covid-19 outbreaks should be transferred. anaesthesia ventilation machines capable of providing controlled ventilation or assisted ventilation may be used outside of the traditional use for anaesthetic indication (20, 27) . the asa and fda provide specific guidance on how to convert anaesthesia machines for use on covid-19 patients in respiratory failure (27) . transport ventilators may be used for prolonged ventilation in certain patients. continuous ventilators labelled for home use may be used in a medical facility setting depending on the features of the ventilator and provided there is appropriate monitoring (as available) of the patient's condition. non-invasive ventilation (niv) patient interfaces capable of prescribed breath may be used for patients requiring such ventilator support, including niv patient interfaces labelled for sleep apnoea. channelling exhalation through a filter is recommended to prevent aerosolisation. continuous positive airway pressure (cpap), auto-cpap and bilevel positive airway pressure (bipap or bpap) machines typically used for treatment of sleep apnoea (either in the home or facility setting) may be used to support patients with respiratory insufficiency. bipap may be used for invasive ventilation. if all other alternatives are exhausted, care providers could consider ventilation of two patients on a single ventilator for short-term use, although there are significant limitations to this strategy. alternatively, manual bag-valve-mask ventilation done by ancillary providers can be considered as a bridging option to mechanical ventilation. the summary of head and neck examination and procedure recommendations can be viewed in table 4 (28) . (28) in general, most tracheostomy procedures should be avoided or delayed (even beyond 14 days) because of the high infectious risks of the procedure and subsequent care until such time as the acute phase of infection has passed, when the likelihood of recovery is high, and when ventilator weaning has become the primary goal of care. avoiding early tracheostomy in patients with covid-19 is suggested because of the higher viral load that may be present at this time. early tracheostomy was not found to be associated with improved mortality or reduced length of intensive care unit stays in a randomised clinical trial of patients on mechanical ventilation. select the patients carefully. if the tracheostomy is assessed as difficult because of anatomy, history, comorbidities or other factors, consider postponing the procedure. considerations may be given to percutaneous dilatational tracheostomy. allow it to be done safely with minimal or no bronchoscopy, endotracheal suctioning and disruption of the ventilator circuit. adequate sedation provided including paralysis to eliminate the risk of coughing during the procedure. ventilation should be paused (apnoea) at end-expiration when the trachea is entered and any time the ventilation circuit is disconnected. choose a non-fenestrated, cuffed, tracheostomy tube on the smaller side to make the tracheostomy hole smaller overall (shiley size 6 for both men and women is adequate). keep the cuff inflated to limit the spread of virus through the upper airway. tracheostomy suctioning is performed using a closed suction system with a viral filter. heat moisture exchanger device is used instead of tracheostomy collar during weaning to prevent virus spread or reinfection of patients. changing the tracheostomy tube should be delayed until the viral load is as low as possible. case series of open tracheostomies performed during the severe acute respiratory syndrome (sars) outbreak can be viewed in table 5 (29) (30) (31) (32) . making in times of covid-19 crisis: a proposal to safe and sustainable practice in times of crisis neurotrauma (33) neurotrauma forms the bulk of emergency neurosurgical cases presenting or referred to neurosurgical centres, varying from cases of concussion to severe head injuries requiring urgent surgical intervention. in the current climate of a pandemic crisis, neurotrauma poses various management and logistics issues to the neurosurgical team in the following aspects as listed. time between injury to intervention determines outcome. urgency of intervention outlines management of patient. ongoing dynamic pathological process in trauma may alter clinical picture between referral to presentation. pre-emptive management plan is essential to ensure optimum outcome from intervention where feasible. pre-operative screening is vital, particularly those requiring surgical management (34) . all cases undergoing surgery poses high risk to operative team due to potential aerosol generating procedure that may occur from intubation/extubation, positioning of patient to prone/park bench position, tracheostomy procedures and prolonged proximity of surgeon to the head region of patient (33, 36) neurotrauma cases should be managed in a neurosurgical centre. most neurosurgical departments in malaysia are situated in major hospitals, often managing high volume of high risk or covid-19 cases. principle logistic consideration is to whether trauma cases referred from a non-covid-19 designated hospital should be managed in covid-19 designated hospital as this may increase risk of exposure to patients. alternative options should be taken into consideration where feasible, such as team deployment to manage patients in referring hospitals, training and privileging general surgeons in management of cases and transfer of patients back to referral hospitals for continuity of intensive care management postoperatively. resource availability (37) neurotrauma patients require postoperative ventilation with icu care, often for prolonged duration which may limit availability in case of urgent needs. ventilators, ppe and icu are precious commodities in this current pandemic, and fluctuate with time depending on epidemiological dynamics. available resources are commonly and rightly so; prioritised to patients afflicted by the ongoing pandemic, health care workers (hcws) involved in their care. rational balance and anticipation of resource need is essential to optimise usage and sustainable availability in times of crisis. early prognostication (37, 38) outcome from neurotrauma depends on various well-defined parameters. brain damage incurred in primary injury remains irreversible in majority of patients; compounded by secondary factors. early prognostication is essential in times of crisis for resource allocation. it is paramount to ensure that optimum patient care and outcome remains priority of intention to treat. determining long term outcome using available prognostic models for decision making in proceeding with active treatment or withdrawing treatment is essential; albeit exceptionally difficult to ensure continuous availability of limited resource. prognostication based decision is best made with team consensus using all available scientific evidence present. (6) all brain trauma management is in accordance with the brain trauma foundation (btf) guidelines recommendations. all neurosurgical emergencies must be referred to the respective neurosurgical team for consultation and management plans (table 6 ) (39). brain trauma requiring urgent surgical intervention (decompression) with or without intensive care monitoring is best managed in hospitals with dedicated neurosurgical facilities or available neurosurgical services (level ii). brain trauma not requiring urgent decompressive surgical intervention, but which may require or benefit from intracranial pressure (icp) monitoring and intensive care management (level iib) is best managed in centres with available resources to provide objective assessment and management plan, reduce the duration of icu stay and intensive management and early weaning from intensive therapy. brain trauma not requiring urgent decompressive surgical intervention, but which may benefit from icp monitoring and intensive care management in situations where resource availability is limited may be managed with cerebral perfusion pressure (cpp) based target therapy (level iii) and serial ct scan at 6 h-12 h intervals in an intensive care setting where feasible. brain trauma requiring surgical intervention but with limited resources available at dedicated neurosurgical facilities; the following may be considered (anecdotal evidence based on local/regional practice): brain trauma not requiring any surgical intervention but requiring close observation is best managed in dedicated neurosurgical centres or available neurosurgical services if the risk of potential deterioration is deemed to be high (e.g. burst temporal/frontal lobes) and duration and distance of transfer may result in a delay of treatment. brain trauma requiring multidisciplinary management is best transferred and managed in dedicated i) deployment of neurosurgical team to primary referral hospital where feasible to facilitate timely intervention ii) surgical intervention in neurosurgical facilities with subsequent transfer back to primary referring hospitals for continuity of intensive care management (40) screening for traumatic brain injury cases is strongly recommended for safety of hcws. screening recommendations are in accordance with moh guidelines (figure 2 ). risk of covid-19/pui/severe acute respiratory infections (sari) should be ruled out as per moh guidelines and hospital protocols prior to transfer of cases for further management (figure 3 ). secondary screening should be done by attending neurosurgical team on arrival. relatives must accompany for confirmation of history of potential exposure as per moh protocol and directives. confounding factors must be taken into consideration during screening, including: i) potential aspiration in patients with low glasgow coma scale (gcs); ii) metabolic response resulting in abnormal white blood cell count (wcc) and elevated temperature; iii) co-existing chest injuries; and iv) post-intubation changes on chest radiograph (cxr) common. note: all ventilated cases pose a high risk of aerosol exposure to hcws. it is vital to be meticulous and vigilant for potential risk: critical resources for optimum neurosurgical services remain limited and may continue to fluctuate in time of crisis. these include ventilators, ppe, icu availability and operative instruments. the rationale for early prognostication is recommended for optimum resource usage and allocation to ensure beneficial outcome and sustainable supply. prognostication is based on available scientific evidence to guide in management options and rationale of resource allocation. early triage is required for timely and appropriate treatment and enables surgeons to prioritise management according to available resources and the potential outcome. this will help in limiting the proportion of patients in a vegetative state and limiting burden to family and available resources at the time of crisis. in the end, it will help to prepare family with a realistic outlook on the potential outcome. prognostic factors include: i) age > 60; ii) gcs post-resuscitation: motor score m2 -poor outcome; iii) pupils-bilateral fixed/ dilated pupils; iv) systolic blood pressure < 90 mmhg -sustainable/multiple episodes; and v) marshall ct grade. age, gcs motor score and pupillary changes are the three main prognostic factors determining the outcome. the caveats to prognosticating outcome include: aneurysmal sah is a devastating clinical entity. the natural history of aneurysmal sah remains unfavourable with a cumulative rerupture rate at 50% at 2 weeks after initial presentation and overall mortality of 60%. prognostication of aneurysmal sah is well defined according to the world federation of neurosurgery (wfns) grade system predictive of figure 4 . proposed workflow of patients referred for sah outcome following aneurysmal rupture and hunt & hess grade which predicts mortality rate in patients. management of aneurysmal sah during times of crisis must be guided by expected prognosis as defined using these grading systems. this is essential in times of pandemic crisis as difficult decisions need to be made to preserve life and function in face of limited and precious resources essential to the management of patients (41). the proposed recommendations can be viewed in figure 4 . aneurysmal sah (44) adequate resuscitation measures should be instituted on admission where required. these include the airway, breathing and circulation (abc) and mechanical ventilatory support as required with correction of fluid and electrolyte abnormalities if present at primary referral centres. the physician receiving the referral should get an accurate assessment of wfns, and hunt & hess grades on presentation. if hydrocephalus is present on ictus, urgent ventricular drainage should be performed at centres with neurosurgical facilities or trained and privileged surgeons at the designated non neurosurgical centres. a noncontrast ct brain and ct angiogram (cta) are the first line investigative parameter at the admitting hospital before transfer to a centre with neurosurgical facilities or services. when perimesencephalic sah is the likely diagnosis after confirmation by a neuroradiologist, then the patient should be managed expectantly. there will be no further imaging required. however, if aneurysmal rupture cannot be ruled out, then the recommendation is based on the wfns grading. for wfns 1-3, a digital subtraction angiography (dsa) is recommended at the primary centre if available or transfer to centres with available facilities and neurosurgical services. for wfns 4 and 5, the patient should stay at the primary centre if feasible with a repeat cta in 1 week. a continuous neurological assessment should be documented and if whenever an improvement is noted, then the patient should be considered for transfer. poor grade aneurysm cases may benefit from continued neuroprotection. however, multiple factors should be taken into accounts such as age, comorbidities and available resources to sustain prolonged care in such patients. the decision to consider conservative management if no further improvement in wfns score is the prerogative of attending consultants. the quality of cta is important in determining the next treatment of care. for patients with wfns grade 1-3, if cta deemed adequate by attending consultants for safe and effective definitive management by surgical clipping, then the recommendation is to proceed for surgical treatment as urgently possible at the centre with available neurosurgical services. if cta deemed inadequate for definitive management, then the patient should be transferred for dsa at centres with available radiological and neurosurgical services. the choice of treatment between surgical treatment and endovascular treatments should remain similar to current standards. however, interventional neurovascular services in malaysia are limited to a few major hospitals. transferring patients across states in times of limited resources may result in unnecessary delays and worsening outcomes from potential deterioration during the interim period. thus, various factors should be taken into consideration when deciding the best treatment options in times of crisis. they include: if dsa is required, the option of definitive management of endovascular coiling at the same setting should be considered. there are several reasons which include: i) minimising the risk of aerosol disbursement that is highest during intubation/extubation; ii) early definitive management can be achieved at the same setting with reduced risk of re-rupture; iii) treatment of vasospasm if present for applicable cases done at the same setting; and iv) reducing the risk of exposure to personnel from a second ga procedure. patients with wfns grade 4 may benefit from neuroprotective measures. definitive management should be considered in selected cases such as: i) young age; ii) no morbidities/comorbidities; and iii) choice of treatment depends on available services and following discussion between attending consultant and family. for patients with wfns grade 5, conservative management should be considered if no further improvement achieved following a period of neuroprotection. the decision is made through a collective discussion between attending physician and family members. a thorough history should be elicited to determine any evidence of sentinel haemorrhage that may appear trivial to patients. an appropriate diagnostic modality is required to look for radiological evidence of recent i.e 'teat sign'. within an applicable timeframe, a lumbar puncture should be considered. an aneurysm with neurological symptoms and signs should be planned and treated in a timely manner as a semi-emergency case; an example is a patient with posterior communicating artery aneurysm presenting with ptosis, rather than a delayed surgery in this current pandemic of uncertain duration to avoid potential irreversible neurological compromise or worsening deterioration. in cases of multiple aneurysms, the treatment should be undertaken for ruptured aneurysm as well as aneurysm with increased risk of rupture, if deemed feasible at the same sitting. arteriovenous malformations (avms) are a heterogeneous group of neurovascular abnormalities with an incidence of 1.1/100000 population. anatomically avms are defined as a complex of abnormal arteries and veins that communicate directly without an intervening capillary bed. avm presents with haemorrhage in as many as 50% of cases. the natural history of avms is more favourable as compared to aneurysmal sah, with an annual rupture rate of 4%, and recurrent haemorrhage rate of 6%-17% in the first year following a rupture (45) . cases of avm presenting with haemorrhage may require urgent surgical management. the proposed recommendations are divided into three categories: i) avm rupture with mass effect; ii) avm rupture without mass effect; and iii) avms not presenting with haemorrhage (46) (47) (48) . any ruptured avm with mass effect should be transferred to a centre with neurosurgical services or facilities. a cta should be performed on admission to confirm the diagnosis of ruptured avm and to determine the location of avm in relation to clot. this will aid a safe surgical access planning. following an urgent surgical evacuation of a clot, the patient should be managed in an intensive care setting for neuroprotection. a post-operative dsa/cta is warranted to look for potential high risk factors for haemorrhage, such as nidal aneurysm/varix and to consider an endovascular treatment if feasible and required. definitive treatment should be deferred safely to a later date if feasible. the patient should be transferred to a centre with neurosurgical facilities, particularly when avm presents with intraventricular haemorrhage (ivh) or cta shows evidence of nidal aneurysm or varix. if no ivh present and cta shows no high risk factors of haemorrhage, the patient may be managed at a non neurosurgical centre with early follow up scheduled in the clinic for review. the management is mainly medical treatment to optimise seizure control or headache. all definitive treatment should be deferred to a later date. (49) these are rare conditions that comprise of fistulas connecting branches of dural arteries to dural veins or venous sinuses. dural arteriovenous fistulas (davfs) are typically stable lesions with a reported annual haemorrhage risk ranging between 6%-8% (10), and mortality rate ranges at 6%-20%. endovascular modalities remain the diagnostic and therapeutic modality of choice. the recommendations are proposed for the management of (1) ruptured cranial davf and ruptured spinal davf. patients who presented with ruptured cranial davf should be transferred to a neurosurgical centre with endovascular facilities for urgent surgical management of clot with mass effect, if present, and definitive endovascular management. patients who presented with ruptured spinal davf requires transfer to a neurosurgical centre with endovascular facilities for urgent treatment, especially when there is rapid neurological deterioration. some patients presented with spontaneous hypertensive haemorrhage that may or may not require surgical intervention. patients that are not a candidate for surgical interventions include: i) small, deep haemorrhage; ii) large haemorrhage without hydrocephalus, ivh or neurological deterioration; and iii) those with supratentorial haemorrhage with a gcs score below 8 unless this is because of hydrocephalus (50) . a poor prognosis is expected in the following conditions: ii) candidate with gcs score is 5 or less; and ii) the haematoma is very large and death is expected (50) . in this condition, a careful consideration should be taken and a family meeting should be done sooner. surgical interventions are recommended in the following categories: the diagnosis of middle cerebral artery (mca) infarction depends on the clinical presentation, neurological findings, followed by radiological imaging. patients with suspected transient ischaemic attack (tia) should be assessed by a specialist physician before a decision on brain imaging is made, except when haemorrhage requires exclusion in patients taking an anticoagulant or with a bleeding disorder when noncontrast ct should be performed urgently (50) . further imaging, such as carotid imaging is essential for any patient presenting with symptoms suggesting of an anterior circulation cerebral ischaemia who might be suitable for intervention for carotid stenosis. patients with tia or acute non-disabling stroke with stable neurological symptoms who have symptomatic severe carotid stenosis of 50%-99% (nascet method) should receive an urgent carotid endarterectomy (within 7 days). the treatment tends to happen in a vascular surgical centre routinely participating in national audit (50) . the indications for mechanical thrombectomy (mt) (50) are when there are proximal large artery occlusion as an adjunct to intravenous thrombolysis (ivt), and for those patients with contraindications to ivt but not to mt. another indication is when major vessel occlusion is in the posterior circulation, up to 24 h from known onset. the indications for decompressive hemicraniectomy are as follows (50) (53), ventriculostomy is recommended in the treatment of obstructive hydrocephalus. concomitant or subsequent decompressive craniectomy may or may not be necessary on the basis of factors such as: i) the size of the infarction; ii) neurological condition; iii) degree of brainstem compression; and iv) effectiveness of medical management. there are times when an emergency carotid endarterectomy (cea)/ carotid angioplasty and stenting will be useful as clinical indicators or brain imaging suggests (53) . an example is when a small infarct core with large territory at risk (e.g. penumbra), compromised by inadequate flow from critical carotid stenosis or occlusion. however, in patients with unstable neurological status (e.g. stroke-in-evolution), the efficacy of emergency or urgent cea /carotid angioplasty and stenting is not well established. stroke complicated covid-19 infection in 5.9% of patients at a median 10 days after symptom onset. stroke mechanisms may vary and could include hypercoagulability from critical illness and cardioembolism from virusrelated cardiac injury. the clinical presentation in stroke patients typically manifested as cns involvements. the most common neurological manifestations in covid-19 patients were dizziness (16.8%), headache (13.1%) and encephalopathy (2.8%). the most common peripheral signs and symptoms were anosmia (5.1%), dysgeusia (5.6%) and muscle injury (10.1%, detected by elevated creatine kinase). patients with stroke were older, had more cardiovascular comorbidities, and more severe pneumonia. ideally, every stroke patient would be treated as potentially infected, hence the requirement of ppe. many teams have begun using telemedicine both within their own ed and regionally. this solution avoids the use of needed ppe, allows a reasonable stroke evaluation, avoids unnecessary interfacility transfers, and reduces exposure risk for the stroke team. in the setting of the pandemic, full compliance to clinical practice guidelines has become a goal, not an expectation. each team must use their judgement, guided by local realities, and continue to try to treat as many acute stroke patients as possible. patients with large intracerebral haemorrhages, sah or large ischemic strokes at risk for herniation must be monitored in an intensive care setting with appropriately trained personnel, where possible. appropriate resource should be allocated for critically ill stroke patients. appropriate intensive care of these seriously ill patients with haemorrhagic stroke, some of whom are also young and with an excellent long term outcome, should be maintained. however, in each locality, specialists from all intensive care specialities e.g. pulmonary, cardiology, neurology, neurosurgery must discuss the relative merits of prolonged icu care for any particular patient. (55) the establishment of stroke networks and care systems can deliver a high quality emergency stroke care at all times, particularly at times of crisis. although there is a strong case for such centres to be the system of care, it is particularly important to have services that can continue to function. the hospital should inform the emergency medical system and the public that these centres will be protected and will remain fully operational even during crises. the hospital or stroke team should regularly update and educates the health professionals and the public, especially those who are at high risk of stroke to recognise a stroke and call emergency medical services immediately. those patients should be taken to one of the designated stroke centres to avoid significant delay in transferring patient from one hospital to the other. categorising elective neurosurgical cases at a time of covid-19 pandemic is adapted and as per guidelines (with minimal modification) -perioperative mortality review (pomr): prioritisation of cases for emergency and elective surgery (2nd revision) (56) ( table 7 ). the tier status of each case is according to the urgency and the decision will be based on: i) natural history of the disease; ii) patient's neurological status; and iii) availability of manpower and equipment's for surgery ( figure 6 ). to summarised, all elective neurosurgery should be postponed (1, 21) . in patients with suspected covid-19, the surgery should be deferred for at least 14 days, with an appropriate test taken to confirm the status (1, 21) . the elective urgent inpatient diagnostic and surgical procedures should be shifted to outpatient settings, when feasible (2). dangers during neurosurgical procedure (2, 18, 19, 24, 28, 57) according to limited data from cdc, covid-19 has been detected in blood specimens and it is unknown whether the virus is viable or infectious in extrapulmonary (outside the lungs) specimens. there have been some reports that covid-19 is present in stool and maybe transmissible through the faecal-oral route. bronchoscopy, tracheostomy and thoracic cases may have a higher risk for airborne transmission of covid-19 because the nature of the procedures involves the respiratory tract, which could lead to aerosolisation of the virus. procedures that may aerosolise blood and body fluids during surgery include: i) electrocautery of blood or tissue; ii) laparoscopy; iii) endoscopy; iv) use of intraoperative debridement devices with irrigation (e.g. hydrosurgery, pulse lavage or low frequency ultrasonic debridement); and v) use of high speed powered equipment (e.g. saws and drills). surgical smoke represents another important issue to tackle during surgery. it is recommended for the evacuation of all surgical smoke as it contains hazardous chemicals, ultrafine particles, viruses, bacteria and cancer cells. the earliest detected case of covid-19 was in china on 17 november 2019. as such, there is currently no research on the transmission of the virus through surgical smoke. however, there is no indication or proof that covid-19 is not transmissible through surgical smoke. research studies have demonstrated the presence of viruses (e.g. human papillomavirus) in surgical smoke with documented transmission to health care providers. according to limited data from the cdc, sars-cov-2 rna has been detected in blood specimens and it is unknown whether the virus is viable or infectious in extrapulmonary (outside the lungs) specimens. in similar coronaviruses, viable and infectious sars-cov was isolated from blood specimens, although infectious mers-cov was only isolated from the respiratory tract. of importance to neurosurgeons, the use of high speed drills and also electrocautery during surgery will cause aerosolised blood and body fluid. thus, increasing exposure of neurosurgeons to the virus. however, the risk of transmission of covid-19 through aerosolised blood and body fluids is unknown. thus, extra precautionary measures must be taken during procedures for protection. proper ppe must be worn during any neurosurgical procedure to prevent transmission. (58, 59) covid-19 was declared a pandemic by who on 11 march 2020 because of its rapid worldwide spread. covid-19 has achieved effective and sustained human-to-human transmission via contact, droplet and likely airborne routes. as with previous outbreaks such as severe acute respiratory syndrome (sars), influenza a (h1n1) 2009 infection and the middle east respiratory syndrome, this would require heightened precautions and tailoring our anaesthetic practice to reduce exposure to patients' respiratory secretions and the risk of perioperative viral transmission to healthcare workers and other patients. in particular, this should involve minimising the many aerosolgenerating procedures we perform during ga, such as bag mask ventilation, open airway suctioning and endotracheal intubation. during the sars outbreak, intubation was one of the independent risk factors for super-spreading nosocomial outbreaks affecting many healthcare workers in hong kong and guangzhou, china. nevertheless, to avoid any airway manipulation, the use of ra techniques (e.g. peripheral nerve blocks and/or central neuraxial blocks) may be consideration should be given to the available resources, facilities, equipment, consumable and real time logistic capability and feasibility. designated covid-19 hospitals may not be able to support all elective cases, in particular those that require post-operative intensive care or significant use of blood and blood products surgeons, in consultation with anaesthetist, nursing colleagues as well as patients (or legally accepted next of kin), should weigh the risks of proceeding (exposure, lack of resources) against those of deferment, (progression of disease, worse patients outcomes) including the expectation of delay of 2-3 months or more or until the covid-19 is less prevalent figure 6 . availability of manpower and equipment for surgery preferred. thus, ra manipulation should be considered whenever surgery is planned for a suspected or confirmed covid-19 patient or any patient who poses an infection risk. ra has benefits of preservation of respiratory function, avoidance of aerosolisation and hence viral transmission. there is no proper guideline and recommendation as of today regarding the use of ra in covid-19 patients. however, general precautions and ppe should be applied for all the healthcare workers even though the patient is undergoing ra. this is because, in case of failed ra, ga must be used for the surgery. anaesthesia providers for these patients should be well-versed in both ga and ra techniques. for neurosurgery patients, ra such as scalp block must be considered in simple procedures such as borehole. for emergency neurosurgery cases, most of it would be involving patients with poor gcs thus making ra not as feasible as the patient would be already intubated. covid-19 is an infectious disease introduced to humans for the first time. individuals can be infected by breathing in the virus within 1 metre of a person who has covid-19, or by touching a contaminated surface and then touching their own mouth, nose, or possibly their eyes. on 30 january 2020, who declared the outbreak as a public health emergency of international concern (pheic), and by 11 march 2020, the outbreak has rapidly accelerated to become pandemic. until 3 april 2020, there were 976, 249 confirmed cases, with 50,489 deaths, affecting 207 countries, including malaysia (60). following the pandemic of covid-19, there is a major shift of practices among surgical departments in response to an unprecedented surge in reducing the transmission of disease. with pooling and outsourcing of more hcws to emergency room, public health care services and medical services, further in hospital resources are prioritised to those in need. along with slowing and breaking the transmission of covid-19 by social distancing, the neurosurgical outpatient clinic, elective and non-emergency surgery are delayed. this will reduce the face-toface contact with potential covid-19 cases, and shields patients and hcws from the virus. every neurosurgical team has to reevaluate the timing of operation in those patients with neurosurgical disease that are in need of treatment. the real risk of proceeding and the real risk of delay should be carefully assessed. when considering a delay in treatment to a time where covid-19 is less prevalent, the decision making process must always take into account each patient's courses of disease, social circumstances and needs. it is imperative to balance the requirements of caring for covid-19 patients with imminent risk of delay to others who need care (61). currently, patient's screening process is crucial. the moh recommendations of screening involve questionnaires to identify suspected patients (1, 62) . patients who meet certain criteria should be evaluated as a patient under investigation (pui). these general questions to all patients include: i) do you have any fever or acute respiratory infection (sudden onset of respiratory infection with at least one of: shortness of breath, cough or sore throat)? ii) do you have any history of travelling to or residing in affected countries in the past 14 days? iii) did you have any contact with a confirmed covid-19 case within the past 14 days? there are two laboratory tests that can be used to detect covid-19 (1, 61): rt-pcr. the sample commonly taken is upper airway specimens (pharyngeal swabs, nasal swabs, nasopharyngeal secretions). among patients with confirmed positive in respiratory tract, ~ 50%-60% of patients have detected viral load in faeces, ~30%-40% in the blood, while the lowest positive rate is in urine samples. ii) rapid test kit (rtk) serology for serum antibody igm and/or igg. this can be used as diagnostic criteria for suspected patients with negative pcr detection. during follow-up monitoring, igm is detectable 10 days after symptom onset and igg is detectable 12 days after symptom onset. the viral load gradually decreases with the increase of serum antibody levels. urgent/emergent cases are previously defined as patients requiring access to surgical treatment within 24 h of the decision to operate (63) . however, with the current pandemic, access to surgical treatment may be delayed and some patients could face increasing morbidity/ mortality by the time surgery happens. other countries have now come up with guidelines for the triage, or ranking in order of priority, of surgical patients. the american college of surgeons (acs) describes the acuity scales based on tier classification, with most cancers and highly symptomatic patients considered tier 3a (do not postpone) (64) . other than trauma and life threatening condition, other treatments are recommended to postpone, if possible. then what will happen to all elective cases that will be pushed back for a further few months? will that add to the mounting burden of long waiting lists that is already stretched? to delineate the current situation, we propose a few steps that will in future, limit and protect both patients and surgeons from the risk of transmission (figure 7) . special consideration is given to pre-operative patients needing endoscopic transnasal surgery, even for asymptomatic patients (8, 57) . the transmission of covid-19 is predominantly via respiratory droplets (e.g. coughing and sneezing) and contact with contaminated surfaces (18, 60, 65) . however, earlier studies have shown the presence of the virus in conjunctival secretions and even stool (65) . hence all body fluids except for sweat should be considered as potentially infectious (66) . contamination of the surrounding environment may also occur following aerosol-generating procedures (agp) which include the use of high-speed devices or when splashing or spillage of bodily fluid is expected (66) . appropriate steps especially in these environments need to be taken to disrupt the transmission of covid-19 and reduce risk of infection. these environments are considered as high-risk environments and include the icu, high-dependency unit (hdu) and ots. the emergency rhesus areas where suspected or confirmed cases of covid-19 are managed are also considered as high-risk areas (66) . all highrisk areas require level iii ppe (table 8 ) (66) . ppe is only a part of the safe system of working (67) . clinical staff must be trained and competent in the use of ppe in their respective hospitals. table 8 shows the recommended ppe for clinical setting (15, 61, 68) . ppe should be located close to the point of use and should be stored in a clean and dry area to prevent contamination. ideally, ppe is for single use and changed between patients unless in a situation of ppe shortage or when re-usable ppe is used. the used ppe must be disposed of in designated waste streams. the practice of donning (putting on) and doffing (taking off) of ppe must be done in designated areas safe for the respective procedures (18, 24) . different hospitals may have different arrangements of clinical areas (ot, wards, clinics, etc.). hence, the physicians must make sure to be aware of the designated areas for donning and doffing prior to putting on ppe. ideally, each clinical staff donning must be supervised by another competent clinical staff especially to assist in donning and to make a final visual inspection of ppe. recommended ppe components: i) protective medical gown should be long in length, long sleeves, rear-fastening and fluid-resistant. also, include protective, fluid-resistant boots with disposable fluid-resistant covers when appropriate (high-risk procedures). for the gloves, the recommendation is to use disposable, non-sterile latex gloves for non-sterile procedures, whereas for sterile procedures is to use disposable sterile latex gloves. double gloving is essential in those procedures. (15) ii) for the face/eye protector, ideally a disposable visor which covers the whole face including chin will give better protection than glasses and contact lenses. iii) for the respirator/mask, papr is recommended and preferred for high-risk procedures including agp. a minimum of n95 mask with face protector (i.e. visor) for agp (28, (69) (70) (71) . for sars-cov, there is limited evidence (from observational studies) showing a protective effect of up to 80% of n95 masks (equivalent to ffp2 masks) used by healthcare workers. hence, although the cdc recommends n95 masks or higher level respirators for agp, n95 respirators are not recommended for agp in the uk (19, 69) . the masks used should be fitted to the face without airleaks. in general clinical setting (other than aerosol-producing procedures), a fluidresistant mask is required. while fabric masks are widely available, this should not be used in any clinical setting. figure 8 shows how to perform a particulate respirator seal check (72) . i) essential to sanitise hand with alcohol gel before, in between each step and after donning of ppe ii) ppe must be put on in an order that ensures adequate placement of ppe equipment and prevents self-contamination and self-inoculation while using ppe and when taking off ppe (69, 71) . figure 9 shows levels of ppe. figure 10 shows the recommended ppe to be used at the primary triage and non-sari area, while figure 11 shows the recommended ppe in the ot, the ideal pressure system is a negative pressure room and if available, the recommended location is at the corner of the operating complex (57, 61). the theatre should have a separate entrance. for intubation, the surgeons and personnel that are not involved in intubation should wait outside of the ot until anaesthetic induction and intubation are completed (12, 15, 61) . during surgery (except for endoscopic endonasal procedures), procedures involving high speed devices are considered as aerosol-producing procedures and are high risk. the number of personnel in an ot should be minimised (58) and full ppe should be applied. a n95 mask or masks that offer a higher level of protection should be used (28, 65, 66) . endoscopic endonasal procedures are not safe and should be avoided (28, 33) . if the surgery cannot be postponed, consider a craniotomy or microscope-based transsphenoidal procedure. during a shortage of ppe, the hospital or physicians are encouraged to minimise the use of ppe (16, 69) . there are options available, such as considering telemedicine, where appropriate, to avoid direct contact with patients hence removing the necessity of ppe. the use of sterile gloves should be reserved only for procedures requiring sterility (61, 65, 66) . all elective or non-urgent procedures, which usually require components of ppe should be delayed (65) . certain areas should be monitored with restricted access, such as areas where suspected or confirmed covid-19 patients are being treated. some activities that require to be done at proximity to the patient (e.g. at bedside) must be planned early and bundle them together to minimise the number of times entering the room. visitors should not be allowed unless necessary, with restricted numbers and amount of time spent in the area. visitors must have clear instructions and guidance when donning and doffing with strict hand hygiene (20, 61) . the use of appropriate ppe should be prioritised (19, 61) and rationalised according to the risk of exposure and transmission dynamics of pathogens (air droplets, contact). overuse of ppe will further impact on supply shortages. (table 8) the physician usually have to tailor the ppe usage based on the setting and activity being performed. below are some recommendations: extend the use of surgical gowns, masks and face protectors between patients with the same disease, who were confined in the same area without changing in between patients and whilst performing low risk procedures (14, 19, 61) ii) consider re-usable face protectors (i.e. visors or googles) ( the ultraviolet (uv) spectrum is best known for uva, uvb and uvc (germicidal radiation). the spectral ranges for uva, uvb and uvc are 315 nm-400 nm, 280 nm-315 nm and 100 nm-280 nm, respectively. uvc is the one with the strongest antimicrobial/antiviral properties (74, 75) . with the rising healthcare awareness, some industry has demonstrated the effectiveness of radiation disinfection, especially uv light disinfection system on surface contamination, such as floors and equipment after the manual chemical disinfection process is completed (76) . uv light disinfection is an implementation of 'no-touch' technology, is chemical free, does not require changes in the room's ventilation and will not leave a residue after treatment. in healthcare facilities such as icu and ot, this may be an adjunct to disinfection process (77) . a laboratory study has shown that coronavirus could effectively be inactivated by uvc light (74, 75, 78) . nevertheless, the uv light device is not a substitute for handwashing, mask-wearing and distancing. moreover, the international commission on non-ionizing radiation protection (icnirp) does not recommend the usage of lamps in the home. this is due to lack of adequate instructions of installation, duration of disinfection and increasing cases of skin and eye burns (79) . who has come out with a fact that uv lamps should not be used to disinfect hands or other skin areas. furthermore, reiteration was made that 'cleaning your hands with alcohol-based hand rub or washing your hands with soap and water are the most effective ways to remove the virus' (80) . the malaysian medical council has formed an advisory group to define and monitor virtual consultation (during the covid-19 pandemic). this advisory is guided by the medical act 1971 (amended 2012) which regulates the registration and practice of medicine in malaysia and the malaysian medical council's code of professional conduct. a virtual consultation is a form of telemedicine. telemedicine (teleconsultation, video conferencing, teleworkers, televideo) is a medical service provided remotely via information and communication technology. when the consultation is conducted without physical contact and does not necessarily involve long distances, then it is known as remote consultation. the role of the council is to regulate physicians, not technology. the council reminds physicians that the use of technology does not alter the ethical, professional and legal requirements in the provision of care. the malaysian medical council's jurisdiction is within this country only and physicians must ensure appropriate liability protection is in place to provide indemnity for malpractice. when the health care delivery is affected by any national epidemic or global pandemic, or any other movement restrictions imposed on the public by the government, the use of communication technology can improve the access to care. in this unprecedented time where the situation is seen to be very urgent, rapidly changing and where there is a fine balance between public safety and individual health, it is equally important for medical practitioners to have the virtues of accountability and truth telling. the code of professional conduct clearly says a physical examination is ethically mandatory. a non-physical contact virtual consultation makes a physical examination incomplete other than the visual and auditory observation. however, if a physician under current circumstances conducting such telemedicine virtual consultation feels this is so in good faith, then appropriate treatment can be initiated based on such, without the need for a physical examination in person. in providing medical care using telecommunications technologies, physicians are advised that they must possess adequate training and competency to manage patients through telemedicine. the ethical and legal requirements such obtaining valid informed consent from the patient should be taken, at the same time ensuring that the physician's identity, place of practice and registration status are made known to the patient, and the identity of the patient is confirmed at each consultation. the identities of all other participants involved in the telemedicine are disclosed and approved by the patient, and documented in the patient record. both the physician-site and the patient-site are using appropriate technology that complies with legal requirements regarding privacy and security and accreditation standards where required. considerations must be given to safety and maintaining a high standard of patient care. the physicians must consider whether the telemedicine medium affords adequate assessment of the presenting problem, and if it does not, an arrangement for a timely in-person assessment should be taken. the physician should be prepared to advise remote patients about how and where to arrange for necessary care when follow-up is indicated. with the limitation of telemedicine, the physicians should exercise caution when providing prescriptions or other treatment recommendations to patients whom they have not personally examined. when carrying out a diagnostic evaluation or prescribing medication, a physician conducting a remote interaction should: i) verify the patient's identity; ii) confirm that the remote interaction is appropriate to the patient's situation and medical needs; iii) write any prescriptions in keeping with best practice guidelines and formulary restrictions (and in keeping with ethics guidance on prudent stewardship); and iv) document the clinical evaluation and prescription, as well as any instructions given to the patient. a medical record of the consultation, in accordance with professional and legal requirements, are kept and available to other health care professionals for the provision of ongoing patient care. this is especially important when there is a followup and referral to other specialities. hence, the physician must ensure adherence to the same obligations for patient follow up in telemedicine as is expected with in-person consultation. many centres have implemented the telemedicine in neurosurgical consultation, specifically in patients with confirmed covid-19, or recovered patients (pcr negative and beyond 14 days incubation period) that may need comprehensive clinical assessment to be performed. throughout all levels, neurosurgeons are encouraged to convert meetings (with staff, colleagues and patients) to teleconsultation and/or video conferencing (6) . teleconsultation minimises face-to-face clinic visits for all doctors and patients, including neurosurgeons and their patients (3). staff and patients over the age of 65 are encouraged to avoid coming to the hospital and clinic. the conversion of many clinic visits as medically appropriate to this new modality allow patients to stay safe at home and allows clinic nurses and staff to help care for covid-19 patients. another speciality that is using telemedicine is neurology, mainly for the assessment of patients with a suspected stroke. the telemedicine should enable the physician to discuss the case with the assessing clinician, talk to the patient and/or family/carers directly and review radiological investigations (50) . hence, it is important that a high-quality video link is maintained to enable the remote physician to observe the clinical examination. the physician providing care (at both ends of the system) should be appropriately trained in the hyperacute assessment of people with suspected acute stroke, in the delivery of thrombolysis and the use of this approach and technology. the impact on the quality of care, efficacy of telemedicine and decision-making using telemedicine should be regularly audited (81) in keeping with physician's fiduciary obligations to patients across that continuum (82) . timely updates from trusted sources about the relative risk of contracting the novel disease versus a more common one are critical (83, 84) . strategic social media use (e.g. hashtags) may be an effective way for agencies to communicate accurate information to the public during times of crisis. residents may be advised to connect with and follow local health agencies and service providers for the most geographically relevant information. researchers may use publicly available 'big data' (e.g. localised tweets) to gauge the risk of communication efforts of local agencies. (84) (85) (86) in the emergency department, there is a surge control for 'forward triage', meaning utilisation of sorting the patients before they arrive in the emergency department. this allows patients to be efficiently screened, is both patient-centred and conducive to self-quarantine, and it protects patients, clinicians and the community from exposure. the physicians and patients are still able to communicate 24/7, either by using smartphones or webcam-enabled computers. the respiratory symptoms (which may be early signs of covid-19) are among the conditions most commonly evaluated with this approach. telemedicine consultations for oncologic patients may not be suitable and individual clinicians must be able to make an appropriate judgment. however, patients will greatly benefit from such virtual clinic consultations over a cancellation. (87, 88) the presence of virus within csf fluid and during autopsy can be tested via electron microscopy, immunohistochemistry and realtime reverse transcriptional. there are 36.4% of patients had neurologic manifestations due to neurotropic potential in the covid-19 virus found in one study. during an early or later phase of the infection, the dissemination of covid-19 in the systemic circulation or across the cribriform plate of the ethmoid bone takes place. the ability to cross the blood brain barrier into the cerebral circulation is due to the properties of the covid-19 virus spike protein with angiotensin-converting enzyme 2 (ace2) receptors expressed in the capillary endothelium. the receptor has been detected over glial cells and neurons. covid-19 virus exploits the ace2 receptors to gain entry inside the cells (89) causing neuronal death in mice by invading the brain via the nose close to the olfactory epithelium. in an uncomplicated early stage, findings like an altered sense of smell or hyposmia can be found. once the virus caused respiratory manifestation, there will be neurological involvement with loss of involuntary control over breathing (90) . tuberculosis (91) the physician should maintain continuity of essential services for people affected with tuberculosis (tb) during the covid-19 pandemic. it is anticipated that ill patients with both tb and covid-19 may have poorer treatment outcomes, especially if tb treatment is interrupted. therefore, accurate diagnostic tests are essential for both tb and covid-19. simultaneous testing of the same patient for both tb and covid-19 would generally be indicated for three main reasons (subject to the specific setting in the country): i) clinical features that are common to both diseases; or ii) simultaneous exposure to both diseases; or iii) presence of a risk factor for poor outcomes to either disease. in tuberculous meningitis with communicating hydrocephalus, the recommendation is to treat with furosemide with or without acetazolamide. some institutions favour daily lumbar punctures with icp monitoring through manometry (92) . in tuberculous meningitis with noncommunicating hydrocephalus, this will involve invasive neurosurgical procedures such as an external ventricular drain (evd), ventriculoperitoneal shunting or endoscopic third ventriculostomy (etv) (92) . acute necrotising encephalopathy is a condition that can be triggered by viral infections like influenza and herpes. a case report of a woman who tested positive for covid-19 developed acute necrotising encephalopathy (93) . the patient presented altered mental status and a noncontrast head ct images demonstrated symmetric hypoattenuation within the bilateral medial thalami with a normal cta and ct venogram. brain mri demonstrated a haemorrhagic rim enhancing lesions within the bilateral thalami, medial temporal lobes, and subinsular regions. the patient was started on intravenous immunoglobulin. this is the first reported case of meningitis associated with sars-cov-2 who presented with convulsion followed by unconsciousness (94) . the patient had transient generalised seizures that lasted about a minute. the specific sars-cov-2 rna was not detected in the nasopharyngeal swab but was detected in a csf. brain mri showed hyperintensity along the wall of right lateral ventricle and hyperintense signal changes in the right mesial temporal lobe and hippocampus, suggesting the possibility of sars-cov-2 meningitis. paediatric neurosurgery accounts for up to 15% of neurosurgical admissions. in this current crisis, covid-19 infection among children remains limited in numbers. however, paediatric patients are at risk of exposure from potential family members and caretakers that may harbour the virus and remain asymptomatic. the main consideration is therefore to be vigilant and screen caretakers and family of patients for risk of exposure based on current and updated guidelines provided by the moh (1). the priority as for all cases in the pandemic crisis remains the protection of healthcare personnel and other non-infected patients as well as the working environment at healthcare facilities. the guidelines provided by moh (1) applies equally for paediatric neurosurgery cases; principally in deciding for the need of surgical care and intensive management in times of reduced availability of resources. this guiding principle forms the core basis of decision making for paediatric neurosurgery in malaysia as the availability of specialised paediatric intensive care units and specialised instruments are typically present in major hospitals with dedicated neurosurgical units and facilities. with the ongoing pandemic crisis, these subspecialised resources are crucial for the treatment of patients afflicted by covid-19. (95) all non-essential outpatient cases should be postponed. some new cases with symptoms and signs of raised icp or neurological compromise should be reviewed urgently by a neurosurgeon. whereas, new cases with no symptoms or signs of raised icp or neurological compromise should be reviewed via teleconsultation. any pending surgeries should be reviewed with team and mdt to prioritise cases based on the urgency of surgical intervention, taking into account symptoms and signs, radiological evidence of mass effect or vital structure compression, expected radiological progression over time and expected histology along with the availability of vital specialised resources of intensive care, equipment requirements and ot availability. certain logistic factors, such as patient travel and family economic factor that requires one or both parents to be away from work should also be taken into account in the decision making process to ensure compliance of patient and caretakers to the management plan. paediatric neurotrauma (38) all cases must be screened for risk of covid-19 as per hospital protocols. the management of paediatric neurotrauma is based on the brain trauma foundation (btf) guidelines. all cases undergoing emergency surgery must be performed under full ppe as per hospital/moh protocols (1, 62) . the initial referral should be reviewed by the neurosurgical team or consulted via teleconferencing with the neurosurgical team on admission. the modified paediatric gcs score system (table 9 ) must be applied and made available to referring or primary management team where applicable (96) . cases of neurotrauma with surgical lesions must be transferred to a hospital with a neurosurgical facility and or services for management. frequent repeats of ct scan should be avoided where feasible and should be factored into the decision making process for applicable cases. there are certain cases of neurotrauma that has positive ct findings but with a nonsurgical lesion (97) . if the treatment requires an icp monitoring, then the patient should be transferred to a centre with neurosurgical services or facilities. if the treatment does not require an icp monitoring but there is a potential risk of progression and deterioration, then the patient should also be transferred over. however, for patients who do not require intensive care with low risk of deterioration or progression, it is advisable to transfer to centres with available neurosurgical services. if it is not feasible, then the patient should be managed by attending paediatrician/surgeon at primary referral centres with regular consultations to the neurosurgical team. cases with no positive ct brain findings (97) may be managed at primary referral centres if deemed suitable with a consultation to the neurosurgery team. in a non-traumatic paediatric neurosurgery case, the approach is the same; all cases must be screened for risk of covid-19 as per hospital protocols. suitable use of ppe must be adhered to for all cases undergoing surgery. the surgeon should: i) consider the option of fastest and simples access route to the lesion; ii) consider biopsy if deemed appropriate over surgical guidelines covid-19 management in malaysia covid-19: recommendations for management of elective surgical procedures american association of neurological surgeons. covid-19 and neurosurgery cms adult elective surgery and procedures recommendations neurosurgery during the covid-19 pandemic: update from lombardy, northern italy letter: the coronavirus disease 2019 global pandemic: a neurosurgical treatment algorithm guidance for surgeons working during the covid-19 pandemic letter: precautions for endoscopic transnasal skull base surgery during the covid-19 pandemic just the facts: airway management during the coronavirus disease 2019 (covid-19) pandemic adoption of a safe or cautious approach towards surgery covid-19 preparedness within the surgical, obstetric, and anesthetic ecosystem in sub-saharan africa update: the use of personal protective equipment by anesthesia professionals during the covid-19 pandemic covid-19 among medical personnel in the operating room what we do when a covid-19 patient needs an operation: operating room preparation and guidance just the facts: protecting frontline clinicians during the covid-19 pandemic strategies for optimizing the supply of isolation gowns personal protective equipment: questions and answers managing icu surge during the covid-19 crisis: rapid guidelines us department of health and human services. personal protective equipment (ppe) coronavirus disease 2019 (covid-19): critical care and airway management issues operational considerations for personal protective equipment in the context of global supply shortages for coronavirus disease 2019 (covid-19) pandemic: non-us healthcare settings ministry of health malaysia. intensive care preparedness and management of covid-19 centers for disease control and prevention. contact tracing for covid-19 public health service commissed corps. strategies to optimize provision of mechanical ventilation safety recommendations for evaluation and surgery of the head and neck during the covid-19 pandemic surgical considerations for tracheostomy during the covid-19 pandemic: lessons learned from the severe acute respiratory syndrome outbreak safe tracheostomy for patients with severe acute respiratory syndrome clinical guide for the management of neuro trauma patients during the coronavirus pandemic preliminary recommendations for surgical practice of neurosurgery department in the central epidemic area of 2019 coronavirus infection guidelines on management of coronavirus disease 2019 (covid-19) in surgery response to covid-19 in chinese neurosurgery and beyond neurosurgery in the storm of covid-19: suggestions from the lombardy region, italy (ex malo bonum) on pandemics: the impact of covid-19 on the practice of neurosurgery triage of scarce critical care resources in covid-19. an implementation guide for regional allocation: an expert panel report of the task force for mass critical care and the american college of chest physicians society of british neurological surgeons. bnvg/ sbns guide for the neurosurgical management of neurovascular conditions during the covid-19 pandemic guidelines for the management of aneurysmal sah: a guideline for healthcare professionals from the american heart association/american stroke association arteriovenous malformation (avm) management of incidental cerebral avms in the post-aruba era arteriovenous malformations of the posterior fossa: a systematic review responses to aruba: a systematic review and critical analysis for the design of future arteriovenous malformation trials intracranial dural arteriovenous fistulas: a review the latest national clinical guideline for stroke guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the american heart association/american stroke association using the national institutes of health stroke scale: a cautionary tale guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the temporary emergency guidance to us stroke centers during the coronavirus disease 2019 (covid-19) pandemic: on behalf of the american heart association/american stroke association stroke council leadership challenges and potential solutions of stroke care during the coronavirus disease 2019 (covid-19) outbreak ministry of health malaysia. perioperative mortality review (pomr): prioritisation of cases for emergency and elective surgery (2nd revision) [internet]. malaysia: medical development division society of american gastrointestinal and endoscopic surgeons. covid-19 statement and recommendations from the asociacion espanola de cirujanos practical considerations for performing regional anesthesia: lessons learned from the covid-19 pandemic preparing for a covid-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore handbook of covid-19 prevention and treatment ministry of health malaysia. garis panduan kementerian kesihatan malaysia protocol for urgent and emergent cases at a large academic level 1 trauma center covid-19: guidance for triage of non-emergent surgical procedures covid-19 -infection prevention and control measures covid-19: infection prevention and control (ipc) guidelines for management of neurosurgical cases during covid-19 pandemic effectiveness of masks and respirators against respiratory infections in healthcare workers: a systematic review and meta-analysis infection prevention and control of epidemic and pandemic prone acute respiratory infections in health care letter: considerations for performing emergent neurointerventional procedures in a covid-19 environment minimizing sars-cov-2 exposure when performing surgical interventions during the covid-19 pandemic infectious diseases society of america guidelines on infection prevention in patients with suspected or known covid-19 ultraviolet irradiation doses for coronavirus inactivation -review and analysis of coronavirus photoinactivation studies far-uvc light (222 nm) efficiently and safely inactivates airborne human coronaviruses 2020 covid-19 coronavirus ultraviolet susceptibility evaluation of an ultraviolet c (uvc) light-emitting device for disinfection of high touch surfaces in hospital critical areas susceptibility of sars-cov-2 to uv irradiation germany international commission on non-ionizing radiation protection. icnirp note on use of uvc lamps to kill/inactivate the coronavirus (sars-cov-2) world health organization. coronavirus disease (covid-19) advice for the public the impact of professional isolation on teleworker job performance and turnover intentions: does time spent teleworking, interacting face-toface, or having access to communicationenhancing technology matter? providing patient care remotely in a pandemic the novel coronavirus (covid-2019) outbreak: amplification of public health consequences by media exposure telemedicine in neurosurgery: lessons learned and transformation of care during the covid-19 pandemic telehealth and telemedicine in the covid-19 era: a world of opportunities for the neurosurgeons malaysian medical council advisory on virtual consultation (during the covid-19 pandemic) vascular endothelial growth factor (vegf) as a vital target for brain inflammation during the covid-19 outbreak evidence of the covid-19 virus targeting the cns: tissue distribution, host-virus interaction, and proposed neurotropic mechanisms fluorescence and electron microscopic localization of f-actin in the ependymocytes world health organization (who) information note: tuberculosis and covid-19 tuberculous meningitis in adults: a review of a decade of developments focusing on prognostic factors for outcome covid-19-associated acute hemorrhagic necrotizing encephalopathy: ct and mri features a first case of meningitis/encephalitis associated with sarscoronavirus-2 impact of the coronavirus (covid-19) pandemic on surgical practice -part 2 (surgical prioritisation) performance of the pediatric glasgow coma scale score in the evaluation of children with blunt head trauma the society of british neurological surgeons. clinical guide for the management of paediatric neurosurgery patients during the coronavirus pandemic early lessons in the management of covid-19 for the pediatric neurosurgical community from the leadership of the american society of pediatric neurosurgeons anaesthesia and sars infographic for principles of airway management in covid-19 world federation of societies of anesthesiologists this publication is not a proposed national guideline for the covid-19 management of covid-19 neurosurgical patients but a review of management and protocols from local and international peer reviewed and non-peer reviewed publications, web-based information and data until the month of august 2020. we hope that this publication will be used to improve care of neurological or neurosurgical patients and their caregivers/frontlines globally especially in developing countries. none. none. appendix 2. principles of airway management in coronavirus covid-19 (100) www.mjms.usm.my 189 key: cord-294916-xc9ozxyn authors: oehmen, josef; locatelli, giorgio; wied, morten; willumsen, pelle title: risk, uncertainty, ignorance and myopia: their managerial implications for b2b firms date: 2020-07-31 journal: industrial marketing management doi: 10.1016/j.indmarman.2020.05.018 sha: doc_id: 294916 cord_uid: xc9ozxyn abstract rare events are common: even though any particular type of ‘rare event’ a world war, global economic collapse, or pandemic for that matter should only occur once every 100 years, there are enough of those types of ‘rare events’ that overall, they commonly occur about once every 10 years. as we are currently experiencing with the covid-19 pandemic, we do not sufficiently leverage the rich toolset that risk management offers to prepare for and mitigate the resulting uncertainty. this article highlights four aspects of risk management, and their practical and theorical implications. they are: 1) risk (in the narrower sense), where possible future outcomes can be captured through probability distributions. 2) a situation of uncertainty, where there is transparency regarding what is not known, but probability distributions are unknown, as well as causal relationships influencing the outcome in question. 3) a situation of ignorance, where there is no understanding that certain possible future developments are even relevant. and finally: 4) the emergence of organizational and inter-organizational myopia as an effect of risk, uncertainty and ignorance on collective human behaviour. the outbreak of the current covid-19 pandemic was not a practically unforeseeable 'black swan event', as regularly claimed by media and online pundits (bloomberg tv, 2020) . not only is a general pandemic preparedness (typically for a much more severe pandemic influenza) part of standard government's emergency planning, but it has been communicated as a practical near-future certainty in expert forums and the general public alike (gates, 2015) . even a scenario worryingly close to what is currently unfolding (though with much higher mortality rates) was role-played by an international team of health experts in the fall of 2019 at the center for health security at johns hopkins university. their resulting recommendations (center for health security, 2019) mirror precisely the shortcomings we are experiencing today. sadly, their findings and those of earlier similar exercises collected dust in various drawers around the world. taking a step back, disruptive global events are not as rare as they may seem. the world is exposed to a significant amount of "1 in a 100 year" events, so that they occur with some regularity. they include for example : world war i (1914 ), spanish flu (1918 , the great depression (1929 ), world war ii (1939 , the cuban missile crisis (1962) , opec oil embargo (1973) , us-on-soviet union nuclear attack false alarm (1983) , collapse of the soviet union and the iron curtain several events, such as the cuban missile crisis of 1962, the false alarm regarding a nuclear attack in 1983, or the global near-collapse of the financial system in 2007/2008, were near-misses that could have just as easily rewritten the social and economic history of the world. the collapse of the soviet union in 1989 did change history, and in hindsight we easily forget the tensions that existed when the cold war status-quo was changing to some unknown future state. more generally speaking, the management of risk is an acknowledged challenge in managing business partnerships (zhang & banerji, 2017) . organizations (governments, companies and even universities) have little influence on the occurrence of these "exogenous shocks" (hartmann & lussier, 2020) , nor can the occurrence of any one specific event be pinpointed to an exact point in time in the future. nevertheless, there exists a rich toolbox of risk management practices to support decision-makers across organizations. as the economic impact of the current covid-19 disruption demonstrates, these tools are not leveraged effectively. one fundamental barrier to successful use of risk management practices is that risk and risk management is a highly diverse field, and for better or worse, under constant debate and development. moreover, decision-makers do not think in terms of risk, mostly because they have not been educated in those terms. they think in terms of cost-benefit analysis, a mental framework that is appropriated for simple short-term decisions but can lead to "organizational myopia" to long term, more complex decisions. this article briefly illuminates the broader field of risk management and highlights practical and theoretical research challenges. we believe that all of them are relevant for businesses today during the covid-19 crisis. we can broadly discern four contexts where organizations and decision makers face risk. contexts 1-3 are characterized by decreasing level of knowledge regarding the future: 1) risk (in the narrower sense), where possible future outcomes can be captured through probability distributions. a typical response is risk management (section 2). 2) a situation of uncertainty, where there is transparency regarding what is not known, but probability distributions are unknown, as well as causal relationships influencing the outcome in question. robust decision making is a possible response (section 3). 3) a situation of ignorance, where there is no understanding that certain possible future developments are even relevant. we discuss resilience as an organizational response (section 4). the fourth managerial context emphasizes not just the level of available knowledge, but how organizations culturally react to the resulting uncertainty: 4) the emergence of 'organizational myopia' (including inter-organizational myopia) as an effect of risk, uncertainty and ignorance on collective human behaviour. as a possible response, we discuss organizational mindfulness (section 5). in this article, we consider situations of 'practical' risk, uncertainty, and ignorance, i.e. we do not discuss if certain information would have theoretically been knowable at a certain point in time, but if it was practically known by decision makers. in that sense, the current pandemic falls into the category of "ignorance" for many organizations, although technically, it was a well understood, described and quantified risk. lastly, the discussion of organizational myopia illuminates the practical effects on the organizational level. table 1 summarizes the key theoretical and practice challenges. there are a multitude of competing definitions on what 'risk' is (aven, 2012 (aven, , 2016 . a definition following knight (1921) understands risk as uncertainty that can be modelled and quantified monetarily: risk is uncertainty that can for example be expressed as a probability distribution. as such, risk can be effectively insured against, or be weight and traded off against other risks and opportunities. to what extent this category is truly relevant in managerial practice is debated (aven, 2012 (aven, , 2017 ward & chapman, 2003) , but it is firmly established in organizational practice. examples include the already mentioned insurances, resource allocation, or the design and optimization of investment portfolios. the iso 31000 standard (iso, 2018) defines risk more broadly as the 'effect of uncertainties on objectives', generalizing from financial impacts to impacts on any type of stakeholder value (including, for example, well-being or reputation). this general definition and understanding of risk promotes professionalization of risk management practice (olechowski, oehmen, seering, & ben-daya, 2016) and underpins many existing practitioner standards for risk management -from domains such as systems engineering (incose, 2015) , to finance (allen, 2012) , to supply chain management (de oliveira, marins, rocha, & salomon, 2017; zsidisin & ritchie, 2008) , to project management (pmi, 2019) and of course data analytics (jaynes, edwin, & bretthorst, 2003) . despite multiple established standards in the field, there remain considerable foundational challenges. very simply, for example, consider situations with unclear or conflicting objectives-what are 'risks' under those circumstances (aven, 2012) . it is an interesting paradox that risk management focusses on uncertainty and its potential impact, yet the prescriptions found in the risk management literature can be shrouded in uncertainty and hidden assumptions (willumsen, oehmen, stingl, & geraldi, 2019) . in practice, risk management ranges from gut-feeling-based risk matrices with illdefined (or undefined) evaluation scales for probability and impact (cox jr., 2009) , to highly sophisticated quantitative models (allen, 2012; jaynes et al., 2003) . these foundational issues in risk management create challenges for practitioners. for example, risk management should be customized (iso, 2018; oehmen et al., 2014) as different risk management practices vary in their ability to create value in different contexts (willumsen, oehmen, stingl, & geraldi, 2019) . the clear implication for the current covid-19 crisis (that arguably affects all companies), there will be no 'one size fits all' risk management solution. one such difference relates to the availability and quality of data, which heavy influences if a method is applicable (tegeltija, 2018) . hubbard, (2009) has shown that using inappropriate risk management methods can be worse than doing nothing, as it leads decision makers towards a false sense of certainty. a common challenge is using expert judgement in the assessment of probability distributions of outcomes, or in simpler applications, in the estimation of probability-impact pairs for the occurrence of specific events. expert judgement can provide valuable insight in situations where available data is lacking (cooke, 1991; renn, 1998; zio, 2009 ). however, careful consideration of multiple factors such as level of expertise, confidence and subjective bias is needed (cooke, 1991; fortin & gagnon, 2006) . given the current scarcity of 'hard facts' during the covid-19 pandemic, expert judgement plays a significant role in decision making. the challenge of operationalizing risk management in practise extends to determining the maturity of such systems in their context (chapman, 2019) . having 'more' risk management does not necessarily improve the management of risk (oehmen et al., 2014) . rather, the contextual fit of risk management systems is of such importance that traditional process maturity scales falls short (tegeltija, 2018) . a number of challenges exist regarding risk management theory. as mentioned, the definition of risk itself is an ongoing debate, and no consensus has been reached. similarly multiple conceptualizations and interpretations of uncertainty exist, as discussed in the following sections. the different conceptualizations of uncertainty require different approaches in terms of modelling and management, and research into these foundational challenges is ongoing (aven, 2012 (aven, , 2016 tegeltija, 2018) . when studying the empirical research it becomes clear that the management of uncertainty and risk stretches beyond the risk management process in a narrow sense. for example, other processes in a company might serve to manage risk, such as stakeholder or knowledge management (neves, da silva, salomon, da silva, & sotomonte, 2014; xia, zou, griffin, wang, & zhong, 2018) , making it challenging to understand how risks are actually managed (szczepański & światowiec-szczepańska, 2012) . there are reports of a discrepancy between theory and practice (ahlemann et al., 2013; kutsch & hall, 2010) . according to kutsch and hall (2009) ; kutsch, browning, and hall (2014) there is limited research about how risks are managed or not managed in practice, and why. the strict probabilistic interpretation of uncertainty discussed above as 'risk' makes several axiomatic and practical assumptions that are easily violated in application. these include the fundamental assumption of measurability of uncertainty (bernardo & smith, 1994) , the identification and quantification of causal links influencing uncertainty (renn, klinke, & van asselt, 2011) , the availability of data (including quantitative data, expert judgement and experience) to evaluate uncertainty (klinke & renn, 2002; lough, stone, & tumer, 2009) , an infinite mental capacity to process information and draw factual conclusions (simon, 1990) , and an absence of ambiguity, i.e. divergence in the interpretation of identical factual information by different stakeholders (klinke & renn, 2002) . this is an area of significant ongoing research and debate (aven & cox, 2015; aven & zio, 2011; flage, aven, zio, & baraldi, 2014; zio, 2009) . for simplicities sake, we refer to 'uncertainty' as opposed to 'risk' for situations where we do not have a probabilistic quantification of the uncertainty, but we are aware that (not probabilistically quantified) uncertainty exists. this is a common challenge when dealing with novel situations such as the covid-19 pandemic: we know that there are a lot of factors in play, and we are aware of some relationships and some of the data -but we also know that we do not fully understand their interact, or how reliable our data is, or how to model the future with some sufficient quality. currently, significant resources are expended to better understand what impact what combination of non-pharmaceutical interventions has on reproduction numbers, or what the medium-and long-term economic effect of these actions is going to be for what part of the economy. this continues to the firm level, where we know that we are facing some supply chain disruptions and demand changes, but when, and where, and how bad, and with what exact consequences is difficult to pinpoint. a host of methods and approaches exist to deal with this wide range of limitations: bayesian statistics builds a bridge between 'risk' and 'uncertainty' by explicitly modelling both aleatoric (i.e. stochastic) uncertainty, as well as epistemological uncertainty, i.e. uncertainty due to a lack of knowledge. both are expressed in the language of probabilities (bernardo & smith, 1994) . the domain of imprecise probability (walley, 1991) extends the treatment of epistemic uncertainty, e.g. coherent upper and lower boundaries (colyvan, 2008; kozin, 1996) that relaxes one of the central assumptions of bayesian statistics by not requiring a single additive probability measure. it has found technical applications in the field of artificial intelligence and safety risk assessment. the dempster-shafer theory of evidence (beynon, curry, & morgan, 2000; dempster, 1967) allows to also model ambiguity by accounting for the weight of evidence. again, applications are mostly in technical domains such as facial recognition or medical diagnosis (yen, 1989) . there are specific risk communication approaches that extend classic probabilistic methods, e.g. the nusap scheme (funtowicz & ravetz, 1990) . the nusap scheme was originally developed to facilitate the communication of probabilistic models in climate science to a non-expert audience. it addresses the question of how to communicate the complexities that underly a risk or uncertainty assessment by not only communicating the (n)umber, (u)nit and (s)pread (i.e. the basic probabilistic information), but also qualitative information through the (a)ssessment, describing quality of the underlying the information (i.e. epistemic uncertainty), and the (p)edigree, i.e. an overall assessment of the quality of the applied method and result. while currently not in wide-spread use, descriptive schemes like nusap are very promising to better communicate the quality (and inherent uncertainty) of assessments. this richer communication helps resolve latent issues that decision makers face when they need to decide what information to trust or consider in a decision. this is a common occurrence in the current covid-19 situation, as executives are evaluating projections of spread of infection, associated government action, market reactions, and supply chain impact. finally, there is a class of methods based on the concept of exploratory modelling, where computational experiments are used to develop plausible future scenarios, and evaluate current decision options against those scenarios. the core idea is not to identify the 'optimum' solution to address uncertainties, as that solution may be very sensitive to assumptions (that had to be made due to a lack of table 1 summary of theoretical and practice challenges in risk management. theoretical challenges practice challenges • risk: possible outcomes with known probabilities (knight, 1921) • risk management: coordinated activities to direct and control an organization regarding its risks (iso, 2018) • conflicting definitions of 'risk' and 'risk management' (aven, 2012 (aven, , 2016 aven & renn, 2019) • articulation of organizational value of risk management (willumsen, oehmen, stingl, & geraldi, 2019) • one-size-fits-all expectation of risk management standards vs. need for customization (oehmen, olechowski, robert kenley, & ben-daya, 2014) • idealized formal risk management neglects actual risk management (including its informal aspects) (ahlemann, el arbi, kaiser, & heck, 2013; elmar kutsch & hall, 2010) • choice of appropriate risk management methods for given decision context and data quality (tegeltija, 2018) 2. management of uncertainty (section 3) • uncertainty: possible outcomes with unknown probabilities (knight, 1921) • robust decision making: assessing performance across a broad range of possible futures to minimize regret (walker, haasnoot, & kwakkel, 2013) • delineation of uncertainty and risk (aven, 2012; flage, aven, zio, & baraldi, 2014) • development of some mathematically very advanced reasoning into actionable methods, while maintaining rigor (tegeltija, 2018) • incorporation and communication of uncertainty in decision making (funtowicz & ravetz, 1990) • implementing and operationalizing novel uncertainty management methods (tegeltija, 2018) 3. management of ignorance (section 4) • ignorance: unknown outcomes with unknown probabilities (michael smithson, 1989) • resilience: the ability to resist or recover from unexpected events without foresight (holling, 1973) • theoretically sound operationalization of resilience concepts into organizational practice (wied, koch-ørvad, welo, & oehmen, 2020) • reconciliation of expectation of productivity with need for resilience (r. l. martin, 2019) • articulation of specific and explicit resilience strategies for organizations (wied et al., 2020) • orchestrate cultural shift from 'predict and plan' to 'monitor and react' (hall, turner, & kutsch, 2015; rolstadås, hetland, knowledge). instead, they seek to 'minimize regret', i.e. ensure that a decision avoids unacceptable outcomes under all plausible future scenarios, thus limiting the worse case scenario. all acceptable options can then for example be evaluated regarding their cost. a prominent example of such a method is robust decision making (rdm) (dewar, builder, hix, & levin, 1993; lempert, 2002; walker, haasnoot, & kwakkel, 2013) . rdm has been used to decide on climate change adaptation actions (lempert, 1996) or economic policy (seong, popper, & zheng, 2005) . the possible benefits of such a method for business decisions are obvious: instead of attempting to 'maximize value' with little more than educated guesses, an approach of 'minimizing regret' emphasizes the survival of the organization under all plausible circumstances, while explicitly acknowledging the uncertainties surrounding the decision. approaches such imprecise probabilities or exploratory modelling require new quantitative modelling capabilities and corresponding maturity in the decision making processes. however, if organizations honestly want to address the novelty, uniqueness, and first-of-a-kind challenges that covid-19 entails, they cannot rely on classic probabilistic approaches alone (gidel, gautier, & duchamp, 2005) . on the academic side, work remains to apply and validate these more advanced methods of uncertainty modelling in business practice (tegeltija, 2018; tegeltija, oehmen, & kozin, 2017) . at the same time, foundational discussions continue on the nature of risk and uncertainty, and how to coherently conceptualize them in the field of risk management (flage, aven, zio, & baraldi, 2014) . we are ignorant about the future when we do not know possible future outcomes (including their probabilities of occurring). as knight (1921) already pointed out, that is the common state of affairs in most real-world situations. typically, the number of possible outcomes (and combinations of them) is vast and practically infeasible to enumerate, and there is no historical basis for assigning statistical probabilities to all of them, and have them sum neatly to 1. under ignorance, rolstadås et al. (2011) likened navigating the future to crossing an eight-lane city street packed with vehicles of all kinds, moving at varying speeds, and in both directions. here, any detailed plan of crossing would likely be obsolete before making it across the first lane. instead, all we can do is to broadly outline a general direction, try one lane at the time, and respond to whatever unfolds (see wied et al. (2020) for an in-depth discussion of the relevant literature). resilience is an organization's ability to manage ignorance. holling (1973) first used the term to describe the ability to resist or recover from unexpected events, without the necessity of foresight. from a resilience perspective, ignorance is not the problem. rather, the problem is unrecognised, unpopular, or wilfully denied ignorance. this is when we think we know the future (or pretend to), but we really do not (taleb, 2007) . when this happens, we irreversibly commit to overspecialized plans and businesses models (specialized for an expected future), and over-confidently head out into oncoming traffic. this may be a sentiment that managers can relate to in the current covid-19 situation. in the words of holling (1973) , specialization is an adaptive response to a stable environment, whereas resilience is an adaptive response to a dynamic environment. while risk management, and to some lesser extent, management approaches focused on uncertainty, rely on a 'predict and plan' mindset (e.g. van poucke, matthyssens, van weele, & van bockhaven, 2019), resilience builds capabilities to 'monitor and react' (hall et al., 2015) : this includes building capabilities in four areas: 1) preparation, financially and operationally, for unexpected disruption (sheffi, 2017) ; 2) resistance, the immediate crisis management that moves the organization out of its denial and complacency, and minimizes the negative impact without delay (henry & ramirez-marquez, 2016) ; 3) recovery, when the organization works to regain pre-crisis performance by repairing damage, improvising, and making do; and 4) learning, implementing new solutions refining them than possibly surpassing precrisis performance (taleb, 2013) . or to paraphrase the intrepid explorer roald amundsen: preparation is called 'luck', whereas lack of necessary precautions is called 'bad luck'. during the covid-19 pandemic, we have to give our organizations a chance to 'be lucky' during and after a disruption. as the covid-19 situation evolves, disruptions will keep emerging across the value chain, and resilience will remain a core necessity. looking at instances of 'luck' during the covid-19 epidemic, this is a virtual manifesto against over-specialization and towards local adaptation. in the first days of the crisis, long outmoded ventilators were brought out of storage (and dumpsters), and animal hospital ventilators were rapidly adapted for human patients. a range of medical professionals were brought in and retrained in their use (hersher, 2020) . whiskey manufacturers switched to distilling batches hand sanitizer (c. levenson, 2020) . 3d printer hobbyists churned out face masks (brooks, 2020) . super markets and drug stores became door-todoor delivery services overnight despite the health risks (randle, 2020) . public and private spaces were re-organized for social distancing (tavares & stevens, 2020). churches, schools, and concert halls became online-only entities within a few weeks (freedman, 2020) . there is much to learn from these creative outbursts, outlining both practical and theoretical challenges for businesses. in the past, crises were followed by complacency (ayotte, gerberding, & morrison, 2019) . when normality returns, resilience thinking will, once again, be swimming against the steady current of specialization and optimization. at no point are uncertainty and ignorance harder to imagine than in predictable times (taleb, 2005) . already, detailed 'post-crisis' plans are potentially obscuring the view to a future that is, essentially, no less surprising than before (weick & sutcliffe, 2007) . denial, nostalgia and arrogance of past successes quickly reassert themselves (hamel & välikangas, 2003) , now amplified by survivorship and hindsight bias. preserving and harnessing the creative, flexible, imaginative, engaged, 'one-day-at-a-time' state of alertness (hall et al., 2015) will be a major challenge for businesses. preparing for the next surprise will involve remaining in the sweet spot between complacency and panic (henderson, 2020) . theoretically, the challenge is to move beyond a probabilistic and 'event-specific' understanding of risk, and towards a paradigm of 'general preparedness' (aven, 2017b) . in this respect, there is some way to go to reconcile holling's attitude of socratic humility about the future (holling, 1973) with the necessity of specialization, optimization and regular risk management. it is challenging to appreciate the value of 'post surprise' strategies like multi-functionality, redundancy, reversibility, incremental learning, modifiability and opportunism (wied et al., 2020) , before they are actually needed. importantly, resilience thinking does not preclude sophisticated anticipatory planning, but encourages us to prepare for even our best-laid plans to be wrong. despite all guidelines, mathematical models and software, risk management remains a human-centric activity. it is people deciding if and which risk management perspective and process to adopt, which scenarios or inputs to analyses, and what to with the results (discussed for example by cui, su, feng, & hertz, 2019 in the context of servitization). these human-centric activities are subject to several limitations, that can be analysed at two different levels: individual and organizational. at the individual level, humans dealing with risk, suffer from the socalled "cognitive bias". the term cognitive bias was popularized by the work of tversky and kahneman (1974) which identified cognitive biases as errors in thinking stemming from heuristics. these heuristics are principles which are used to reduce the complexity of decision making leading to errors in an individuals thoughts. pohl (2004) imagines cognitive biases as illusions that can cause an individual's thoughts, memories or judgements to deviate from reality. cognitive biases usually tend to affect complex decisions and individuals are not usually aware of the presence of such biases in their decision making. according to reyna, chick, corbin, and hsia (2014) experienced individuals were more likely to display cognitive biases in their decision making when compared to the group of inexperienced people. as the covid-19 situation unfolds, we can individually reflect on our own thinking and decision making biases, particularly in the early phases of the pandemic. cognitive biases, such as optimism bias, have been popularized in project and risk management literature by flyvbjerg's books and papers claiming that cognitive biases are key reasons why for example largescale projects are often delivered over budget and late (flyvbjerg, 2006; flyvbjerg, garbuio, & lovallo, 2009 ). however, the idea of cognitive biases in project and risk management is at least 20 years old. mccray et al. (2002) highlight the significant effect that cognitive biases may have on complex projects where project managers tend to rely on prior experience or rules of thumb (heuristics) that they have created over the years in order to deal with project complexity. the number of cognitive biases described in the literature is in the order of 100. one bias that is relatively infrequently discussed, but very relevant for our discussion, is the dunning-kruger effect. the term was first coined in 1999 when david dunning and justin kruger first observed the effects of incompetence on self-judgement (kruger & dunning, 1999) ; in addition to making wrong decisions, incompetent people are also unable to realize their incompetence. kruger and dunning (kruger & dunning, 1999) called this the "dual burden of incompetence". this poses a particular challenge in the covid-19 pandemic: in order to recognize the competence of other people in a specific domain, an individual should possess a certain level of competence in that domain as well; since an incompetent person will not be able to judge their performance correctly, that person will tend to overestimate their ability, e.g. in performing an appropriate risk analysis. advancing to the organizational level, humans dealing with risk suffer from "collective myopia", also called organizational and interorganizational myopia (chikudate, 2002) . organizational myopia received less attention and research than cognitive bias but is no less important. "collective myopia is a […] condition where the sensemaking capabilities among the members in collectivities are limited to their contexts. emerging orders or patterns are like the flocks of sheep that are nicely organized. each sheep knows how to behave and watch out for each other in a collectivity. but none observes their collective behaviours as a whole. […] the sense-making of these members is, thus, confined to the limited context of their own concerns in certain organizations or communities." (chikudate, 2015, p16) . the concept of collective myopia has been associated with the studies of ethics in organizational practices (chikudate, 2002) , where the ethical judgement of the individuals are suppressed by an overarching perspective from the organization. in this "ethical blindness" individuals, as part of an organization, might act unethically without being aware of it. they become ethically blind (palazzo, krings, & hoffrage, 2012) . this blindness has implications for risk management and decision making, like in the emblematic cases of the ford pinto (gioia, 1992) and fukushima daiichi (chikudate, 2015) where misjudged risk analyses had dramatic consequence on people, business and the environment. it is starting to become evident in the context of covid-19, when for example certain groups start discussing very matter-of-factly how we should deliberately sacrifice vulnerable populations for the greater good, completely oblivious of their ethical transgressions and proximity to eugenics (jones, 2020) . at individual level cognitive bias and, at an organizational level, collective myopia can at least in part explain how educated and intelligent people consistently failed to appreciate and take actions to mitigate a pandemic risk its implications. the risk management models reflected the bias and myopia of the people preparing them, and miserably failed. myopia, and ethical blindness, are major barriers in developing successful interorganisational relationships, as they push the organization to develop a tunnel vision. the organization loses its ability to develop empathetic relationship with its stakeholders, including understanding what represents "value" for them, greatly diminishing their ability to address the various forms of risk. the organization might even fail to recognize key stakeholders that can support the organization in achieving its objectives and responding to risk, uncertainty and ignorance. a way for addressing organizational myopia is "organizational mindfulness" (sutcliffe et al., 2016) . organizations can address the issues organizational myopia by closely monitoring failures (own failures and failures from other organizations), paying attentions to frontline operations, resist the temptation to oversimplifying the interpretations of events and situation privileging expertise over hierarchy (catino, 2013) . the case of the uk government failing to procure personal protective equipment (ppe) for its healthcare system is an exemplar case of how myopia undermined the interorganisational relationships, and it is discussed in the following section. on april 28, 2020, the bbc opened with a dramatic headline "the government failed to buy crucial protective equipment to cope with a pandemic" (bbc, 2020d). for the bbc, this news article was quite unique, as it showed two rare characteristics: (i) an almost alarmist tone, reminiscent of a tabloid, in stark contrast with the bbc's usually softer tone; and (ii) the headline being a direct attack on the uk government. however the situation was dramatic: "the consequence of not planning; not ordering kit; not having stockpiles is that we are sending into the front line doctors, nurses, other health workers and social care workers without the equipment to keep them safe". according to the government minister victoria atkins, "like every other country in the world, [the virus] is unprecedented and the requirements for [personal protection equipment] ppe have risen exponentially and we are doing our absolute best to address those needs and will continue to do so throughout this crisis" (bbc, 2020d). the nhs is the uk's national health care system. the nhs offers medical care across the uk to all those who reside there, including first aid, short and long-term hospital stay, and specialist services such as dental services. it came into operation on july 5, 1948. most of the services are tax financed, and as such, free of direct cost for patients. the issues related to the provision of ppe originated even before the covid-19 was recognised by the world health organization (who). a bbc report "found that vital items were left out of the stockpile when it was set up in 2009 and that the government subsequently ignored a warning from its own advisers to buy missing equipment. […] the expert committee that advises the government on pandemics, the new and emerging respiratory virus threats advisory group (nervtag), recommended the purchase of gowns last june. gowns are currently one of the items in shortest supply in the uk and they are now difficult to source because of the global shortage of ppe. doctors and nurses have complained that there are also shortages of the life-saving ffp3 respirator masks. panorama has discovered that millions of ffp3 respirator masks are unaccounted for. there were 33 million on the original 2009 procurement list for the stockpile, but only 12 million have been handed out. the government refuses to explain where the other masks have gone." (bbc, 2020d) . while many of these facts were knowable (or known to someone), the central decision makers were largely in positions of ignorance. what caused the later escalation of the situation is that the general level of resilience -a sufficient capability of preparation and ability to resist, recover and learn from an incident, in our case specifically escalation ppe demand -was very low. even the easiest option, stockpiling of cheap but critical items such as ppe, had not been realized. during the early phase of the outbreak, very little statistically relevant information was available that could have informed classic probabilistic risk assessments, but it was known that a novel virus was spreading. decision makers were no longer operating under conditions of ignorance, but significant uncertainty: according to who (2020c), on the 31st of december 2019 chinese authorities reported a group of cases of pneumonia in wuhan. a new coronavirus was recognised. shortly thereafter, on the 4th of january 2020, the who reported the news about a cluster of pneumonia cases with no deaths in wuhan. the following day the who distributed the first disease outbreak news about the virus. this type of announcement, intended for media, scientific and public health community, includes a risk assessment section, concluding that "there is limited information to determine the overall risk" (who, 2020a) -summarizing that decision makers are indeed operating under conditions of uncertainty, not risk. we can observe several actions taken under these conditions to 'minimize regret', i.e. actions minimizing the impact of a worst-case scenario. for example, on the 10th of january, the who issued a comprehensive package of technical guidance online with advice to all countries on how to detect, test and manage potential cases, based on what was known about the virus at the time. this guidance was shared with who's regional emergency directors to be shared with who representatives in countries. it is reasonable to assume that by the 10th of january, uk authorities were informed about the new virus, but it is not obvious that aggressive actions were taken to strengthen national capabilities. by january 12, china had publicly shared the genetic sequence of covid-19 to facilitate scientific endeavours for diagnosis, treatment and vaccination. on the 22nd of january, the department of health and social care and public health england published the first government statement. after another 9 days (31st of january), there are the first two cases of covid-19 confirmed in the uk. a few days later (3rd of february), the who releases the 28 page 'strategic preparedness and response plan' (who, 2020b) to support states with weaker health systems. it includes an updated risk assessment, now being based on over 10′000 confirmed cases globally, confirmed human-to-human transmission, and robust quarantine and lockdown measures being taken in china. arguably, the situation evolved into a scenario where larger amounts of data are becoming available, enabling probabilistic risk assessments. it is accompanied by increasingly aggressive eu-level activities to procure critical ppe. on the 31st of january four uk countries (not including the uk) suggest a need for ppe "in case of an expanding situation in the eu". (the guardian, 2020b) . on the 28th of february the eu launches its first joint procurement of £1.2 m worth of gloves and gowns/overalls. the procurement fails due to a lack of suitable suppliers. it is relaunched on 15 march -the uk was not involved in either (the guardian, 2020b) . one very visible turning point in the engagement with risk-based models was the publication of the so-called 'imperial model' by a research group from imperial college london on march 16 (ferguson et al., 2020) . based on some of the most detailed modelling to-date and the latest known characteristics of the covid-19 spread, it projected mortality figures for the uk and the us, which triggered the first significant actions in both countries in the following days regarding nonpharmaceutical interventions. as the covid-19 situation evolved, instances of organizational myopia became more and more apparent: for example, by the 11 of february there were eight confirmed covid-19 cases in the uk, but steve oldfield, chief commercial officer at the department of health and social care, reassured staff that the "nhs and wider health system are extremely well prepared for these types of outbreaks" (financial times, 2020) . only two days later uk dentists started to discuss the potential lacking of ppe (express, 2020) . in another instance, on the 24th of february (two days after the first major lockdowns in italy occurred), a meeting of officials, to which the uk was invited, hears an update from the european commission on the joint procurement of ppe. commission officials call on countries to confirm "their exact needs latest today … to move forward with next steps". no representative from the uk attends the meeting (the guardian, 2020b) . two days later emergency units in the uk start to be overcrowded and patients have to be looked after in hospital corridors (the guardian, 2020a) . on the 4th of march there is the 100 officially recognised victims in italy, and the following day there is the first victim of coronavirus in the uk (bbc, 2020a). over the next two weeks the number of victims in italy increases to more than 3000 and the italian healthcare system is, in the most affected zone, collapsing. however, still on the 18th of march (two days after the publication of the 'imperial model'), the uk prime minister boris johns declared "we have stockpiles of ppe equipment and we're proceeding in accordance with the best scientific advice." (bbc, 2020c). the uk is still largely operating 'business as usual' with children going to schools and pubs and restaurants opened (almost one month after the first lockdowns italy). on the 19th of march the uk eventually takes up an invitation to join the eu joint procurement agreement steering committee, which makes decisions on mass purchases. the uk does not join a procurement for laboratory supplies that is put out to tender on the same day (the guardian, 2020b). the following day, in a unique historic escalation of the uk's response to the outbreak, the uk prime minister boris johnson orders all gym, restaurants, pubs, churches and other social venues across the uk to stay closed indefinitely (the independent, 2020). on the 23rd of march, almost three months after the outbreak in china became public knowledge, the health secretary, matt hancock, confesses there have been "challenges" with suppling ppe after complaints by nhs staff (including doctors and nurse) from across the country. the uk army is drafted into the effort to support the distribution (the guardian, 2020b). while the presented case presents a rough progression from conditions of ignorance to those of uncertainty and risk, this cannot be generally assumed. as is the case in the example, this progression is also specific to each issue at hand. furthermore, the role that organizational myopia plays as the behavioural reaction to risk, uncertainty and ignorance evolved as the situation evolved. it is important to distinguish between ignorance and myopia, which are two distinct, yet complementary phenomena. at the beginning the government displayed prevalently ignorance. before the crisis started there was already a shortage of ppe. the government ignored the warning coming from nervtag, bill gate's now-famous ted talk (gates, 2015) and more generally the various expert assessments of possible future pandemics. at the time, the uk government was focused on the issues related to the exit of the uk from the european union ('brexit'). although these insights were technically knowable by uk department of health and social care (and most likely known by some), they were not considered for or implemented in the design of the healthcare and broader response system. however, after the who alerts and the first deaths in italy and spain, the situation progresses from ignorance to uncertainty. the uk government 'knows' about covid-19 but, for a long time, was refusing to acknowledge its relevance, that the system was poorly prepared, and the need for taking appropriate actions. instead, it propagated an increasingly untenable narrative that the nhs was well prepared to face the pandemic, ignoring available facts. myopia reduces the number of options assessed by decision makers making them rely on their own bounded rationality. the "big picture" is lost and future opportunities are missed (czakon & kawa, 2018) . in march, organizational myopia reaches a level where the government pretends to have ppe that does not exist. still in may, the nhs is struggling to access basic ppe (bbc, 2020b). arguably, organizational myopia was a moderating factor that negatively influenced uk government capability to adequately address all three conditions -risk, uncertainty and ignorance. as a result, prudent preparation where not taken, the lack of those preparations was ignored, timely steps to 'minimize regret' were not taken, and ultimately, even the increasing amount of scientific evidence and more advanced models only led to tangible action after significant delay. we can draw a number of managerial implications from the previous discussion (see fig. 1 ): first, it is important to note that the most widely used approach, risk management, is typically not geared towards providing meaningful responses to high-impact, low-probability events, such as the current covid-19 pandemic. these events in the 'fat tail' of the probability distribution typically do not meet threshhold criteria for taking substantial action, as standard cost-benefit tradeoffs fail to appropriately capture low likelihood events, or events expected to occur in the 10+ year future. an obvious task is to revise risk management procedures to adequately prioritize mitigation actions for this type of event. second, we have to acknowledge that rare events are characterized -by their nature -by less available data. our approaches to characterize those events must be chosen appropriately. if a quantitative risk assessment is not meaningful, organizations must employ methods that are appropriate for these situations, such as robust decision making, or resilience thinking. third, related to the previous point, decision makers have to reflect on the level of (practically) available knowledge, and actively discuss their current decision making context. in situations of significant uncertainty, or where we can reasonably expect a large degree of ignorance regarding future devleopments, managers should again emphasize resilience (i.e. general preparedness for noticing, resisting, recovering, and learning from distruptions), and robust decision making-type actions (e.g. minimizing regret under plausible future scenarios). fourth, the factual basis that is available to decision makers is only part of the equation. equally, if not more, important are the cultural and behavioural actions at the individual and organizational level. these have to be understood and reflected in the way that decisions are made and communicated. these implications are broadly supported by the ongoing discussions in the risk management domain, specifically regarding the need to tailor our responses to specific contexts (tegeltija, 2018) , as well as the discussions surrounding the relationship and integration of various models of and responses to uncertainty (aven, 2018) . the uk national risk register of civil emergencies was last updated in 2017. in contains a detailed description of what would happen during a pandemic, the impact on the uk, and what actions would need to be taken. it was ranked as the highest risk in the catalogue (national risk register of civil emergencies, 2017), with a near-certain probability of occurrence during our lifetimes. reports of that kind existed for practically all governments. the failure to take action to mitigate an obvious risk is not just the failure of our governments, it is also the failure of (most) major corporations, and us as individuals. we are paying a very high price for having neglected risk management in all its facets, as briefly laid out in this article. even articulating what we mean by 'risk management' is difficult. we suggest to use resilience -for example as 'resilient organizations' and 'resilient inter-organizational relationships' -as a shorthand to summarize the goal of the much needed transformation. if interpreted in a wider sense, the preparation phase inherent in resilience can accommodate all necessary risk and uncertainty management activities. additionally, the capabilities to resist, recover, and learn provide a framework to discuss other desirable attributes, such as flexibility, adaptability, or robustness. for over 200 years, we have embraced productivity as the guiding star of our societal development. it took us more than 50 years to start taking serious actions regarding sustainability. now is the time to embrace the third column that modern societies rest on: resilience. a process framework for theoretically grounded prescriptive research in the project management field financial risk management : a practitioner's guide to managing market and credit risk (2nd foundational issues in risk assessment and risk management risk assessment and risk management: review of recent advances on their foundation a conceptual foundation for assessing and managing risk, surprises and black swans. the illusion of risk control how some types of risk assessments can support resilience analysis and management the call for a shift from risk to resilience: what does it mean? risk analysis some foundational issues related to risk governance and different types of risks some considerations on the treatment of uncertainties in risk assessment for practical decision making introduction to special virtual issue: foundations of risk analysis. risk analysis (pp. 1-2). society for risk analysis ending the cycle of crisis and complacency in u.s. global health security. a report of the csis commission on strengthening america's health security coronavirus: man in 80s is second person to die of virus in uk coronavirus: newly-promoted nhs consultant says "it's time to step up coronavirus: nhs staff "at risk" over lack of protective gear coronavirus: uk failed to stockpile crucial ppe bayesian theory the dempster-shafer theory of evidence: an alternative approach to multicriteria decision modelling nassim taleb says "white swan" coronavirus pandemic was preventable silverton-area man makes masks for health care workers with 3d printer organizational myopia: problems of rationality and foresight in organizations event 201 -public-private cooperation for pandemic preparedness and response -a call to action exploring the value of risk management for projects: improving capability through the deployment of a maturity model collective myopia and disciplinary power behind the scenes of unethical practices: a diagnostic theory on japanese organization collective myopia in japanese organizations: a transcultural approach for identifying corporate meltdowns is probability the only coherent approach to uncertainty experts in uncertainty: opinion and subjective probability in science what's wrong with hazard-ranking systems? an expository note causal or effectual? dynamics of decision making logics in servitization. industrial marketing management network myopia: an empirical study of network perception. industrial marketing management upper and lower probabilities induced by a multivalued mapping assumption-based planning: a planning tool for very uncertain times coronavirus face mask shortage: uk dentists issue desperate warning amid killer outbreak impact of non-pharmaceutical interventions (npis) to reduce covid19 mortality and healthcare demand how poor planning left the uk without enough ppe | free to read concerns, challenges, and directions of development for the issue of representing uncertainty in risk assessment from nobel prize to project management: getting risks right delusion and deception in large infrastructure projects: two models for explaining and preventing executive disaster interpreting major industrial landscapes: social follow-up on meanings, the case of two aluminium smelters local churches adapt to covid-19. go online … or keep doors open?times uncertainty and quality in science for policy. uncertainty and quality in science for policynetherlands the next outbreak? we're not ready. ted conference ted2015 decision-making framework methodology: an original approach to project risk management in new product design pinto fires and personal ethics: a script analysis of missed opportunities project resilence: the art of noticing, interpreting, preparing, containing and recovering the quest for resilience managing the sales force through the unexpected exogenous covid-19 crisis between complacency and panic on the impacts of power outages during hurricane sandy-a resilience-based analysis improvisation and retraining may be key to saving patients in new york's icus resilience and stability of ecological systems the failure of risk management: why it's broken and how to fix it the guide to the systems engineering body of knowledge (sebok risk management -principles and guidelines probability theory : the logic of science eugenics isn't going to get us out of this mess a new approach to risk evaluation and management: riskbased, precaution-based, and discourse-based strategies risk, uncertainty and profit. risk, uncertainty and profitboston, ma: houghton mifflin company obtaining reliability and safety assessments on the basis of non-probabilistic methods unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments the rational choice of not applying project risk management in information technology projects bridging the risk gap: the failure of risk management in information systems projects deliberate ignorance in project risk management when we don't know the costs or the benefits: adaptive strategies for abating climate change a new decision sciences for complex systems anheuser-busch and distilleries race to make hand sanitizer amid coronavirus pandemic the risk in early design method rethinking efficiency. the high price of efficiency project management under uncertainty: the impact of heuristics and biases risk management in software projects through knowledge management techniques: cases in brazilian incubated technology-based firms analysis of the effect of risk management practices on the performance of new product development programs the professionalization of risk management: what role can the iso 31000 risk management principles play? the iso 31000 standard in supply chain risk management ethical blindness the standard for risk management in portfolios, programs, and projects cognitive illusions : a handbook on fallacies and biases in thinking, judgement and memory i feel like a hero": a day in the life of a grocery delivery man three decades of risk research: accomplishments and new challenges coping with complexity, uncertainty and ambiguity in risk governance: a synthesis developmental reversals in risky decision making risk navigation strategies for major capital projects: beyond the myth of predictability strategic choices in science and technology: korea in the era of a rising china the power of resilience: how the best companies manage the unexpected bounded rationality. utility and probability ignorance and uncertainty: emerging paradigms errors, lies and misunderstandings: systematic review on behavioural decision making in projects mindfulness in organizations: a crosslevel review risk management system in business relationships-polish case studies. industrial marketing management fooled by randomness : the hidden role of chance in life and in the markets the black swan: second edition: the impact of the highly improbable cities will endure, but urban design must adapt to coronavirus risks and fears assessing the capabilities of advanced risk quantification methods for engineering systems managementtechnical risk management challenges in large-scale energy pss timeline of uk's coronavirus ppe shortage coronavirus: a timeline of how britain went from 'low risk' to an unprecedented national shutdown judgement under uncertainty -heuristics and biases the effects of purchasing proactivity on value creation and supply risk reduction in sourcing projects: implications for marketers' capabilities. industrial marketing management adapt or perish: a review of planning approaches for adaptation under deep uncertainty transforming project risk management into project uncertainty management managing the unexpected: resilient performance in an age of uncertainty pneumonia of unknown cause -china strategic preparedness and response plan who timeline -covid-19 managing exploratory projects: a repertoire of approaches and their shared underpinnings value creation through project risk management towards integrating construction risk management and stakeholder management: a systematic literature review and future research agendas gertis: a dempster-shafer approach to diagnosing hierarchical hypotheses challenges of servitization: a systematic literature review. industrial marketing management reliability engineering: old problems and new challenges supply chain risk : a handbook of assessment, management, and performance key: cord-028285-n4dommet authors: weilongorska, natasha l.; ekwobi, chidi c. title: covid-19: what are the challenges for nhs surgery? date: 2020-07-02 journal: curr probl surg doi: 10.1016/j.cpsurg.2020.100856 sha: doc_id: 28285 cord_uid: n4dommet nan in december, 2019 while covid-19 was unfolding in china, surgeons in the uk were enjoying some of their last few months of normality. by april, 2020 all national health service (nhs) trusts in the uk had halted their non-urgent elective operating, 1 and much of the surgical community had been redistributed to roles far from their specialized career trajectories. the first uk identified case of covid-19 was recorded in february, 2020. 2 by the march 11, 2020, the world health organisation (who) had declared a global pandemic. 3 it became rapidly apparent that despite the nhs being a highly revered healthcare system, it was sorely underprepared. with some of the lowest ratios in europe of beds per population (2.5 per 1000) and doctors per population (2.8 per 1000), combined with the lack of experience of recent epidemics (severe acute respiratory syndrome-1, middle eastern respiratory syndrome, ebola), which were successfully contained by other continents, covid-19 presented an emergent humanitarian crisis for the uk. the risk of nosocomial infection to the surgical workforce through both direct contact with surfaces, droplet or aerosol spray, or through intraoperative generation of fomites have led to abrupt changes in surgical practice during this unprecedented period. in the face of covid-19, the risk profile of surgery to both patients and the operative team has dramatically increased. routine procedural activities such as open suctioning, smoke generation (monopolar, bipolar diathermy, laser), and the opening of pressurised cavities or orifices, are now considered high-risk. 4 to mitigate these risks, surgical services (across all surgical specialities) have made pandemic-response changes to their practice as guided by their specialist organizations, the department of health, public health england and input from the royal surgical colleges. as part of the immediate nhs response to the pandemic, surgical services were restructured to enable redistribution of resources. surgical patients were grouped (obligatory inpatients, nonoperative, inpatient management, day case surgery, and outpatients), with guidance offered on the management of each category. 5 key recommendations included consultant led decisionmaking, daily review of inpatient status, and extension of imaging (whenever required) to include chest screening. all operative scheduling should be consultant sanctioned, when an emphasis on conservative management where feasible. decisionmaking for acute surgical presentations, namely between operative and non-operative management, or modifications to routine surgical strategies (such as open techniques versus laparoscopy, or other adjustments to surgical approach), have been informed by speciality guidance, but, ultimately, are the responsibility of the on-call or lead consultant. most departments have initiated multiple consultant decisionmaking for acute admissions, in response to the pandemic. with there being a short interval from the time of the first covid-19 case presentation, to the development of a global pandemic, validated management algorithms to support changes in operative strategies are lacking. 6 the royal surgical colleges stipulated that maintaining emergency surgical capacity, including major trauma provision, was the primary aim during the covid-19 pandemic. 7 nhs surgical organizations have worked in collaboration with the international community to pool knowledge and adopt recommended practices from countries earlier exposed to the pandemic. internationally, grading systems have been adopted to denote the services available at each stage, depending on a hospital's pandemic burden. in some examples, these are quantified by number of cases, 8 whereas the nhs guidance is based on low, medium, high, or very high prevalence due to nationwide variation in hospital capacity. 9 some specialities have adopted a 2-tier consultant-on-call arrangement to aid emergency work load, as well as providing contingency cover for unpredictable changes in professional fitness to practice, or isolation requirements. 10 similarly, a prioritization system for cancer surgery has been implemented throughout the nhs (levels 1a -3), to provide uniform understanding of oncological urgency (table 2) . 11, 12 operations proceed based on their assigned prioritization level, often in conjunction with daily prioritization meetings that enable multiple speciality discussions to ensure an agreed case order. ultimately, the reduction in capacity has, for some patients, led to delays in cancer treatment and rescheduling of cases. the nhs 2-week wait standards (for review of new or suspected cancer diagnoses) has been maintained, with an acceptance that first contact may be via telephone clinic. 13 oncological management (whether medical or surgical) requires careful consideration between (1) safety and availability of treatment in the current climate, versus (2) the risk of metastasis. surgeons have been required to liaise closely with oncologists, their mdt, and adopt a service-limited, less invasive approach. the key components of nhs preoperative patient screening for covid-19 are: structured questionnaires with temperature monitoring, viral real-time polymerase chain reaction (rt pcr) for sars-cov-2, and chest imaging. the aim of screening is to prevent pandemic spread and minimize the risk to patients and staff. on the other hand, covid-19 screening investigations are performed only in response to risks identified through questionnaires, patient temperature, or clinical presentation. not all surgical patients are screened by all possible modalities. patients can be categorized as confirmed covid-19 positive, suspected covid-19 (includes any patient with or without symptoms who has not been screened), and covid-19 negative (following robust screening). as hospitals are high-risk environments, a patient's status may change during an inpatient admission. attention should be paid to possible symptoms, accepting that multiple viral screening swabs may become necessary. increasingly, surgical patients are tracked down 1 of 2 pathways: covid-19 positive (includes confirmed and suspected patients) or likely covid-19 negative, recognizing that absolute certainty about status is not possible. segregation of patients based on viral status occurs throughout nhs surgical pathways; however, complete separation of patients to different hospital sites has generally not been possible. accordingly, hospital sites are deemed high-risk areas for potential transmission of covid-19. as part of the exit strategy, independent hospitals have been recruited in the effort to return to elective operating. as these institutions have not housed acute covid-19 positive patients, they are viewed as "covid-free", "covid-light", or "covid-cold" zones. the use of a traffic light system has been adopted in many nhs trusts for clinical areas, including oprating rooms. using this system, red denotes areas with confirmed covid-19 cases, amber for suspected cases when results are not yet available, and green for patients where covid-19 is not suspected. strategies employed to increase safety within the operating suite are discussed in more detail in the section on surgical process. all nhs patients are questionnaire screened to identify risk of covid-19 prior to surgery. questions determine the presence of symptoms, history of exposure, isolation status, temperature status, presence of high-risk factors (eg, key workers) and vulnerable patient features. in the case of acute or unplanned surgical admissions, preoperative screening questions are completed on admission. patients may have symptoms, as part of their surgical pathology, that could be associated with covid-19. low-grade pyrexia is particularly troublesome and should be monitored carefully for signs of progression. in true emergency operating, screening may be impractical and therefore cases have had to be managed as suspected covid-19. for scheduled cases (planned trauma or elective operating), where delays to operating may be possible, screening occurs prior to admission. the aim is to determine covid-19 status prior to surgery and, if possible, to delay operating until the patient can be managed through a covid-19 negative pathway. screening questionnaires are performed by phone and, if the patient is deemed low risk, a provisional date for surgery is given with enough time for viral swabs to be performed and reported. any case in which there is a suspicion of covid-19 infection or the presence of risk factors, will be referred to the lead consultant for discussion. all patients are re-screened by questionnaire and temperature check on the day of surgery as part of the admission and pre-operative assessment. patient screening tools are essential for minimizing pandemic spread; however, they are not uniform across all nhs hospitals, rely on patient reporting, and are not formally validated. the gold standard for testing for covid-19 is pharyngeal swab rt-pcr for sars-cov-2 which detects viral rna in situ. routine testing involves nasopharyngeal and oropharyngeal swab, with sampling of the tonsillar region. performing swabs is therefore difficult in some groups, which may affect the sensitivity of the test, making screening less reliable and unsuitable for patient directed hometesting. location of viral expression appears to change with disease progression, impacting site detectability, and further complicating screening. 14 covid-19 has been detected in blood, urine, peritoneal fluid, and stool; however, transmission from these modalities is thought to be low. [15] [16] [17] faecal viral rt-pcr for sars-cov-2 may remain positive for a longer duration than other modalities, 18 particularly in children, which has implications for endoscopic, general surgery, urology, and paediatric procedures. in the advent of covid-19, the uk government's pandemic strategy differed from the strict measures of testing, tracing, and isolation recommended by the who. 19 the decision not to perform widespread testing and contact tracing was highly scrutinized and led to significant implications for the healthcare workforce. 20 compared to many countries, the uk's facility for covid-19 rt-pcr testing has been very limited. in response to public outrage, the government pledged to prioritize increasing the capacity of viral testing. unlike most countries, routine patient testing for all hospital admissions is not yet conceivable. revisions to the uk testing and tracing strategies seem to have missed the metaphorical "boat". 21 limitations in screening capacity, unsatisfactory delays to result reporting (initially up to 72 hours), 22 and a high false negative rate (up to 20%) 23, 24 have complicated preoperative screening. the prolonged incubation period of covid-19 (up to 14 days) has also been problematic. 25 the triad of asymptomatic carriers, non-specific symptoms, and absence of routine viral screening, reaped havoc to surgical workflow in the early weeks of the pandemic. subsequently, all aerosol generating procedures (agp) required full personal protective equipment (ppe), regardless of the rt-pcr result. in response to these challenges, the royal college of surgeons released a consensus statement in april, 2020 detailing the screening pathway prior to elective surgery. 26 patients require isolation (with shielding) for 14 days prior to surgery, to be asymptomatic for the preceding 7 days, and have a negative rt-pcr pharyngeal swab within 48 hours of surgery. international guidance recommends dual testing for preoperative surgical patients who have no history of exposure or symptoms. 27 accordingly, patients with 2 consecutive negative results may be managed as covid-19 negative in the operative setting. 28 many nhs trusts do not yet have this system in place; however, with the uk government warning of a prolonged emergence from the pandemic, effective pathways will need to be followed to combat the backlog of surgical cases safely. chest imaging has been shown to have a key diagnostic role in covid-19 and is the final modality of screening employed for some surgical patients. 29 the british society for thoracic imaging released guidance supporting the use of computerised tomography (ct) and chest radiographs (cxr) to identify features of covid-19 infection. 30 screening of the chest is not routine for all surgical patients; however, ct chest is indicated in patients requiring intensive care postoperatively. 26 extending imaging to include the chest (either ct or cxr) is recommended in acute abdominal presentations, 26 and may be considered in other surgical presentations. again, radiological signs vary with the course of disease and, therefore, imaging findings can be open to interpretation. a covid-19 diagnostic algorithm has been developed to aid decisionmaking. 31 the increased imaging demand has been matched by an expanded capacity for hot reporting. acute staffing changes, required to maintain these requirements, may be problematic as normal nhs workflow returns. ultimately, there are many complexities regarding screening for covid-19. the unique risks of upper airway viral titers, in relation to anaesthesia and agp, require careful consideration of all surgical cases. variable carriage of viral load, progression of disease signs and symptoms, and problematic investigation sensitivities all complicate the picture. accordingly, surgeons are required to review the whole patient panel of results, which includes screening questionnaires, swabs, supporting blood tests, and any imaging performed, with a low threshold for repeat investigations. developments in rt-pcr for sars-cov-2 testing within the nhs include decentralization of processing (enabling quicker turnover locally) and use of quicker detection systems. 32 ideally, rapid and reliable point of care testing for covid-19 would be available with a low false negative rate; however, due to the characteristics of the virus, it is unlikely that this will be realized. focus should instead be on how to improve investigation effectiveness, processing time, and reliability of reporting. the protection and preservation of the surgical workforce was listed as the second priority in the "guidance for surgeons working during the covid-19 pandemic". 33 the widespread impact on staffing numbers has been dramatic due to isolation requirements, sickness, and redeployment. surgical services have required adequate staffing, with the potential to adjust to changing disease prevalence, despite a depleted workforce. accordingly, staff flexibility and resilience have been crucial. most scheduls include the provision of standby staff; residing at home, these personnel are readied for work and can be called in to cover shortfalls in staffing levels and/or sickness. the main aims are to minimize the exposure of the surgical workforce, enable adequate rest, and have escalation plans in place, if required. redeployment strategies implemented at the local level vary hugely between nhs trusts. professionals across the board have faced redeployment, often to unfamiliar roles. some of the 10,000 nhs returners who responded to the national 'bring staff back' initiative will have returned to the surgical workforce. 34 these individuals require additional training and support as part of their re-introduction to practice. since the advent of covid-19, the operating rooms environment is a very different workplace. the general dynamic in operating rooms is less relaxed due to a multitude of challenges. staff numbers are minimized for safety and their roles are more clearly defined. operative cases are required to be consultant led. ppe is uncomfortable, impairs staff recognition, renders spoken communication difficult, and largely eliminates non-verbal communication from facial expressions. unfamiliarity of staff with safety protocols can lead to inefficiencies and staff anxiety. as staff are assigned to a specific section of the operative suite, in keeping with their designated roles (operating room, anesthetic room, or corridor), there is increased segregation of staff and less interaction. with experience, there is an improvement in staff confidence and efficiency with covid-19 safety protocols. over time, individuals adapt to the cultural change involved in daily operating rooms turnover. 35 post-procedural debriefs are crucial to staff development, as well as providing a platform to acknowledge any physical or psychological difficulties associated with current processes. staff requiring quarantine on account of their personal health requirements have been assigned low risk or contact-free activities. changes to the on-call arrangements of the surgical specialities vary throughout the nhs, depending on staffing, services demand, and local policy. some departments have maintained their pre-covid-19 shift system, whereas others have required restructuring. cross cover, doubling of staff cover, and contingency scheduls are strategies employed in nhs trusts. 36 on account of occupational changes to working hours and roles, remuneration may be required in some incidences. during the covid-19 pandemic, there have been many changes to practice. for some individuals, this has been overwhelming and frequent guideline updates have been difficult to interpret. dissemination of information to all members of the surgical team has been implemented largely by senior clinical staff. using a communication task-force has been suggested as a strategy to reduce duplication of work and to keep team members informed. 37 gaps in knowledge lead to increased staff anxiety. the use of daily trust-wide email updates has been employed by most nhs organizations to inform staff of updates within their own workplace. in the surgical setting, covid-19 transmission can occur through droplet, aerosol, and contact spread. ppe is required to mitigate against each of these routes. uk guidelines on ppe requirements have been subject to multiple changes and have been the source of controversy. in the early phase of the nhs covid-19 experience, discussions about ppe dominated workforce concerns and the national media. conflicting information, variance in local ppe recommendations, and restricted availability of required equipment led to significant workforce anxiety. extensive workforce training has been required to ensure nhs staff are safely and appropriately using ppe. ffp3 mask or respirator fit-testing, as well as simulation training in donning and doffing ppe are now part of mandatory training for all patient facing personnel in the nhs. full ppe (fluid resistant gown, double gloving, visor or goggles, fit-tested ffp3 mask or respirator, disposable hat, shoe covers) should be worn in the operating rooms for any suspected or positive covid-19 case, for agp 38 (table 3) , and for procedures for which the risk is unknown. despite initial discrepancies in the recommended ppe requirements, guidance released by the royal surgical colleges and affiliated speciality organisations on march 27, 2020 reclassified laparotomy, laparoscopy, and endoscopy as high-risk procedures 39 . updates detailing ppe requirements for surgery and re-classifying agp were released by public health england [40] [41] [42] but did not answer the supply chain concerns. later guidance, in response to acknowledged ppe shortages, suggested a reduction in intraoperative protection, 43 surgical ward staff also require access to ppe. routine procedural tasks such as replacing feeding tubes, as well as general care of tracheostomies and general stomas, are all associated with higher risk of transmission. covid-19 safety protocols suggest that these skilled aspects of patient care should be performed by experienced staff. 45 the use of heat and moisture filters for tracheostomies has also increased safety. nasogastric and nasojejunal tube insertion frequently induces aerosol generation by local irritation-induced cough or sneeze response. 46,47 likewise, chest physiotherapy can be considered from a similar stance. routine care for covid-19 positive patients with an active cough, also requires full ppe. accordingly, the ppe requirement of the wider surgical team of healthcare professionals has been underestimated. supply of appropriate ppe has been a problem throughout the nhs, with severe shortages 48 compounded by a high case burden over a short period. 49 in april, a survey of uk surgeons and surgical trainees demonstrated that more than one half had experienced shortages of ppe over the preceding month, and approximately one third felt ppe was still inadequate and unsafe. 50 a survey of otorhinolaryngology surgeons revealed that 20% of trusts did not have the required ppe available and 95% of respondents felt the supply would run out during the crisis. 51 furthermore, concerns about trust rationing, self-funded ppe, and reports of emotional blackmail or gagging surfaced. 52,53 reuse protocols and cleaning of visors is now commonplace in the nhs. across the surgical community, there are also concerns that uk guidance does not meet internationally reported standards. 54, 55 inconsistencies in guidance, combined with difficulties in patient screening, have undoubtedly resulted in higher expenditure of ppe than necessary. in most nhs trusts, a range of ffp3 masks were initially available to staff. with depletion of stocks, many healthcare workers have had to repeat fit-testing with alternative masks or respirators as certain models have become unavailable. a worrying gender imbalance in the suitability of ppe has surfaced. 56 the majority of ppe has been designed to fit an average man. 57 masks and respirators are of particular concern, often being unsuitable, and resulting in high proportions of failed fit-tests in the female workforce. given that 77% of the nhs workforce are women, many have been unable to work in high-risk areas, putting further strain on the system. 58 the wearing of full ppe is generally not a pleasant experience for most healthcare workers and can have a significant impact on morale. 59 goggles, ffp3 masks, and respirators all have a significant impact on skin. constant use can lead to abrasions, dermatitis, and pressure areas 60 which may necessitate the alternating of roles or days off work. 61 wearing full ppe during operations is hot and restrictive. in certain specialist operating rooms, additional requirements, such as high ambient temperatures for burns surgery or radiation protection in orthopaedic procedures, exacerbate the unpleasantness. operative discomfort may increase the risk of technical error. ppe can also interfere with important operative aids such as operating microscope, loupes, or headlights . 62 the impact of ppe on surgical efficiency is dramatic. case duration is prolonged due to donning, doffing, down-time (to allow for air changes following intubation and extubation), surgical factors, and cleaning. 4 with process familiarity there is upskilling, leading to improvements in procedural duration, but this does not match standard operating times. 63 as elective operating recommences, adjustment of scheduling times will be necessary. regardless of the backlog of cases, surgical centers will need to accept reduced efficiency as a trade-off for increased safety. on account of the unavailability of covid-19 testing in the uk, personnel testing for covid-19 has been exceptionally limited. it is recognised that healthcare workers are at higher risk of exposure, could be asymptomatic carriers, and may unknowingly be the source of hospital-acquired infection in patients. nhs trusts have had to adopt a rough risk analysis of patients on admission (instead of routine testing), despite the fact that approximately 80% of people who test positive for covid 19 are either asymptomatic, or experience only non-specific symptoms. 64 consequently, unscreened staff are frequently exposed to untested members of the public, providing potential for viral transmission to either party. without adequate testing solutions available, the nhs has faced a dramatic rise in absenteeism. in line with the uk government's isolation recommendations, individuals have been instructed to completely self-isolate for 14 days in the presence of symptoms, and 7 days following close contact with a symptomatic person. a high proportion of nhs staff have had to self-isolate either due to personal or close-contact symptoms. in practice, without access to testing, an enormous number of households have had to self-impose cautionary isolation due to the presence of a symptomatic individual. in families with young children this has been particularly problematic. many staff had to take multiple absences without clarity on whether they had suffered from covid-19. not only has this been incredibly frustrating for those involved but has also put pressure on the rest of the workforce. a survey by the royal college of physicians in april, 2020, found that more than 20% of respondents were isolating either with symptoms, or due to contact with a member of the household with symptoms. only 31% had access to testing. 65 the nhs employee absence rates for 2020 have not yet been released, but these are expected to be the highest in recorded history, 66 with a huge impact on the total cost of covid-19. later, testing was offered for symptomatic staff (following sanction by the trust microbiology or infectious diseases teams), in an attempt to return a proportion of the isolating workforce. as the emphasis on viral testing has increased nationally, and availability of tests has expanded, staff displaying symptoms now warrant screening. against the backdrop of a national data vacuum, small data samples arising from isolated nhs trusts, which have adopted routine testing for all symptomatic staff, 67,68 unsurprisingly demonstrate the highest proportion of nhs workers testing positive for covid-19 were those working in patient facing roles. in the absence of a proficient immunity test, multiple rt-pcr sars-cov2 viral swabs may be necessary per individual healthcare worker. the lack of routine screening for asymptomatic staff has important social implications for healthcare workers and their families. with covid-19 status unknown, as we move out of lockdown, nhs staff will be unable to be in contact with vulnerable individuals. the government has now pledged that with increased testing capacity, screening will be available regularly to asymptomatic staff 34 but a program for this has not yet been rolled out. compulsory weekly viral screening for everyone may be the most robust strategy moving forward. 69, 70 the covid-19 pandemic has seen lower levels of training. from march 16, 2020, all courses, conferences, examinations, and other surgical education-based activities requiring physical attendance were cancelled. 71 planned rotations in april, 2020 were suspended by health education england to minimise disruption. across all surgical specialities, the training curriculums are competency based. it is recognised that the covid-19 pandemic has been hugely disruptive to training and individualized placement objectives may not have been met. although the annual review of competency progression (arcp) process will allow some concessions, based on the covid-19 pandemic, surgical trainees will still be required to meet the same standards in order to complete their training. accordingly, senior trainees may be more adversely affected and in some circumstances additional time may be required to meet these competencies. postponement of the final speciality examinations will, for some unfortunate candidates, result in extended training. for those trainees redeployed on account of covid-19, alternative duties may provide unique experiences, but in most cases, will lack direct surgical experience. the joint committee on surgical training (jcst) has emphasised that redeployed trainees will not be disadvantaged; however, it is recognized that the curriculum requirements will need to be achieved in future placements. the role of the who surgical safety checklist (developed in june, 2008 and mandated into routine nhs practice in january, 2009), 75 has been largely omitted from recommended covid-19 guidelines, but has nevertheless played an intrinsic role during the pandemic. as is standard in surgical practice, meetings are held at the beginning of operative lists to disseminate case based information, using the who checklist as a guide. these meetings are compulsory and are attended by all members of the team. during the pandemic, routine checklists have been expanded to include vital case-specific covid-19 information. all surgical cases require a discussion about the patient's covid-19 status, the degree of aerosol risk for each part of the procedure (induction of anaesthesia, extubation, and for all operative phases), with ppe requirement stated for each stage. important logistical considerations should also form part of the preoperative checklist, such as: wait-time for air changes following induction and termination of anesthesia, location of operating rooms donning and doffing areas, designated staff roles, and a detailed itinerary of the required (and potentially required) surgical instrumentation. 76 frequent, structured communications are key to safe practice and particularly important during the covid-19 pandemic. 77 workplace risk remains high; predictions expect heightened risk level to remain for months to years. accordingly, changes made to systems, staff handover, and general communications may become incorporated into routine nhs practice for the longer term, despite originally introduced as covid-19 related cultural changes. it should be assumed that the operating rooms environment and its contents are contaminated , 54 providing exposure for development of nosocomial covid-19 infection. furthermore, agp are highrisk for viral transmission to healthcare workers, and must be managed in concordance with stringent safety protocols. necessary adjustments to operating suite layout, staff working, and operating rooms flow have been implemented throughout the nhs surgical services to mitigate these risks. to ensure safety throughout the phases of a surgical procedure, modifications have been made to each component of the operative pathway. viewed as separate parts, these include preprocedure team meeting (who checklist), transfer, induction of anesthesia, operative steps, extubation, and transfer to recovery. wait times following instrumentation of the pharynx should be considered part of the anesthetic procedure. ventilation systems have been the subject of dispute. in the majority of nhs hospitals, operating rooms ventilation runs on positive pressure systems, with or without laminar flow. literature from other countries recommending negative pressure ventilation in the management of covid-19 cases, 78,79 initially generated concern. a consensus statement between the royal surgical colleges, affiliated organizations and public health england have approved that positive flow ventilation systems are considered safe for the management of covid-19 cases, 39 and that laminar flow is recommended. acute restructuring of nhs operating rooms ventilations systems has not been feasible during the pandemic, but safe ventilation management has been crucial. doors between the operating rooms and adjacent spaces should be kept closed to maintain effective airflow. 80 most nhs operating operating rooms have a degree of open plan design. the heightened requirement for ventilation and reduced contamination has changed the demands of the operating suite. 81 anesthetic rooms do not routinely have high frequency ventilation, and scrubbing up areas are usually confluent with the operating rooms space. transforming operating suites into covid-19 safe work spaces overnight, has been challenging. example operating rooms layouts are provided for our institution, prior to covid-19 (fig. 1) , and demonstrating the repurposing of workspace areas during the covid-19 pandemic (fig. 2) . under current circumstances, all parts of the patient's pathway (induction of anesthesia, the operating procedure and recovery), now occur in the main operating suite. in our institution, the absence of doors between the scrubbing up area and the main operating rooms has required scrubbing and donning to be performed in the repurposed, anesthetic room. access to operating rooms for the delivery of additional equipment should occur through the newly assigned "staff entrance and donning area". the lack of a designated storage space for equipment which is separate from the main operating rooms space has required "external runners" to deliver kit into operating rooms, through the clean donning area (which would have previously been the anesthetic room). equipment is passed from the "external runners" in the operating rooms corridor, to staff in full ppe stationed within the clean area. knocking on the operating rooms door signifies to the internal theatre team that the equipment is available. the "internal runner", when ready, opens the door for a minimal period, accepting the required equipment. pauses in operating, while this process is actioned, can prolong the procedural time. operations on children should be avoided due to the unique risks of asymptomatic carriers and difficulty of performing pediatric screening, examinations, and procedures. in exceptional circumstances, essential procedures can be performed. all children are managed as high-risk for covid-19 transmission. the surgical pathway for children has been modified for safety accordingly. generally, children are cannulated on the ward and accompanied by a parent or guardian to the operating rooms entrance, where staff in full ppe meet them. the patient is then anaesthetized without the parent present. in some parts of the uk, child services have been reduced in peripheral hospitals, favoring centralization of cases to designated pediatric hospitals, thereby maximizing expertise. the need to segregate suspected or confirmed covid-19 patients into designated operating rooms has spurred the use of traffic light systems to denote case status. ideally, completely separate operating suites, with isolated ventilation systems, should be used for suspected or positive covid-19 patients. all non-essential equipment should be removed from the operating rooms environment and essential apparatus should be covered with plastic wrapping. 82 a detail run through of all required equipment should be detailed in the team briefing and kept sterile in a clean area within theatres enabling swift access. unused items should be returned to stores without being contaminated. whenever possible, staff perform a dedicated role for the duration of an operation, thereby minimizing the number of people in the operating rooms, and reducing handovers. due to additional steps and segregation of areas within the operating suite, the staffing requirement overall is greater. 63 social distancing should be maintained, when practical, within the operating rooms environment. based on national guidance, local nhs trusts individualize their covid-19 response based on the existing infrastructure of individual hospital sites. structural layout, ppe availability, and disease prevalence are taken into consideration. all nhs trusts, but not all hospitals, have a critical care capacity. the total number of nhs critical care beds for combined adults and pediatric occupancy (under usual circumstances), totals 5,900 beds, 83 or 7.5 beds per 100,000 population. 84 this figure is lower than many european countries and posed an immediate concern in the advent of covid-19. halting elective operating and reassigning operating spaces has been the main contributor to nhs england's plan for an additional 30,000 critical care beds. 85 difficulties in the procurement of essential equipment, including ventilators (due to supply flow problems and a global shortage) has, in some cases, resulted in redistribution of operating equipment. in other locations, due to an expanded critical care bed requirement, areas with capacity for ventilation were identified, recruited, and converted. most commonly in nhs hospitals, these have been operating rooms, anesthetic rooms, and recovery areas, which has had an immediate effect on operative capacity. the consolidation of surgical cases (across all specialities) into the remaining operating rooms lists, has required daily multidisciplinary meetings to discuss prioritizations. operational adjustments to redirect elective surgeries to "covid-19-free" zones, has seen the reopening of some surgical areas and utilization of private sector establishments. block-buying of independent sector capacity has occurred on a national scale and is being managed by local nhs trusts. 85 during the covid-19 pandemic, across all specialities, modifications to the technical aspects of surgical practice have been implemented. within nhs practice, certain pandemic principles have emerged to reduce the risk profile of surgery (table 4 ). it is accepted that many surgical conditions may be managed conservatively. as a result, some patients who would have been transferred to specialist centers will have been managed locally. 86, 87 in the current climate, a trend is observed towards increased imaging to inform surgical decisionmaking. patients with acute general surgical conditions such as suspected appendicitis and cholecystitis, should either have open procedures (due to the unknown risk of laparoscopic surgery) or be managed conservatively. similarly, management of acute mastoiditis should now be medical with imaging support. 88 a detailed, collaborative, covid-19 response has redefined the trauma management standards during the pandemic. 89 increasingly, trauma cases that can be managed with local anesthetic procedures are performed whenever possible in the emergency department or trauma clinic setting to reduce the operating room burden. 9 the covidharem study has been announced to capture the impact on morbidity and mortality of differing approaches to the management of acute appendicitis during covid-19. 90 emergency surgery during this period has been complicated by later surgical presentations, most likely due to patient compliance with isolation or anxiety around entering a high-risk clinical area. reports demonstrating a relative increase in the number of bowel obstructions during the covid-19 pandemic are not surprising, making surgery more challenging and having a negative impact on patient outcomes. 91 given that conservative management is being considered for a larger cohort of patients, the use of surgical scoring systems may help stratify patients. 80 the avoidance of general anaesthesia (ga) is primarily due to the associated aerosol risk; however, there are also secondary advantages such as potential reduction in postoperative bed requirement and anesthesia related complications. the move away from ga has seen a reciprocal increase in use of regional anaesthesia. newer techniques such as "wide awake local anaesthetic no tourniquet" (walant) technique 92 have gained an overnight increase in popularity. walant has been recommended by the british society for surgery of the hand for routine practice during covid-19 and is increasingly being used for other anatomical regions. many standard operative devices such as laser, bone saws, high-speed drills, skin dermatome, harmonic scalpel, and other tissue-sealing devices have been evaluated as high aerosol risk and have been temporarily replaced with alternative techniques. in real terms this has meant a temporary return to more traditional surgical techniques. 72 settings of cautery devices should be as low as possible to reduce the generation of smoke and used with suction or intrinsic vacuum. 93, 94 there is an ongoing debate about the risks of open surgery versus laparoscopic surgery. the intercollegiate general surgery guidance advised against laparoscopic surgery due to the unquantified risk. 93, 95 insufflation of body cavities may be associated with aerosol generation due to escape of fluid with high pressure gas. more detailed guidance later suggested that laparoscopic techniques for cases with clear benefit, could be used over alternative techniques, with use of full ppe to mitigate against potential transmission. 96 prior to use, all equipment must be checked meticulously and operating room ventilation should be appropriate. adjustments to technique to maximize safety include careful introduction of trocars to minimize leak, aspiration of abdominal cavity insufflation prior to removal of trocars, and the use of air filters. a consensus on safety of laparoscopic surgery has not been reached. the association of laparoscopic surgeons of great britain and ireland has provided a series of safety recommendations for laparoscopic practice in cases where there is a clear benefit. 97 certain procedures involving the head and neck cannot eliminate exposure to agp. for these highrisk operations, procedural planning is key. an emphasis on clear stepwise processes increases safety. 98 tracheostomy placement and changes, whenever possible, should be delayed until patient is proven covid-19 negative. when necessary, strict protocols should be followed incorporating modifications to standard practice, such as advancement of the endotracheal tube below the incision level to mitigate aerosol generation. 63 in keeping with the "essential surgery only" approach, many complex surgeries are simply not being performed. surgical choices focusing on reduced operative time, low complication rates and minimizing the inpatient stay are favored. in the current climate, breast cancer patients are not being offered primary reconstructions. similarly, in the severely injured limb, early amputation should be considered over limb salvage and reconstruction, requiring multiple procedures. in gastrointestinal surgery, patients are more likely to be offered a temporary stoma formation to reduce the risk of anastomotic leak and longer inpatient stays. 4,99 surgical management of fragility fractures (the incidence of which remains high) are a priority, with acceptance that hemi-arthroplasty and sliding hip screw fixation in the current climate offer a beneficial reduction in operative time. 100 surgical techniques to reduce complexity and follow-up contact are preferential. examples include the use of absorbable sutures and percutaneous k-wires for fracture fixation. minimizing staffing numbers in the operating room also extends to the number of surgeons. operator requirements are dependent on the technical challenges of the procedure. in some operations, such as pediatric otolaryngology cases, a minimum of 2 surgeons are still recommended during the pandemic for safety reasons. 63 the uk's daily figures for covid-19 proven infections, hospital admissions, and deaths, appear to suggest that we are emerging from the peak. lockdown measures have been, to some extent loosened, without a detectible effect on these trends. with the most vulnerable groups of people still under strict isolation, and with no clear strategy for their safe emergence, we may be falsely reassured. recorded figures are valuable, but should be interpreted cautiously, taking into consideration the uk's screening challenges and the international variation in testing and recording practices. some of the surgical specialty organizations have released literature detailing the next phase of the pandemic response, encouraging a move towards resuming elective services. 104 the priority must be for safe return to surgical pathways and the readiness to do this will vary across nhs trusts. gradual resolution of elective surgery will be limited by a multitude of factors, many of which have been discussed in this manograph. prolonged procedure time will continue to have a dramatic effect, and it is unlikely that services will return to the pre-covid-19 level of turnover. should subsequent surges in covid-19 prevalence occur, there may be a similar regression in availability of surgical services. all surgical staff will continue to play a role in reducing the risk of transmission, thereby continuing to mitigate against the impact on patients and staff. surgical trainees, who have been flexible during the pandemic period, will need their training requirements planned into the next phase response. changes to working patterns and surgical schedules have been extremely disruptive and decisions will need to be made about how these will be readjusted. since january, 2020, the uk is no longer part of the european union, which could lead to major changes in workplace standards. it is unclear if the ewtd rules for safe working will be abolished. proposals to target the disruption to services, may encourage a move towards 7-day working. at the same time, covid-19 delivered rapid delivery of flexible working, previously unimagined in the nhs. it is likely that the nhs will be challenged to maintain more adaptable ways of working for some individuals. the effect of covid-19 on patients has been dramatic and very difficult to quantify. the covid-19 pandemic has brought a novel sense of risk around healthcare, with particular caution surrounding surgery. the psychological effects of social isolation, and the impact of media should not be underestimated. as we emerge from the peak, an emphasis on high quality research is now needed to generate data on critical deficiencies in knowledge, and to help inform decisionmaking in surgical care. early data suggest that covid-19 has a detrimental effect on surgical outcomes. the overall mortality rate, in the presence of covid-19 infection prior to, or following surgery, is higher than would be expected. 105, 106 this is highly concerning for patients, surgeons, and healthcare providers. robust research is required into the impact of covid-19 on surgical outcomes. one quarter of the uk population are deemed high-risk. 107 patients' vulnerability factors will influence their level of anxiety around attendance to healthcare institutions and treatment decisions. delays to cancer operartions, on account of service availability, oncological prioritization, or patient choice will have magnified the stress and uncertainty experienced by cancer patients and their families. increasingly, data are emerging suggesting there may be patterns in susceptibility to covid-19. broadly, these could be grouped into potentially-modifiable and non-modifiable factors [107] [108] [109] [110] [111] (table 5 ). although some of the literature is speculative, these potential links are the cause of significant anxiety and require expedient scientific investigation. the increased risk of covid-19-relatedmortality is particularly problematic for cancer patients requiring treatment. ultimately, in some cases, the presence of risk factors will complicate treatment discussions and decisions. clearly, trends in susceptibility affect patients and staff alike. looking forward, possible implications include the need for differential management of patients or staff based on the presence of risk factors, increased preoperative or occupational screening, and potentially, public health initiatives to address modifiable risks. this raises the question: as the largest employer in the uk, should be the nhs be more responsible for addressing the health of its workforce? if so, covid-19 could result in an infrastructural shift towards greater emphasis on occupational health and well-being. interestingly, in the uk healthcare workers have not been shown to have higher death rates when compared to the general population. 112 healthcare workers from black, asian and minority ethnic (bame) groups, have been shown to have a significantly increased risk of mortality when compared to white healthcare workers. 113 furthermore, national data suggests that black, pakistani and bangladeshi individuals are at increased risk of mortality from covid-19. 108 although the data are striking, they are unlikely to represent ethnicity factors alone. essential research investigating the link between ethnicity and risk of mortality, as well as other contributory factors, should be a national priority. as the uk moves into the next phase of covid-19, a focus on understanding and managing vulnerability factors will be key. globally, an estimated 37.6% of cancer surgeries and 81% of benign operations will be delayed on account of the pandemic. 114 many patients will have accepted alternative treatment pathways on account of covid-19, with unknown effect on outcomes. pathways designed to aid decisionmaking between surgeon and patient do have a role, but are not validated. 105 the nhs safeguards patient care by delivering treatment pathways within a series of strict timelines. cancer waiting times include standards for the time to diagnosis (31 days) and time to treatment (31 days from treatment decision, 62 days from initial referral). clearly, in the current climate these may be more difficult to maintain; however, cancer care will be most protected. the management of benign conditions will inevitably suffer delays. the maximum duration for treatment of non-urgent conditions should be 18 weeks. any breach of these standard waits results in a fine for the nhs trust. currently, most patient pathways have been frozen (on account of the exceptional circumstances), therefore not incurring these penalties. how suspensions to pathways, prolonged wait times for operations and, patients' expectations will be managed, has not yet been publicized. an emphasis on cancer management and other time-dependant operations will be the primary focus as services resume. the cancellation of some operations may have already led to harm, or may require adjustment to planned surgical interventions due to disease progression. rapid resolution of transplant, cardiothoracic, and vascular surgery services will be necessary to reduce the secondary morbidity and mortality associated with covid-19. transplant services in the uk have been dramatically affected by covid-19. live donations were held due to the relative risks to both patients. the complex infrastructure required for rapid organ retrieval, matching, and transplantation could not be maintained uniformly over the peak pandemic. pancreas, liver and kidney services have been particularly affected, with the majority of centers still closed. 115 the national reduction in transplantation and donor availability will have contributed to the number of potentially preventable deaths. 116, 117 non-urgent benign operations are likely to be suspended indefinitely until a strategy has been agreed for the urgent procedures. these patients are likely to be disappointed by prolonged waiting times. delays to surgery will in many cases result in progression of disease and an associated impact on the technical complexity of surgery. pediatric surgery is a particularly difficult area. in general, surgeries are only performed in children when they are clinically urgent. due to the challenges of performing adequate pharyngeal swabs in children and the frequent requirement for ga, all pediatric operations will need to be managed as high-risk cases. age dependent operations such as cleft lip and palate are generally performed within a narrow window, based on a delicate balance of risks. with ongoing uncertainty about the risks of surgery in the presence of covid-19 infection, pediatric surgeons will need to carefully consider the safe return to elective operating. outpatient cancer surveillance and imaging has largely been held. telemedicine clinics, which are reliant on patient reported signs and symptoms, are unlikely to have been a substitute for professional assessments. 118 as a consequence, we are likely to see a rise in cancer recurrence, presenting later. high-risk imaging for oncological surveillance will resume, but managing the backlog will be challenging. the longer imaging gap in some patients will mean later detection of oncological metastasis or recurrence. the government's decision to halt elective operating over the covid-19 pandemic peak was necessary, but has led to an accumulation of cases. it has been estimated that clearing the backlog of these operations will take an estimated 45 weeks, working at a 20% increase in productivity. 114 trusts invested in targeting these delayed procedures will however, be confronted with limited surgical capacity and reduced efficiency. an expansion of staff provision, operating room availability, and associated support services will be necessary. in practice, this translates into a systems approach to increased capacity, with as much emphasis on dressings clinics, physiotherapists, and radiographers as it has on surgeons and operating room staff. how this will be funded is not yet clear, but the uk is facing estimated costs of â£2 billion. 114 the use of independent sector hospital services will play a key role in the expansion of nhs surgical capacity. many patients will prefer to have procedures in covid-19 "light" or "cold" sites, which may be safer. the logistics of managing patients through additional sites, is problematic. information technology systems are different and are often not compatible with the parent nhs trust systems, leading to challenges with access to patient records and data protection. many hospitals have not yet confirmed their position on trainee access to alternative sites, which, if denied, could have an ongoing detrimental effect on training. on account of the many delays and unplanned changes to patient management decisions, the nhs will experience a unique wave of healthcare litigation. cases of clinical negligence may target nhs trusts or the individual. organizations such as the british medical association and the general medical council have provided guidance for members on practicing during the covid-19 pandemic; however, there is ongoing professional concern about the personal level of risk. returning nhs professionals may be particularly vulnerable. undoubtedly there will have been preventable harm and deaths suffered as a consequence of the covid-19 pandemic. surgical specialty organizations have adopted a key role in the dissemination of available evidence to aid safe practice and should be used as a guide for professionals. individuals should carefully discuss and document all patient management decisions influenced by the covid-19 pandemic. current indemnity arrangements will cover events incurred over the covid-19 period; however, the uk government has launched an additional covid-19 clinical negligence scheme for additional scope. 119 the coronavirus act 2020 covers the services outsourced to independent hospitals on account of covid-19. 120 other high-risk areas of potential litigation include the manufacture of equipment and pharmaceuticals. 121 use of telemedicine clinics has bridged an important gap in the availability of services, but the rapid development of virtual services, with temporary slackening on data protection standards, will have implications for patient confidentiality, with legal implications. 122 the rapid introduction of new systems are often associated with greater potential for error and breach of information standards. the development of increasingly data-safe systems will be paramount. covid-19 has resulted in a significant number of challenges for surgery in the uk. by detailing the unique nhs experience, as well as the evolving responses to the covid-19 pandemic, we offer a view into the current impact on surgical services. at the time of writing, the uk is thought to be emerging from peak prevalence. navigating a safe return to surgical pathways, as the pressure on the health system changes, will be a slow process and will generate further challenges. with many countries entering their pandemic experience later, a map of the nhs surgical challenges will likely inform expectations and practice. the consolidation of the challenges into the subgroups of surgical workforce, surgical patients, and surgical process has aimed to address the concerns of different nhs stakeholders, within a constantly evolving landscape. many uncertainties remain, and the effects of covid-19 on surgical practice are likely to be longstanding. the first weeks of the pandemic were an unsettling time for the nations as new ground was being navigated. the dynamic nature of the covid-19 pandemic has made the generation of this monograph both interesting and challenging. despite the devastating loss of life, healthcare disruption, and international anxiety, we must identify the wealth of lessons gleaned from the covid-19 pandemic and cultivate from them positive changes for our healthcare systems. the sharing of international experiences has been invaluable in tackling the covid-19 response. consensus statements have been crucial in guiding care decisions, but as we move forward an increased emphasis will be on evidence based medicine. the response of both the public and the international healthcare community in tackling covid-19 has been impressive. we will need continued vigor to manage the ongoing challenges facing surgery. table 2 . nhs prioritisation system in covid-19 pandemic 12 . emergency -operation needed within 24 hours urgent -operation needed with 72 hours surgery that can be deferred for up to 4 weeks surgery that can be delayed for up to 3 months surgery that can be delayed for more than 3 months table 3 . uk procedures classified as aerosol generating procedures covid-19: all non-urgent elective surgery is suspended for at least three months in england first cases of coronavirus disease 2019 (covid-19) in the who european region 4. 2nd-update-intercollegiate-general-surgery-guidance-on-covid-19-5-april covid-19 and emergency surgery presidents update 27_03_20 report from the american society for microbiology covid-19 international summit detection of sars-cov-2 in different types of clinical specimens novel coronavirus can be detected in urine, blood, anal swabs and oropharyngeal swabs samples. infectious diseases (except hiv/aids) fecal specimen diagnosis 2019 novel coronavirus-infected pneumonia offline: covid-19 and the nhs--a national scandal covid-19: uk pledges to reintroduce contact tracing to fight virus 22. guidance-and-sop-covid-19-virus-testing-in-nhs-laboratories-v1.pdf. accessed correlation of chest ct and rt-pcr testing in coronavirus disease 2019 (covid-19) in china: a report of 1014 cases improved molecular diagnosis of covid-19 by the novel, highly sensitive and specific covid-19-rdrp/hel real-time reverse transcription-pcr assay validated in vitro and with clinical specimens updated understanding of the outbreak of 2019 novel coronavirus (2019-ncov) in wuhan recommendations for surgery during the novel coronavirus (covid-19) epidemic sustainable response to the covid-19 pandemic in the operating theatre: we need more than just personal protective equipment clinical characteristics of coronavirus pneumonia 2019 (covid-19): an updated systematic review. infectious diseases (except hiv/aids) thoracic imaging in covid-19 infection the continuing evolution of covid-19 imaging pathways in the uk: a british society of thoracic imaging expert reference group update guidance for surgeons working during the covid-19 pandemic. the surgical royal colleges of the united kingdom and ireland social distancing: implications for the operating room in the face of covid-19 global guidance for surgical care during the covid-19 pandemic annotation: the covid-19 pandemic and clinical orthopaedic and trauma surgery covid-19 personal protective equipment (ppe). gov.uk. accessed covid-19 statements | asgbi -association of surgeons of gb. accessed recommended ppe for healthcare workers by secondary care inpatient clinical setting, nhs and independent sector covid-19 personal protective equipment (ppe). gov.uk. accessed reducing the risk of transmission of covid-19 in the hospital setting considerations for acute personal protective equipment (ppe) shortages. gov.uk. accessed entuk guidelines for changes in ent during covid-19 pandemic tracheostomy in the covid-19 era: global and multidisciplinary guidance. the lancet respiratory medicine aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. semple mg covid-19: government cannot say whether nhs will run out of protective gowns this weekend covid-19: 90% of cases will hit nhs over nine week period, chief medical officer warns covid-19: third of surgeons do not have adequate ppe, royal college warns covid-19: doctors are warned not to go public about ppe shortages surgical treatment for esophageal cancer during the outbreak of covid-19 sexism on the covid-19 frontline: -ppe is made for a 6ft 3in rugby player.â�� the guardian gender-in-the-nhs-2018.pdf. accessed covid-19 epidemic: skin protection for health care workers must not be ignored skin reactions to non-glove personal protective equipment: an emerging issue in the covid-19 pandemic personal protective equipment induced facial dermatoses in healthcare workers managing covid-19 cases operating during the covid-19 pandemic: how to reduce medical error. british journal of oral and maxillofacial surgery practical insights for paediatric otolaryngology surgical cases and performing microlaryngobronchoscopy during the covid-19 pandemic covid-19: four fifths of cases are asymptomatic, china figures indicate covid-19 and its impact on nhs workforce. rcp london first experience of covid-19 screening of health-care workers in england. the lancet. 2020;0(0) roll-out of sars-cov-2 testing for healthcare workers at a large nhs foundation trust in the united kingdom universal weekly testing as the uk covid-19 lockdown exit strategy. the lancet covid-19: pcr screening of asymptomatic healthcare workers at london hospital. the lancet 71. joint-policy-statement-on-covid-19.pdf. accessed immediate and long-term impact of the covid-19 pandemic on delivery of surgical services orthopaedic education during the covid-19 innovations in neurosurgical education during the covid-19 pandemic: is it time to reexamine our neurosurgical training models? decade of improved outcomes for patients thanks to surgical safety checklist surgical tracheostomies in covid-19 patients: important considerations and the -5tsâ�� of safety. british journal of oral and maxillofacial surgery preparing for a covid-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore what we do when a covid-19 patient needs an operation: operating room preparation and guidance european society of trauma and emergency surgery (estes) recommendations for trauma and emergency surgery preparation during times of covid-19 infection cutting edge -the surgical blog from bjs. cutting edge managing covid-19 in surgical systems: annals of surgery nhs hospital bed numbers. the king's fund how is intensive care reimbursed? a review of eight european countries sbns :: covid. accessed pdf?utm_source =all+ent+uk+members+no+events+comms+24.03.20&utm_campaign=441cf7538a-email_campaign_2020_03_23_05_26_copy_01&utm_medium=email&utm_term=0_6 covid-19-boasts-combined-v1final.pdf. accessed association of surgeons of gb reduction in emergency surgery activity during covid-19 pandemic in three spanish hospitals wide awake hand surgery handbook v2.pdf intercollegiate general surgery guidance on covid-19 update. the royal college of surgeons of edinburgh safe management of surgical smoke in the age of covid-19 updated intercollegiate general surgery guidance on covid-19. royal college of surgeons laparoscopy in the covid-19 environment -alsgbi position statement a framework for open tracheostomy in covid-19 patients treatment strategy for gastrointestinal tumor under the outbreak of novel coronavirus pneumonia in china 100. c0086_specialty-guide-_fragility-fractures-and-coronavirus-v1-26-march.pdf. accessed recovery of surgical services during and after covid-19. royal college of surgeons acpgbi-considerations-on-resumption-of-elective-colorectal-surgery-during-covid-19-v28-4-20.pdf. accessed clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid-19 infection. eclinicalmedicine covid-19: risk factors for severe disease and death covid-19) related deaths by ethnic group, england and wales -office for national statistics deaths involving covid-19 by local area and socioeconomic deprivation -office for national statistics clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study. the lancet cancer patients and research during covid-19 pandemic: a systematic review of current evidence covid-19) related deaths by occupation, england and wales -office for national statistics exclusive: deaths of nhs staff from covid-19 analysed elective surgery cancellations due to the covid-19 pandemic: global predictive modelling to inform surgical recovery plans transplant centre closures and restrictions. odt clinical -nhs blood and transplant the covid-19 outbreak in italy: initial implications for organ transplantation programs telemedicine and plastic surgery: a review of its applications, limitations and legal pitfalls clinical negligence scheme for coronavirus. nhs resolution. accessed patient safety and litigation in the nhs post-covid-19 covid-19: can orthopaedic surgeons really work from home? accessed key: cord-035137-uxtaw02u authors: chowdhury, anis z.; jomo, k. s. title: responding to the covid-19 pandemic in developing countries: lessons from selected countries of the global south date: 2020-11-10 journal: development (rome) doi: 10.1057/s41301-020-00256-y sha: doc_id: 35137 cord_uid: uxtaw02u reviewing selected policy responses in asia and south america, this paper draws pragmatic lessons for developing countries to better address the covid-19 pandemic. it argues that not acting quickly and adequately incurs much higher costs. so-called ‘best practices’, while useful, may be inappropriate, especially if not complemented by effective and suitable socio-economic measures. public understanding, support and cooperation, not harsh and selective enforcement of draconian measures, are critical for successful implementation of containment strategies. this requires inclusive and transparent policy-making, and well-coordinated and accountable government actions that build and maintain trust between citizens and government. in short, addressing the pandemic crisis needs ‘all of government’ and ‘whole of society’ approaches under credible leadership. test for the 'international community' since the un's formation. 3 he urged developed countries to immediately help less developed countries to bolster their health systems and capacity to check disease, especially covid-19 transmission. failure to do so, he warned, would contribute to 'the nightmare of the disease spreading like wildfire in the global south with millions of deaths and the prospect of the disease re-emerging where it was previously suppressed'. early precautionary measures in much of the rest of china and east asia, and in places such as kerala state in southwest india, were largely successful in containing the spread of the epidemic, at least thus far. but most national authorities outside of east asia did not take adequate early precautionary measures speedily enough to contain the spread of the outbreak, typically by promoting safe 'physical distancing', obligatory use of masks in public areas, and other measures to reduce the spread and likelihood of infection. societal vulnerability to infection and capacity to respond depend on many factors, including health care system preparedness, leadership experience and ability to manage specific challenges posed. government capacity to respond depends crucially on system capacity and capabilities-e.g., authorities' ability to speedily trace, isolate and treat the infected-and available fiscal resources-e.g., to quickly enhance testing capacity and secure personal protective equipment (ppe). funding cuts, privatization and other abuses of recent decades-in the face of rising costs, not least for medicines-have further constrained and undermined most public health systems, albeit on various different pretexts. of course, socio-cultural factors, such as more cooperation due to greater 'trust' in the authority, less individualistic and narcissistic cultures, and even the shared memory and experience of past outbreaks such as sars and nipah, have also been important. this review seeks to draw pragmatic lessons for developing countries to better address the covid-19 pandemic. it begins with a brief discussion seeking to understand distinctive characteristics of the pandemic infecting a large share of the world's population. it then evaluates the principal strategies adopted to address the health crisis, especially to enable national health systems to cope with the emergency. it is followed by reflections on the causes and implications of public health capacity vulnerabilities in developing countries. finally, it draws some implications of different policy responses in east asia, southeast asia-especially vietnam, and india's kerala state-argentina, brazil and peru, that are relevant for other countries. it argues that the costs of not acting quickly and adequately are higher. it further argues that so-called 'best practices', while useful, may be inappropriate, especially if not complemented by effective and suitable socio-economic measures. high degrees of public support and cooperation are critical for successful implementation of containment strategies without having to resort to wasteful and self-defeating draconian measures. this requires inclusive and transparent policy-making, and well-coordinated and accountable government actions that build and maintain trust between citizens and government. in short, addressing a pandemic crisis of this scale needs 'all of government' and 'whole of society' approaches under credible leadership. the covid-19 pandemic, caused by the sars-cov-2 virus, is now widely considered more infectious than other viral epidemics in last century following the 1918 spanish flu pandemic, especially since the deadly asian flu of the late 1950s and hong kong flu of 1968. 4 the covid-19 fatality rate is lower than for the first severe acute respiratory syndrome (caused by sars-cov-1) in [2002] [2003] 5 and is not more infectious than the h1n1 virus, but has infected many more people nonetheless. 6 several factors have made covid-19 more dangerous than other recent viral epidemics. first, its symptoms and consequences are rather diverse and can be quite severe, varying with age. for example, while covid-19 primarily affects the respiratory system, causing pneumonia, it has also been associated with gastrointestinal and neurological manifestations (christakis 2020) . those infected may also mistakenly attribute their symptoms to influenza or other health conditions. importantly, those infected with the sars-cov2 virus may be infectious well before showing any symptoms, 4 seven coronavirus varieties have infected humans thus far: four caused sniffles, one caused the deadly mers outbreak in the middle east, first reported in saudi arabia in 2012, with two others causing major international epidemics. the first caused sars, which petered out quickly, despite its high fatality rate, while the other causes according to the who, a total of 8,098 people in 26 countries had sars; 774 died between november 2002 and july 2003, i.e., a death rate of 9.6%, whereas the covid-19 death rate was 3.6%, when it was declared a pandemic (woodley 2020) . 6 consider two pathogens, x and y. for every thousand people, both cause 20 people to become seriously ill, killing two each. but the second pathogen y also infects 180 more people, only making them mildly or moderately ill, i.e., not killing them. so, the 'case fatality' rate (number of deaths per infected person) for x is 10% (2 out of 20), whereas for y, it is 1% (2 out of 200). but although this rate is lower for the second pathogen, y, it is no less lethal (christakis 2020) . 3 'transcript of the un secretary-general's virtual press encounter to launch the report on the socio-economic impacts of covid-19′. united nations https ://www.un.org/sg/en/conte nt/sg/press -encou nter/2020-03-31/trans cript -of-un-secre tary-gener al%e2%80%99svirtu al-press -encou nter-launc h-the-repor t-the-socio -econo mic-impac ts-of-covid -19. accessed 3 august 2020. while as many as half of those infected, and hence infectious, may be asymptomatic, i.e., not show any symptoms of illness. hence, reliable new cheap and rapid tests for covid-19 infection promise to be a major 'game-changer'. r 0 is the average number of individuals that an infected person infects when no interventions have been implemented; this number does not change. the 'reproduction rate'-referred to as r t or r e depending on preference or convention-will likely change as interventions are put in place, while the number of those susceptible changes due to infection and possible immunity. major variations due to 'super spreader' episodes further complicate understanding of the significance of average rates and of variations. while 'super-spreader' episodes have received much publicity, they have been exceptional with a lower variation in r t and hence less important for explaining contagion than 'normal' networks of viral transmission of covid-19. 7 again, with a lower fatality rate-the probability of a person dying-covid-19 has been particularly hard to contain as there are more infectious people around than if it were more deadly. 8 hence, movement restrictions, physical distancing, self-isolation and other precautionary and preventive measures are important. the virus can spread from person to person during close direct or indirect contact with an infectious person (even before they have symptoms), contact with aerosol-or droplet-borne virus from an infected person, either directly or indirectly. infection, via mucous membranes in the mouth, nose or eyes, starts in the upper respiratory tract, typically in the throat or upper airways. elderly persons and people with other health issues, such as asthma, diabetes, obesity, hypertension, etc. are more vulnerable, and likely to face complications and death. improved understanding of covid-19 has been critical for designing and improving policy responses. the sars-cov2 virus was considered novel as it had never been seen in humans before. thus, initial responses in east, including southeast asia were drawn from known 'best practices' for testing, contact tracing, isolation and treatment. but, for various reasons, even these were not done in most countries outside asia. once the virus had spread widely, it was no longer practical or even possible to belatedly implement best practices effectively as case-loads not only overwhelmed hospitals, but also public health systems. differences with earlier viruses and epidemics meant that simple emulation of past containment measures have not always been appropriate, let alone optimally effective for containing covid-19. government policymakers need to consider the general nature and specific variations of the covid-19 pandemic and its uniquely changing and varied implications in particular contexts. a standardized set of interventions, even ostensible best practices, is unlikely to be universally applicable, as the covid-19 pandemic has different ramifications in varied circumstances over time. the incubation period 9 will require corresponding periods of quarantine or 'self-isolation'. the varied duration of 'mismatches'-e.g., due to incubation exceeding, or lasting longer than latency periods 10 -imply that countries need to urgently acquire the ability to rapidly and reliably test as widely as necessary. as this has not been affordable for many, especially in poorer countries, the development of cheap, quick and reliable tests promises to be crucial. once widely available and used, such improvements in the speed, reliability and affordability of testing will have significant consequences. 11 no one can be exempted from preventive or containment measures until it is definitively medically confirmed that all those once infected can be neither infected or infectious again. for the time being, face masks and shields, physical distancing and hand hygiene remain vital to containment efforts. the long-term health and economic impacts of covid-19 imply that public health and social protection systems should be well prepared to manage them. unfortunately, persuaded by the most influential, early western discourses, many politicians and others everywhere did not take the contagion threat seriously enough initially 7 covid-19 appears to have lower r 0 variation than sars, for example. 8 this explains why the ebola epidemics with a terrifying fatality rate 80-90% waned reasonably quickly. 9 the period between becoming infected with a pathogen and showing symptoms is called the 'incubation period'. 10 the 'latency period' is the time between becoming infected and being able to spread the disease to, i.e., infect others. there can be mismatches between the virus incubation period and the latency period. when the latency period is longer, an infected person may only display symptoms after they have actually become infectious, i.e., capable of infecting others. the sars-cov2 virus incubation period is generally longer than the latency period. thus, an infected person can spread the virus before symptoms of having covid-19 are visible. 11 a saliva-based laboratory diagnostic test developed by researchers at yale to determine whether someone is infected with the novel sars-cov-2 virus was granted emergency use authorization by the us food and drug administration (fda) on 15 august 2020. with the technique made available on an open access basis, the cost and speed of testing can be radically reduced for all, with major implications for current precautionary and preventive practices and requirements. https ://news.yale.edu/2020/08/15/yales -rapid -covid -19-saliv a-test-recei ves-fda-emerg ency-use-autho rizat ion. accessed 21 august 2020. since june, south africa has been conducting trials for a 5-min covid-19 breath test, while israeli scientists claim to have developed a 30-s coronavirus breath test. https ://www.the-scien tist. com/news-opini on/in-south -afric a-covid -19-breat h-test-trial -set-forjune-67631 ; accessed 21 august 2020; https ://medic alxpr ess.com/ news/2020-07-israe li-firm-secon d-coron aviru s.html. accessed 21 august 2020. for various reasons. these include not only cultural prejudice, but also misinformation and confidence in alternative approaches, such as 'herd immunity', 12 all facilitated by the greater influence of social media. if and when an effective vaccine becomes available, there is no guarantee that it will be affordable and available to all without a strong multilateral commitment to ensure that it quickly becomes universally accessible. furthermore, there are likely to be significant populations who may refuse to be vaccinated en masse, e.g., where civil libertarian ideologies and mistrust of vaccines and authorities are pervasive. without such a shared commitment to universal access, it may be impossible to completely eradicate the covid-19 threat in the foreseeable future. 13 recent us actions have not been encouraging for a concerted global response to the pandemic. as the largest financial contributor, the us decision to formally withdraw from the who will certainly hamper its efforts, not only for dealing with the current pandemic, but also for preventing or preparing for the next viral epidemic (mckeever 2020). earlier in april, president trump, using a korean war-era law, sought to redirect surgical masks manufactured by the us transnational firm 3m in other countries to the us, and to stop exporting masks manufactured by the company in the us (swanson et al. 2020 ). 14 the us confiscated 200,000 us-made face masks bound for germany in bangkok, and redirected them back to the us for use there, a move the german minister condemned as 'modern piracy'. 15 us buyers also offered three times more to secure face masks from china destined for france (willsher et al. 2020 when the who declared covid-19 a 'pandemic' on march 11, more than 90% of cases were in four countries (china, iran, italy and south korea), with new infections declining significantly in china and south korea, 81 countries reporting no cases, and 57 reporting 10 cases or less (world health organization 2020a). then, the who director-general (dg) expressed the hope that countries could still check the pandemic by mobilizing resources to detect, test, isolate, trace and treat those infected, quarantining them while they remain infectious. however, only a handful of east and southeast asian economies and kerala state in southwest india acted early, urgently and adequately, thus avoiding highly disruptive total lockdowns and associated human and economic costs. they also secured greater community support for containment, while minimizing draconian enforcement measures. had far more countries done so, while requiring safe physical distancing, mask wearing and other precautionary measures, the contagion could have been contained. and where communities or clusters had significant infection rates, urgent, targeted measures could have helped 'turn the tide' on covid-19 with decisive early actions, as in china, korea and vietnam, without imposing nationwide 'stay in shelter' or 'shelter in place' lockdowns, 16 or restrictions on movements of people within its borders. lulled into complacency, most others were slow to respond, with some hoping or expecting the virus would bypass them, or believing that 'herd immunity' would protect most exposed to the virus. a few headstrong, but very influential government leaders refused to acknowledge the severity of the covid-19 threat, distracting many with conspiracy theories and 'blame games', instead of quickly learning from and correcting policy errors made as new knowledge became available. in the uk, developing 'herd immunity' in the population, by allowing the epidemic to spread, prevailed as official policy until the first imperial college of london (icl) study was issued on 17 march. much harm could have been avoided if early precautionary actions had been taken. 13 more than 140 world leaders and experts signed an open letter before the world health assembly (wha) began on 18 may, calling on governments to commit to a 'people's vaccine' against covid-19, also calling for all vaccines, treatments and tests to be patent-free, mass produced, fairly distributed and available to all, in every country, free of charge https ://www.unaid s.org/en/resou rces/press centr e/ press relea seand state menta rchiv e/2020/may/20200 514_covid 19-vacci ne. accessed 21 august 2020. although the leaders of china, germany, france, norway and italy pledged at the wha to make vaccines developed in their countries a global public good, the usa remains non-committal. the united nations secretary-general also emphasized that everybody must have access to the vaccine when available. the wha unanimously acknowledged that vaccines, treatments and tests are global public goods, but was vague on the practical implications of the declaration. since then, the us, the uk, australia and other countries have signed up with the developers of 'candidate vaccines' to secure supplies for their own countries. 14 'ceasing all export of respirators produced in the united states would likely cause other countries to retaliate and do the same, as some have already done', 3 m said. 'if that were to occur, the net number of respirators being made available to the united states would actually decrease. that is the opposite of what we and the administration, on behalf of the american people, both seek' (swanson et al. 2020). 15 https ://www.bbc.com/news/world -52161 995. accessed 26 august 2020. the who maintained that physical distancing, 'effective' hand washing and related sanitary practices were the most effective, practically 'do-able' and affordable, and apparently did not want to distract from such 'non-pharmaceutical interventions'. 17 one problem has been that many people believe that wearing masks is sufficiently protective in lieu of physical distancing and hand washing. but the use of protective face masks was actively discouraged by some national authorities, citing the very same who as the policy authority. 18 the ostensible reason was to ensure adequate personal protective equipment (ppe) for 'frontline' workers, a view first associated with us presidential adviser, anthony fauci, as panic buying exhausted supplies and raised prices. thus, new infections and deaths quickly rose exponentially as the epidemic rapidly spread to other countries, especially to advanced countries in the west, better connected by passenger air travel. as developing countries struggle with inadequate vitally needed resources, many developed countries have acted in a jingoistic way by restricting exports of vital medical supplies, in contravention of the 2005 ihr and who recommendations. the principal strategy adopted by most governments is to 'flatten the curve', so that countries' health systems can cope with new infections by tracing, testing, isolating and treating those infected until an approved vaccine or 'cure' is available to all. but this is easier said than done. if testing, contact tracing and other early containment measures had been adequately done in a timely manner to stem viral transmission, nationwide lockdowns would not have been necessary, and only limited areas would have had to be locked down for quarantine purposes. the effectiveness of containment measures, including lockdowns, are typically judged primarily by their ability to quickly reduce new infections, 'flatten the curve' and avoid subsequent waves of infections. however, lockdowns can have many effects, depending on context, and typically incur huge economic costs, unevenly distributed in economies and societies. most 'casual' labourers, petty businesses reliant on daily cash turnover, and others in the 'informal' economy typically find it especially difficult to survive extended lockdowns. hence, success should not be measured by lockdown duration, enforcement stringency or even temporary declines in new cases. governments must be mindful of costs, including disruptions, and also of how policies affect various people differently. lockdowns have undoubtedly set back economic and social progress and people's welfare, but public policy should be directed to make such setbacks reversible, and to ensure they do not deliver economic 'knockouts' to the vulnerable. good planning, implementation and enforcement of movement restrictions, as well as adequate provisioning for those adversely affected, are crucial, not only for equity, efficacy and compliance, but also for transitions before, during, and after lockdowns. physical distancing, mask use and other precautionary measures, besides mass testing, tracing, isolation and treatment, have been able to check the contagion without resorting to draconian 'stay in shelter' lockdowns. such measures have been quite successful so far in much of east asia, vietnam and kerala. precautionary measures must be appropriate and affordable. those living in crammed conditions, e.g., urban slums, cannot realistically be expected to consistently practice safe distancing, but can nonetheless be enabled to sustainably take other precautionary measures within their modest means, e.g., by using washable masks or reusable shields in public areas. to minimize the risk of infection, authorities can encourage and enable, if not require, changes that demand 'physical distancing' in social interactions, including work and other public space arrangements, e.g., for offices, factories, shops, public transportation and classrooms. health systems in most developing countries are unevenly inadequate, even in normal times. despite several pandemics in recent years, most countries have remained poorly prepared, even for the specific challenges posed by covid-19. even many health systems in europe and north america have faced major shortages of doctors, respirators/ventilators, basic infection prevention (bip) gear, ppe and testing kits. 19 17 https ://apps.who.int/iris/bitst ream/handl e/10665 /33098 7/who-ncov-ipc_masks -2020.1-eng.pdf?seque nce=1&isall owed=y. accessed 21 august 2020. 18 owing to the critical shortage of medical masks, the who's initial advice was to prioritize the use of face masks for people with covid-19 symptoms, those looking after those infected and other 'frontline' personnel. the who revised its policy with new interim reccomendations on 5 june 2020, https ://www.who.int/publi catio ns/i/ item/advic e-on-the-use-of-masks -in-the-commu nity-durin g-homecare-and-in-healt hcare -setti ngs-in-the-conte xt-of-the-novel -coron aviru s-(2019-ncov)-outbr eak. a recent survey of the availability of four bip and four ppe items in seven poor countries (afghanistan, bangladesh, democratic republic of congo [drc], haiti, nepal, senegal and tanzania) found less than a third of clinics and health centres in bangladesh, the drc, nepal and tanzania had any face masks (gage and bauhoff 2020) . in all seven countries, clinics and health centres, often the first point of public contact with the health system, had, on average, just 2.3 (of four) bip items and two (of four) ppe items. most countries also scored poorly on health workers' preparedness with reference to the 2005 ihr to prevent disease spread. while the us has about 33 intensive care unit (icu) beds per 100,000 population, the ratio is around 2 per 100,000 in india, pakistan and bangladesh in south asia. in sub-saharan africa, the situation is even more dire: zambia has 0.6 icu beds per 100,000, gambia 0.4, and uganda 0.1 (malley and malley 2020) . in 43 of africa's 55 countries, total icu beds number less than 5000, or about 5 beds per million, compared with about 4000 per million in europe. there are also serious respirator shortages in africa, with 41 african countries together having fewer than 2000 as of mid-april, and ten with none at all, while the us had 170,000 respirators in mid-march (maclean and marks 2020). the average low-income country has 0.2 physicians and 1.0 nurses per thousand people, compared to 3.0 and 8.8 respectively in high-income countries (gage and bauhoff 2020) . global markets for crucial who designated covid-19 products are highly concentrated (espitia et al. 2020 ). the eu, us, china, japan and korea-account for 80% of total imports. the import shares of products needed for case management and diagnostics are even higher, close to 90%. import shares for ppe and hygiene products are somewhat lower, around 50-60%, requiring countries to compete on the basis of their respective means, regardless of need. developing countries are also extremely vulnerable to changes in exporter policies, such as export restrictions on covid-19 tests, treatments and ppe. besides affecting availability, export restrictions-supposedly due to domestic shortages-have pushed up world prices. espitia et al. (2020) estimate that current export restrictions could initially increase prices of medical masks by 20.5%, venturi masks by 9.1%, and protective equipment, such as aprons and gloves by 1% and 2% respectively. if exporting countries tighten export restrictions in response to domestic price rises, prices of such covid-19 relevant goods could rise by 23% on average; most affected would be ppe, such as aprons (52% increase) as well as goggles and masks (40% increase) (espitia et al. 2020) . therefore, as high-income countries scramble to secure crucial supplies such as face masks, low-income countries face much tougher choices. their budgets are far more limited, and they typically lack local producers for most ppe, relying on donors and multilateral organizations for procurement in the face of unreliable supply chains. the covid-19 threat to frontline health workers in lowincome countries has been largely ignored. only a small fraction of needed ppe has gone to them. the who has dispatched 0.5 million ppe sets, while unicef has dispatched 100,000 n95 masks, 4.3 million gloves and other ppe. billionaire philanthropist jack ma has donated 100,000 masks and 1000 protective suits each to every african country and 1.8 million masks to 10 asian countries (gage and bauhoff 2020) . in recent decades, developed economies, through the imf and world bank, have used aid conditionalities to demand fiscal cuts and neoliberal health reforms, e.g., by imposing user fees in developing countries (lister and labonté 2009) . instead of improving efficiency, quality and coverage, these reforms have had deleterious implications for public health, besides exacerbating inequalities in access to health care (stubbs and kentikelenis 2017; forstera et al. 2019; sobhani 2019) .their structural adjustment programmes in developing countries, particularly in africa, have resulted in underinvestment in health care systems, causing them to be poorly prepared to respond to the ebola epidemic (nkwanga 2015) . besides imf and world bank programmes, such underinvestment was also due to compromised fiscal capacities and regressive fiscal priorities (sanders et al. 2015; scott et al. 2016 ). with no known effective treatment for the infection, as the deadly nature of the virus became clear, many countries, even the world's most 'advanced' and richest, have adopted draconian measures, such as total or nationwide 'stay in shelter' lockdowns, often in panic and ignorant of other options. accustomed to adopting supposed 'best practices' prescribed by the rich and powerful, all too many developing country governments are implementing such measures without sufficiently taking into account country-specific circumstances and other challenges. besides the obvious differences between developed and developing countries, especially in terms of resources, demography, governance and other institutional capacities, there are significant differences among the developing countries themselves. in most slums and villages, many people often live together in one or two rooms, sharing common facilities. safe physical distancing is virtually impossible in such circumstances. even basic hygiene and other prescribed sanitary measures are not easy when even clean running water is scarce. 20 most of the population in many developing countries is in the informal sector, earning meagre, typically daily incomes, and with paltry savings. all too many developing countries do not have enough fiscal space to provide sufficient relief for vulnerable populations and small businesses for very long. hence, extending strict lockdown measures and causing an economy to be locked down for too long may erode public support, even if high at the outset. but as it is often too late to rely solely on early preventive and precautionary measures, authorities typically see no choice but to implement strict and effective contagion containment at the expense of disrupting livelihoods. this dilemma is often misrepresented as choosing between life and the economy. transmission patterns are determined by many factors, some social, local and intimate. international and even national public health decision makers are often oblivious to some such factors, which community members know all too well. therefore, joint learning, involving both experts and affected communities, can be vital for effective responses. brazil and peru are two of the worst hit countries in latin america, but for different reasons. while the failure in brazil has been due to complacency, denial and lack of national/ social solidarity, the peruvian setback has been due to poor design of relief measures. despite life-threatening risks, brazil's president bolsonaro chose to emulate us president trump, infamously comparing the covid-19 threat to a 'little flu' or 'cold', even dismissing it as a media-hyped 'fantasy (borges 2020) . he also dismissed preventive measures as 'hysterical' and repeatedly demanded that state governors withdraw their physical distancing and stay-in-shelter lockdown orders. displeased by his public remarks on the need for lockdowns and physical distancing, bolsonaro fired his health minister, causing outrage across brazil. lockeddown citizens of brazil protested, even charging 'bolsonaro murder' (quinn 2020) . instead of an 'all of government' approach, bolsonaro also started disputes with brazil's congress and supreme court (oliveira 2020; santos 2020; bbc news 2020) . peru, on the other hand, acted early and as decisively as argentina, but met with different outcomes. peru imposed lockdowns, closed schools and borders, cancelled international flights, and introduced relief measures. but its response was flawed as the government had not sufficiently considered the country's socio-economic conditions. for example, most poor peruvians living in slums do not have bank accounts, and had to stand long hours queuing for cash relief grants. ironically, this became a major cause of contagion (ghitis 2020) . the government's relief and preventive public health measures did not address the needs of the most vulnerable sectors of society, including the poor, self-employed, informally employed, indigenous communities and indebted middle-income households. rather, the government targeted its subsidies at large companies, who were presumed to be the major employers. its safety-net programmes were based on census and municipality records, suffering serious data deficiencies. hence, government measures barely reached those in greatest need (martínez 2020) . more than 21% of peru's population live in extreme poverty, with around 70% in the informal sector depending on daily work for their livelihoods. while poor people, especially in cities, find it almost impossible to comply with lockdown restrictions as they struggled to survive, officials and much of the media portrayed them as 'irresponsible'. trust and community support for government measures were undermined with the revelation of corruption scandals in the procurement of sanitary, protective, testing, medical and other supplies (martínez 2020) . other resource constrained developing countries, like vietnam and argentina, and india's kerala state have tackled the pandemic far more effectively, at low cost and with impressive results. some key features of their policy responses are highlighted below: the kerala state government invited religious leaders, local bodies and civil society organisations (csos) to participate in policy design and implementation. it refused to use the term 'social distancing', which has caste and class connotations, and instead emphasized 'physical distancing' as part of a more socially inclusive approach to more people-centric development practices based on social solidarity. it carefully crafted political messages, such as 'break the chain', with larger political connotations, e.g., breaking the chains of oppression and popular emancipation. instead of using the pandemic for political advantage against argentina's long history of fiercely divisive politics, president alberto fernandez invited and stood together with leaders from across the political spectrum when he announced lockdown measures on 19 march in a rare display of national political consensus (gillespie and do rosario 2020) . social, religious and business groups partnered to deliver food cartons to more than two million people in buenos aires and the surrounding areas (alcoba 2020) . the argentine national government has worked closely with opposition party state governors, as well as private and union-linked health providers to secure private cooperation without nationalization (who 2020c). fernandez organized another display of national unity to announce that argentina would not pay external creditors while dealing with the pandemic, demanding favourable debt-restructuring terms, a bold approach which appears to be working. the kerala state government mobilized more than 300,000 volunteers to help implement various infection control measures. it successfully mobilized csos to support its 'break the chain' awareness campaign, and got numerous micro-enterprises to produce hand sanitizers and face masks, while distributing interest-free loans worth 200 billion rupees to needy families (krishna 2020) . in vietnam, citizens were encouraged-via social media, text messages and tv broadcasts-to donate to the campaign to buy medical and protective equipment for doctors, nurses, police and soldiers in close contact with patients, and for those quarantined. 21 both the kerala and vietnam governments took measures to prevent stigmatization. the kerala government organized hundreds of community kitchens with the help of csos and local-level leaders to discreetly deliver free meals to those infected with the virus, without publicly identifying them to avoid possible social stigmatization (krishna 2020) . in vietnam, the identities of those infected were protected by only referring to them by their case numbers. when local businesses were reportedly ostracizing foreigners, vietnam's prime minister spoke out against such discrimination. 22 such measures encouraged people to be more open and cooperate fully in contact-tracing, testing and treatment. administrations that have successfully managed the pandemic have mobilized the all of government and demonstrated effective coordination among government departments and between their various layers. for example, the kerala government set up 18 inter-departmental committees involving all branches of government, which meet daily to evaluate the situation. vietnam's national steering committee for covid-19 prevention and control was nicknamed the 'general headquarters'-a reference to a military coordinating body in existence until the war ended in 1975. in argentina, the chief of the cabinet of ministers has responsibility for the 'general coordination unit of the comprehensive plan for the prevention of public health events of international importance'. the kerala government organized daily press conferences, when the state health minister and chief minister calmly explained what was going on and what her department was doing. communities were provided with essential epidemiological information to better understand the threat and related issues, to ensure compliance with prescribed precautionary measures and to avoid inadvertently causing panic. vietnam has not shied away from broadcasting the seriousness of the covid-19 threat, with the ministry of health's online portal immediately publicizing each new case with details including location, mode of infection and action taken. exceptionally, vietnam's communist partyled government published the identity and itinerary of a prominent party figure who had tested positive (vinh le and nguyen 2020). instead of communicating in traditionally formal ways, the government has been creative, e.g., by teaming up with two famous pop singers to produce, promote and broadcast an effectively educational song about the threat. it has also commissioned artists to create posters, and mobilized influential youth figures to broadcast supportive messages to raise the morale of those quarantined and others as appropriate (bui 2020 ). some governments and other authorities designed effective relief measures with consideration of challenges posed by specific conditions, including urban slum environments. for example, argentina's president alberto fernández ensured that no essential services-electricity, gas, water, mobile services, fixed landlines, internet and cable television-were cut for retirees, social welfare recipients and low-income households on account of non-payment of bills (sugarman 2020 ). argentina's government has devoted over us$30 million for food assistance alone. at national, provincial and municipal levels, the government has supported public kitchens, while the president has promised those in desperate circumstances the food and other resources needed to survive (alcoba 2020) . in a similar vein, the kerala state government has organized the physical delivery of food, medicine and other essentials as well as necessary services to those under lockdown (krishna 2020) . it took immediate actions to reduce the risk of hunger and starvation of the poorest segments of the population by organizing free rations for all for a month, distributing food kits, consisting of 17 items for every household, irrespective of income status (pothan et al. 2020) . kerala and vietnam have been internationally acclaimed as role models, especially as they are both considered poor, and suffering resource constraints. by acting early, decisively and inclusively, kerala and vietnam successfully avoided highly disruptive total lockdowns as well as associated human and economic costs. they achieved a high level of buy-in and popular support for their governments' covid-19 containment measures. as they achieved a high degree of voluntary compliance, draconian enforcement measures to 'flatten the curve' did not have to be imposed. while covid-19 crisis challenges are undoubtedly unique, they are not exceptional insofar as such challenges all have unique characteristics. nevertheless, the challenges have probably been far greater than for other recent epidemics, raising questions about earlier tested modes of response. full social mobilization is undoubtedly needed, but such exceptional 'emergency' or even 'wartime-like' measures must not be abused, e.g., by the temptation to skew implementation for despotic, political or pecuniary advantage. hence, success can be greatly enabled by legitimate, credible and exemplary leadership, government and otherwise. countries can have less disruptive and less costly, but yet very effective containment strategies, especially if they act early, quickly and adequately. the ability to trace and test as many suspected cases as possible, e.g., those who have recently come into close physical proximity with an infected person, is also crucial. effective containment depends heavily on voluntary compliance, and hence, community acceptance and trust, helped by transparency and shared understanding of what needs to be done. all these require state capabilities working together ('all of government') as well as credible and inclusive leadership to mobilize and co-ordinate the 'whole of society' for effective containment of contagion, as in the southwest indian state of kerala and vietnam. bbc news. 2020. brazil. federal court prohibits government from running campaign against social isolation a little flu': brazil's bolsonaro playing down corona virus crisis trump's trade policy is hampering the us fight against covid-19. peterson institute for international economics aggressive testing and pop songs: how vietnam contained the coronavirus. the guardian fighting covid-19 by truly understanding the virus. the economist trade and the covid-19 crisis in developing countries public health experts: coronavirus could overwhelm the developing world 238-6d4f-11ea-a156-0048b 62cdb 51_ story globalization and health equity: the impact of structural adjustment programs on developing countries health systems in low-income countries will struggle to protect health workers from covid-19 why even peru's top-notch plans failed to stop the coronavirus pandemic argentina sacrifices economy to ward off virus, winning praise india's kerala is combating covid-19 through participatory governance. the bullet globalization and health: pathways, evidence and policy 10 african countries have no ventilators. the new york times when the pandemic hits the most vulnerable: developing countries are hurtling toward coronavirus catastrophe peru passes coronavirus risk to working class here's what we'll lose if the u.s. cuts ties with the who covid-19 will hit the developing world's cities hardest. here's why the ebola crisis in west africa and the enduring legacy of the structural adjustment policies alexandre de moraes suspends section of mp that changed rules of the access to information law. policy controlling covid-19 will carry devastating economic cost for developing countries. conversation local food systems and covid-19; a glimpse on india's responses. fao, 22 april bolsonaro fires brazil's health minister as infections grow. foreign policy ebola epidemic exposes the pathology of the global economic and political system judge suspends bolsonaro decree that takes churches and lottery out of quarantine. conjur newsletter critiquing the response to the ebola epidemic through a primary health care approach from privatization to health system strengthening: how different international monetary fund (imf) and world bank policies impact health in developing countries international financial institutions and human rights: implications for public health argentina is showing the world what a humane covid-19 response looks like, the nation trump seeks to block 3m mask exports and grab masks from its overseas customers. the new york times how vietnam learned from china's coronavirus mistakes. the diplomat us hijacking mask shipments in rush for coronavirus protection. the guardian covid-19 will hit developing countries hard. financial times how does coronavirus compare with previous global outbreaks? the royal australian college of general practitioners service availability and readiness assessment (sara) world health organization (who). 2020a. who director-general's opening remarks at the media briefing on covid-19 world health organization (who). 2020b. rational use of personal protective equipment (ppe) for coronavirus disease (covid-19) argentina: there is no economy without health. who the article is based on authors' opinion pieces in inter press service (ips) news agency, which can be assessed at https ://www.ipsne ws.net/autho r/anis-chowd hury/; and https ://www. ipsne ws.net/autho r/jomo-kwame -sunda ram/. the authors would like to thank professor mj cardosa for her advice, comments and suggestions to improve the readability of the article, and lim siang jin for his editorial advice, but implicate neither in the final version. key: cord-102456-6jt4ksha authors: taylor-cousar, jennifer l.; maier, lisa; downey, gregory p.; wechsler, michael e. title: how i do it: restarting respiratory clinical research in the era of the covid19 pandemic date: 2020-11-13 journal: nan doi: 10.1016/j.chest.2020.11.001 sha: doc_id: 102456 cord_uid: 6jt4ksha the clinical research we do to improve our understanding of disease and development of new therapies has temporarily been paused or delayed as the global healthcare enterprise has focused its attention on those impacted by covid-19. while rates of sars-cov-2 infection are decreasing in many areas, many locations continue to have a high prevalence of infection. nonetheless, research must continue and institutions are considering approaches to re-starting non-covid related clinical investigation. those restarting respiratory research must navigate the added planning challenges that take into account outcome measures that require aerosol generating procedures. such procedures potentially increase risk of transmission of sars-cov-2 to research staff, utilize limited personal protective equipment, and require conduct in negative pressure rooms. one must also be prepared to address the potential for covid-19 resurgence. with research subject and staff safety and maintenance of clinical trial data integrity as the guiding principles, here we review key considerations and suggest a step-wise approach for resuming respiratory clinical research. clinical research is critical to our understanding of disease mechanisms and leads to life-saving therapies. during the time that worldwide efforts have been appropriately focused on describing and treating disease caused by the sars-cov-2 virus, most non-covid19 clinical research has paused and or pivoted to a covid-19 research focus. however, now that we have navigated the initial surge of sars-cov-2 cases, many are considering how to reintroduce non-covid-19 clinical research conduct while protecting participants, staff and ensuring data integrity. because of the many aerosol generating procedures (agp) that are necessary to generate critical outcomes in respiratory research (e.g. lung sampling with bronchoscopy, nasal brushing, spirometry, administration of nebulized medications, and sputum induction amongst others), the challenges to resuming clinical research in pulmonary disease are numerous, and potentially more complicated than in other areas. here we review key considerations and suggest a step-wise approach for resuming clinical research including observational research, registry trials, and interventional trials, as well as potential data confounding related to covid-19 infections that are important to consider as research studies restart and data are analyzed. in january 2020, a 63-year-old woman enrolled in an 8 week, phase 3 randomized trial with planned open label rollover. based on the increasing number of cases of covid-19 in her state, clinical research conduct was put on hold with the exception of studies that were deemed to have potential benefits to subjects. because the subject was scheduled to roll-over to open label study drug at the end of march 2020, her continued participation was agreed to have benefit. the subject's local government issued a shelter-in-place notice on march 25, 2020. this ordinance, in combination with the potential risk of infection, decreased the subject's enthusiasm to travel to the research site. development of a new process was deemed necessary to ensure her access open label study drug. to resume clinical research in the era of covid-19, several guiding principles should be followed. -research subjects must be kept safe -clinical research staff must be kept safe -the integrity of protocols, data, and outcomes must be maintained. -the process of resuming research should be flexible and dynamic, varying over time and by geography as dictated by the prevalence of covid-19, the availability of testing and personal protective equipment (ppe), and by local institutional and governmental policies. clinical research inherently has certain risks, due to either procedures or investigational agents. in the spirit of "do no harm", it is critical that institutional policies and processes are in place to ensure that there is no significant additional risk of contracting viral respiratory or other infections in the normal course of participation in research studies; now during the covid-19 pandemic, these principles are even more critical. careful consideration should be given regarding screening, enrollment, and continued protocol participation for high-risk participants. equally important, it is imperative that clinical research staff are protected from potential risks of contracting respiratory tract infections including sars-cov-2 from research subjects or individuals accompanying them. maximizing safety of all can be addressed by adopting several strategies to reduce potential exposure to those infected. covid-19 screening/testing: the first line of protection is preventing subjects and staff at risk of infection from contracting and propagating disease. while there is some risk associated with asymptomatic individuals spreading disease, the vast majority of covid-19 transmission is from symptomatic people. in that vein, all staff must self-monitor and self-report any symptoms daily. if these symptoms occur, staff must remove themselves immediately from work and from serving as vectors of infection. similarly, research subjects should be screened for symptoms in the 2-14 days before each visit to evaluate whether the subject has symptoms of covid-19, or is otherwise at high risk of being infected or infectious. this evaluation is particularly important for immunocompromised patients as they may shed virus longer. screening for symptoms should also be repeated upon arrival at the institution with both survey questions and temperature checks. symptomatic or febrile subjects must undergo covid-19 testing with research visits postponed until test results have returned and/or symptoms have resolved. whether all subjects, including asymptomatic subjects, should be tested prior to participation in research depends on several factors including local community standards of care, prevalence and testing availability including rapid turnaround time (2) . testing of some individuals before j o u r n a l p r e -p r o o f they undergo a procedure that is likely to produce a high level of aerosol generation such as bronchoscopy, should be strongly considered and has been implemented at many academic institutions (3) . at this time, sars-cov-2 antibody testing has significant limitations due to sensitivity and specificity depending on the platform, and is currently not recommended. however, as testing characteristics improve in the future, this may be helpful in evaluating the safety of research participation and potential for confounding due to covid-19 as noted below. reducing exposures with administrative and engineering controls and personal protective equipment (ppe). other measures should be taken to reduce potential exposure, including directing access of participants strictly to entrances where monitoring stations are present, limiting or avoiding visitors accompanying participants, minimizing the number or duration of participant visits, using remote monitoring such as telehealth if possible, and staggering participant visits to reduce exposures. additional administrative measures to reduce exposures include limiting non-essential/non-research staff interactions with participants and research areas, and limiting research staff from directly interacting with participants; the latter will also conserve ppe. these preventive measures can be done by managing access to research units, developing one way hallways for 6-minute walk testing and using plexiglass/plastic barriers and good ventilation in areas when staff and or participants are in close proximity. furthermore, staff and participants should be safely positioned in workplaces and research areas to optimize social distancing. adherence to centers for disease control (cdc), professional society and/or local and state guidelines and policies should be followed for allocation of ppe for research, with priority of allocation for use in clinical care. as outlined by the cdc, central purchase and storage of ppe may be considered to ensure adequate supplies as well as conservation of ppe, especially for face masks and protective eyewear (e.g. face shields, safety glasses and goggles). participants and research staff should be educated in the appropriate use of ppe, including donning and doffing and exposure reduction measures. all must be required to wear face masks or surgical masks as well as protective eyewear for study personnel if available to reduce the spread of infectious droplets and aerosols. aerosol generating procedures, including pulmonary function testing, exhaled nitric oxide measurement, sputum induction, nasopharyngeal sampling, laryngoscopy, and bronchoscopy require additional ppe, inclusive of at least an n95 filtering facepiece respirator (ffr) and a face shield or a controlled air purifying respirator (capr), gown and gloves. while the occupational safety and health administration (osha) has currently waived the yearly fit testing requirement for ffrs, this testing is necessary if it has not been done recently. the agps should be performed with appropriate engineering controls, including negative pressure and increased air exchanges and filtration, allowing appropriate time for air clearance between procedures, as well as donning and doffing of ppe. scheduling patients' visits must include consideration of ppe, as well as air clearance, required intensified sanitization of the room and or equipment; consideration should be given to limit the number of visits occurring at any given time and to space out participant visits. environmental sampling for sars-cov2 virus should be considered to evaluate exposures and cleaning and disinfection processes. as an example, surface sampling based on world health organization (4) or other methods could be considered in potential areas of exposure, including rooms in which agps are performed as well as the equipment used for testing. viral sampling of air in examination and j o u r n a l p r e -p r o o f procedure rooms, and uv light decontamination of rooms and surfaces may be considered using routine industrial hygiene techniques depending on available resources and expertise. a key principle of clinical research is ensuring protocol and data integrity to maximize the generalizability of clinical trial/study results including the endpoints, efficacy, and safety of studied interventions. research goals include timely recruitment, proper adherence to protocolspecified procedures, high retention of participants, and proper statistical analyses to avoid undue loss of statistical power and increased risk of bias due to informative missing data. fleming et al recently recommended several strategies to protect scientific integrity (5). these approaches include potentially delaying or pausing enrollment, pre-specifying analyses to address effects of the pandemic on trial integrity, and addressing analytical issues such as missing data with validated statistical approaches. considerations for remote study visits: another consideration is to modify protocols to accomplish study goals without interfering with the spirit of the study. these modifications may involve reconsideration of the necessity of all study visits and procedures. in that regard, one could consider implementing telehealth, home health visits and smart technology to facilitate clinical research. prior to the pandemic, the use of telehealth and home outcome assessment (e.g. spirometry, sputum collection and even patient reported outcomes) were limited. the rapid deployment of these clinical tools has allowed their application to clinical research studies, and in some cases ensuring the continued conduct of study consent, safety visits and assessments, and collection of outcome measurements. based on the positive reception from trial participants, it is anticipated that, as in clinical care, telehealth and home assessment options will continue to be incorporated into clinical trials subsequent to the pandemic. the standardization of acquisition and reproducibility of home measurements for cross-sectional and longitudinal studies will need to be established. for example, increased variability in home spirometry measurements may lead to the need to increase sample size to maintain adequate study power to detect differences in outcomes. use of research coordinator tele-coaching for the maneuver could improve reproducibility. as another example, collection of a sputum sample at home by the participant could be inadequate, or the sample could be lost in transit, thus increasing the work of study statisticians to account for missing data points. furthermore, assessment of physical exam findings is limited to those that can be ascertained by observation, and may limit recording of study-related adverse events. on the other hand, use of telehealth for clinical research may increase access to research for potential participants who have previously avoided participation because of time and/or distance from the research site. sponsors and investigators will need to find the balance between access to study participation and the current limitations of telehealth and accuracy of home outcome measures. 1). the impact on other assays, such as genomic, epigenetic or immunologic and the duration of the impact is unknown, but is likely to occur with the potential for extensive impact on the immune system (7) and needs to be considered in analyses. finally, for multi-center studies, the variance in regional allowance of on-site visits and study procedures will need to be considered and the resulting bias adjusted for in data analysis. in addition, consideration may be given to modifying the study procedures to minimize risk. for example, if repeated agps are required to obtain specimens from bronchoscopy, induced sputum or nasopharyngeal sampling, limiting the number of these procedures if required over multiple time points, or pairing with blood specimens to allow comparisons and or allowing studies to substitute collection of specimens with lower risk of viral transmission more frequently might be an option. ensuring use of leftover specimens from procedures being done for clinical purposes and limiting control participant procedures or number are other possibilities. the processing of the specimens needs to be considered as a risk of exposure to staff and some centers have used heat or uv light inactivation of biofluid samples or chemical inactivation (e.g. placement of blood, nasal or bronchial epithelial cells directly into acid-guanidinium-phenol based reagent such as trizol or other virus-inactivating medium) for genomic studies to minimize the possibility of viral exposure. propagation of respiratory epithelial cells collected from a sars-cov-2 infected individual in submerged or air-liquid interface culture may result in generation of high viral titers and should be done under biosafety level-3 (bsl-3) conditions. ideally participants and/or their cells should be tested for sars-cov-2 prior to propagation of respiratory cells in culture. j o u r n a l p r e -p r o o f as each clinical research unit contemplates the approach to re-starting non-covid clinical research at its institution, guidelines from the national, regional and local level should be considered well in advance to allow appropriate preparations to be completed ( figure 1 ). as described above, center for disease control (cdc) (8) recommendations should be considered in establishing return to clinical research approaches in the health care setting and or other setting. institutional and local mandates: the establishment of crisis standards of care in hospitals (e.g. temporary restrictions on elective procedures), as well as at-home isolation orders and travel restrictions for state citizens are impacted by regional variation in leadership and rates of sars-cov-2 infection. similarly, the rescinding of such mandates is not uniform across the country and must be considered to determine not only when participants may travel to the research site for visits, but also when research sponsors and monitors can begin study initiation and oversight. the interpretation of city/state mandates by each institution will also dictate the revision of pandemic policies that restrict clinical study activity, including the conduct of outcome measures that result from agps and require ppe. changes made to protocols must be passed by local and central irbs/ethics committees as well as granting agencies and or sponsors as appropriate. federal guidance: both the fda and national institutes of health (nih) have issued publicly available recommendations (1,9) regarding conduct of research in the setting of the covid-19 pandemic. in the midst of the pandemic, the nih suggested limitation of study visits to those needed for participant safety or those that would be coincident with clinical care, to consideration of the conduct of virtual visits, use of local laboratories for safety monitoring, limitation of unnecessary travel and the cancellation of large gatherings. in acknowledgement of the potential pandemic-related delays in research progress and the incurrence of unanticipated costs, the nih will allow for project extensions and requests for administrative supplements in some cases. similar to the approach of the nih, the fda guidance has used patient safety as the overarching principle to guide recommendations. adherence to good clinical practice (gcp) and minimizing risks to trial integrity are also required. fda guidance encourages sponsors to work closely with investigators and independent ethics committees to determine in which situations subjects' participation in a trial will continue or be paused. furthermore, sponsors and investigators are advised to work closely with institutional review boards to address urgent or emergent changes to the protocol or informed consent that resulted from the pandemic, and to prospectively define procedures to prioritize reporting of protocol deviations that may impact participant safety. necessary protocol modifications that will impact efficacy assessments, data management and statistical analysis plans, should be discussed with the applicable review division. as with all fda research conduct, documentation of changes and their rationale remains critical during the pandemic including changes that "impact on the informed consent process, study visits and procedures, data collection, study monitoring, adverse event reporting, and changes in investigator(s), site staff, and/or monitor(s) secondary to travel restrictions, quarantine measures, or covid-19 illness itself." with the restart of clinical research, reversal of temporary changes must occur and be documented, including updates to study status on clinicaltrials.gov. finally, when submitting clinical trial study reports to the fda, sponsors will need to address the impact of the covid-19 pandemic on the reported safety and efficacy results. in order to re-start clinical trials/studies put on hold as a result of the pandemic, and to prepare for the start of new trials, one should consider implementing a multi-stage, risk-based approach that continues to emphasize participant and staff safety ( table 2 ). in each stage, one should consider the pre-pandemic status of the trial (active or in the study initiation phase), the location of the participant (local versus out of state requiring travel), and most importantly, the procedures that will be associated with the visit. unlike research in many other fields, respiratory clinical trials often include a large number of potential and known agps that are used as primary or secondary efficacy measures and outcomes, including spirometry, induced sputum, nasal potential difference, cardiopulmonary exercise tests, laryngoscopy and bronchoscopy amongst others. as outlined above, the availability of negative pressure rooms, ppe fit-tested staff, adequate well-ventilated space for social distancing of returning staff, safe specimen processing areas, disinfection protocols, and availability of ppe must be established before progression to subsequent re-opening stages. to insure that each of the guiding principles has been considered prior to re-starting clinical research, we created the following checklists: research participant and staff safety establish guidelines for location of specimen processing based on source (lowrisk versus known sars-cov-2 infected subjects and their bodily fluids) ensure laboratory processing space meets safety guidelines for processing of biological specimens re-design 6mwt area to ensure social distancing between subjects/staff re-evaluate study design and ability to use lower risk procedures and/or samples such as peripheral blood cells versus bronchoalveolar lavage cells or change in study timepoints protocol integrity discuss all potential protocol modifications with sponsor, whether federal and or industry, as well as the institutional review board report any pandemic-related unanticipated events and protocol deviations to the sponsor/irb establish sop for conducting research telehealth visits establish process for shipping of investigational product, home testing kits (e.g. urine, sputum) submit protocol modifications to institutional review board/data monitoring committee/fda/nih update clintrials.gov with protocol modifications/enrollment holds (if indicated) contact sponsor (nih, foundation, etc.) to establish impact on study funding flexibility weekly covid planning/update meetings with research managers and medical director to review local case data, changes in state/federal/institutional guidelines weekly review of environmental testing of clinical research areas by medical director adjust newly established sops as indicated by changing case data and state/federal/institutional guidelines clear plan for regular communication to investigators regarding the move forward through stages of re-opening (or cessation of research based on increased infection rates/lack of ppe and/or testing capabilities) this year has taught all of us that flexibility and adaptability are critical aspects of navigating the uncertainties caused by the pandemic. thus, timelines for progressing to the next stage must be adjusted for subject and staff safety based on successful transition through the previous stage. successful transition will include objective measurements, such as the absence of positive sars-cov-2 environmental testing on the clinical research unit, absence of covid related adverse outcomes in research subjects (e.g. positive testing for sars-cov-2 after contact with an asymptomatic but subsequently positive member of the research staff), or local outbreaks of disease in the community. changes in the availability of adequate ppe could also delay the transition from one stage to the next. other considerations moving forward will include the criteria that would lead to another clinical research pause if there is a substantial resurgence of sars-cov-2 infections. this may include rates of covid-19 positive infections, hospital and icu capacity, availability of ppe, participant willingness to continue to be involved in research, and movement to crisis standards of care to name a few. these measures should be discussed and outlined ahead of time so that reversion to a prior stage or staying at a current stage can be clear and transparent for staff and participants. this pandemic has taught us that we may need to consider not just sars-cov-2 infection, but also more closely scrutinize the impact of confounding by other respiratory viruses and infections in many of our vulnerable patient populations as the 'cold and flu season' comes upon us. in order for the subject to remain in the study and continue in the open label arm, the sponsor was contacted to discuss and approve the plan to obtain the minimum required safety tests (urine pregnancy test, complete metabolic panel and complete blood count) at the subject's home, to conduct consent by telephone, and to ship the investigational product to the subject's home. the sponsor reviewed federal drug administration (fda) covid-19 guidelines (1), and submitted the necessary changes to the central institutional review board. at the time of the subsequent scheduled follow-up safety visit, telehealth was in place and the subject accepted the option of a visit via telehealth with a home nurse visit to draw safety laboratory values versus an on-site visit. after the sponsor was notified that research spirometry could not be performed per institutional policy, the subject was provided with a home spirometer from the sponsor. if aerosol generating procedures are able to be performed at the time of her next scheduled safety visit, the subject will be given the option of a remote visit, with blood draw and home spirometry, or an on-site visit with spirometry performed in office or at home prior to the visit. throughout the subject's participation in clinical research during the pandemic, she expressed her appreciation for the opportunity to continue in the study from which she believed she was benefiting, with minimal risk of exposure to infection from sars-cov-2. in sum, while the world has appropriately focused on combating covid-19 for the last several months, we are all now shifting our focus to the resumption of clinical care and clinical research under new circumstances. the main priority in clinical research conduct should continue to be the safety of participants, while also considering the safety of staff and data integrity of trials. flexibility, creativity, vigilance and resilience will be critical aspects of restoring and reinventing clinical research participation, and of designing and conducting the trials of the future. public health emergency guidance for industry, investigators, and institutional review boards recommendation from european respiratory group 9.1 (respiratory function technologists/scientists): lung function testing during covid-19 pandemic and beyond the use of bronchoscopy during the covid-19 pandemic: chest/aabip guideline surface sampling of coronavirus disease (covid-19): a practical "how to" protocol for health care and public health professionals. version 1 conducting clinical research during the covid-19 pandemic protecting scientific integrity pulmonary fibrosis secondary to covid-19: a call to arms? immunology of covid-19: current state of the science guidance for nih-funded clinical trials and human subjects studies affected by covid-19 clinical trials press on for conditions other than covid-19. will the pandemic's effects sneak into their data? capr-controlled air purifying respirator cdc-centers for disease control fda -federal drug administration gcp-good clinical practice ffr-filtering facepiece respirator mbw-multiple breath washout nih-national institutes of health no-nitric oxide npd-nasal potential difference, osha-occupational safety and health administration key: cord-025623-1v9614f8 authors: mahapatra, pallab sinha; chatterjee, souvick; tiwari, manish k.; ganguly, ranjan; megaridis, constantine m. title: surface treatments to enhance the functionality of ppes date: 2020-05-29 journal: trans indian natl doi: 10.1007/s41403-020-00110-0 sha: doc_id: 25623 cord_uid: 1v9614f8 the outbreak of unknown viral pneumonia in wuhan china in december 2019 led to a new coronavirus (sars-cov-2), which attracted worldwide attention, with the related covid-19 disease quickly becoming a global pandemic. in about 5 months, this disease has led to ~ 4 million cases and claimed more than 200 k deaths as a result of its highly contagious nature. the present understanding is that sars-cov-2 is a type of influenza virus that can be transmitted through respiratory droplets and aerosols; lewis (nature 580:175, 2020). the primary methodology to prevent the spreading of this disease has been “social distancing” and usage of personal protective equipment (ppe) at the front lines of healthcare and other critical operations. the scale of the disease has led to unprecedented demand for ppes and increased functionality of the same. this paper focuses on improving ppe functionality in a scalable manner by surface treatment and coating with appropriate materials and other functional enhancements, such as exposure to uv rays or other sterilizing agents (e.g., hydrogen peroxide). viral diseases frequently wreak havoc on public health by bringing inordinate numbers of patients to health care facilities within short time periods. the last 23 years have seen a rampage of several viral pandemics, like the severe acute respiratory syndrome coronavirus (sars-cov) in 2002 -2003 , the h1n1 influenza in 2009, the middle east respiratory syndrome coronavirus (mers-cov) in 2012, and just recently, sars-cov-2 (coronavirus disease 2019). this new virus appears to be highly contagious and has spread globally in record time. when the virus led to 118,000 cases in 114 countries and over 4000 deaths, the world health organization (who) declared covid-19 a pandemic; cascella et al. (2020) . this novel virus is believed to have originated from the wuhan district of china, and the first cases were linked to direct exposure traced to huanan seafood wholesale market of wuhan, hinting towards the animal-human transmission (chan et al. 2020). however, soon it was realized that the virus could be transmitted human-to-human, and symptomatic people became the primary source of covid-19 spread. like other respiratory pathogens, including flu and rhinovirus, the transmission is believed to occur through respiratory droplets from coughing, talking, and sneezing (lewis 2020) . such respiratory droplets are > 5-10 µm in diameter and are the primary source of transmission after a who study of 75,465 cases led to the dismissal of the possibility of airborne transmission. van doremalen et al. (2020) identified that aerosol transmission of sars-cov-2 is possible, and the virus may remain viable in the aerosol for hours. they also mentioned that sars-cov-2 could survive on different surfaces up to a few days. the transmissibility of a virus is quantified by its basic reproduction rate (r 0 ); r 0 > 1 implies the number infected is likely to increase, whereas r 0 < 1 signifies transmission to die down gradually. recent studies have shown that for covid-19, the estimates of r 0 ranged from 1.4 to 6.49, with a mean of 3.28, a median of 2.79, and interquartile range (iqr) of 1.16 . countries like india, which has a population of 1.37 billion and a 2019 population growth rate of 1.08%, are at high risk of such disease transmission. as a means of reducing such transmission, a critical component is the use of personal protective equipment (ppe), as recommended by who (2020a) . in this work, we intend to provide an overview of coatings and treatments that can be used to enhance the functionality of existing ppes or can provide antiviral properties, as demonstrated by other researchers as well as our research groups. to meet the high demand for ppes with proper functionality in such a pandemic situation, we also review easy-to-use coating methodologies, which we have demonstrated earlier in unrelated studies. as per the who guidelines, ppe is one of the most effective measures to avoid direct contamination from highly infectious pathogens, like sars-cov-2. the personal protection is critical for healthcare workers or any person who works in the high-risk zone of contagion. the complete ppe kit includes a face shield, goggles, mask, gloves, gowns/ coveralls, head and shoe covers (who 2020b; mohfw 2020). these ppes are also useful in protection from disease-causing microbes (e.g., viruses, bacteria, fungi, etc.) in general. different components of ppe generally consist of different materials. for example, polycarbonate (pc) or cellulose acetate (ca) is typically used for the face shield, non-woven polypropylene fibers for masks, impermeable fabrics for shoe and headcovers. whereas, gowns/coveralls are made up of materials that are impermeable to blood or other body fluids; mohfw (2020). surface treatments to enhance resistance against diseasecausing microbes, i.e., antimicrobial coatings, have the potential to improve ppe functionalities dramatically. over the last few decades, considerable research effort was made to incorporate antimicrobial coatings on the surfaces of various objects, such as garments and medical devices. given the understandable concerns regarding drug resistance of these pathogens, commonly referred to as antimicrobial resistance (amr), nanomaterial-based antimicrobial treatments are of particular interest. bacteria have a very high tendency to develop amr, whereby they become resistant to antibiotic drugs. ravindra et al. (2010) fabricated antibacterial cotton fibers using silver nanoparticle coatings. the schematic of the coating process is shown in fig. 1 . they used 1 mm-thick cotton fibers and immersed them in silver nitrate-containing leaf-extracted solution. the hydroxyl groups of the leaf extracts (polysaccharides) reduced the silver nitrate into silver nanoparticles on the cotton fibers. they used gram-negative escherichia coli (e. coli) bacteria to confirm the antibacterial activity of such cotton fibers and found excellent antibacterial properties of the cotton fibers even after several washing cycles. such nanosilverbased materials may also provide antiviral features. another complementary strategy comprises rendering the surfaces superhydrophobic. the repellence of the water droplets carrying the virus can give further improvement. the combined properties would hinder the penetration of respiratory droplets, thus facilitating virus containment. hydrophobic coatings make it difficult for droplets/particles to adhere on surfaces and are known to provide antimicrobial characteristics, which are retained after multiple washes; antibacterial and antifungal properties were demonstrated by mukherjee et al. (2008) . klibanov's group at mit has shown extended functionality of hydrophobic coating characteristics against influenza viruses, which get transmitted through respiratory droplets, like sars-cov-2; halder et al. (2008) . the mechanism by which hydrophobization fig. 1 antibacterial silver nanoparticle coating on cotton fibers. e. citriodora (neelagiri) and f. bengalensis (marri) leaf extract were used in the study of ravindra et al. (2010) inactivates the virus has been described in detail by hsu et al. (2011) . addressing the issue of creating hydrophobic coatings, berendjchi et al. (2011) fabricated antibacterial cotton fabrics using copper nanoparticles and superhydrophobic coatings. they used a sol-gel method to make the cotton surface superhydrophobic. quan et al. (2017) used an evaporation-induced salt recrystallization method to create a virus inactivation system. they tested these salt-coated filters as a means against influenza viruses. several nanoparticle-based coatings are also used as antimicrobial coatings. compared to other nanoparticles like cu, cuo, ag, si, zno 2 , etc., titanium dioxide (tio 2 ) nanoparticles provide superior photocatalytic activities. it has been shown earlier that tio 2 -coated surfaces have excellent antimicrobial properties; wei et al. (2014) . due to photocatalytic activity, the antimicrobial performance of the tio 2 -coated surfaces rises in the presence of sunlight; wei et al. (2014) . while typical uv (sunlight) is also known for its antibacterial properties, the photocatalytic activity of tio 2 is especially noteworthy because of its wettability characteristics in addition to its enhanced antibacterial and antiviral action. the photocatalytic properties of tio 2 have been exhaustively characterized by nasikhuddin et al. (2018) who showed significant degradation of methylene blue on a tio 2 coating exposed to uv, as compared to an identical control surface that was not exposed to uv. in prior work, we have demonstrated a facile and scalable method of producing tio 2 nanoparticle coatings. we have examined coating performance on paper-based substrates , non-woven materials (sen et al. 2018 ) as well as polyethylene terephthalate (pet) substrates (morrissette et al. 2017) , or even by electrodeposition on a metal-wire mesh (ghosh et al. 2020) . as reported in morrissette et al. (2017) , to prepare a typical dispersion, we used 1 g tio 2 nanoparticles (< 25 nm, anatase; sigma-aldrich) in 13.25 g of ethanol (200 proof; decan labs). the solution was mixed by stirring and then probe-sonicated with 1000 j energy (750 w, 13 mm probe dia., 40% amplitude; sonics & materials, inc., model vcx-750). 1.25 g of perfluoroalkyl methacrylate copolymer (pmc) (20 wt% in water; dupont, capstone st-100) was added to the tio 2 -ethanol mixture, and the dispersion was left for 24 h to stabilize. after that, 10 min of bath sonication was required before spraying to the substrate. the substrate was heated for 2 h at 80 °c to produce the micro/nano hierarchical superhydrophobic (contact angle * water ∼ 160 • ± 2 • ) coating. it is noted that upon uv exposure, the surface becomes more antimicrobial as well as less hydrophobic. depending on the uv-exposure time, the wettability, as well as the antimicrobial properties, increases gradually. spray or dip coating methods can alternatively be used to apply this coating on the ppe. the above methodology offers a simple, scalable procedure for producing antiviral coatings, to relieve the unprecedented demand for ppes in the present time of distress. additionally, it is crucial to have biodegradable ppes to reduce impact on the environment. the coating methodology described earlier is biocompatible. during the pandemic situation, who has provided a guideline for reusing the disposable as well as reusable ppes; who (2020a). further, for reusing the ppes prepared using the above methods, durability studies are required along with the identification of suitable binder polymers. scalable surface treatment strategies that combine antiviral action with liquid-repelling properties are one of many possible approaches to enhance the functionality of ppes, thereby serving to satisfy their high demand in the healthcare industry and other fronts where the covid-19 pandemic is being fought. we propose a low-cost coating approach that produces water-repellent coatings with additional sanitizing features due to the incorporation of a photocatalytic agent that is widely available commercially. fabrication of superhydrophobic and antibacterial surface on cotton fabric by doped silica-based sols with nanoparticles of copper a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster precise liquid transport on and through thin porous materials photocatalytic activity of electrophoretically deposited tio 2 and zno nanoparticles on fog harvesting meshes hydrophobic polycationic coatings inactivate wild-type and zanamivir-and/or oseltamivir-resistant human and avian influenza viruses mechanism of inactivation of influenza viruses by immobilized hydrophobic polycations is the coronavirus airborne? experts can't agree the reproductive number of covid-19 is higher compared to sars coronavirus rapid, self-driven liquid mixing on open-surface microfluidic platforms practical aspects of hydrophobic polycationic bactericidal "paints study on photocatalytic properties of tio 2 nanoparticle in various ph condition universal and reusable virus deactivation system for respiratory protection fabrication of antibacterial cotton fibres loaded with silver nanoparticles via "green approach surface-wettability patterning for distributing high-momentum water jets on porous polymeric substrates aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 photocatalytic tio 2 nanoparticles enhanced polymer antimicrobial coating catio nsdetai l/ratio nal-use-of-perso nal-prote ctive -equip ment-for-coron aviru s-disea se-(covid -19)-and-consi derat ions-durin g-sever e-short ages world health organization (2020) personal protective equipment publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements we acknowledge the scheme for promotion of academic and research collaboration (sparc) program (project: p644) from the ministry of human resource development, government of india and the associated ukieri support. key: cord-276758-k2imddzr authors: siegel, jane d.; rhinehart, emily; jackson, marguerite; chiarello, linda title: 2007 guideline for isolation precautions: preventing transmission of infectious agents in health care settings date: 2007-12-07 journal: am j infect control doi: 10.1016/j.ajic.2007.10.007 sha: doc_id: 276758 cord_uid: k2imddzr nan . clinical syndromes or conditions warranting additional empiric transmission-based precautions pending confirmation of diagnosis table 3 . infection control considerations for highpriority (cdc category a) diseases that may result from bioterrorist attacks or are considered bioterrorist threats table 4 . recommendations for application of standard precautions for the care of all patients in all health care settings table 5 . components of a protective environment 1. the transition of health care delivery from primarily acute care hospitals to other health care settings (eg, home care, ambulatory care, freestanding specialty care sites, long-term care) created a need for recommendations that can be applied in all health care settings using common principles of infection control practice, yet can be modified to reflect setting-specific needs. accordingly, the revised guideline addresses the spectrum of health care delivery settings. furthermore, the term ''nosocomial infections'' is replaced by ''health care-associated infections'' (hais), to reflect the changing patterns in health care delivery and difficulty in determining the geographic site of exposure to an infectious agent and/ or acquisition of infection. 2. the emergence of new pathogens (eg, severe acute respiratory syndrome coronavirus [sars-cov] associated with sars avian influenza in humans), renewed concern for evolving known pathogens (eg, clostridium difficile, noroviruses, communityassociated methicillin-resistant staphylococcus aureus [ca-mrsa]), development of new therapies (eg, gene therapy), and increasing concern for the threat of bioweapons attacks, necessitates addressing a broader scope of issues than in previous isolation guidelines. 3. the successful experience with standard precautions, first recommended in the 1996 guideline, has led to a reaffirmation of this approach as the foundation for preventing transmission of infectious agents in all health care settings. new additions to the recommendations for standard precautions are respiratory hygiene/cough etiquette and safe injection practices, including the use of a mask when performing certain highrisk, prolonged procedures involving spinal canal punctures (eg, myelography, epidural anesthesia). the need for a recommendation for respiratory hygiene/cough etiquette grew out of observations during the sars outbreaks, when failure to implement simple source control measures with patients, visitors, and health care workers (hcws) with respiratory symptoms may have contributed to sars-cov transmission. the recommended practices have a strong evidence base. the continued occurrence of outbreaks of hepatitis b and hepatitis c viruses in ambulatory settings indicated a need to reiterate safe injection practice recommendations as part of standard precautions. the addition of a mask for certain spinal injections grew from recent evidence of an associated risk for developing meningitis caused by respiratory flora. 4. the accumulated evidence that environmental controls decrease the risk of life-threatening fungal infections in the most severely immunocompromised patients (ie, those undergoing allogeneic hematopoietic stem cell transplantation [hsct] ) led to the update on the components of the protective environment (pe). 5. evidence that organizational characteristics (eg, nurse staffing levels and composition, establishment of a safety culture) influence hcws' adherence to recommended infection control practices, and thus are important factors in preventing transmission of infectious agents, led to a new emphasis and recommendations for administrative involvement in the development and support of infection control programs. 6. continued increase in the incidence of hais caused by multidrug-resistant organisms (mdros) in all health care settings and the expanded body of knowledge concerning prevention of transmission of mdros created a need for more specific recommendations for surveillance and control of these pathogens that would be practical and effective in various types of health care settings. this document is intended for use by infection control staff, health care epidemiologists, health care administrators, nurses, other health care providers, and persons responsible for developing, implementing, and evaluating infection control programs for health care settings across the continuum of care. the reader is referred to other guidelines and websites for more detailed information and for recommendations concerning specialized infection control problems. part i reviews the relevant scientific literature that supports the recommended prevention and control practices. as in the 1996 guideline, the modes and factors that influence transmission risks are described in detail. new to the section on transmission are discussions of bioaerosols and of how droplet and airborne transmission may contribute to infection transmission. this became a concern during the sars outbreaks of 2003, when transmission associated with aerosol-generating procedures was observed. also new is a definition of ''epidemiologically important organisms'' that was developed to assist in the identification of clusters of infections that require investigation (ie multidrug-resistant organisms, c difficile). several other pathogens of special infection control interest (ie, norovirus, sars, centers for disease control and prevention [cdc] category a bioterrorist agents, prions, monkeypox, and the hemorrhagic fever viruses) also are discussed, to present new information and infection control lessons learned from experience with these agents. this section of the guideline also presents information on infection risks associated with specific health care settings and patient populations. part ii updates information on the basic principles of hand hygiene, barrier precautions, safe work practices, and isolation practices that were included in previous guidelines. however, new to this guideline is important information on health care system components that influence transmission risks, including those components under the influence of health care administrators. an important administrative priority that is described is the need for appropriate infection control staffing to meet the ever-expanding role of infection control professionals in the complex modern health care system. evidence presented also demonstrates another administrative concern: the importance of nurse staffing levels, including ensuring numbers of appropriately trained nurses in intensive care units (icus) for preventing hais. the role of the clinical microbiology laboratory in supporting infection control is described, to emphasize the need for this service in health care facilities. other factors that influence transmission risks are discussed, including the adherence of hcws to recommended infection control practices, organizational safety culture or climate, and education and training. discussed for the first time in an isolation guideline is surveillance of health care-associated infections. the information presented will be useful to new infection control professionals as well as persons involved in designing or responding to state programs for public reporting of hai rates. part iii describes each of the categories of precautions developed by the health care infection control practices advisory committee (hicpac) and the cdc and provides guidance for their application in various health care settings. the categories of transmission-based precautions are unchanged from those in the 1996 guideline: contact, droplet, and airborne. one important change is the recommendation to don the indicated personal protective equipment (ppe-gowns, gloves, mask) on entry into the patient's room for patients who are on contact and/or droplet precautions, because the nature of the interaction with the patient cannot be predicted with certainty, and contaminated environmental surfaces are important sources for transmission of pathogens. in addition, the pe for patients undergoing allogeneic hsct, described in previous guidelines, has been updated. five tables summarize important information. table 1 provides a summary of the evolution of this document. table 2 gives guidance on using empiric isolation precautions according to a clinical syndrome. table 3 summarizes infection control recommendations for cdc category a agents of bioterrorism. table 4 lists the components of standard precautions and recommendations for their application, and table 5 lists components of the pe. a glossary of definitions used in this guideline also is provided. new to this edition of the guideline is a figure showing the recommended sequence for donning and removing ppe used for isolation precautions to optimize safety and prevent self-contamination during removal. appendix a provides an updated alphabetical list of most infectious agents and clinical conditions for which isolation precautions are recommended. a preamble to the appendix provides a rationale for recommending the use of 1 or more transmission-based precautions in addition to standard precautions, based on a review of the literature and evidence demonstrating a real or potential risk for person-to-person transmission in health care settings. the type and duration of recommended precautions are presented, with additional comments concerning the use of adjunctive measures or other relevant considerations to prevent transmission of the specific agent. relevant citations are included. new to this guideline is a comprehensive review and detailed recommendations for prevention of transmission of mdros. this portion of the guideline was published electronically in october 2006 and updated in november 2006 (siegel jd, rhinehart e, jackson m, chiarello l and hicpac. management of multidrug-resistant organisms in health care settings, 2006; available from http://www.cdc.gov/ ncidod/dhqp/pdf/ar/mdroguideline2006.pdf), and is considered a part of the guideline for isolation precautions. this section provides a detailed review of the complex topic of mdro control in health care settings and is intended to provide a context for evaluation of mdro at individual health care settings. a rationale and institutional requirements for developing an effective mdro control program are summarized. although the focus of this guideline is on measures to prevent transmission of mdros in health care settings, information concerning the judicious use of antimicrobial agents also is presented, because such practices are intricately related to the size of the reservoir of mdros, which in turn influences transmission (eg, colonization pressure). two tables summarize recommended prevention and control practices using 7 categories of interventions to control mdros: administrative measures, education of hcws, judicious antimicrobial use, surveillance, infection control precautions, environmental measures, and decolonization. recommendations for each category apply to and are adapted for the various health care settings. with the increasing incidence and prevalence of mdros, all health care facilities must prioritize effective control of mdro transmission. facilities should identify prevalent mdros at the facility, implement control measures, assess the effectiveness of control programs, and demonstrate decreasing mdro rates. a set of intensified mdro prevention interventions is to be added if the incidence of transmission of a target mdro is not decreasing despite implementation of basic mdro infection control measures, and when the first case of an epidemiologically important mdro is identified within a health care facility. this updated guideline responds to changes in health care delivery and addresses new concerns about transmission of infectious agents to patients and hcws in the united states and infection control. the primary objective of the guideline is to improve the safety of the nation's health care delivery system by reducing the rates of hais. instruct symptomatic persons to cover mouth/nose when sneezing/ coughing; use tissues and dispose in no-touch receptacle; observe hand hygiene after soiling of hands with respiratory secretions; wear surgical mask if tolerated or maintain spatial separation, .3 feet if possible. *during aerosol-generating procedures on patients with suspected or proven infections transmitted by respiratory aerosols (eg, severe acute respiratory syndrome), wear a fittested n95 or higher respirator in addition to gloves, gown, and face/eye protection. -proper construction of windows, doors, and intake and exhaust ports -ceilings: smooth, free of fissures, open joints, crevices -walls sealed above and below the ceiling -if leakage detected, locate source and make necessary repairs d ventilation to maintain $12 air changes/hour d directed air flow; air supply and exhaust grills located so that clean, filtered air enters from one side of the room, flows across the patient's bed, and exits on opposite side of the room d positive room air pressure in relation to the corridor; pressure differential of .2.5 pa (0.01-inch water gauge) d air flow patterns monitored and recorded daily using visual methods (eg, flutter strips, smoke tubes) or a hand-held pressure gauge d self-closing door on all room exits d back-up ventilation equipment (eg, portable units for fans or filters) maintained for emergency provision of ventilation requirements for pe areas, with immediate steps taken to restore the fixed ventilation system d for patients who require both a pe and an airborne infection isolation room (aiir), use an anteroom to ensure proper air balance relationships and provide independent exhaust of contaminated air to the outside, or place a hepa filter in the exhaust duct. (2) reaffirm standard precautions as the foundation for preventing transmission during patient care in all health care settings; (3) reaffirm the importance of implementing transmission-based precautions based on the clinical presentation or syndrome and likely pathogens until the infectious etiology has been determined ( table 2) ; and (4) provide epidemiologically sound and, whenever possible, evidence-based recommendations. this guideline is designed for use by individuals who are charged with administering infection control programs in hospitals and other health care settings. the information also will be useful for other hcws, health care administrators, and anyone needing information about infection control measures to prevent transmission of infectious agents. commonly used abbreviations are provided, and terms used in the guideline are defined in the glossary. medline and pubmed were used to search for relevant studies published in english, focusing on those published since 1996. much of the evidence cited for preventing transmission of infectious agents in health care settings is derived from studies that used ''quasiexperimental designs,'' also referred to as nonrandomized preintervention and postintervention study designs. 2 although these types of studies can provide valuable information regarding the effectiveness of various interventions, several factors decrease the certainty of attributing improved outcome to a specific intervention. these include: difficulties in controlling for important confounding variables, the use of multiple interventions during an outbreak, and results that are explained by the statistical principle of regression to the mean (eg, improvement over time without any intervention). 3 observational studies remain relevant and have been used to evaluate infection control interventions. 4, 5 the quality of studies, consistency of results, and correlation with results from randomized controlled trials, when available, were considered during the literature review and assignment of evidencebased categories (see part iv: recommendations) to the recommendations in this guideline. several authors have summarized properties to consider when evaluating studies for the purpose of determining whether the results should change practice or in designing new studies. 2,6,7 this guideline contains 4 changes in terminology from the 1996 guideline: 1. the term ''nosocomial infection'' is retained to refer only to infections acquired in hospitals. the term ''health care-associated infection'' (hai) is used to refer to infections associated with health care delivery in any setting (eg, hospitals, long-term care facilities, ambulatory settings, home care). this term reflects the inability to determine with certainty where the pathogen was acquired, because patients may be colonized with or exposed to potential pathogens outside of the health care setting before receiving health care, or may develop infections caused by those pathogens when exposed to the conditions associated with delivery of health care. in addition, patients frequently move among the various settings within the health care system. 8 of infectious agents, a susceptible host with a portal of entry receptive to the agent, and a mode of transmission for the agent. this section describes the interrelationship of these elements in the epidemiology of hais. i.b.1. sources of infectious agents. infectious agents transmitted during health care derive primarily from human sources but inanimate environmental sources also are implicated in transmission. human reservoirs include patients, [20] [21] [22] [23] [24] [25] [26] [27] [28] hcws, 17, [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] and household members and other visitors. [40] [41] [42] [43] [44] [45] such source individuals may have active infections, may be in the asymptomatic and/or incubation period of an infectious disease, or may be transiently or chronically colonized with pathogenic microorganisms, particularly in the respiratory and gastrointestinal tracts. other sources of hais are the endogenous flora of patients (eg, bacteria residing in the respiratory or gastrointestinal tract). [46] [47] [48] [49] [50] [51] [52] [53] [54] i.b.2. susceptible hosts. infection is the result of a complex interrelationship between a potential host and an infectious agent. most of the factors that influence infection and the occurrence and severity of disease are related to the host. however, characteristics of the host-agent interaction as it relates to pathogenicity, virulence, and antigenicity also are important, as are the infectious dose, mechanisms of disease production, and route of exposure. 55 there is a spectrum of possible outcomes after exposure to an infectious agent. some persons exposed to pathogenic microorganisms never develop symptomatic disease, whereas others become severely ill and even die. some individuals are prone to becoming transiently or permanently colonized but remain asymptomatic. still others progress from colonization to symptomatic disease either immediately after exposure or after a period of asymptomatic colonization. the immune state at the time of exposure to an infectious agent, interaction between pathogens, and virulence factors intrinsic to the agent are important predictors of an individual's outcome. host factors such as extremes of age and underlying disease (eg, diabetes 56,57 , human immunodeficiency virus/acquired immune deficiency syndrome [hiv/ aids], 58,59 malignancy, and transplantation 18, 60, 61 ) can increase susceptibility to infection, as can various medications that alter the normal flora (eg, antimicrobial agents, gastric acid suppressors, corticosteroids, antirejection drugs, antineoplastic agents, immunosuppressive drugs). surgical procedures and radiation therapy impair defenses of the skin and other involved organ systems. indwelling devices, such as urinary catheters, endotracheal tubes, central venous and arterial catheters, [62] [63] [64] and synthetic implants, facilitate development of hais by allowing potential pathogens to bypass local defenses that ordinarily would impede their invasion and by providing surfaces for development of biofilms that may facilitate adherence of microorganisms and protect from antimicrobial activity. 65 some infections associated with invasive procedures result from transmission within the health care facility; others arise from the patient's endogenous flora. 46 clothing, uniforms, laboratory coats, or isolation gowns used as ppe may become contaminated with potential pathogens after care of a patient colonized or infected with an infectious agent, (eg, mrsa, 88 vancomycin-resistant enterococci [vre], 89 and c difficile 90 ). although contaminated clothing has not been implicated directly in transmission, the potential exists for soiled garments to transfer infectious agents to successive patients. i.b.3.b. droplet transmission. droplet transmission is technically a form of contact transmission; some infectious agents transmitted by the droplet route also may be transmitted by direct and indirect contact routes. however, in contrast to contact transmission, respiratory droplets carrying infectious pathogens transmit infection when they travel directly from the respiratory tract of the infectious individual to susceptible mucosal surfaces of the recipient, generally over short distances, necessitating facial protection. respiratory droplets are generated when an infected person coughs, sneezes, or talks 91, 92 or during such procedures as suctioning, endotracheal intubation, [93] [94] [95] [96] cough induction by chest physiotherapy, 97 and cardiopulmonary resuscitation. 98, 99 evidence for droplet transmission comes from epidemiologic studies of disease outbreaks, [100] [101] [102] [103] from experimental studies, 104 and from information on aerosol dynamics. 91, 105 studies have shown that the nasal mucosa, conjunctivae, and, less frequently, the mouth are susceptible portals of entry for respiratory viruses. 106 the maximum distance for droplet transmission is currently unresolved; pathogens transmitted by the droplet route have not been transmitted through the air over long distances, in contrast to the airborne pathogens discussed below. historically, the area of defined risk has been a distance of , 3 feet around the patient, based on epidemiologic and simulated studies of selected infections. 103, 104 using this distance for donning masks has been effective in preventing transmission of infectious agents through the droplet route. however, experimental studies with smallpox 107,108 and investigations during the global sars outbreaks of 2003 101 suggest that droplets from patients with these 2 infections could reach persons located 6 feet or more from their source. it is likely that the distance that droplets travel depends on the velocity and mechanism by which respiratory droplets are propelled from the source, the density of respiratory secretions, environmental factors (eg, temperature, humidity), and the pathogen's ability to maintain infectivity over that distance. 105 thus, a distance of , 3 feet around the patient is best considered an example of what is meant by ''a short distance from a patient'' and should not be used as the sole criterion for determining when a mask should be donned to protect from droplet exposure. based on these considerations, it may be prudent to don a mask when within 6 to 10 feet of the patient or on entry into the patient's room, especially when exposure to emerging or highly virulent pathogens is likely. more studies are needed to gain more insight into droplet transmission under various circumstances. droplet size is another variable under investigation. droplets traditionally have been defined as being . 5 mm in size. droplet nuclei (ie, particles arising from desiccation of suspended droplets) have been associated with airborne transmission and defined as , 5 mm in size, 105 a reflection of the pathogenesis of pulmonary tuberculosis that is not generalizeable to other organisms. observations of particle dynamics have demonstrated that a range of droplet sizes, including those of diameter $ 30 mm, can remain suspended in the air. 109 the behavior of droplets and droplet nuclei affect recommendations for preventing transmission. whereas fine airborne particles containing pathogens that are able to remain infective may transmit infections over long distances, requiring aiir to prevent its dissemination within a facility; organisms transmitted by the droplet route do not remain infective over long distances and thus do not require special air handling and ventilation. examples of infectious agents transmitted through the droplet route include b pertussis, 110 influenza virus, 23 adenovirus, 111 rhinovirus, 104 mycoplasma pneumoniae, 112 sars-cov, 21, 96, 113 group a streptococcus, 114 and neisseria meningitides. 95, 103, 115 although rsv may be transmitted by the droplet route, direct contact with infected respiratory secretions is the most important determinant of transmission and consistent adherence to standard precautions plus contact precautions prevents transmission in health care settings. 24, 116, 117 rarely, pathogens that are not transmitted routinely by the droplet route are dispersed into the air over short distances. for example, although s aureus is transmitted most frequently by the contact route, viral upper respiratory tract infection has been associated with increased dispersal of s aureus from the nose into the air for a distance of 4 feet under both outbreak and experimental conditions; this is known as the ''cloud baby'' and ''cloud adult'' phenomenon. [118] [119] [120] i.b.3.c. airborne transmission. airborne transmission occurs by dissemination of either airborne droplet nuclei or small particles in the respirable size range containing infectious agents that remain infective over time and distance (eg, spores of aspergillus spp and m tuberculosis). microorganisms carried in this manner may be dispersed over long distances by air currents and may be inhaled by susceptible individuals who have not had face-to-face contact with (or even been in the same room with) the infectious individual. [121] [122] [123] [124] preventing the spread of pathogens that are transmitted by the airborne route requires the use of special air handling and ventilation systems (eg, aiirs) to contain and then safely remove the infectious agent. 11, 12 infectious agents to which this applies include m tuberculosis, 124-127 rubeola virus (measles), 122 and varicella-zoster virus (chickenpox). 123 in addition, published data suggest the possibility that variola virus (smallpox) may be transmitted over long distances through the air under unusual circumstances, and aiirs are recommended for this agent as well; however, droplet and contact routes are the more frequent routes of transmission for smallpox. 108, 128, 129 in addition to aiirs, respiratory protection with a national institute for occupational safety and health (niosh)-certified n95 or higher-level respirator is recommended for hcws entering the aiir, to prevent acquisition of airborne infectious agents such as m tuberculosis. 12 for certain other respiratory infectious agents, such as influenza 130, 131 and rhinovirus, 104 and even some gastrointestinal viruses (eg, norovirus 132 and rotavirus 133 ) , there is some evidence that the pathogen may be transmitted through small-particle aerosols under natural and experimental conditions. such transmission has occurred over distances . 3 feet but within a defined air space (eg, patient room), suggesting that it is unlikely that these agents remain viable on air currents that travel long distances. aiirs are not routinely required to prevent transmission of these agents. additional issues concerning small-particle aerosol transmission of agents that are most frequently transmitted by the droplet route are discussed below. although sars-cov is transmitted primarily by contact and/or droplet routes, airborne transmission over a limited distance (eg, within a room) has been suggested, although not proven. [134] [135] [136] [137] [138] [139] [140] [141] this is true of other infectious agents as well, such as influenza virus 130 and noroviruses. 132, 142, 143 influenza viruses are transmitted primarily by close contact with respiratory droplets, 23, 102 and acquisition by hcws has been prevented by droplet precautions, even when positive-pressure rooms were used in one center. 144 however, inhalational transmission could not be excluded in an outbreak of influenza in the passengers and crew of an aircraft. 130 observations of a protective effect of ultraviolet light in preventing influenza among patients with tuberculosis during the influenza pandemic of 1957-1958 have been used to suggest airborne transmission. 145, 146 in contrast to the strict interpretation of an airborne route for transmission (ie, long distances beyond the patient room environment), short-distance transmission by small-particle aerosols generated under specific circumstances (eg, during endotracheal intubation) to persons in the immediate area near the patient also has been demonstrated. aerosolized particles , 100 mm in diameter can remain suspended in air when room air current velocities exceed the terminal settling velocities of the particles. 109 sars-cov transmission has been associated with endotracheal intubation, noninvasive positive pressure ventilation, and cardiopulmonary resuscitation. 93, 94, 96, 98, 141 although the most frequent routes of transmission of noroviruses are contact and foodborne and waterborne routes, several reports suggest that noroviruses also may be transmitted through aerosolization of infectious particles from vomitus or fecal material. 142, 143, 147, 148 it is hypothesized that the aerosolized particles are inhaled and subsequently swallowed. roy this conceptual framework can explain rare occurrences of airborne transmission of agents that are transmitted most frequently by other routes (eg, smallpox, sars, influenza, noroviruses). concerns about unknown or possible routes of transmission of agents associated with severe disease and no known treatment often result in the adoption of overextreme prevention strategies, and recommended precautions may change as the epidemiology of an emerging infection becomes more well defined and controversial issues are resolved. i.b.3.d.ii. transmission from the environment. some airborne infectious agents are derived from the environment and do not usually involve person-to-person transmission; for example, anthrax spores present in a finely milled powdered preparation can be aerosolized from contaminated environmental surfaces and inhaled into the respiratory tract. 150, 151 spores of environmental fungi (eg, aspergillus spp) are ubiquitous in the environment and may cause disease in immunocompromised patients who inhale aerosolized spores (through, eg, construction dust). 152, 153 as a rule, neither of these organisms is subsequently transmitted from infected patients; however, there is 1 well-documented report of person-to-person transmission of aspergillus sp in the icu setting that was most likely due to the aerosolization of spores during wound debridement. 154 the pe involves isolation practices designed to decrease the risk of exposure to environmental fungal agents in allogeneic hsct patients. 11, 14, 15, [155] [156] [157] [158] environmental sources of respiratory pathogens (eg, legionella) transmitted to humans through a common aerosol source is distinct from direct patient-to-patient transmission. i.b.3.e. other sources of infection. sources of infection transmission other than infectious individuals include those associated with common environmental sources or vehicles (eg, contaminated food, water, or medications, such as intravenous fluids). although aspergillus spp have been recovered from hospital water systems, 159 the role of water as a reservoir for immunosuppressed patients remains unclear. vectorborne transmission of infectious agents from mosquitoes, flies, rats, and other vermin also can occur in health care settings. prevention of vectorborne transmission is not addressed in this document. this section discusses several infectious agents with important infection control implications that either were not discussed extensively in previous isolation s80 vol. 35 no. 10 supplement 2 guidelines or have emerged only recently. included are epidemiologically important organisms (eg, c difficile), agents of bioterrorism, prions, sars-cov, monkeypox, noroviruses, and the hemorrhagic fever viruses (hfvs). experience with these agents has broadened the understanding of modes of transmission and effective preventive measures. these agents are included for information purposes and, for some (ie, sars-cov, monkeypox), to highlight the lessons that have been learned about preparedness planning and responding effectively to new infectious agents. i.c.1. epidemiologically important organisms. under defined conditions, any infectious agent transmitted in a health care setting may become targeted for control because it is epidemiologically important. c difficile is specifically discussed below because of its current prevalence and seriousness in us health care facilities. in determining what constitutes an ''epidemiologically important organism,'' the following criteria apply: d a propensity for transmission within health care facilities based on published reports and the occurrence of temporal or geographic clusters of more than 2 patients, (eg, c difficile, norovirus, rsv, influenza, rotavirus, enterobacter spp, serratia spp, group a streptococcus). a single case of health care-associated invasive disease caused by certain pathogens (eg, group a streptococcus postoperatively, 160 in a burn unit, 161 or in a ltcf; 162 legionella spp, 14, 163 aspergillus spp 164 ) is generally considered a trigger for investigation and enhanced control measures because of the risk of additional cases and the severity of illness associated with these infections. i.c.1.a. clostridium difficile. c difficile is a sporeforming gram-positive anaerobic bacillus that was first isolated from stools of neonates in 1935 165 and identified as the most frequent causative agent of antibioticassociated diarrhea and pseudomembranous colitis in 1977. 166 this pathogen is a major cause of health care-associated diarrhea and has been responsible for many large outbreaks in health care settings that have proven extremely difficult to control. important factors contributing to health care-associated outbreaks include environmental contamination, persistence of spores for prolonged periods, resistance of spores to routinely used disinfectants and antiseptics, hand carriage by hcws to other patients, and exposure of patients to frequent courses of antimicrobial agents. 167 antimicrobials most frequently associated with increased risk of c difficile include third-generation cephalosporins, clindamycin, vancomycin, and fluoroquinolones. since 2001, outbreaks and sporadic cases of c difficile with increased morbidity and mortality have occurred in several us states, canada, england, and the netherlands. [168] [169] [170] [171] [172] the same strain of c difficile has been implicated in all of these outbreaks; 173 this strain, toxinotype iii, north american pulsedfield gel electrophoresis (pfge) type 1, and polymerase chain reaction (pcr)-ribotype 027 (nap1/027), has been found to hyperproduce toxin a (a 16-fold increase) and toxin b (a 23-fold increase) compared with isolates from 12 other pfge types. a recent survey of us infectious disease physicians found that 40% of the respondents perceived recent increases in the incidence and severity of c difficile disease. 174 standardization of testing methodology and surveillance definitions is needed for accurate comparisons of trends in rates among hospitals. 175 it is hypothesized that the incidence of disease and apparent heightened transmissibility of this new strain may be due, at least in part, to the greater production of toxins a and b, increasing the severity of diarrhea and producing more environmental contamination. considering the greater morbidity, mortality, length of stay, and costs associated with c difficile disease in both acute care and long-term care facilities, control of this pathogen is becoming increasingly important. prevention of transmission focuses on syndromic application of contact precautions for patients with diarrhea, accurate identification of affected patients, environmental measures (eg, rigorous cleaning of patient rooms), and consistent hand hygiene. using soap and water rather than alcohol-based handrubs for mechanical removal of spores from hands and using a bleachcontaining disinfectant (5000 ppm) for environmental disinfection may be valuable in cases of transmission in health care facilities. appendix a provides for recommendations. i.c.1.b. multidrug-resistant organisms. in general, mdros are defined as microorganisms-predominantly bacteria-that are resistant to 1 or more classes of antimicrobial agents. 176 although the names of certain mdros suggest resistance to only a single agent (eg, mrsa, vre), these pathogens are usually resistant to all but a few commercially available antimicrobial agents. this latter feature defines mdros that are considered to be epidemiologically important and deserve special attention in health care facilities. 177 other mdros of current concern include multidrug-resistant streptococcus pneumoniae, which is resistant to penicillin and other broad-spectrum agents such as macrolides and fluroquinolones, multidrug-resistant gram-negative bacilli (mdr-gnb), especially those producing esbls; and strains of s aureus that are intermediate or resistant to vancomycin (ie, visa and vrsa). mdros are transmitted by the same routes as antimicrobial susceptible infectious agents. patient-to-patient transmission in health care settings, usually via hands of hcws, has been a major factor accounting for the increase in mdro incidence and prevalence, especially for mrsa and vre in acute care facilities. [199] [200] [201] preventing the emergence and transmission of these pathogens requires a comprehensive approach that includes administrative involvement and measures (eg, nurse staffing, communication systems, performance improvement processes to ensure adherence to recommended infection control measures), education and training of medical and other hcws, judicious antibiotic use, comprehensive surveillance for targeted mdros, application of infection control precautions during patient care, environmental measures (eg, cleaning and disinfection of the patient care environment and equipment, dedicated single-patient use of noncritical equipment), and decolonization therapy when appropriate. the prevention and control of mdros is a national priority, one that requires that all health care facilities and agencies assume responsibility and participate in community-wide control programs. 176, 177 a detailed discussion of this topic and recommendations for prevention published in 2006 is available at http:// www.cdc.gov/ncidod/dhqp/pdf/ar/mdroguideline2006. pdf. i.c.2. agents of bioterrorism. the cdc has designated the agents that cause anthrax, smallpox, plague, tularemia, viral hemorrhagic fevers, and botulism as category a (high priority), because these agents can be easily disseminated environmentally and/or transmitted from person to person, can cause high mortality and have the potential for major public health impact, might cause public panic and social disruption, and necessitate special action for public health preparedness. 202 general information relevant to infection control in health care settings for category a agents of bioterrorism is summarized in table 3 . (see http:// www.bt.cdc.gov for additional, updated category a agent information as well as information concerning category b and c agents of bioterrorism and updates.) category b and c agents are important but are not as readily disseminated and cause less morbidity and mortality than category a agents. health care facilities confront a different set of issues when dealing with a suspected bioterrorism event compared with other communicable diseases. an understanding of the epidemiology, modes of transmission, and clinical course of each disease, as well as carefully drafted plans that specify an approach and relevant websites and other resources for disease-specific guidance to health care, administrative, and support personnel, are essential for responding to and managing a bioterrorism event. infection control issues to be addressed include (1) identifying persons who may be exposed or infected; (2) preventing transmission among patients, hcws, and visitors; (3) providing treatment, chemoprophylaxis, or vaccine to potentially large numbers of people; (4) protecting the environment, including the logistical aspects of securing sufficient numbers of aiirs or designating areas for patient cohorts when an insufficient number of aiirs is available; (5) providing adequate quantities of appropriate ppe; and (6) identifying appropriate staff to care for potentially infectious patients (eg, vaccinated hcws for care of patients with smallpox). the response is likely to differ for exposures resulting from an intentional release compared with a naturally occurring disease because of the large number of persons that can be exposed at the same time and possible differences in pathogenicity. various sources offer guidance for the management of persons exposed to the most likely agents of bioterrorism. federal agency websites (eg, http://www. usamriid.army.mil/publications/index.html and http:// www.bt.cdc.gov) and state and county health department websites should be consulted for the most upto-date information. sources of information on specific agents include anthrax, 203 smallpox, [204] [205] [206] plague, 207,208 botulinum toxin, 209 tularemia, 210 and hemorrhagic fever viruses. 211, 212 i.c.2.a. pre-event administration of smallpox (vaccinia) vaccine to health care workers. vaccination of hcwsl in preparation for a possible smallpox exposure has important infection control implications. [213] [214] [215] these include the need for meticulous screening for vaccine contraindications in persons at increased risk for adverse vaccinia events; containment and monitoring of the vaccination site to prevent transmission in the health care setting and at home; and management of patients with vaccinia-related adverse events. 216, 217 the pre-event us smallpox vaccination program of 2003 is an example of the effectiveness of carefully developed recommendations for both screening potential vaccinees for contraindications and vaccination site care and monitoring. between december 2002 and february 2005, approximately 760,000 individuals were vaccinated in the department of defense and 40,000 in the civilian or public health populations, including approximately 70,000 who worked in health care settings. no cases of eczema vaccinatum, progressive vaccinia, fetal vaccinia, or contact transfer of vaccinia were reported in health care settings or in military workplaces. 218, 219 outside the health care setting, there were 53 cases of contact transfer from military vaccinees to close personal contacts (eg, bed partners or contacts during participation in sports such as wrestling 220 ). all contact transfers were from individuals who were not following recommendations to cover their vaccination sites. vaccinia virus was confirmed by culture or pcr in 30 cases, 2 of which resulted from tertiary transfer. all recipients, including 1 breast-fed infant, recovered without complications. subsequent studies using viral culture and pcr techniques have confirmed the effectiveness of semipermeable dressings to contain vaccinia. [221] [222] [223] [224] this experience emphasizes the importance of ensuring that newly vaccinated hcws adhere to recommended vaccination site care, especially those caring for high-risk patients. recommendations for pre-event smallpox vaccination of hcws and vacciniarelated infection control recommendations are published in the morbidity and mortality weekly report, 216, 225 with updates posted on the cdc's bioterrorism website. 205 i.c.3. prions. creutzfeldt-jakob disease (cjd) is a rapidly progressive, degenerative neurologic disorder of humans, with an incidence in the united states of approximately 1 person/million population/year. 226, 227 cjd is believed to be caused by a transmissible proteinaceous infectious agent known as a prion. infectious prions are isoforms of a host-encoded glycoprotein known as the prion protein. the incubation period (ie, time between exposure and and onset of symptoms) varies from 2 years to many decades. however, death typically occurs within 1 year of the onset of symptoms. approximately 85% of cjd cases occur sporadically with no known environmental source of infection, and 10% of cases are familial. iatrogenic transmission has occurred, with most cases resulting from treatment with human cadaver pituitary-derived growth hormone or gonadotropin, 228, 229 from implantation of contaminated human dura mater grafts, 230 or from corneal transplants. 231 transmission has been linked to the use of contaminated neurosurgical instruments or stereotactic electroencephalogram electrodes. [232] [233] [234] [235] prion diseases in animals include scrapie in sheep and goats, bovine spongiform encephalopathy (bse, or ''mad cow disease'') in cattle, and chronic wasting disease in deer and elk. 236 bse, first recognized in the united kingdom in 1986, was associated with a major epidemic among cattle that had consumed contaminated meat and bone meal. the possible transmission of bse to humans causing variant cjd (vcjd) was first described in 1996 and was subsequently found to be associated with consumption of bse-contaminated cattle products primarily in the united kingdom. there is strong epidemiologic and laboratory evidence for a causal association between the causative agent of bse and vcjd. 237 although most cases of vcjd have been reported from the united kingdom, a few cases also have been reported from europe, japan, canada, and the united states. most persons affected with vcjd worldwide lived in or visited the united kingdom during the years of a large outbreak of bse (1980) (1981) (1982) (1983) (1984) (1985) (1986) (1987) (1988) (1989) (1990) (1991) (1992) (1993) (1994) (1995) (1996) and may have consumed contaminated cattle products during that time (see http://www.cdc.gov/ncidod/ diseases/cjd/cjd.htm). although there has been no indigenously acquired vcjd in the united states, the sporadic occurrence of bse in cattle in north america has heightened awareness of the possibility that such infections could occur and have led to increased surveillance activities. updated information may be found at http://www.cdc.gov/ncidod/diseases/cjd/cjd.htm. the public health impact of prion diseases has been reviewed previously. 238 vcjd in humans has different clinical and pathologic characteristics than sporadic or classic cjd, 239 including (1) younger median age at death (28 [range, 16 to 48] vs 68 years), (2) longer median duration of illness (14 months vs 4 to 6 months), (3) increased frequency of sensory symptoms and early psychiatric symptoms with delayed onset of frank neurologic signs; and (4) detection of prions in tonsillar and other lymphoid tissues, not present in sporadic cjd. 240 similar to sporadic cjd, there have been no reported cases of direct human-tohuman transmission of vcjd by casual or environmental contact, droplet, or airborne routes. ongoing blood safety surveillance in the united states has not detected sporadic cjd transmission through blood transfusion; 241-243 however, bloodborne transmission of vcjd is believed to have occurred in 2 patients in the uited kingdom. 244, 245 the following fda websites provide information on steps currently being taken in the united states to protect the blood supply from cjd and vcjd: http://www.fda.gov/cber/gdlns/cjdvcjd.htm and http:// www.fda.gov/cber/gdlns/cjdvcjdq&a.htm. standard precautions are used when caring for patients with suspected or confirmed cjd or vcjd. however, special precautions are recommended for tissue handling in the histology laboratory and for conducting an autopsy, embalming, and coming into contact with a body that has undergone autopsy. 246 recommendations for reprocessing surgical instruments to prevent transmission of cjd in health care settings have been published by the world health organization (who) and are currently under review at the cdc. questions may arise concerning notification of patients potentially exposed to cjd or vcjd through contaminated instruments and blood products from patients with cjd or vcjd or at risk of having vcjd. the risk of transmission associated with such exposures is believed to be extremely low but may vary based on the specific circumstance. therefore, consultation on appropriate options is advised. the united kingdom has developed several documents that clinicians and patients in the united states may find useful (see http://www.hpa.org.uk/infections/topics_az/cjd/ information_documents.htm). i.c.4. severe acute respiratory syndrome. sars is a newly discovered respiratory disease that emerged in china late in 2002 and spread to several countries. 135, 140 in particular, mainland china, hong kong, hanoi, singapore, and toronto have been significantly affected. sars is caused by sars-cov, a previously unrecognized member of the coronavirus family. 247, 248 the incubation period from exposure to the onset of symptoms is typically 2 to 7 days, but can be as long as 10 days and in rare cases even longer. 249 the illness is initially difficult to distinguish from other common respiratory infections. signs and symptoms usually include fever above 38.08c and chills and rigors, sometimes accompanied by headache, myalgia, and mild to severe respiratory symptoms. a radiographic profile of atypical pneumonia is an important clinical indicator of possible sars. compared with adults, children are affected less frequently, have milder disease, and are less likely to transmit sars-cov. 135, [249] [250] [251] the overall case fatality rate is approximately 6%; underlying disease and advanced age increase the risk of mortality (see http://www.who.int/csr/sarsarchive/2003_05_07a/en/). outbreaks in health care settings, with transmission to large numbers of hcws and patients, haa been a striking feature of sars; undiagnosed infectious patients and visitors have been important initiators of these outbreaks. 21, [252] [253] [254] the relative contribution of potential modes of transmission is not known precisely. there is ample evidence for droplet and contact transmission; 96, 101, 113 however, opportunistic airborne transmission cannot be excluded. 101, [135] [136] [137] [138] [139] 149, 254 for example, exposure to aerosol-generating procedures (eg, endotracheal intubation, suctioning) has been associated with transmission of infection to large numbers of hcws outside of the united states. 93, 94, 96, 98, 253 therefore, aerosolization of small infectious particles generated during these and other similar procedures could be a risk factor for transmission to others within a multibed room or shared airspace. a review of the infection control literature generated from the sars outbreaks of 2003 concluded that the greatest risk of transmission is to those who have close contact, are not properly trained in use of protective infection control procedures, and do not consistently use ppe, and that n95 or higher-level respirators may offer additional protection to those exposed to aerosol-generating procedures and high-risk activities. 255, 256 organizational and individual factors that affect adherence to infection control practices for sars also were identified. 256 control of sars requires a coordinated, dynamic response by multiple disciplines in a health care setting. 9 early detection of cases is accomplished by screening persons with symptoms of a respiratory infection for history of travel to areas experiencing community transmission or contact with sars patients, followed by implementation of respiratory hygiene/cough etiquette (ie, placing a mask over the patient's nose and mouth) and physical separation from other patients in common waiting areas. the precise combination of precautions to protect hcws has not yet been determined. at the time of this publication, the cdc recommends standard precautions, with emphasis on the use of hand hygiene; contact precautions, with emphasis on environmental cleaning due to the detection of sars-cov rna by pcr on surfaces in rooms occupied by sars patients; 138, 254, 257 and airborne precautions, including use of fit-tested niosh-approved n95 or higher-level respirators and eye protection. 258 in hong kong, the use of droplet and contact precautions, including the use of a mask but not a respirator, was effective in protecting hcws. 113 however, in toronto, consistent use of an n95 respirator was found to be slightly more protective than a mask. 93 it is noteworthy that no transmission of sars-cov to public hospital workers occurred in vietnam despite inconsistent use of infection control measures, including use of ppe, which suggests other factors (eg, severity of disease, frequency of high-risk procedures or events, environmental features) may influence opportunities for transmission. 259 sars-cov also has been transmitted in the laboratory setting through breaches in recommended laboratory practices. research laboratories in which sars-cov was under investigation were the source of most cases reported after the first series of outbreaks in the winter and spring of 2003. 260 lessons learned from the sars outbreaks are useful in devising plans to respond to future public health crises, such as pandemic influenza and bioterrorism events. surveillance for cases among patients and hcws, ensuring availability of adequate supplies and staffing, and limiting access to health care facilities were important factors in the response to sars. 9 guidance for infection control precautions in various settings is available at http://www.cdc.gov/ncidod/sars. i.c.5. monkeypox. monkeypox is a rare viral disease found mostly in the rain forest countries of central and west africa. the disease is caused by an orthopoxvirus that is similar in appearance to smallpox but causes a milder disease. the only recognized outbreak of human monkeypox in the united states was detected in june 2003, after several people became ill after contact with sick pet prairie dogs. infection in the prairie dogs was subsequently traced to their contact with a shipment of animals from africa, including giant gambian rats. 262 this outbreak demonstrates the importance of recognition and prompt reporting of unusual disease presentations by clinicians to enable prompt identification of the etiology, as well as the potential of epizootic diseases to spread from animal reservoirs to humans through personal and occupational exposure. 263 only limited data on transmission of monkeypox are available. transmission from infected animals and humans is believed to occur primarily through direct contact with lesions and respiratory secretions; airborne transmission from animals to humans is unlikely but cannot be excluded, and may have occurred in veterinary practices (eg, during administration of nebulized medications to ill prairie dogs 264 ). in humans, 4 instances of monkeypox transmission in hospitals have been reported in africa among children, usually related to sharing the same ward or bed. 265, 266 additional recent literature documents transmission of congo basin monkeypox in a hospital compound for an extended number of generations. 267 there has been no evidence of airborne or any other person-to-person transmission of monkeypox in the united states, and no new cases of monkeypox have been identified since the outbreak in june 2003. 268 the outbreak strain is a clade of monkeypox distinct from the congo basin clade and may have different epidemiologic properties (including human-to-human transmission potential) from monkeypox strains of the congo basin; 269 this awaits further study. smallpox vaccine is 85% protective against congo basin monkeypox. 270 because there is an associated case fatality rate of , 10%, administration of smallpox vaccine within 4 days to individuals who have had direct exposure to patients or animals with monkeypox is a reasonable policy. 271 for the most current information on monkeypox, see http://www.cdc.gov/ncidod/mon keypox/clinicians.htm. i.c.6. noroviruses. noroviruses, formerly referred to as norwalk-like viruses, are members of the caliciviridae family. these agents are transmitted via contaminated food or water and from person to person, causing explosive outbreaks of gastrointestinal disease. 272 environmental contamination also has been documented as a contributing factor in ongoing transmission during outbreaks. 273, 274 although noroviruses cannot be propagated in cell culture, dna detection by molecular diagnostic techniques has brought a greater appreciation of their role in outbreaks of gastrointestinal disease. 275 reported outbreaks in hospitals, 132 148 and large crowded shelters established for hurricane evacuees 285 has demonstrated their highly contagious nature, their potentially disruptive impact in health care facilities and the community, and the difficulty of controlling outbreaks in settings in which people share common facilites and space. of note, there is nearly a 5-fold increase in the risk to patients in outbreaks when a patient is the index case compared with exposure of patients during outbreaks when a staff member is the index case. 286 the average incubation period for gastroenteritis caused by noroviruses is 12 to 48 hours, and the clinical course lasts 12 to 60 hours. 272 illness is characterized by acute onset of nausea, vomiting, abdominal cramps, and/or diarrhea. the disease is largely self-limited; rarely, death due to severe dehydration can occur, particularly in elderly persons with debilitating health conditions. the epidemiology of norovirus outbreaks shows that even though primary cases may result from exposure to a fecally contaminated food or water, secondary and tertiary cases often result from person-to-person transmission facilitated by contamination of fomites 272, 287 and dissemination of infectious particles, especially during the process of vomiting. 132, 142, 143, 147, 148, 272, 278, 279 widespread, persistent, and inapparent contamination of the environment and fomites can make outbreaks extremely difficult to control. 147, 274, 283 these clinical observations and the detection of norovirus dna on horizontal surfaces 5 feet above the level that might be touched normally suggest that under certain circumstances, aerosolized particles may travel distances beyond 3 feet. 147 it is hypothesized that infectious particles may be aerosolized from vomitus, inhaled, and swallowed. in addition, individuals who are responsible for cleaning the environment may be at increased risk of infection. development of disease and transmission may be facilitated by the low infectious dose (ie, , 100 viral particles) 288 and the resistance of these viruses to the usual cleaning and disinfection agents (ie, they may survive , 10 ppm chlorine). [289] [290] [291] an alternate phenolic agent that was shown to be effective against feline calicivirus was used for environmental cleaning in one outbreak. 275, 292 there are insufficient data to determine the efficacy of alcohol-based hand rubs against noroviruses when the hands are not visibly soiled. 293 absence of disease in certain individuals during an outbreak may be explained by protection from infection conferred by the b histo-blood group antigen. 294 consultation on outbreaks of gastroenteritis is available through the cdc's division of viral and rickettsial diseases. 295 i.c.7. hemorrhagic fever viruses. hfv is a mixed group of viruses that cause serious disease with high fever, skin rash, bleeding diathesis, and, in some cases, high mortality; the resulting disease is referred to as viral hemorrhagic fever (vhf). among the more commonly known hfvs are ebola and marburg viruses (filoviridae), lassa virus (arenaviridae), crimean-congo hemorrhagic fever and rift valley fever virus (bunyaviridae), and dengue and yellow fever viruses (flaviviridae). 212, 296 these viruses are transmitted to humans through contact with infected animals or via arthropod vectors. although none of these viruses is endemic in the united states, outbreaks in affected countries provide potential opportunities for importation by infected humans and animals. furthermore, there is a concern that some of these agents could be used as bioweapons. 212 person-to-person transmission has been documented for ebola, marburg, lassa, and crimean-congo hfvs. in resource-limited health care settings, transmission of these agents to hcws, patients, and visitors has been described and in some outbreaks has accounted for a large proportion of cases. [297] [298] [299] transmission within households also has been documented in individuals who had direct contact with ill persons or their body fluids, but not in those who did not have such contact. 300 evidence concerning the transmission of hfvs has been summarized previously. 212, 301 person-to-person transmission is associated primarily with direct blood and body fluid contact. percutaneous exposure to contaminated blood carries a particularly high risk for transmission and increased mortality. 302, 303 the finding of large numbers of ebola viral particles in the skin and the lumina of sweat glands has raised concerns that transmission could occur from direct contact with intact skin, although epidemiologic evidence to support this is lacking. 304 postmortem handling of infected bodies is an important risk for transmission. 300, 305, 306 in rare situations, cases in which the mode of transmission was unexplained among individuals with no known direct contact have led to speculation that airborne transmission could have occurred. 297 however, airborne transmission of naturally occurring hfvs in humans has not been documented. a study of airplane passengers exposed to an in-flight index case of lassa fever found no transmission to any passengers. 307 in the laboratory setting, animals have been infected experimentally with marburg or ebola virus through direct inoculation of the nose, mouth, and/or conjunctiva 308,309 and by using mechanically generated viruscontaining aerosols. 310, 311 transmission of ebola virus among laboratory primates in an animal facility has been described. 312 the secondarily infected animals were in individual cages separated by approximately 3 meters. although the possibility of airborne transmission was suggested, the investigators were not able to exclude droplet or indirect contact transmission in this incidental observation. guidance on infection control precautions for hvfs transmitted person-to-person have been published by the cdc 1,211 and by the johns hopkins center for civilian biodefense strategies. 212 the most recent recommendations at the time of publication of this document were posted on the cdc website on may 19, 2005. 313 inconsistencies among the various recommendations have raised questions about the appropriate precautions to use in us hospitals. in less developed countries, outbreaks of hfvs have been controlled with basic hygiene, barrier precautions, safe injection practices, and safe burial practices. 298, 305 the preponderance of evidence on hfv transmission indicates that standard, contact, and droplet precautions with eye protection are effective in protecting hcws and visitors coming in contact with an infected patient. single gloves are adequate for routine patient care; doublegloving is advised during invasive procedures (eg, surgery) that pose an increased risk of blood exposure. routine eye protection (ie goggles or face shield) is particularly important. fluid-resistant gowns should be worn for all patient contact. airborne precautions are not required for routine patient care; however, use of aiirs is prudent when procedures that could generate infectious aerosols are performed (eg, endotracheal intubation, bronchoscopy, suctioning, autopsy procedures involving oscillating saws). n95 or higher-level respirators may provide added protection for individuals in a room during aerosol-generating procedures ( table 3 , appendix a). when a patient with a syndrome consistent with hemorrhagic fever also has a history of travel to an endemic area, precautions are initiated on presentation and then modified as more information is obtained ( table 2) . patients with hemorrhagic fever syndrome in the setting of a suspected bioweapons attack should be managed using airborne precautions, including aiirs, because the epidemiology of a potentially weaponized hemorrhagic fever virus is unpredictable. numerous factors influence differences in transmission risks among the various health care settings. these factors include the population characteristics (eg, increased susceptibility to infections, type and prevalence of indwelling devices), intensity of care, exposure to environmental sources, length of stay, and frequency of interaction between patients/residents with each other and with hcws. these factors, as well as organizational priorities, goals, and resources, influence how different health care settings adapt transmission prevention guidelines to meet their specific needs. 314, 315 infection control management decisions are informed by data regarding institutional experience/epidemiology; trends in community and institutional hais; local, regional, and national epidemiology; and emerging infectious disease threats. i.d.1. hospitals. infection transmission risks are present in all hospital settings. however, certain hospital settings and patient populations have unique conditions that predispose patients to infection and merit special mention. these are often sentinel sites for the emergence of new transmission risks that may be unique to that setting or present opportunities for transmission to other settings in the hospital. i.d.1.a. intensive care units. intensive care units (icus) serve patients who are immunocompromised by disease state and/or by treatment modalities, as well as patients with major trauma, respiratory failure, and other life-threatening conditions (eg, myocardial infarction, congestive heart failure, overdose, stroke, gastrointestinal bleeding, renal failure, hepatic failure, multiorgan system failure, and extremes of age). although icus account for a relatively small proportion of hospitalized patients, infections acquired in these units account for . 20% of all hais. 316 in the national nosocomial infection surveillance (nnis) system, 26.6% of hais were reported from icu and high-risk nursery (neonatal icu [nicu]) patients in 2002 (nnis, unpublished data). this patient population has increased susceptibility to colonization and infection, especially with mdros and candida spp, 317,318 because of underlying diseases and conditions, the invasive medical devices and technology used in their care (eg central venous catheters and other intravascular devices, mechanical ventilators, extracorporeal membrane oxygenation, hemodialysis/filtration, pacemakers, implantable left-ventricular assist devices), the frequency of contact with hcws, prolonged lengths of stay, and prolonged exposure to antimicrobial agents. [319] [320] [321] [322] [323] [324] [325] [326] [327] [328] [329] [330] furthermore, adverse patient outcomes in this setting are more severe and are associated with a higher mortality. 331 outbreaks associated with various bacterial, fungal, and viral pathogens due to common-source and person-to-person transmissions are frequent in adult icus and pediatric icus (picus). 31, [332] [333] [334] [335] [336] [337] i.d.1.b. burn units. burn wounds can provide optimal conditions for colonization, infection, and transmission of pathogens; infection acquired by burn patients is a frequent cause of morbidity and mortality. 319, 338, 339 the risk of invasive burn wound infection is particularly high in patients with a burn injury involving . 30% of the total body surface area (tbsa). 340, 341 infections occurring in patients with burn injuries involving , 30% of the tbsa are usually associated with the use of invasive devices. mssa, mrsa, enterococci (including vre), gram-negative bacteria, and candida spp are prevalent pathogens in burn infections, 53, 339, [342] [343] [344] [345] [346] [347] [348] [349] and outbreaks of these organisms have been reported. [350] [351] [352] [353] shifts over time in the predominance of pathogens causing infections in burn patients often lead to changes in burn care practices. 342, [354] [355] [356] [357] burn wound infections caused by aspergillus spp or other environmental molds may result from exposure to supplies contaminated during construction 358 or to dust generated during construction or other environmental disruption. 359 hydrotherapy equipment is an important environmental reservoir of gram-negative organisms. its use in burn care is discouraged based on demonstrated associations between the use of contaminated hydrotherapy equipment and infections. burn wound infections and colonization, as well as bloodstream infections, caused by multidrug-resistant p aeruginosa, 360 acinetobacter baumannii, 361 and mrsa 351 have been associated with hydrotherapy; thus, excision of burn wounds in operating rooms is the preferred approach. advances in burn care (specifically, early excision and grafting of the burn wound, use of topical antimicrobial agents, and institution of early enteral feeding) have led to decreased infectious complications. other advances have included prophylactic antimicrobial use, selective digestive decontamination, and use of antimicrobial-coated catheters; however, few epidemiologic studies and no efficacy studies have been performed to investigate the relative benefit of these measures. 356 there is no consensus on the most effective infection control practices to prevent transmission of infections to and from patients with serious burns (eg, single-bed rooms, 357 laminar flow, 362 and high-efficiency particulate air [hepa] filtration, 359 or maintaining burn patients in a separate unit with no exposure to patients or equipment from other units 363 ). there also is controversy regarding the need for and type of barrier precautions in the routine care of burn patients. one retrospective study demonstrated the efficacy and cost-effectiveness of a simplified barrier isolation protocol for wound colonization, emphasizing handwashing and use of gloves, caps, masks, and impermeable plastic aprons (rather than isolation gowns) for direct patient contact. 364 however, to date no studies have determined the most effective combination of infection control precautions for use in burn settings. prospective studies in this area are needed. i.d.1.c. pediatrics. studies of the epidemiology of hais in children have identified unique infection control issues in this population. 63, 64, [365] [366] [367] [368] [369] pediatric icu patients and the lowest birth weight babies in the nicu monitored in the nnis system have had high rates of central venous catheter-associated bloodstream infections. 64 38, 377 ) . close physical contact between hcws and infants and young children (eg. cuddling, feeding, playing, changing soiled diapers, and cleaning copious uncontrolled respiratory secretions) provides abundant opportunities for transmission of infectious material. such practices and behaviors as congregation of children in play areas where toys and bodily secretions are easily shared and rooming-in of family members with pediatric patients can further increase the risk of transmission. pathogenic bacteria have been recovered from toys used by hospitalized patients; 378 contaminated bath toys were implicated in an outbreak of multidrug-resistant p. aeruginosa on a pediatric oncology unit. 80 in addition, several patient factors increase the likelihood that infection will result from exposure to pathogens in health care settings (eg, immaturity of the neonatal immune system, lack of previous natural infection and resulting immunity, prevalence of patients with congenital or acquired immune deficiencies, congenital anatomic anomalies, and use of life-saving invasive devices in nicus and picus). 63 there are theoretical concerns that infection risk will increase in association with innovative practices used in the nicu for the purpose of improving developmental outcomes, such factors include cobedding 379 and kangaroo care, 380 which may increase opportunity for skin-to-skin exposure of multiple gestation infants to each other and to their mothers, respectively; although the risk of infection actually may be reduced among infants receiving kangaroo care. 381 children who attend child care centers 382, 383 and pediatric rehabilitation units 384 may increase the overall burden of antimicrobial resistance by contributing to the reservoir of ca-mrsa. [385] [386] [387] [388] [389] [390] patients in chronic care facilities may have increased rates of colonization with resistant garm-negative bacilli and may be sources of introduction of resistant organisms to acute care settings. 50 i.d.2. nonacute health care settings. health care is provided in various settings outside of hospitals, including long-term care facilities (ltcfs) (eg nursing homes), homes for the developmentally disabled, behavioral health service settings, rehabilitation centers, and hospices. 391 in addition, health care may be provided in non-health care settings, such as workplaces with occupational health clinics, adult day care centers, assisted-living facilities, homeless shelters, jails and prisons, school clinics, and infirmaries. each of these settings has unique circumstances and population risks that must be considered when designing and implementing an infection control program. several of the most common settings and their particular challenges are discussed below. although this guideline does not address each setting, the principles and strategies provided herein may be adapted and applied as appropriate. i.d.2.a. long-term care. the designation ltcf applies to a diverse group of residential settings, ranging from institutions for the developmentally disabled to nursing homes for the elderly and pediatric chronic care facilities. [392] [393] [394] nursing homes for the elderly predominate numerically and frequently represent longterm care as a group of facilities. approximately 1.8 million americans reside in the nation's 16,500 nursing homes. 395 estimates of hai rates of 1.8 to 13.5 per 1000 resident-care days have been reported, with a range of 3 to 7 per 1000 resident-care days in the more rigorous studies. [396] [397] [398] [399] [400] the infrastructure described in the department of veterans affairs' nursing home care units is a promising example for the development of a nationwide hai surveillance system for ltcfs. 401 lctfs are different from other health care settings in that elderly patients at increased risk for infection are brought together in one setting and remain in the facility for extended periods; for most residents, it is their home. an atmosphere of community is fostered, and residents share common eating and living areas and participate in various facility-sponsored activities. 402, 403 because able residents interact freely with each other, controlling infection transmission in this setting can be challenging. 404 a residents who is colonized or infected with certain microorganisms are in some cases restricted to his or her room. however, because of the psychosocial risks associated with such restriction, balancing psychosocial needs with infection control needs is important in the ltcf setting. 405 274, 277, 278, 280 ) and bacteria, including group a streptococcus, 162 , b pertussis, 414 nonsusceptible s pneumoniae, 197, 198 other mdros, and c difficile 415 ). these pathogens can lead to substantial morbidity and mortality, as well as increased medical costs; prompt detection and implementation of effective control measures are needed. risk factors for infection are prevalent among ltcf residents. 394, 416, 417 age-related declines in immunity may affect the response to immunizations for influenza and other infectious agents and increase the susceptibility to tuberculosis. immobility, incontinence, dysphagia, underlying chronic diseases, poor functional status, and age-related skin changes increase susceptibility to urinary, respiratory, and cutaneous and soft tissue infections, whereas malnutrition can impair wound healing. [418] [419] [420] [421] [422] medications (eg, drugs that affect level of consciousness, immune function, gastric acid secretions, and normal flora, including antimicrobial therapy) and invasive devices (eg, urinary catheters and feeding tubes) heighten the susceptibility to infection and colonization in ltcf residents. [423] [424] [425] finally, limited functional status and total dependence on hcws for activities of daily living have been identified as independent risk factors for infection 400, 416, 426 and for colonization with mrsa 427,428 and esbl-producing klebsiella pneumoniae. 429 several position papers and review articles provide guidance on various aspects of infection control and antimicrobial resistance in ltcfs. [405] [406] [407] [430] [431] [432] [433] [434] [435] the centers for medicare and medicaid services has established regulations for the prevention of infection in ltcfs. 436 because residents of ltcfs are hospitalized frequently, they can transfer pathogens between ltcfs and health care facilities in which they receive care. 8, [437] [438] [439] [440] this also is true for pediatric long-term care populations. pediatric chronic care facilities have been associated with the importation of extendedspectrum cephalosporin-resistant, gram-negative bacilli into a picu. 50 children from pediatric rehabilitation units may contribute to the reservoir of community-associated mrsa. 384, [388] [389] [390] i.d.2.b. ambulatory care. over the past decade, health care delivery in the united states has shifted from the acute, inpatient hospital to various ambulatory and community-based settings, including the home. ambulatory care is provided in hospital-based outpatient clinics, nonhospital-based clinics and physicians' offices, public health clinics, free-standing dialysis centers, ambulatory surgical centers, urgent care centers, and other setting. in 2000, there were 83 million visits to hospital outpatient clinics and more than 823 million visits to physicians' offices; 441 ambulatory care now accounts for most patient encounters with the health care system. 442 adapting transmission prevention guidelines to these settings is challenging, because patients remain in common areas for prolonged periods waiting to be seen by a health care provider or awaiting admission to the hospital, examination or treatment rooms are turned around quickly with limited cleaning, and infectious patients may not be recognized immediately. furthermore, immunocompromised patients often receive chemotherapy in infusion rooms, where they stay for extended periods along with other types of patients. little data exist on the risk of hais in ambulatory care settings, with the exception of hemodialysis centers. 18, 443, 444 transmission of infections in outpatient settings has been reviewed in 3 studies. [445] [446] [447] goodman and solomon 445 summarized 53 clusters of infections associated with the outpatient setting between 1961 and 1990. overall, 29 clusters were associated with common source transmission from contaminated solutions or equipment, 14 were associated with person-to-person transmission from or involving hcws, and 10 were associated with airborne or droplet transmission among patients and health care workers. transmission of bloodborne pathogens (ie, hbv, hcv, and, rarely, hiv) in outbreaks, sometimes involving hundreds of patients, continues to occur in ambulatory settings. these outbreaks often are related to common source exposures, usually a contaminated medical device, multidose vial, or intravenous solution. 82, [448] [449] [450] [451] [452] in all cases, transmission has been attributed to failure to adhere to fundamental infection control principles, including safe injection practices and aseptic technique. this subject has been reviewed, and recommended infection control and safe injection practices have been summarized. 453 airborne transmission of m tuberculosis and measles in ambulatory settings, most often emergency departments, has been reported. 34, 127, 445, 447, [454] [455] [456] measles virus was transmitted in physicians' offices and other outpatient settings during an era when immunization rates were low and measles outbreaks in the community were occurring regularly. 34, 122, 457 rubella has been transmitted in the outpatient obstetric setting; 33 there are no published reports of varicella transmission in the outpatient setting. in the ophthalmology setting, adenovirus type 8 epidemic keratoconjunctivitis has been transmitted through incompletely disinfected ophthalmology equipment and/or from hcws to patients, presumably by contaminated hands. 17, 445, 447, [458] [459] [460] [461] preventing transmission in outpatient settings necessitates screening for potentially infectious symptomatic and asymptomatic individuals, especially those at possible risk for transmitting airborne infectious agents (eg, m tuberculosis, varicella-zoster virus, rubeola [measles]), at the start of the initial patient encounter. on identification of a potentially infectious patient, implementation of prevention measures, including prompt separation of potentially infectious patients and implementation of appropriate control measures (eg, respiratory hygiene/cough etiquette and transmission-based precautions) can decrease transmission risks. 9, 12 transmission of mrsa and vre in outpatient settings has not been reported, but the association of ca-mrsa in hcws working in an outpatient hiv clinic with environmental ca-mrsa contamination in that clinic suggests the possibility of transmission in that setting. 462 patient-to-patient transmission of burkholderia spp and p aeruginosa in outpatient clinics for adults and children with cystic fibrosis has been confirmed. 463, 464 i.d.2.c. home care. home care in the united states is delivered by more than 20,000 provider agencies, including home health agencies, hospices, durable medical equipment providers, home infusion therapy services, and personal care and support services providers. home care is provided to patients of all ages with both acute and chronic conditions. the scope of services ranges from assistance with activities of daily living and physical and occupational therapy to the care of wounds, infusion therapy, and chronic ambulatory peritoneal dialysis. the incidence of infection in home care patients, other than that associated with infusion therapy, has not been well studied. [465] [466] [467] [468] [469] [470] however, data collection and calculation of infection rates have been done for central venous catheter-associated bloodstream infections in patients receiving home infusion therapy [469] [470] [471] [472] [473] and for the risk of blood contact through percutaneous or mucosal exposures, demonstrating that surveillance can be performed in this setting. 474 draft definitions for home care-associated infections have been developed. 475 transmission risks during home care are presumed to be minimal. the main transmission risks to home care patients are from an infectious home care provider or contaminated equipment; a provider also can be exposed to an infectious patient during home visits. because home care involves patient care by a limited number of personnel in settings without multiple patients or shared equipment, the potential reservoir of pathogens is reduced. infections of home care providers that could pose a risk to home care patients include infections transmitted by the airborne or droplet routes (eg, chickenpox, tuberculosis, influenza), skin infestations (eg, scabies 69 and lice), and infections transmitted by direct or indirect contact (eg, impetigo). there are no published data on indirect transmission of mdros from one home care patient to another, although this is theoretically possible if contaminated equipment is transported from an infected or colonized patient and used on another patient. of note, investigations of the first case of visa in home care 186 and the first 2 reported cases of vrsa 178, 180, 181, 183 found no evidence of transmission of visa or vrsa to other home care recipients. home health care also may contribute to antimicrobial resistance; a review of outpatient vancomycin use found that 39% of recipients did not receive prescribed antibiotics according to recommended guidelines. 476 although most home care agencies implement policies and procedures aimed at preventing transmission of organisms, the current approach is based on the adaptation of the 1996 guideline for isolation precautions in hospitals, 1 as well as other professional guidance. 477, 478 this issue has proven very challenging to the home care industry, and practice has been inconsistent and frequently not evidence-based. for example, many home health agencies continue to observe ''nursing bag technique,'' a practice that prescribes the use of barriers between the nursing bag and environmental surfaces in the home. 479 although the home environment may not always appear clean, the use of barriers between 2 noncritical surfaces has been questioned. 480, 481 opportunites exist to conduct research in home care related to infection transmission risks. 482 i.d.2.d. other sites of health care delivery. facilities that are not primarily health care settings but in which health care is delivered include clinics in correctional facilities and shelters. both of these settings can have suboptimal features, such as crowded conditions and poor ventilation. economically disadvantaged individuals who may have chronic illnesses and health care problems related to alcoholism, injected drug use, poor nutrition, and/or inadequate shelter often receive their primary health care at such sites. 483 infectious diseases of special concern for transmission include tuberculosis, scabies, respiratory infections (eg, n meningitides, s pneumoniae), sexually transmitted and bloodborne diseases (eg, hiv, hbv, hcv, syphilis, gonorrhea), hepatitis a virus, diarrheal agents such as norovirus, and foodborne diseases. 285, [484] [485] [486] [487] a high index of suspicion for tuberculosis and ca-mrsa in these populations is needed; outbreaks in these settings or among the populations they serve have been reported. [488] [489] [490] [491] [492] [493] [494] [495] [496] patient encounters in these types of facilities provide an opportunity to deliver recommended immunizations and screen for m tuberculosis infection, along with diagnosing and treating acute illnesses. 497 recommended infection control measures in these nontraditional areas designated for health care delivery are the same as for other ambulatory care settings. therefore, these settings must be equipped to observe standard precautions and, when indicated, transmission-based precautions. as new treatments emerge for complex diseases, unique infection control challenges associated with special patient populations must be addressed. i.e.1. immunocompromised patients. patients who have congenital primary immune deficiencies or acquired disease (eg. treatment-induced immune deficiencies) are at increased risk for numerous types of infections while receiving health care; these patients may be located throughout the health care facility. the specific immune system defects determine the types of infections most likely to be acquired (eg, viral infections are associated with t cell defects, and fungal and bacterial infections occur in patients who are neutropenic). as a general group, immunocompromised patients can be cared for in the same environment as other patients; however, it is always advisable to minimize exposure to other patients with transmissible infections, such as influenza and other respiratory viruses. 498, 499 the use of more intense chemotherapy regimens for treatment of childhood leukemia may be associated with prolonged periods of neutropenia and suppression of other components of the immune system, extending the period of infection risk and raising the concern that additional precautions may be indicated for select groups. 500, 501 with the application of newer and more intense immunosuppressive therapies for various medical conditions (eg, rheumatologic disease, 502, 503 inflammatory bowel disease 504 ), immunosuppressed patients are likely to be more widely distributed throughout a health care facility rather than localized to single patient units (eg, hematologyoncology). guidelines for preventing infections in certain groups of immunocompromised patients have been published previously. 15, 505, 506 published data provide evidence to support placing patients undergoing allogeneic hsct in a pe. 15, 157, 158 in addition, guidelines have been developed that address the special requirements of these immunocompromised patients, including use of antimicrobial prophylaxis and engineering controls to create a pe for the prevention of infections caused by aspergillus spp and other environmental fungi. 11, 14, 15 as more intense chemotherapy regimens associated with prolonged periods of neutropenia or graft-versus-host disease are implemented, the period of risk and duration of environmental protection may need to be prolonged beyond the traditional 100 days. 507 i.e.2. cystic fibrosis patients. patients with cystic fibrosis (cf) require special consideration when developing infection control guidelines. compared with other patients, cf patients require additional protection to prevent transmission from contaminated respiratory therapy equipment. [508] [509] [510] [511] [512] such infectious agents as b cepacia complex and p aeruginosa. 463, 464, 513, 514 have unique clinical and prognostic significance. in cf patients, b cepacia infection has been associated with increased morbidity and mortality, [515] [516] [517] whereas delayed acquisition of chronic p aeruginosa infection may be associated with an improved long-term clinical outcome. 518, 519 person-to-person transmission of b cepacia complex has been demonstrated among children 516 and adults 520 with cf in health care settings 463, 521 and from various social contacts, 522 most notably attendance at camps for patients with cf 523 and among siblings with cf. 524 successful infection control measures used to prevent transmission of respiratory secretions include segregation of cf patients from each other in ambulatory and hospital settings (including use of private rooms with separate showers), environmental decontamination of surfaces and equipment contaminated with respiratory secretions, elimination of group chest physiotherapy sessions, and disbanding of cf camps. 97, 525 the cystic fibrosis foundation has published a consensus document with evidence-based recommendations for infection control practices in cf patients. 20 i.f. new therapies associated with potentially transmissible infectious agents i.f.1. gene therapy. gene therapy has has been attempted using various viral vectors, including nonreplicating retroviruses, adenoviruses, adeno-associated viruses, and replication-competent strains of poxviruses. unexpected adverse events have restricted the prevalence of gene therapy protocols. the infectious hazards of gene therapy are theoretical at this time but require meticulous surveillance due to the possible occurrence of in vivo recombination and the subsequent emergence of a transmissible genetically altered pathogen. the greatest concern attends the use of replication-competent viruses, especially vaccinia. to date, no reports have described transmission of a vector virus from a gene therapy recipient to another individual, but surveillance is ongoing. recommendations for monitoring infection control issues throughout the course of gene therapy trials have been published. [526] [527] [528] i.f.2. infections transmitted through blood, organs, and other tissues. the potential hazard of transmitting infectious pathogens through biologic products is a small but ever-present risk, despite donor screening. reported infections transmitted by transfusion or transplantation include west nile virus infection, 529 cytomegalovirus infection, 530 cjd, 230 hepatitis c, 531 infections with clostridium spp 532 and group a streptococcus, 533 malaria, 534 babesiosis, 535 chagas disease, 536 lymphocytic choriomeningitis, 537 and rabies. 538, 539 therefore, it is important to consider receipt of biologic products when evaluating patients for potential sources of infection. i.f.3. xenotransplantation. transplantation of nonhuman cells, tissues, and organs into humans potentially exposes patients to zoonotic pathogens. transmission of known zoonotic infections (eg, trichinosis from porcine tissue) is of concern. also of concern is the possibility that transplantation of nonhuman cells, tissues, or organs may transmit previously unknown zoonotic infections (xenozoonoses) to immunosuppressed human recipients. potential infections that potentially could accompany transplantation of porcine organs have been described previously. 540 guidelines from the us public health service address many infectious diseases and infection control issues that surround the developing field of xenotransplantation; 541 549 policies and procedures that explain how standard precautions and transmission-based precautions are applied, including systems used to identify and communicate information on patients with potentially transmissible infectious agents, are essential to ensure the success of these measures. these policies and procedures may vary according to the characteristics of the organization. a key administrative measure is the provision of fiscal and human resources for maintaining infection control and occupational health programs that are responsive to emerging needs. specific components include bedside nurse 550 and infection prevention and control professional (icp) staffing levels, 551 inclusion of icps in facility construction and design decisions, 11 clinical microbiology laboratory support, 552, 553 adequate supplies and equipment including facility ventilation systems, 11 adherence monitoring, 554 assessment and correction of system failures that contribute to transmission, 555, 556 and provision of feedback to hcws and senior administrators. 433, 547, 548, 557 the positive influence of institutional leadership has been demonstrated repeatedly in studies of hcws' adherence to recommended hand hygiene practices. 176, 177, 433, 547, 548, [558] [559] [560] [561] [562] [563] health care administrators' involvement in the infection control processes can improve their awareness of the rationale and resource requirements for following recommended infection control practices. several administrative factors may affect the transmission of infectious agents in health care settings, including the institutional culture, individual hcw behavior, and the work environment. each of these areas is suitable for performance improvement monitoring and incorporation into the organization's patient safety goals. 542, 543, 545, 564 ii.a.1.a. scope of work and staffing needs for infection control professionals. the effectiveness of infection surveillance and control programs in preventing nosocomial infections in ust hospitals was assessed by the cdc through the study on the efficacy of nosocomial infection control (senic project) conducted between 1970 and 1976. 565 in a representative sample of us general hospitals, those with a trained infection control physician or microbiologist involved in an infection control program and at least 1 infection control nurse per 250 beds were associated with a 32% lower rate of the 4 infections studied (cvc-associated bloodstream infections, ventilator-associated pneumonias, catheter-related urinary tract infections, and surgical site infections). since the publication of that landmark study, responsibilities of icps have expanded commensurate with the growing complexity of the health care system, the patient populations served, and the increasing numbers of medical procedures and devices used in all types of health care settings. the scope of work of icps was first assessed in 1982 566-568 by the certification board of infection control, and has been reassessed every 5 years since that time. 557, [569] [570] [571] the findings of these analyses have been used to develop and update the infection control certification examination, which was first offered in 1983. with each new survey, it becomes increasingly apparent that the role of the icp is growing in complexity and scope beyond traditional infection control activities in acute care hospitals. activities currently assigned to icps in response to emerging challenges include (1) surveillance and infection prevention at facilities other than acute care hospitals (eg, ambulatory clinics, day surgery centers, ltcfs, rehabilitation centers, home care); (2) oversight of employee health services related to infection prevention (eg, assessment of risk and administration of recommended treatment after exposure to infectious agents, tuberculosis screening, influenza vaccination, respiratory protection fit testing, and administration of other vaccines as indicated, such as smallpox vaccine in 2003); (3) preparedness planning for annual influenza outbreaks, pandemic influenza, sars, and bioweapons attacks; (4) adherence monitoring for selected infection control practices; (5) oversight of risk assessment and implementation of prevention measures associated with construction and renovation; (6) prevention of transmission of mdros; (7) evaluation of new medical products that could be associated with increased infection risk (eg, intravenous infusion materials); (8) communication with the public, facility staff, and state and local health departments concerning infection control-related issues; and (9) participation in local and multicenter research projects. 433, 548, 551, 557, 572, 573 none of the certification board of infection control job analyses addressed specific staffing requirements for the identified tasks, although the surveys did include information about hours worked; the 2001 survey included the number of icps assigned to the responding facilities. 557 there is agreement in the literature that a ratio of 1 icp per 250 acute care beds is no longer adequate to meet current infection control needs; a delphi project that assessed staffing needs of infection control programs in the 21 st century concluded that a ratio of 0.8 to 1.0 icp per 100 occupied acute care beds is an appropriate staffing level. 551 a survey of participants in the nnis system found an average daily patient census of 115 per icp. 315 results of other studies have been similar: 3 per 500 beds for large acute care hospitals, 1 per 150 to 250 beds in ltcfs, and 1.56 per 250 in small rural hospitals. 572, 574 the foregoing demonstrates that infection control staffing no longer can be based on patient census alone, but rather must be determined by the scope of the program, characteristics of the patient population, complexity of the health care system, tools available to assist personnel to perform essential tasks (eg, electronic tracking and laboratory support for surveillance), and unique or urgent needs of the institution and community. 551 furthermore, appropriate training is required to optimize the quality of work performed. 557, 571, 575 ii.a.1.a.i. infection control nurse liaison. designating a bedside nurse on a patient care unit as an infection control liaison or ''link nurse'' is reported to be an effective adjunct to enhance infection control at the unit level. [576] [577] [578] [579] [580] [581] such individuals receive training in basic infection control and have frequent communication with icps, but maintain their primary role as bedside caregiver on their units. the infection control nurse liaison increases the awareness of infection control at the unit level. he or she is especially effective in implementating new policies or control interventions because of the rapport with individuals on the unit, an understanding of unit-specific challenges, and ability to promote strategies that are most likely to be successful in that unit. this position is an adjunct to, not a replacement for, fully trained icps. furthermore, the infection control liaison nurses should not be counted when considering icp staffing. there is increasing evidence that the level of bedside nurse staffing influences the quality of patient care. 582, 583 adequate nursing staff makes it more likely that infection control practices, including hand hygiene, standard precautions, and transmission-based precautions, will be given appropriate attention and applied correctly and consistently. 551 a national multicenter study reported strong and consistent inverse relationships between nurse staffing and 5 adverse outcomes in medical patients, 2 of which were hais (urinary tract infections and pneumonia). 582 the association of nursing staff shortages with increased rates of hai has been demonstrated in several outbreaks in hospitals and ltcfs, and with increased transmission of hepatitis c virus in dialysis units. 22, 417, 550, [584] [585] [586] [587] [588] [589] [590] [591] [592] [593] [594] [595] [596] in most cases, when staffing was improved as part of a comprehensive control intervention, the outbreak ended or the hai rate declined. in 2 studies, 589,595 the composition of the nursing staff (''pool'' or ''float'' vs regular staff nurses) influenced the rate of primary bloodstream infections, with an increased infection rate occurring when the proportion of regular nurses decreased and that of pool nurses increased. ii.a.1.c. clinical microbiology laboratory support. the critical role of the clinical microbiology laboratory in infection control and health care epidemiology has been well described 552, 553, [597] [598] [599] and is supported by the infectious disease society of america's policy statement on the consolidation of clinical microbiology laboratories published in 2001. 552 the clinical microbiology laboratory contributes to preventing transmission of infectious diseases in health care settings by promptly detecting and reporting epidemiologically important organisms, identifying emerging patterns of antimicrobial resistance, and assessing the effectiveness of recommended precautions to limit transmission during outbreaks. 597 outbreaks of infections may be recognized first by laboratorians. 161 health care organizations need to ensure the availability of the recommended scope and quality of laboratory services, a sufficient number of appropriately trained laboratory staff members, and systems to promptly communicate epidemiologically important results to those who will take action (eg, providers of clinical care, infection control staff, health care epidemiologists, and infectious disease consultants). 600 as concerns about emerging pathogens and bioterrorism grow, the role of the clinical microbiology laboratory assumes ever-greater importance. for health care organizations that outsource microbiology laboratory services (eg, ambulatory care, home care, ltcfs, smaller acute care hospitals), it is important to specify by contract the types of services (eg, periodic institution-specific aggregate susceptibility reports) required to support infection control. several key functions of the clinical microbiology laboratory are relevant to this guideline: ii.a.2. institutional safety culture and organizational characteristics. safety culture (or safety climate) refers to a work environment in which a shared commitment to safety on the part of management and the workforce is understood and maintained. 558, 619, 620 the authors of the institute of medicine's report titled to err is human 542 acknowledged that causes of medical error are multifaceted but emphasized the pivotal role of system failures and the benefits of a safety culture. a safety culture is created through (1) the actions that management takes to improve patient and worker safety, (2) worker participation in safety planning, (3) the availability of appropriate ppe, (4) the influence of group norms regarding acceptable safety practices, and (5) the organization's socialization process for new personnel. safety and patient outcomes can be enhanced by improving or creating organizational characteristics within patient care units, as demonstrated by studies of surgical icus. 621, 622 each of these factors has a direct bearing on adherence to transmission prevention recommendations. 256 measurement of an institution's culture of safety is useful in designing improvements in health care. 623, 624 several hospitalbased studies have linked measures of safety culture with both employee adherence to safe practices and reduced exposures to blood and body fluids. [625] [626] [627] [628] [629] [630] [631] one study of hand hygiene practices concluded that improved adherence requires integration of infection control into the organization's safety culture. 560 several hospitals that are part of the veterans administration health care system have taken specific steps toward improving the safety culture, including error-reporting mechanisms, root cause analyses of identified problems, safety incentives, and employee education. [632] [633] [634] ii.a.3. adherence of health care workers to recommended guidelines. hcws' adherence to recommended infection control practices decreases the transmission of infectious agents in health care settings. 116, 561, [635] [636] [637] [638] [639] several observational studies have shown limited adherence to recommended practices by hcws. 558, [639] [640] [641] [642] [643] [644] [645] [646] [647] [648] [649] [650] [651] [652] [653] [654] [655] [656] observed adherence to universal precautions ranged from 43% to 89%. 640, 641, 648, 650, 651 the degree of adherence often depended on the specific practice that was assessed and, for glove use, the circumstance in which the practice was applied. observed rates of appropriate glove use has ranged from a low of 15% 644 to a high of 82%. 649 however, 92% and 98% adherence with glove use have been reported during arterial blood gas collection and resuscitation, respectively, procedures in which considerable blood contact may occur. 642, 655 differences in observed adherence have been reported among occupational groups in the same health care facility 640 and between experienced and nonexperienced professionals. 644 in surveys of hcws, self-reported adherence was generally higher than actual adherence found in observational studies. furthermore, where an observational component was included with a self-reported survey, self-perceived adherence was often greater than observed adherence. 656 among nurses and physicians, increasing years of experience is a negative predictor of adherence. 644, 650 education to improve adherence is the primary intervention that has been studied. whereas positive changes in knowledge and attitude have been demonstrated, 639, 657 no or only limited accompanying changes in behavior often have been found. 641, 643 self-reported adherence is higher in groups that received an educational intervention. 629, 658 in one study, educational interventions that incorporated videotaping and performance feedback were successful in improving adherence during the study period, but the long-term effect of such interventions is not known. 653 the use of videotaping also served to identify system problems (eg, communication and access to ppe) that otherwise may not have been recognized. interest is growing in the use of engineering controls and facility design concepts for improving adherence. whereas the introduction of automated sinks was found to have a negative impact on consistent adherence to handwashing in one study, 659 the use of electronic monitoring and voice prompts to remind hcws to perform hand hygiene and improving accessibility to hand hygiene products increased adherence and contributed to a decrease in hais in another study. 660 more information is needed regarding ways in which technology might improve adherence. improving adherence to infection control practices requires a multifaceted approach that incorporates continuous assessment of both the individual and the work environment. 558, 560 using several behavioral theories, kretzer and larson concluded that a single intervention (eg, a handwashing campaign or putting up new posters about transmission precautions) likely would be ineffective in improving hcws adherence. 661 improvement requires the organizational leadership to make prevention an institutional priority and integrate infection control practices into the organization's safety culture. 560 a recent review of the literature concluded that variations in organizational factors (eg, safety climate, policies and procedures, education and training) and individual factors (eg, knowledge, perceptions of risk, past experience) were determinants of adherence to infection control guidelines for protection against sars and other respiratory pathogens. 256 surveillance is an essential tool for case finding of single patients or clusters of patients who are infected or colonized with epidemiologically important organisms (eg, susceptible bacteria such as s aureus, s pyogenes [group a streptococcus] or enterobacter-klebsiella spp; mrsa, vre, and other mdros; c difficile; rsv; influenza virus) for which transmission-based precautions may be required. surveillance is defined as the ongoing systematic collection, analysis, interpretation, and dissemination of data regarding a health-related event for use in public health action to reduce morbidity and mortality and to improve health. 662 the work of ignaz semmelweis delineating the role of person-toperson transmission in puerperal sepsis is the earliest example of the use of surveillance data to reduce transmission of infectious agents. 663 surveillance of both process measures and the infection rates to which they are linked is important in evaluating the effectiveness of infection prevention efforts and identifying indications for change. 554, [664] [665] [666] [667] the study on the efficacy of nosocomial infection control (senic) found that different combinations of infection control practices resulted in reduced rates of nosocomial surgical site infections, pneumonia, urinary tract infections, and bacteremia in acute care hospitals; 565 however, surveillance was the only component essential for reducing all 4 types of hais. although a similar study has not been conducted in other health care settings, a role for surveillance and the need for novel strategies in ltcfs 397, 433, 668, 669 and in home care [469] [470] [471] [472] have been described. the essential elements of a surveillance system are (1) standardized definitions, (2) identification of patient populations at risk for infection, (3) statistical analysis (eg, risk adjustment, calculation of rates using appropriate denominators, trend analysis using such methods as statistical process control charts), and (4) feedback of results to the primary caregivers. [670] [671] [672] [673] [674] [675] data gathered through surveillance of high-risk populations, device use, procedures, and facility locations (eg, icus) are useful in detecting transmission trends. [670] [671] [672] identification of clusters of infections should be followed by a systematic epidemiologic investigation to determine commonalities in persons, places, and time and to guide implementation of interventions and evaluation of the effectiveness of those interventions. targeted surveillance based on the highest-risk areas or patients has been preferred over facility-wide surveillance for the most effective use of resources. 672, 675 however, for certain epidemiologically important organisms, surveillance may need to be facility-wide. surveillance methods will continue to evolve as health care delivery systems change 391, 676 and user-friendly electronic tools for electronic tracking and trend analysis become more widely available. 673, 677, 678 individuals with experience in health care epidemiology and infection control should be involved in selecting software packages for data aggregation and analysis, to ensure that the need for efficient and accurate hai surveillance will be met. effective surveillance is increasingly important as legislation requiring public reporting of hai rates is passed and states work to develop effective systems to support such legislation. 679 the education and training of hcws is a prerequisite for ensuring that policies and procedures for standard and transmission-based precautions are understood and practiced. understanding the scientific rationale for the precautions will allow hcws to apply procedures correctly, as well as to safely modify precautions based on changing requirements, resources, or health care settings. 14,654,680-687 one study found that the likelihood of hcws developing sars was strongly associated with less than 2 hours of infection control training and poor understanding of infection control procedures. 688 education regarding the important role of vaccines (eg, influenza, measles, varicella, pertussis, pneumococcal) in protecting hcws, their patients, and family members can help improve vaccination rates. [689] [690] [691] [692] education on the principles and practices for preventing transmission of infectious agents should begin during training in the health professions and be provided to anyone who has an opportunity for contact with patients or medical equipment (eg, nursing and medical staff; therapists and technicians, including respiratory, physical, occupational, radiology, and cardiology personnel; phlebotomists; housekeeping and maintenance staff; and students). in health care facilities, education and training on standard and transmission-based precautions are typically provided at the time of orientation and should be repeated as necessary to maintain competency; updated education and training are necessary when policies and procedures are revised or when a special circumstance occurs, such as an outbreak that requires modification of current practice or adoption of new recommendations. education and training materials and methods appropriate to the hcw's level of responsibility, individual learning habits, and language needs can improve the learning experience. 657, [693] [694] [695] [696] [697] [698] [699] [700] [701] education programs for hcws have been associated with sustained improvement in adherence to best practices and a related decrease in device-associated hais in teaching and nonteaching settings 638, 702 and in medical and surgical icus (coopersmith, 2002 #2563) . several studies have shown that in addition to targeted education to improve specific practices, periodic assessment and feedback of the hcw's knowledge and adherence to recommended practices are necessary to achieve the desired changes and identify continuing education needs. 561, [703] [704] [705] [706] [707] the effectiveness of this approach for isolation practices has been demonstrated in the control of rsv. 116, 683 patients, family members, and visitors can be partners in preventing transmission of infections in health care settings. 9,42,708-710 information on standard precautions, especially hand hygiene, respiratory hygiene/cough etiquette, vaccination (especially against influenza), and other routine infection prevention strategies, may be incorporated into patient information materials provided on admission to the health care facility. additional information on transmission-based precautions is best provided when these precautions are initiated. fact sheets, pamphlets, and other printed material may include information on the rationale for the additional precautions, risks to household members, room assignment for transmission-based precautions purposes, explanation of the use of ppe by hcws, and directions for use of such equipment by family members and visitors. such information may be particularly helpful in the home environment, where household members often have the primary responsibility for adherence to recommended infection control practices. hcws must be available and prepared to explain this material and answer questions as needed. hand hygiene has been frequently cited as the single most important practice to reduce the transmission of infectious agents in health care settings 558, 711, 712 and is an essential element of standard precautions. the term ''hand hygiene'' includes both handwashing with either plain or antiseptic-containing soap and water and the use of alcohol-based products (gels, rinses, foams) that do not require water. in the absence of visible soiling of hands, approved alcohol-based products for hand disinfection are preferred over antimicrobial or plain soap and water because of their superior microbiocidal activity, reduced drying of the skin, and convenience. 558 have been associated with a sustained decrease in the incidence of mrsa and vre infections primarily in icus. 560, 561, [713] [714] [715] [716] the scientific rationale, indications, methods, and products for hand hygiene have been summarized in previous publications. 558, 716 the effectiveness of hand hygiene can be reduced by the type and length of fingernails. 558, 717, 718 individuals wearing artificial nails have been shown to harbor more pathogenic organisms, especially gram-negative bacilli and yeasts, on the nails and in the subungual area compared with individuals with native nails. 719, 720 in 2002, the cdc/hicpac recommended (category ia) that artificial fingernails and extenders not be worn by hcws who have contact with high-risk patients (eg, those in icus and operating rooms), due to the association with outbreaks of gram-negative bacillus and candidal infections as confirmed by molecular typing of isolates. 30, 31, 558, [721] [722] [723] [724] the need to restrict the wearing of artificial fingernails by all hcws who provide direct patient care and those who have contact with other high-risk groups (eg, oncology and cystic fibrosis patients) has not been studied but has been recommended by some experts. 20 currently, such decisions are at the discretion of an individual facility's infection control program. there is less evidence indicating that jewelry affects the quality of hand hygiene. although hand contamination with potential pathogens is increased with ring-wearing, 558, 725 no studies have related this practice to hcw-to-patient transmission of pathogens. ppe refers to various barriers and respirators used alone or in combination to protect mucous membranes, airways, skin, and clothing from contact with infectious agents. the choice of ppe is based on the nature of the patient interaction and/or the likely mode(s) of transmission. specific guidance on the use of ppe is provided in part iii of this guideline. a suggested procedure for donning and removing ppe aimed at preventing skin or clothing contamination is presented in figure 1 . designated containers for used disposable or reusable ppe should be placed in a location convenient to the site of removal, to facilitate disposal and containment of contaminated materials. hand hygiene is always the final step after removing and disposing of ppe. the following sections highlight the primary uses of and criteria for selecting this equipment. ii.e.1. gloves. gloves are used to prevent contamination of hcw hands when (1) anticipating direct contact with blood or body fluids, mucous membranes, nonintact skin and other potentially infectious material; (2) having direct contact with patients who are colonized or infected with pathogens transmitted by the contact route (eg, vre, mrsa, rsv 558, 726, 727 ); or (3) handling or touching visibly or potentially contaminated patient care equipment and environmental surfaces. 72, 73, 558 gloves can protect both patients and hcws from exposure to infectious material that may be carried on hands. 73 the extent to which gloves will protect hcws from transmission of bloodborne pathogens (eg, hiv, hbv, hcv) after a needlestick or other puncture that penetrates the glove barrier has not yet been determined. although gloves may reduce the volume of blood on the external surface of a sharp by 46% to 86%, 728 the residual blood in the lumen of a hollow-bore needle would not be affected; therefore, the effect on transmission risk is unknown. gloves manufactured for health care purposes are subject to fda evaluation and clearance. 729 nonsterile disposable medical gloves made of various materials (eg, latex, vinyl, nitrile) are available for routine patient care. 730 the selection of glove type for nonsurgical use is based on various factors, including the task to be performed, anticipated contact with chemicals and chemotherapeutic agents, latex sensitivity, sizing, and facility policies for creating a latex-free environment. 17, [731] [732] [733] for contact with blood and body fluids during nonsurgical patient care, a single pair of gloves generally provides adequate barrier protection. 733 however, there is considerable variability among gloves; both the quality of the manufacturing process and type of material influence their barrier effectiveness. 734 whereas there is little difference in the barrier properties of unused intact gloves, 735 studies have shown repeatedly that vinyl gloves have higher failure rates than latex or nitrile gloves when tested under simulated and actual clinical conditions. 730, [734] [735] [736] [737] for this reason, either latex or nitrile gloves are preferable for clinical procedures that require manual dexterity or will involve more than brief patient contact. a facility may need to stock gloves in several sizes. heavier, reusable utility gloves are indicated for non-patient care activities, such as handling or cleaning contaminated equipment or surfaces. 11, 14, 738 during patient care, transmission of infectious organisms can be reduced by adhering to the principles of working from ''clean'' to ''dirty'' and confining or limiting contamination to those surfaces directly needed for patient care. it may be necessary to change gloves during the care of a single patient to prevent cross-contamination of body sites. 558, 739 it also may be necessary to change gloves if the patient interaction also involves touching portable computer keyboards or other mobile equipment transported from room to room. discarding gloves between patients is necessary to prevent transmission of infectious material. gloves must not be washed for subsequent reuse, because microorganisms cannot be removed reliably from glove surfaces, and continued glove integrity cannot be ensured. furthermore, glove reuse has been associated with transmission of mrsa and gram-negative bacilli. [740] [741] [742] when gloves are worn in combination with other ppe, they are put on last. gloves that fit snugly around the wrist are preferred for use with an isolation gown, because they will cover the gown cuff and provide a more reliable continuous barrier for the arms, wrists, and hands. proper glove removal will prevent hand contamination (fig 1) . hand hygiene after glove removal further ensures that the hands will not carry potentially infectious material that might have penetrated through unrecognized tears or that could have contaminated the hands during glove removal. 558, 727, 740 ii.e.2. isolation gowns. isolation gowns are used as specified by standard and transmission-based precautions to protect the hcw's arms and exposed body areas and prevent contamination of clothing with blood, body fluids, and other potentially infectious material. 24, 88, 261, [743] [744] [745] the need for and the type of isolation gown selected is based on the nature of the patient interaction, including the anticipated degree of contact with infectious material and potential for blood and body fluid penetration of the barrier. the wearing of isolation gowns and other protective apparel is mandated by the occupational safety and health administration's (osha) bloodborne pathogens standard. 738 clinical and laboratory coats or jackets worn over personal clothing for comfort and/or purposes of identity are not considered ppe. when applying standard precautions, an isolation gown is worn only if contact with blood or body fluid is anticipated. however, when contact precautions are used (ie, to prevent transmission of an infectious agent that is not interrupted by standard precautions alone and is associated with environmental contamination), donning of both gown and gloves on room entry is indicated, to prevent unintentional contact with contaminated environmental surfaces. 54, 72, 73, 88 the routine donning of isolation gowns on entry into an icu or other high-risk area does not prevent or influence potential colonization or infection of patients in those areas, however. 364, [746] [747] [748] [749] isolation gowns are always worn in combination with gloves, and with other ppe when indicated. gowns are usually the first piece of ppe to be donned. full coverage of the arms and body front, from neck to the mid-thigh or below, will ensure protection of clothing and exposed upper body areas. several gown sizes should be available in a health care facility to ensure appropriate coverage for staff members. isolation gowns should be removed before leaving the patient care area to prevent possible contamination of the environment outside the patient's room. isolation gowns should be removed in a manner that prevents contamination of clothing or skin (fig 1) ; the outer, ''contaminated'' side of the gown is turned inward and rolled into a bundle, and then discarded into a designated container for waste or linen to contain contamination. ii.e.3. face protection: masks, goggles, and face shields. ii.e.3.a. masks. masks are used for 3 primary purposes in health care settings: (1) placed on hcws to protect them from contact with infectious material from patients (eg, respiratory secretions and sprays of blood or body fluids), consistent with standard precautions and droplet precautions; (2) placed on hcws engaged in procedures requiring sterile technique, to protect patients from exposure to infectious agents carried in the hcw's mouth or nose; and (3) placed on coughing patients to limit potential dissemination of infectious respiratory secretions from the patient to others (ie, respiratory hygiene/cough etiquette). masks may be used in combination with goggles to protect the mouth, nose, and eyes, or, alternatively, a face shield may be used instead of a mask and goggles to provide more complete protection for the face, as discussed below. masks should not be confused with particulate respirators used to prevent inhalation of small particles that may contain infectious agents transmitted through the airborne route, as described below. the mucous membranes of the mouth, nose, and eyes are susceptible portals of entry for infectious agents; other skin surfaces also may be portals if skin integrity is compromised (by, eg, acne, dermatitis). 66, [750] [751] [752] [753] therefore, use of ppe to protect these body sites is an important component of standard precautions. the protective effect of masks for exposed hcws has been demonstrated previously. 93, 113, 754, 755 procedures that generate splashes or sprays of blood, body fluids, secretions, or excretions (eg, endotracheal suctioning, bronchoscopy, invasive vascular procedures) require either a face shield (disposable or reusable) or a mask and goggles. [93] [94] [95] [96] 113, 115, 261, 738, 756 the wearing of masks, eye protection, and face shields in specified circumstances when blood or body fluid exposure is likely is mandated by osha's bloodborne pathogens standard. 738 appropriate ppe should be selected based on the anticipated level of exposure. two mask types are available for use in health care settings: surgical masks that are cleared by the fda and required to have fluid-resistant properties, and procedure or isolation masks. 757,#2688 to date, no studies comparing mask types to determine whether one mask type provides better protection than another have been published. because procedure/isolation masks are not regulated by the fda, they may be more variable in terms of quality and performance than surgical masks. masks come in various shapes (eg, molded and nonmolded), sizes, filtration efficiency, and method of attachment (eg, ties, elastic, ear loops). health care facilities may find that different types of masks are needed to meet individual hcw needs. ii.e.3.b. goggles and face shields. guidance on eye protection for infection control has been published. 758 the eye protection chosen for specific work situations (eg, goggles or face shield) depends on the circumstances of exposure, other ppe used, and personal vision needs. personal eyeglasses and contact lenses are not considered adequate eye protection (see http://www.cdc.gov/ niosh/topics/eye/eye-infectious.html). niosh guidelines specify that eye protection must be comfortable, allow for sufficient peripheral vision, and adjustable to ensure a secure fit. a health care facility may need to provide several different types, styles, and sizes of eye protection equipment. indirectly vented goggles with a manufacturer's antifog coating may provide the most reliable practical eye protection from splashes, sprays, and respiratory droplets from multiple angles. newer styles of goggles may provide better indirect airflow properties to reduce fogging, as well as better peripheral vision and more size options for fitting goggles to different workers. many styles of goggles fit adequately over prescription glasses with minimal gaps. although effective as eye protection, goggles do not provide splash or spray protection to other parts of the face. the role of goggles in addition to a mask in preventing exposure to infectious agents transmitted through respiratory droplets has been studied only for rsv. reports published in the mid-1980s demonstrated that eye protection reduced occupational transmission of rsv. 759, 760 whether this was due to the prevention hand-eye contact or the prevention of respiratory droplet-eye contact has not been determined. however, subsequent studies demonstrated that rsv transmission is effectively prevented by adherence to standard precautions plus contact precautions and that routine use of goggles is not necessary for this virus. 24, 116, 117, 683, 761 it is important to remind hcws that even if droplet precautions are not recommended for a specific respiratory tract pathogen, protection for the eyes, nose, and mouth using a mask and goggles or a face shield alone is necessary when a splash or spray of any respiratory secretions or other body fluids is likely to occur, as defined in standard precautions. disposable or nondisposable face shields may be used as an alternative to goggles. 758 compared with goggles, a face shield can provide protection to other facial areas besides the eyes. face shields extending from the chin to crown provide better face and eye protection from splashes and sprays; face shields that wrap around the sides may reduce splashes around the edge of the shield. removal of a face shield, goggles, and mask can be performed safely after gloves have been removed and hand hygiene performed. the ties, earpieces, and/or headband used to secure the equipment to the head are considered ''clean'' and thus safe to touch with bare hands. the front of a mask, goggles, and face shield are considered contaminated (fig 1) . ii.e.4. respiratory protection. the subject of respiratory protection as it applies to preventing transmission of airborne infectious agents, including the need for and frequency of fit testing is under scientific review and was the subject of a 2004 cdc workshop. 762 respiratory protection currently requires the use of a respirator with n95 or higher-level filtration to prevent inhalation of infectious particles. information about respirators and respiratory protection programs is summarized in the guideline for preventing transmission of mycobacterium tuberculosis in health care settings. 12 respiratory protection is broadly regulated by osha under the general industry standard for respiratory protection (29 cfr 1910 .134), 763 which requires that us employers in all employment settings implement a program to protect employees from inhalation of toxic materials. osha program components include medical clearance to wear a respirator; provision and use of appropriate respirators, including fit-tested niosh-certified n95 and higher-level particulate filtering respirators; education on respirator use, and periodic reevaluation of the respiratory protection program. when selecting particulate respirators, models with inherently good fit characteristics (ie, those expected to provide protection factors of $ 10% to 95% of wearers) are preferred and theoretically could preclude the need for fit testing. 764, 765 issues pertaining to respiratory protection remain the subject of ongoing debate. information on various types of respirators is available at http://www.cdc.gov/niosh/ npptl/respirators/respsars.html and in several previously published studies. 764, 766, 767 a user-seal check (formerly called a ''fit check'') should be performed by the wearer of a respirator each time that the respirator is donned, to minimize air leakage around the face piece. 768 the optimal frequency of fit testing has not been determined; retesting may be indicated if there is a change in wearer's facial features, onset of a medical condition that would affect respiratory function in the wearer, or a change in the model or size of the respirator that was initially assigned. 12 respiratory protection was first recommended for protection of us hcws from exposure to m tuberculosis in 1989. that recommendation has been maintained in 2 successive revisions of the guidelines for prevention of transmission of tuberculosis in hospitals and other health care settings. 12, 126 the incremental benefit from respirator use, in addition to administrative and engineering controls (ie, aiirs, early recognition of patients likely to have tuberculosis and prompt placement in an aiir, and maintenance of a patient with suspected tuberculosis in an aiir until no longer infectious), for preventing transmission of airborne infectious agents (eg, m tuberculosis) remains undetermined. although some studies have demonstrated effective prevention of m tuberculosis transmission in hospitals in which surgical masks instead of respirators were used in conjunction with other administrative and engineering controls. 636, 769, 770 the cdc currently recommends n95 or higher-level respirators for personnel exposed to patients with suspected or confirmed tuberculosis. currently, this recommendation also holds for other diseases that could be transmitted through the airborne route, including sars 261 and smallpox, 108,129,771 until inhalational transmission is better defined or health care-specific ppe more suitable for preventing infection is developed. wearing of respirators is also currently recommended during the performance of aerosol-generating procedures (eg, intubation, bronchoscopy, suctioning) in patients with sars-cov infection, avian influenza, and pandemic influenza (see appendix a). although airborne precautions are recommended for preventing airborne transmission of measles and varicella-zoster viruses, no data are available on which to base a recommendation for respiratory protection to protect susceptible personnel against these 2 infections. transmission of varicella-zoster virus has been prevented among pediatric patients using negativepressure isolation alone. 772 whether respiratory protection (ie, wearing a particulate respirator) will enhance protection from these viruses has not yet been studied. because most hcws have natural or acquired immunity to these viruses, only immune personnel generally care for patients with these infections. [773] [774] [775] [776] although there is no evidence suggesting that masks are not adequate to protect hcws in these settings, for purposes of consistency and simplicity, or because of difficulties in ascertaining immunity, some facilities may require the use of respirators for entry into all aiirs, regardless of the specific infectious agent present. procedures for safe removal of respirators are provided in figure 1 . in some health care settings, particulate respirators used to provide care for patients with m tuberculosis are reused by the same hcw. this is an acceptable practice providing that the respirator is not damaged or soiled, the fit is not compromised by a change in shape, and the respirator has not been contaminated with blood or body fluids. no data are available on which to base a recommendation regarding the length of time that a respirator may be safely reused. sharps-related injuries. injuries due to needles and other sharps have been associated with transmission of hbv, hcv, and hiv to hcws. 777, 778 the prevention of sharps injuries has always been an essential element of universal precautions and is now an aspect of standard precautions. 1, 779 these include measures to handle needles and other sharp devices in a manner that will prevent injury to the user and to others who may encounter the device during or after a procedure. these measures apply to routine patient care and do not address the prevention of sharps injuries and other blood exposures during surgical and other invasive procedures addressed elsewhere. [780] [781] [782] [783] [784] since 1991, when osha first issued its bloodborne pathogens standard to protect hcws from blood exposure, the focus of regulatory and legislative activity has been on implementing a hierarchy of control measures. this has included focusing attention on removing sharps hazards through the development and use of engineering controls. the federal needlestick safety and prevention act, signed into law in november 2000, authorized osha's revision of its bloodborne pathogens standard to more explicitly require the use of safety-engineered sharps devices. 785 the cdc has provided guidance on sharps injury prevention, 786,787 including guidelines for the design, implementation and evaluation of a comprehensive sharps injury prevention program. 788 ii.f.2. prevention of mucous membrane contact. exposure of mucous membranes of the eyes, nose, and mouth to blood and body fluids has been associated with the transmission of bloodborne viruses and other infectious agents to hcws. 66, 751, 753, 778 the prevention of mucous membrane exposures has always been an element of universal precautions and is now an element of standard precautions for routine patient care 1, 752 and is subject to osha bloodborne pathogen regulations. safe work practices, in addition to wearing ppe, are designed to protect mucous membranes and nonintact skin from contact with potentially infectious material. these include keeping contaminated gloved and ungloved hands from touching the mouth, nose, eyes, or face and positioning patients to direct sprays and splatter away from the caregiver's face. careful placement of ppe before patient contact will help avoid the need to make adjustments to ppe and prevent possible face or mucous membrane contamination during use. in areas where the need for resuscitation is unpredictable, mouthpieces, pocket resuscitation masks with 1-way valves, and other ventilation devices provide an alternative to mouth-to-mouth resuscitation, preventing exposure of the caregiver's nose and mouth to oral and respiratory fluids during the procedure. ii.f.2.a. precautions during aerosol-generating procedures. the performance of procedures that can generate small-particle aerosols (aerosol-generating procedures), such as bronchoscopy, endotracheal intubation, and open suctioning of the respiratory tract, have been associated with transmission of infectious agents to hcws, including m tuberculosis, 789 sars-cov, 93, 94, 98 and n meningitidis. 95 protection of the eyes, nose, and mouth, in addition to gown and gloves, is recommended during performance of these procedures in accordance with standard precautions. the use of a particulate respirator is recommended during aerosol-generating procedures when the aerosol is likely to contain m tuberculosis, sars-cov, or avian or pandemic influenza viruses. ii.g.1. hospitals and long-term care facilities. options for patient placement include single-patient rooms, 2-patient rooms, and multibed wards. of these, single-patient rooms are preferred when transmission of an infectious agent is of concern. although some studies have failed to demonstrate the efficacy of single-patient rooms in preventing hais, 790 other published studies, including one commissioned by the aia and the facility guidelines institute, have documented a beneficial relationship between private rooms and reduced infectious and noninfectious adverse patient outcomes. 791, 792 the aia notes that private rooms are the trend in hospital planning and design. however, most hospitals and ltcfs have multibed rooms and must consider many competing priorities when determining the appropriate room placement for patients (eg, reason for admission; patient characteristics, such as age, gender, and mental status; staffing needs; family requests; psychosocial factors; reimbursement concerns). in the absence of obvious infectious diseases that require specified airborne infection isolation rooms (eg, tuberculosis, sars, chickenpox), the risk of transmission of infectious agents is not always considered when making placement decisions. when only a limited number of single-patient rooms is available, it is prudent to prioritize room assignments for those patients with conditions that facilitate transmission of infectious material to other patients (eg, draining wounds, stool incontinence, uncontained secretions) and those at increased risk of acquisition and adverse outcomes resulting from hais (due to, eg, immunosuppression, open wounds, indwelling catheters, anticipated prolonged length of stay, total dependence on hcws for activities of daily living). 15, 24, 43, 429, 793, 794 single-patient rooms are always indicated for patients placed on airborne precautions in a pe and are preferred for patients requiring contact or droplet precautions. 23, 24, 409, 434, 795, 796 during a suspected or proven outbreak caused by a pathogen whose reservoir is the gastrointestinal tract, the use of single-patient rooms with private bathrooms limits opportunities for transmission, especially when the colonized or infected patient has poor personal hygiene habits or fecal incontinence, or cannot be expected to assist in maintaining procedures that prevent transmission of microorganisms (eg, infants, children, and patients with altered mental status or developmental delay). in the absence of continued transmission, it is not necessary to provide a private bathroom for patients colonized or infected with enteric pathogens as long as personal hygiene practices and standard precautions (especially hand hygiene and appropriate environmental cleaning) are maintained. assignment of a dedicated commode to a patient, and cleaning and disinfecting fixtures and equipment that may have fecal contamination (eg, bathrooms, commodes, 797 scales used for weighing diapers) and the adjacent surfaces with appropriate agents may be especially important when a single-patient room cannot be assigned, because environmental contamination with intestinal tract pathogens is likely from both continent and incontinent patients. 54, 798 the results of several studies that investigated the benefit of a single-patient room in preventing transmission of c difficile were inconclusive. 167, [799] [800] [801] some studies have shown that being in the same room with a colonized or infected patient is not necessarily a risk factor for transmission; 790,802-804 however, for children, the risk of health care-associated diarrhea is increased with the increased number of patients per room. 805 these findings demonstrate that patient factors are important determinants of infection transmission risks. the need for a single-patient room and/or private bathroom for any patient is best determined on a case-by-case basis. cohorting is the practice of grouping together patients who are colonized or infected with the same organism to confine their care to a single area and prevent contact with other patients. cohorts are created based on clinical diagnosis, microbiologic confirmation (when available), epidemiology, and mode of transmission of the infectious agent. avoiding placing severely immunosuppressed patients in rooms with other patients is generally preferred. cohorting has been extensively used for managing outbreaks of mdros, including mrsa, 22 813 rotavirus, 814 and sars. 815 modeling studies provide additional support for cohorting patients to control outbreaks; 816-818 however, cohorting often is implemented only after routine infection control measures have failed to control an outbreak. assigning or cohorting hcws to care only for patients infected or colonized with a single target pathogen limits further transmission of the target pathogen to uninfected patients, 739, 818 but is difficult to achieve in the face of current staffing shortages in hospitals 582 and residential health care sites. [819] [820] [821] however, cohorting of hcws may be beneficial when transmission continues after implementing routine infection control measures and creating patient cohorts. during periods when rsv, human metapneumovirus, 822 parainfluenza, influenza, other respiratory viruses, 823 and rotavirus are circulating in the community, cohorting based on the presenting clinical syndrome is often a priority in facilities that care for infants and young children. 824 for example, during the respiratory virus season, infants may be cohorted based solely on the clinical diagnosis of bronchiolitis, due to the logistical difficulties and costs associated with requiring microbiologic confirmation before room placement and the predominance of rsv during most of the season. however, when available, single-patient rooms are always preferred, because a common clinical presentation (eg, bronchiolitis), can be caused by more than 1 infectious agent. 822, 823, 825 furthermore, the inability of infants and children to contain body fluids, and the close physical contact associated with their care, increases the risk of infection transmission for patients and personnel in this setting. 24, 794 ii.g.2. ambulatory care settings. patients actively infected with or incubating transmissible infectious diseases are frequently seen in ambulatory settings (eg, outpatient clinics, physicians' offices, emergency departments) and potentially expose hcws and other patients, family members, and visitors. 21, 34, 127, 135, 142, 826 in response to the global outbreak of sars in 2003 and in preparation for pandemic influenza, hcws working in outpatient settings are urged to implement source containment measures (eg, asking coughing patients to wear a surgical mask or cover coughing with tissues) to prevent transmission of respiratory infections, beginning at the initial patient encounter, 9,261,827 as described in section iii.a.1.a. signs can be posted at the facility's entrance or at the reception or registration desk requesting that the patient or individuals accompanying the patient promptly inform the receptionist of any symptoms of respiratory infection (eg, cough, flulike illness, increased production of respiratory secretions). the presence of diarrhea, skin rash, or known or suspected exposure to a transmissible disease (eg, measles, pertussis, chickenpox, tuberculosis) also could be added. prompt placement of a potentially infectious patient in an examination room limits the number of exposed individuals in the common waiting area. in waiting areas, maintaining a distance between symptomatic and nonsymptomatic patients (eg, . 3 feet), in addition to source control measures, may limit exposures. however, infections transmitted through the airborne route (eg, m tuberculosis, measles, chickenpox) require additional precautions. 12, 125, 828 patients suspected of having such an infection can wear a surgical mask for source containment, if tolerated, and should be placed in an examination room (preferably an aiir) as soon as possible. if this is not possible, then having the patient wear a mask and segregating the patient from other patients in the waiting area will reduce the risk of exposing others. because the person(s) accompanying the patient also may be infectious, application of the same infection control precautions may be extended to these persons if they are symptomatic. 21, 251, 829 family members accompanying children admitted with suspected m tuberculosis have been found to have unsuspected pulmonary tuberculosis with cavitary lesions, even when asymptomatic. 42, 830 patients with underlying conditions that increase their susceptibility to infection (eg, immunocompromised status 43, 44 or cystic fibrosis 20 ) require special efforts to protect them from exposure to infected patients in common waiting areas. informing the receptionist of their infection risk on arrival allows appropriate steps to further protect these patients from infection. in some cystic fibrosis clinics, to avoid exposure to other patients who could be colonized with b cepacia, patients have been given beepers on registration so that they may leave the area and receive notification to return when an examination room becomes available. 831 ii.g.3. home care. in home care, patient placement concerns focus on protecting others in the home from exposure to an infectious household member. for individuals who are especially vulnerable to adverse outcomes associated with certain infections, it may be beneficial to either remove them from the home or segregate them within the home. persons who are not part of the household may need to be prohibited from visiting during the period of infectivity. for example, in a situation where a patient with pulmonary tuberculosis is contagious and being cared for at home, very young children (age under 4 years) 832 and immunocompromised persons who have not yet been infected should be removed or excluded from the household. during the sars outbreak of 2003, segregation of infected persons during the communicable phase of the illness was found to be beneficial in preventing household transmission. 249, 833 several principles guide the transport of patients requiring transmission-based precautions. in the inpatient and residential settings, these include the following: 1. limiting transport of such patients to essential purposes, such as diagnostic and therapeutic procedures that cannot be performed in the patient's room. 2. when transport is necessary, applying appropriate barriers on the patient (eg, mask, gown, wrapping in sheets or use of impervious dressings to cover the affected areas) when infectious skin lesions or drainage are present, consistent with the route and risk of transmission. 3. notifying hcws in the receiving area of the patient's impending arrival and of the necessary precautions to prevent transmission. 4. for patients being transported outside the facility, informing the receiving facility and the medi-van or emergency vehicle personnel in advance about the type of transmission-based precautions being used. for tuberculosis, additional precautions may be needed in a small shared air space, such as in an ambulance. 12 cleaning and disinfecting noncritical surfaces in patient care areas is an aspect of standard precautions. in general, these procedures do not need to be changed for patients on transmission-based precautions. the cleaning and disinfection of all patient care areas is important for frequently touched surfaces, especially those closest to the patient, which are most likely to be contaminated (eg, bedrails, bedside tables, commodes, doorknobs, sinks, surfaces and equipment in close proximity to the patient). 11, 72, 73, 834 the frequency or intensity of cleaning may need to be changed, based on the patient's level of hygiene and the degree of environmental contamination and for certain infectious agents with reservoirs in the intestinal tract. 54 this may be particularly important in ltcfs and pediatric facilities, where patients with stool and urine incontinence are encountered more frequently. in addition, increased frequency of cleaning may be needed in a pe to minimize dust accumulation. 11 special recommendations for cleaning and disinfecting environmental surfaces in dialysis centers have been published previously. 18 in all health care settings, administrative, staffing, and scheduling activities should prioritize the proper cleaning and disinfection of surfaces that could be implicated in transmission. during a suspected or proven outbreak in which an environmental reservoir is suspected, routine cleaning procedures should be reviewed, and the need for additional trained cleaning staff should be assessed. adherence should be monitored and reinforced to promote consistent and correct cleaning. us environmental protection agency-registered disinfectants or detergents/disinfectants that best meet the overall needs of the health care facility for routine cleaning and disinfection should be selected. 11, 835 in general, use of the existing facility detergent/disinfectant according to the manufacturer's recommendations for amount, dilution, and contact time is sufficient to remove pathogens from surfaces of rooms where colonized or infected individuals were housed. this includes those pathogens that are resistant to multiple classes of antimicrobial agents (eg, c difficile, vre, mrsa, mdr-gnb 11, 24, 88, 434, 745, 795, 836 ). most often, environmental reservoirs of pathogens during outbreaks are related to a failure to follow recommended procedures for cleaning and disinfection, rather than to the specific cleaning and disinfectant agents used. [837] [838] [839] [840] certain pathogens (eg, rotavirus, noroviruses, c difficile) may be resistant to some routinely used hospital disinfectants. 274, 291, [841] [842] [843] [844] [845] [846] the role of specific disinfectants in limiting transmission of rotavirus has been demonstrated experimentally. 841 also, because c difficile may display increased levels of spore production when exposed to non-chlorine-based cleaning agents, and because these spores are more resistant than vegetative cells to commonly used surface disinfectants, some investigators have recommended the use of a 1:10 dilution of 5.25% sodium hypochlorite (household bleach) and water for routine environmental disinfection of rooms of patients with c difficile when there is continued transmission. 843, 847 one study found an association between the use of a hypochlorite solution and decreased rates of c difficile infections. 846 the need to change disinfectants based on the presence of these organisms can be determined in consultation with the infection control committee. 11, 846, 847 detailed recommendations for disinfection and sterilization of surfaces and medical equipment that have been in contact with prion-containing tissue or high risk body fluids, and for cleaning of blood and body substance spills, are available in the guidelines for environmental infection control in health care facilities 11 and in the guideline for disinfection and sterilization. 847 medical equipment and instruments/devices must be cleaned and maintained according to the manufacturers' instructions to prevent patient-to-patient transmission of infectious agents. 86, 87, 324, 848 cleaning to remove organic material always must precede highlevel disinfection and sterilization of critical and semicritical instruments and devices, because residual proteinacous material reduces the effectiveness of the disinfection and sterilization processes. 835, 847 noncritical equipment, such as commodes, intravenous pumps, and ventilators, must be thoroughly cleaned and disinfected before being used on another patient. all such equipment and devices should be handled in a manner that will prevent hcw and environmental contact with potentially infectious material. it is important to include computers and personal digital assistants used in patient care in policies for cleaning and disinfection of noncritical items. the literature on contamination of computers with pathogens has been summarized, 849 and 2 reports have linked computer contamination to colonization and infections in patients. 850, 851 although keyboard covers and washable keyboards that can be easily disinfected are available, the infection control benefit of these items and their optimal management have not yet been determined. in all health care settings, providing patients who are on transmission-based precautions with dedicated noncritical medical equipment (eg, stethoscope, blood pressure cuff, electronic thermometer) has proven beneficial for preventing transmission. 74, 89, 739, 852, 853 when this is not possible, disinfection of this equipment after each use is recommended. other previously published guidelines should be consulted for detailed guidance in developing specific protocols for cleaning and reprocessing medical equipment and patient care items in both routine and special circumstances. 11, 14, 18, 20, 739, 835, 847 in home care, it is preferable to remove visible blood or body fluids from durable medical equipment before it leaves the home. equipment can be cleaned onsite using a detergent/disinfectant and, when possible, should be placed in a plastic bag for transport to the reprocessing location. 20,738 although soiled textiles, including bedding, towels, and patient or resident clothing, may be contaminated with pathogenic microorganisms, the risk of disease transmission is negligible if these textiles are handled, transported, and laundered in a safe manner. 11, 854, 855 key principles for handling soiled laundry are (1) avoiding shaking the items or handling them in any way that may aerosolize infectious agents, (2) avoiding contact of one's body and personal clothing with the soiled items being handled, and (3) containing soiled items in a laundry bag or designated bin. if a laundry chute is used, it must be maintained to minimize dispersion of aerosols from contaminated items. 11 methods of handling, transporting, and laundering soiled textiles are determined by organizational policy and any applicable regulations; 738 guidance is provided in the guidelines for environmental infection control in health care facilities. 11 rather than rigid rules and regulations, hygienic and common sense storage and processing of clean textiles is recommended. 11, 856 when laundering is done outside of a health care facility, the clean items must be packaged or completely covered and placed in an enclosed space during transport to prevent contamination with outside air or construction dust that could contain infectious fungal spores that pose a risk for immunocompromised patients. 11 institutions are required to launder garments used as ppe and uniforms visibly soiled with blood or infective material. 738 little data exist on the safety of home laundering of hcw uniforms, but no increase in infection rates was observed in the one published study, 857 and no pathogens were recovered from home-or hospital-laundered scrubs in another study. 858 in the home, textiles and laundry from patients with potentially transmissible infectious pathogens do not require special handling or separate laundering and may be washed with warm water and detergent. 11, 857, 858 the management of solid waste emanating from the health care environment is subject to federal and state regulations for medical and nonmedical waste. 859, 860 no additional precautions are needed for nonmedical solid waste removed from rooms of patients on transmission-based precautions. solid waste may be contained in a single bag of sufficient strength. 861 the combination of hot water and detergents used in dishwashers is sufficient to decontaminate dishware and eating utensils. therefore, no special precautions are needed for dishware (eg, dishes, glasses, cups) or eating utensils. reusable dishware and utensils may be used for patients requiring transmission-based precautions. in the home and other communal settings, eating utensils and drinking vessels should not be shared, consistent with principles of good personal hygiene and to help prevent transmission of respiratory viruses, herpes simplex virus, and infectious agents that infect the gastrointestinal tract and are transmitted by the fecal/oral route (eg, hepatitis a virus, noroviruses). if adequate resources for cleaning utensils and dishes are not available, then disposable products may be used. important adjunctive measures that are not considered primary components of programs to prevent transmission of infectious agents but nonetheless improve the effectiveness of such programs include (1) antimicrobial management programs, (2) postexposure chemoprophylaxis with antiviral or antibacterial agents, (3) vaccines used both for pre-exposure and postexposure prevention, and (4) screening and restricting visitors with signs of transmissible infections. detailed discussion of judicious use of antimicrobial agents is beyond the scope of this document; however, this topic has been addressed in a previous cdc guideline (http://www.cdc.gov/ncidod/dhqp/pdf/ar/ mdroguideline2006.pdf). ii.n.1. chemoprophylaxis. antimicrobial agents and topical antiseptics may be used to prevent infection and potential outbreaks of selected agents. infections for which postexposure chemoprophylaxis is recommended under defined conditions include b pertussis, 17,862 n meningitides, 863 b anthracis after environmental exposure to aeosolizable material, 864 influenza virus, 610 hiv, 865 and group a streptococcus. 160 orally administered antimicrobials also may be used under defined circumstances for mrsa decolonization of patients or hcws. 866 another form of chemoprophylaxis involves the use of topical antiseptic agents. for example, triple dye is routinely used on the umbilical cords of term newborns to reduce the risk of colonization, skin infections, and omphalitis caused by s aureus, including mrsa, and group a streptococcus. 867, 868 extension of the use of triple dye to low birth weight infants in a nicu was one component of a program that controlled a long-standing mrsa outbreak. 22 topical antiseptics (eg, mupirocin) also are used for decolonization of hcws or selected patients colonized with mrsa, as discussed in the mdro guideline 866, [869] [870] [871] [872] ii.n.2. immunoprophylaxis. certain immunizations recommended for susceptible hcws have decreased the risk of infection and the potential for transmission in health care facilities. 17, 873 the osha mandate requiring employers to offer hbv vaccination to hcws has played a substantial role in the sharp decline in incidence of occupational hbv infection. 777, 874 the routine administration of varicella vaccine to hcws has decreased the need to place susceptible hcws on administrative leave after exposure to patients with varicella. 774 in addition, reports of health care-associated transmission of rubella in obstetric clinics 33, 875 and measles in acute care settings 34 demonstrate the importance of immunization of susceptible hcws against childhood diseases. many states have requirements for vaccination of hcws for measles and rubella in the absence of evidence of immunity. annual influenza vaccine campaigns targeted at patients and hcws in ltcfs and acute care settings have been instrumental in preventing or limiting institutional outbreaks; consequently, increasing attention is being directed toward improving influenza vaccination rates in hcws. 35, 610, 689, [876] [877] [878] transmission of b pertussis in health care facilities has been associated with large and costly outbreaks that include both hcws and patients. 17, 36, 41, 100, 682, 826, 879, 880 hcws in close contact with infants with pertussis are at particularly high risk because of waning immunity and, until 2005, the absence of a vaccine appropriate for adults. but 2 acellular pertussis vaccines were licensed in the united states in 2005, 1 for use in individuals age 11 to 18 years and the other for use in those age 10 to 64 years. 881 current advisory committee on immunization practices provisional recommendations include immunization of adolescents and adults, especially those in contact with infants under age 12 months and hcws with direct patient contact. 882, 883 immunization of children and adults will help prevent the introduction of vaccine-preventable diseases into health care settings. the recommended immunization schedule for children is published annually in the january issues of the morbidity and mortality weekly report, with interim updates as needed. 884, 885 an adult immunization schedule also is available for healthy adults and those with special immunization needs due to high-risk medical conditions. 886 some vaccines are also used for postexposure prophylaxis of susceptible individuals, including varicella, 887 influenza, 610 hepatitis b, 777 and smallpox 225 vaccines. 17, 873 in the future, administration of a newly developed s aureus conjugate vaccine (still under investigation) to selected patients may provide a novel method of preventing health care-associated s aureus (including mrsa) infections in high-risk groups (eg, hemodialysis patients and candidates for selected surgical procedures). 888, 889 immune globulin preparations also are used for postexposure prophylaxis of certain infectious agents under specified circumstances (eg, varicella-zoster virus, hbv, rabies, measles and hepatitis a virus 17, 832, 873 ). the rsv monoclonal antibody preparation palivizumab may have contributed to controlling a nosocomial outbreak of rsv in one nicu, but there is insufficient evidence to support a routine recommendation for its use in this setting. 890 ii.n. 3 24, 43, 44, 372 and sars 21, [252] [253] [254] . effective methods for visitor screening in health care settings have not yet been studied, however. visitor screening is especially important during community outbreaks of infectious diseases and for high-risk patient units. sibling visits are often encouraged in birthing centers, postpartum rooms, pediatric inpatient units, picus, and residential settings for children; in hospital settings, a child visitor should visit only his or her own sibling. screening of visiting siblings and other children before they are allowed into clinical areas is necessary to prevent the introduction of childhood illnesses and common respiratory infections. screening may be passive, through the use of signs to alert family members and visitors with signs and symptoms of communicable diseases not to enter clinical areas. more active screening may include the completion of a screening tool or questionnaire to elicit information related to recent exposures or current symptoms. this information is reviewed by the facility staff, after which the visitor is either permitted to visit or is excluded. 832 family and household members visiting pediatric patients with pertussis and tuberculosis may need to be screened for a history of exposure, as well as signs and symptoms of current infection. potentially infectious visitors are excluded until they receive appropriate medical screening, diagnosis, or treatment. if exclusion is not considered to be in the best interest of the patient or family (ie, primary family members of critically or terminally ill patients), then the symptomatic visitor must wear a mask while in the health care facility and remain in the patient's room, avoiding exposure to others, especially in public waiting areas and the cafeteria. visitor screening is used consistently on hsct units. 15, 43 however, considering the experience during the 2003 sars outbreaks and the potential for pandemic influenza, developing effective visitor screening systems will be beneficial. 9 education concerning respiratory hygiene/cough etiquette is a useful adjunct to visitor screening. ii.n.3.b. use of barrier precautions by visitors. the use of gowns, gloves, and masks by visitors in health care settings has not been addressed specifically in the scientific literature. some studies included the use of gowns and gloves by visitors in the control of mdros but did not perform a separate analysis to determine whether their use by visitors had a measurable impact. [892] [893] [894] family members or visitors who are providing care to or otherwise are in very close contact with the patient (eg, feeding, holding) may also have contact with other patients and could contribute to transmission in the absence of effective barrier precautions. specific recommendations may vary by facility or by unit and should be determined by the specific level of interaction. there are 2 tiers of hicpac/cdc precautions to prevent transmission of infectious agents, standard precautions and transmission-based precautions. standard precautions are intended to be applied to the care of all patients in all health care settings, regardless of the suspected or confirmed presence of an infectious agent. implementation of standard precautions constitutes the primary strategy for the prevention of health care-associated transmission of infectious agents among patients and hcws. transmission-based precautions are for patients who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically important pathogens, which require additional control measures to effectively prevent transmission. because the infecting agent often is not known at the time of admission to a health care facility, transmission-based precautions are used empirically, according to the clinical syndrome and the likely etiologic agents at the time, and then modified when the pathogen is identified or a transmissible infectious etiology is ruled out. examples of this syndromic approach are presented in table 2 . the hicpac/cdc guidelines also include recommendations for creating a protective environment for allogeneic hsct patients. the specific elements of standard and transmission-based precautions are discussed in part ii of this guideline. in part iii, the circumstances in which standard precautions, transmission-based precautions, and a protective environment are applied are discussed. tables 4 and 5 summarize the key elements of these sets of precautions standard precautions combine the major features of universal precautions 779, 895 and body substance isolation 639 and are based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents. standard precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which health care is delivered (table 4 ). these include hand hygiene; use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. also, equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents (eg, wear gloves for direct contact, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another patient). the application of standard precautions during patient care is determined by the nature of the hcw-patient interaction and the extent of anticipated blood, body fluid, or pathogen exposure. for some interactions (eg, performing venipuncture), only gloves may be needed; during other interactions (eg, intubation), use of gloves, gown, and face shield or mask and goggles is necessary. education and training on the principles and rationale for recommended practices are critical elements of standard precautions because they facilitate appropriate decision-making and promote adherence when hcws are faced with new circumstances. 654, [680] [681] [682] [683] [684] [685] an example of the importance of the use of standard precautions is intubation, especially under emergency circumstances when infectious agents may not be suspected, but later are identified (eg, sars-cov, n meningitides). the application of standard precautions is described below and summarized in table 4 . guidance on donning and removing gloves, gowns and other ppe is presented in figure 1 . standard precautions are also intended to protect patients by ensuring that hcws do not carry infectious agents to patients on their hands or via equipment used during patient care. 21, 254, 896 the strategy proposed has been termed respiratory hygiene/cough etiquette 9, 827 and is intended to be incorporated into infection control practices as a new component of standard precautions. the strategy is targeted at patients and accompanying family members and friends with undiagnosed transmissible respiratory infections, and applies to any person with signs of illness including cough, congestion, rhinorrhea, or increased production of respiratory secretions when entering a health care facility. 40, 41, 43 the term cough etiquette is derived from recommended source control measures for m tuberculosis. 12, 126 the elements of respiratory hygiene/cough etiquette include (1) education of health care facility staff, patients, and visitors; (2) posted signs, in language(s) appropriate to the population served, with instructions to patients and accompanying family members or friends; (3) source control measures (eg, covering the mouth/nose with a tissue when coughing and prompt disposal of used tissues, using surgical masks on the coughing person when tolerated and appropriate); (4) hand hygiene after contact with respiratory secretions; and (5) spatial separation, ideally .3 feet, of persons with respiratory infections in common waiting areas when possible. covering sneezes and coughs and placing masks on coughing patients are proven means of source containment that prevent infected persons from dispersing respiratory secretions into the air. 107, 145, 897, 898 masking may be difficult in some settings, (eg, pediatrics), in which case the emphasis by necessity may be on cough etiquette. 899 physical proximity of , 3 feet has been associated with an increased risk for transmission of infections through the droplet route (eg, n meningitidis 103 and group a streptococcus 114 ) and thus supports the practice of distancing infected persons from others who are not infected. the effectiveness of good hygiene practices, especially hand hygiene, in preventing transmission of viruses and reducing the incidence of respiratory infections both within and outside [900] [901] [902] health care settings is summarized in several reviews. 558, 716, 903 these measures should be effective in decreasing the risk of transmission of pathogens contained in large respiratory droplets (eg, influenza virus, 23 adenovirus, 111 b pertussis, 826 and m pneumoniae 112 ). although fever will be present in many respiratory infections, patients with pertussis and mild upper respiratory tract infections are often afebrile. therefore, the absence of fever does not always exclude a respiratory infection. patients who have asthma, allergic rhinitis, or chronic obstructive lung disease also may be coughing and sneezing. although these patients often are not infectious, cough etiquette measures are prudent. hcws are advised to observe droplet precautions (ie, wear a mask) and hand hygiene when examining and caring for patients with signs and symptoms of a respiratory infection. hcws who have a respiratory infection are advised to avoid direct patient contact, especially with high-risk patients. if this is not possible, then a mask should be worn while providing patient care. iii.a.1.b. safe injection practices. the investigation of 4 large outbreaks of hbv and hcv among patients in ambulatory care facilities in the united states identified a need to define and reinforce safe injection practices. 452 the 4 outbreaks occurred in a private medical practice, a pain clinic, an endoscopy clinic, and a hematology/oncology clinic. the primary breaches in infection control practice that contributed to these outbreaks were reinsertion of used needles into a multiple-dose vial or solution container (eg, saline bag) and use of a single needle/syringe to administer intravenous medication to multiple patients. in 1 of these outbreaks, preparation of medications in the same workspace where used needle/syringes were dismantled also may have been a contributing factor. these and other outbreaks of viral hepatitis could have been prevented by adherence to basic principles of aseptic technique for the preparation and administration of parenteral medications. 452, 453 these include the use of a sterile, single-use, disposable needle and syringe for each injection given and prevention of contamination of injection equipment and medication. whenever possible, use of single-dose vials is preferred over multiple-dose vials, especially when medications will be administered to multiple patients. outbreaks related to unsafe injection practices indicate that some hcws are unaware of, do not understand, or do not adhere to basic principles of infection control and aseptic technique. a survey of us health care workers who provide medication through injection found that 1% to 3% reused the same needle and/or syringe on multiple patients. 904 among the deficiencies identified in recent outbreaks were a lack of oversight of personnel and failure to follow up on reported breaches in infection control practices in ambulatory settings. therefore, to ensure that all hcws understand and adhere to recommended practices, principles of infection control and aseptic technique need to be reinforced in training programs and incorporated into institutional polices that are monitored for adherence. 453 iii.a.1.c. infection control practices for special lumbar puncture procedures. in 2004, the cdc investigated 8 cases of postmyelography meningitis that either were reported to the cdc or identified through a survey of the emerging infections network of the infectious disease society of america. blood and/or cerebrospinal fluid of all 8 cases yielded streptococcal species consistent with oropharyngeal flora and there were changes in the csf indices and clinical status indicative of bacterial meningitis. equipment and products used during these procedures (eg, contrast media) were excluded as probable sources of contamination. procedural details available for 7 cases determined that antiseptic skin preparations and sterile gloves had been used. however, none of the clinicians wore a face mask, giving rise to the speculation that droplet transmission of oralpharyngeal flora was the most likely explanation for these infections. bacterial meningitis after myelography and other spinal procedures (eg, lumbar puncture, spinal and epidural anesthesia, intrathecal chemotherapy) has been reported previously. [905] [906] [907] [908] [909] [910] [911] [912] [913] [914] as a result, the question of whether face masks should be worn to prevent droplet spread of oral flora during spinal procedures (eg, myelography, lumbar puncture, spinal anesthesia) has been debated. 915, 916 face masks are effective in limiting the dispersal of oropharyngeal droplets 917 and are recommended for the placement of central venous catheters. 918 in october 2005, hicpac reviewed the evidence and concluded that there is sufficient experience to warrant the additional protection of a face mask for the individual placing a catheter or injecting material into the spinal or epidural space. there are 3 categories of transmission-based precautions: contact precautions, droplet precautions, and airborne precautions. transmission-based precautions are used when the route(s) of transmission is (are) not completely interrupted using standard precautions alone. for some diseases that have multiple routes of transmission (eg, sars), more than 1 transmission-based precautions category may be used. when used either singly or in combination, they are always used in addition to standard precautions. see appendix a for recommended precautions for specific infections. when transmission-based precautions are indicated, efforts must be made to counteract possible adverse effects on patients (ie, anxiety, depression and other mood disturbances, 919-921 perceptions of stigma, 922 reduced contact with clinical staff, [923] [924] [925] and increases in preventable adverse events 564 ) to improve acceptance by the patients and adherence by hcws. iii.b.1. contact precautions. contact precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment as described in section i.b.3.a. the specific agents and circumstance for which contact precautions are indicated are found in appendix a. the application of contact precautions for patients infected or colonized with mdros is described in the 2006 hicpac/cdc mdro guideline. 926 contact precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission. a single-patient room is preferred for patients who require contact precautions. when a single-patient room is not available, consultation with infection control personnel is recommended to assess the various risks associated with other patient placement options (eg, cohorting, keeping the patient with an existing roommate). in multipatient rooms, $ 3 feet spatial separation between beds is advised to reduce the opportunities for inadvertent sharing of items between the infected/colonized patient and other patients. hcws caring for patients on contact precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. donning ppe on room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (eg, vre, c difficile, noroviruses and other intestinal tract pathogens, rsv). 54, 72, 73, 78, 273, 274, 739 iii.b.2. droplet precautions. droplet precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions as described in section i.b.3.b. because these pathogens do not remain infectious over long distances in a health care facility, special air handling and ventilation are not required to prevent droplet transmission. infectious agents for which droplet precautions are indicated are listed in appendix a and include b pertussis, influenza virus, adenovirus, rhinovirus, n meningitides, and group a streptococcus (for the first 24 hours of antimicrobial therapy). a single-patient room is preferred for patients who require droplet precautions. when a single-patient room is not available, consultation with infection control personnel is recommended to assess the various risks associated with other patient placement options (eg, cohorting, keeping the patient with an existing roommate). spatial separation of $ 3 feet and drawing the curtain between patient beds is especially important for patients in multibed rooms with infections transmitted by the droplet route. hcws wear a mask (a respirator is not necessary) for close contact with infectious patient; the mask is generally donned on room entry. patients on droplet precautions who must be transported outside of the room should wear a mask if tolerated and follow respiratory hygiene/cough etiquette. iii.b.3. airborne precautions. airborne precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air (eg, rubeola virus [measles], varicella virus [chickenpox], m tuberculosis, and possibly sars-cov), as described in section i.b.3.c and appendix a. the preferred placement for patients who require airborne precautions is in an aiir, a single-patient room equipped with special air handling and ventilation capacity that meet the aia/facility guidelines institute standards for aiirs (ie, monitored negative pressure relative to the surrounding area; 12 air exchanges per hour for new construction and renovation and 6 air exchanges per hour for existing facilities; air exhausted directly to the outside or recirculated through hepa filtration before return). 12, 13 some states require the availability of such rooms in hospitals, emergency departments, and nursing homes that care for patients with m tuberculosis. a respiratory protection program that includes education about use of respirators, fit testing, and user seal checks is required in any facility with aiirs. in settings where airborne precautions cannot be implemented due to limited engineering resources (eg, physician offices), masking the patient, placing the patient in a private room (eg, office examination room) with the door closed, and providing n95 or higher-level respirators or masks if respirators are not available for hcws will reduce the likelihood of airborne transmission until the patient is either transferred to a facility with an aiir or returned to the home environment, as deemed medically appropriate. hcws caring for patients on airborne precautions wear a mask or respirator, depending on the disease-specific recommendations (see section ii.e.4, table 2 , and appendix a), that is donned before room entry. whenever possible, nonimmune hcws should not care for patients with vaccine-preventable airborne diseases (eg, measles, chickenpox, smallpox). diagnosis of many infections requires laboratory confirmation. because laboratory tests, especially those that depend on culture techniques, often require 2 or more days for completion, transmission-based precautions must be implemented while test results are pending, based on the clinical presentation and likely pathogens. use of appropriate transmission-based precautions at the time a patient develops symptoms or signs of transmissible infection, or arrives at a health care facility for care, reduces transmission opportunities. although it is not possible to identify prospectively all patients needing transmission-based precautions, certain clinical syndromes and conditions carry a sufficiently high risk to warrant their use empirically while confirmatory tests are pending (see table 2 ). icps are encouraged to modify or adapt this table according to local conditions. transmission-based precautions remain in effect for limited periods (ie, while the risk for transmission of the infectious agent persists or for the duration of the illness (see appendix a). for most infectious diseases, this duration reflects known patterns of persistence and shedding of infectious agents associated with the natural history of the infectious process and its treatment. for some diseases (eg, pharyngeal or cutaneous diphtheria, rsv), transmission-based precautions remain in effect until culture or antigen-detection test results document eradication of the pathogen and, for rsv, symptomatic disease is resolved. for other diseases (eg, m tuberculosis), state laws and regulations and health care facility policies may dictate the duration of precautions. 12 in immunocompromised patients, viral shedding can persist for prolonged periods of time (many weeks to months) and transmission to others may occur during that time; therefore, the duration of contact and/or droplet precautions may be prolonged for many weeks. 499, [927] [928] [929] [930] [931] [932] the duration of contact precautions for patients who are colonized or infected with mdros remains undefined. mrsa is the only mdro for which effective decolonization regimens are available. 866 however, carriers of mrsa who have negative nasal cultures after a course of systemic or topical therapy may resume shedding mrsa in the weeks after therapy. 933, 934 although early guidelines for vre suggested discontinuation of contact precautions after 3 stool cultures obtained at weekly intervals proved negative, 739 subsequent experiences have indicated that such screening may fail to detect colonization that can persist for . 1 year. 27, [935] [936] [937] likewise, available data indicate that colonization with vre, mrsa, 938 and possibly mdr-gnb can persist for many months, especially in the presence of severe underlying disease, invasive devices, and recurrent courses of antimicrobial agents. it may be prudent to assume that mdro carriers are colonized permanently and manage them accordingly. alternatively, an interval free of hospitalizations, antimicrobial therapy, and invasive devices (eg, 6 or 12 months) before reculturing patients to document clearance of carriage may be used. determination of the best strategy awaits the results of additional studies. see the 2006 hicpac/cdc mdro guideline 926 for a discussion of possible criteria to discontinue contact precautions for patients colonized or infected with mdros. although transmission-based precautions generally apply in all health care settings, exceptions exist. for example, in home care, aiirs are not available. furthermore, family members already exposed to diseases such as varicella and tuberculosis would not use masks or respiratory protection, but visiting hcws would need to use such protection. similarly, management of patients colonized or infected with mdros may necessitate contact precautions in acute care hospitals and in some ltcfs when there is continued transmission, but the risk of transmission in ambulatory care and home care has not been defined. consistent use of standard precautions may suffice in these settings, but more information is needed. a pe is designed for allogeneic hsct patients to minimize fungal spore counts in the air and reduce the risk of invasive environmental fungal infections (see table 5 for specifications). 11, [13] [14] [15] the need for such controls has been demonstrated in studies of aspergillosis outbreaks associated with construction. 11, 14, 15, 157, 158 as defined by the aia 13 and presented in detail in the cdc's 2003 guideline for environmental infection control in health care facilities, 11,860 air quality for hsct patients is improved through a combination of environmental controls that include (1) hepa filtration of incoming air, (2) directed room air flow, (3) positive room air pressure relative to the corridor, (4) well-sealed rooms (including sealed walls, floors, ceilings, windows, electrical outlets) to prevent flow of air from the outside, (5) ventilation to provide $ 12 air changes per hour, (6) strategies to minimize dust (eg, scrubbable surfaces rather than upholstery 939 and carpet, 940 and routinely cleaning crevices and sprinkler heads), and (7) prohibiting dried and fresh flowers and potted plants in the rooms of hsct patients. the latter is based on molecular typing studies that have found indistinguishable strains of aspergillus terreus in patients with hematologic malignancies and in potted plants in the vicinity of the patients. [941] [942] [943] the desired quality of air may be achieved without incurring the inconvenience or expense of laminar airflow. 15, 157 to prevent inhalation of fungal spores during periods when construction, renovation, or other dust-generating activities that may be ongoing in and around the health care facility, it has been recommended that severely immunocompromised patients wear a high-efficiency respiratory protection device (eg, an n95 respirator) when they leave the pe. 11, 14, 944 the use of masks or respirators by hsct patients when they are outside of the pe for prevention of environmental fungal infections in the absence of construction has not been evaluated. a pe does not include the use of barrier precautions beyond those indicated for standard precuations and transmission-based precautions. no published reports support the benefit of placing patients undergoing solid organ transplantation or other immunocompromised patients in a pe. these recommendations are designed to prevent transmission of infectious agents among patients and hcws in all settings where health care is delivered. as in other cdc/hicpac guidelines, each recommendation is categorized on the basis of existing scientific data, theoretical rationale, applicability, and, when possible, economic impact. the cdc/hicpac system for categorizing recommendations is as follows: category ia. strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies. category ib. strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale. category ic. required for implementation, as mandated by federal and/or state regulation or standard. category ii. suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale. no recommendation; unresolved issue. practices for which insufficient evidence or no consensus regarding efficacy exists. health care organization administrators should ensure the implementation of recommendations specified in this section. agents into the objectives of the organization's patient and occupational safety programs. 542 assume that every person is potentially infected or colonized with an organism that could be transmitted in the health care setting and apply the following infection control practices during the delivery of health care. iv.a.1. during the delivery of health care, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces. 72 airborne precautions does not need to wear a mask or respirator during transport if the patient is wearing a mask and infectious skin lesions are covered. category ii v.d.6. exposure management immunize or provide the appropriate immune globulin to susceptible persons as soon as possible after unprotected contact (ie, exposure) to a patient with measles, varicella, or smallpox: category ia d administer measles vaccine to exposed susceptible persons within 72 hours after the exposure or administer immune globulin within 6 days of the exposure event for high-risk persons in whom vaccine is contraindicated. 17,1030-1033 d administer varicella vaccine to exposed susceptible persons within 120 hours after the exposure or administer varicella immune globulin (vzig or an alternative product), when available, within 96 hours for high-risk persons in whom vaccine is contraindicated (eg, immunocompromised patients, pregnant women, newborns whose mother's varicella onset was , 5 days before or within 48 hours after delivery). 887,1033-1035 d administer smallpox vaccine to exposed susceptible persons within 4 days after exposure. 108 vi. protective environment (see table 4 airborne infection isolation room (aiir). formerly known as a negative-pressure isolation room, an aiir is a single-occupancy patient care room used to isolate persons with a suspected or confirmed airborne infectious disease. environmental factors are controlled in aiirs to minimize the transmission of infectious agents that are usually transmitted from person to person by droplet nuclei associated with coughing or aerosolization of contaminated fluids. aiirs should provide negative pressure in the room (so that air flows under the door gap into the room), an air flow rate of 6 to 12 air changes per hour (ach) (6 ach for existing structures, 12 ach for new construction or renovation), and direct exhaust of air from the room to the outside of the building or recirculation of air through a highefficiency particulate air filter before returning to circulation. ( ambulatory care setting. a facility that provides health care to patients who do not remain overnight; examples include hospital-based outpatient clinics, non-hospital-based clinics and physician offices, urgent care centers, surgicenters, free-standing dialysis centers, public health clinics, imaging centers, ambulatory behavioral health and substance abuse clinics, physical therapy and rehabilitation centers, and dental practices. bioaerosol. an airborne dispersion of particles containing whole or parts of biological entities, including bacteria, viruses, dust mites, fungal hyphae, and fungal spores. such aerosols usually consist of a mixture of monodispersed and aggregate cells, spores, or viruses carried by other materials, such as respiratory secretions and/or inert particles. infectious bioaerosols (ie, those containing biological agents capable of causing an infectious disease) can be generated from human sources (eg, expulsion from the respiratory tract during coughing, sneezing, talking, singing, suctioning, or wound irrigation), wet environmental sources (eg, high-volume air consitioning and cooling tower water with legionella) or dry sources (eg, construction dust with spores produced by aspergillus spp). bioaerosols include large respiratory droplets and small droplet nuclei (cole ec. ajic 1998; 26: 453-64) . caregiver.. any person who is not an employee of an organization, is not paid, and provides or assists in providing health care to a patient (eg, family member, friend) and acquire technical training as needed based on the tasks that must be performed. cohorting. in the context of this guideline, this term applies to the practice of grouping patients infected or colonized with the same infectious agent together to confine their care to one area and prevent contact with susceptible patients (cohorting patients). during outbreaks, health care personnel may be assigned to a cohort of patients to further limit opportunities for transmission (cohorting staff). colonization. proliferation of microorganisms on or within body sites without detectable host immune response, cellular damage, or clinical expression. the presence of a microorganism within a host may occur with varying durations but may become a source of potential transmission. in many instances, colonization and carriage are synonymous. droplet nuclei. microscopic particles , 5 mm in size that are the residue of evaporated droplets and are produced when a person coughs, sneezes, shouts, or sings. these particles can remain suspended in the air for prolonged periods and can be carried on normal air currents in a room or beyond, to adjacent spaces or areas receiving exhaust air. engineering controls. removal or isolation of a workplace hazard through technology. an airborne infection isolation room, a protective environment, engineered sharps injury prevention device, and a sharps container are examples of engineering controls. epidemiologically important pathogen. an infectious agent that has one or more of the following characteristics: (1) readily transmissible, (2) a proclivity toward causing outbreaks, (3) possible association with a severe outcome, and (4) difficult to treat. examples include acinetobacter spp, aspergillus spp, burkholderia cepacia, clostridium difficile, klebsiella or enterobacter spp, extended-spectrum beta-lactamaseproducing gram-negative bacilli, methicillin-resistant staphylococcus aureus, pseudomonas aeruginosa, vancomycin-resistant enterococci, vancomycin-resistant staphylococcus aureus, influenza virus, respiratory syncytial virus, rotavirus, severe acute respiratory syndrome coronavirus, noroviruses, and the hemorrhagic fever viruses. hand hygiene. a general term that applies to any one of the following: (1) handwashing with plain (nonantimicrobial) soap and water, (2) antiseptic handwashing (soap containing antiseptic agents and water), (3) antiseptic handrub (waterless antiseptic product, most often alcohol-based, rubbed on all surfaces of hands), or (4) surgical hand antisepsis (antiseptic handwash or antiseptic handrub performed preoperatively by surgical personnel to eliminate transient hand flora and reduce resident hand flora). 558 health care-associated infection (hai). an infection that develops in a patient who is cared for in any setting where health care is delivered (eg, acute care hospital, chronic care facility, ambulatory clinic, dialysis center, surgicenter, home) and is related to receiving health care (ie, was not incubating or present at the time health care was provided). in ambulatory and home settings, hai refers to any infection that is associated with a medical or surgical intervention. because the geographic location of infection acquisition is often uncertain, the preferred term is considered to be health care-associated rather than health care-acquired. healthcare epidemiologist. a person whose primary training is medical (md, do) and/or masters-or doctorate-level epidemiology who has received advanced training in health care epidemiology. typically these professionals direct or provide consultation to an infection control program in a hospital, long-term care facility, or health care delivery system (also see infection control professional). health care personnel, health care worker (hcw). any paid or unpaid person who works in a health care setting (eg, any person who has professional or technical training in a health care-related field and provides patient care in a health care setting or any person who provides services that support the delivery of health care such as dietary, housekeeping, engineering, maintenance personnel). hematopoietic stem cell transplantation (hsct). any transplantation of blood-or bone marrow-derived hematopoietic stem cells, regardless of donor type (eg, allogeneic or autologous) or cell source (eg, bone marrow, peripheral blood, or placental/umbilical cord blood), associated with periods of severe immunosuppression that vary with the source of the cells, the intensity of chemotherapy required, and the presence of graft versus host disease (mmwr 2000; 49: rr-10). high-efficiency particulate air (hepa) filter. an air filter that removes .99.97% of particles . 0.3 mm (the most penetrating particle size) at a specified flow rate of air. hepa filters may be integrated into the central air handling systems, installed at the point of use above the ceiling of a room, or used as portable units (mmwr 2003; 52: rr-10). home care. a wide range of medical, nursing, rehabilitation, hospice, and social services delivered to patients in their place of residence (eg, private residence, senior living center, assisted living facility). home health care services include care provided by home health aides and skilled nurses, respiratory therapists, dieticians, physicians, chaplains, and volunteers; provision of durable medical equipment; home infusion therapy; and physical, speech, and occupational therapy. immunocompromised patient. a patient whose immune mechanisms are deficient because of a congenital or acquired immunologic disorder (eg, human immunodeficiency virus infection, congenital immune deficiency syndromes), chronic diseases such as diabetes mellitus, cancer, emphysema, or cardiac failure, intensive care unit care, malnutrition, and immunosuppressive therapy of another disease process [eg, radiation, cytotoxic chemotherapy, anti-graft rejection medication, corticosteroids, monoclonal antibodies directed against a specific component of the immune system]). the type of infections for which an immunocompromised patient has increased susceptibility is determined by the severity of immunosuppression and the specific component(s) of the immune system that is affected. patients undergoing allogeneic hematopoietic stem cell transplantation and those with chronic graft versus host disease are considered the most vulnerable to health care-associated infections. immunocompromised states also make it more difficult to diagnose certain infections (eg, tuberculosis) and are associated with more severe clinical disease states than persons with the same infection and a normal immune system. infection. the transmission of microorganisms into a host after evading or overcoming defense mechanisms, resulting in the organism's proliferation and invasion within host tissue(s). host responses to infection may include clinical symptoms or may be subclinical, with manifestations of disease mediated by direct organisms pathogenesis and/or a function of cell-mediated or antibody responses that result in the destruction of host tissues. infection control and prevention professional (icp). a person whose primary training is in either nursing, medical technology, microbiology, or epidemiology and who has acquired specialized training in infection control. responsibilities may include collection, analysis, and feedback of infection data and trends to health care providers; consultation on infection risk assessment, prevention, and control strategies; performance of education and training activities; implementation of evidence-based infection control practices or those mandated by regulatory and licensing agencies; application of epidemiologic principles to improve patient outcomes; participation in planning renovation and construction projects (eg, to ensure appropriate containment of construction dust); evaluation of new products or procedures on patient outcomes; oversight of employee health services related to infection prevention; implementation of preparedness plans; communication within the health care setting, with local and state health departments, and with the community at large concerning infection control issues; and participation in research. certification in infection control is available through the certification board of infection control and epidemiology. infection control and prevention program. a multidisciplinary program that includes a group of activities to ensure that recommended practices for the prevention of health care-associated infections are implemented and followed by health care workers, making the health care setting safe from infection for patients and health care personnel. the joint commission on accreditation of healthcare organizations requires the following 5 components of an infection control program for accreditation: (1) surveillance: monitoring patients and health care personnel for acquisition of infection and/or colonization; (2) investigation: identification and analysis of infection problems or undesirable trends; (3) prevention: implementation of measures to prevent transmission of infectious agents and to reduce risks for device-and procedure-related infections; (4) control: evaluation and management of outbreaks; and (5) reporting: provision of information to external agencies as required by state and federal laws and regulations (see http://www.jcaho.org). the infection control program staff has the ultimate authority to determine infection control policies for a health care organization with the approval of the organization's governing body. long-term care facility (ltcf). a residential or outpatient facility designed to meet the biopsychosocial needs of persons with sustained self-care deficits. these include skilled nursing facilities, chronic disease hospitals, nursing homes, foster and group homes, institutions for the developmentally disabled, residential care facilities, assisted living facilities, retirement homes, adult day health care facilities, rehabilitation centers, and long-term psychiatric hospitals. mask. a term that applies collectively to items used to cover the nose and mouth and includes both procedure masks and surgical masks (see http://www.fda. gov/cdrh/ode/guidance/094.html#4). multidrug-resistant organism (mdro). in general, a bacterium (excluding mycobacterium tuberculosis) that is resistant to 1 or more classes of antimicrobial agents and usually is resistant to all but 1 or 2 commercially available antimicrobial agents (eg, methicillin-resistant staphylococcus aureus, vancomycin-resistant enterococci, extended-spectrum beta-lactamase-producing or intrinsically resistant gram-negative bacilli). 176 nosocomial infection. derived from 2 greek words, ''nosos'' (disease) and ''komeion'' (to take care of), refers to any infection that develops during or as a result of an admission to an acute care facility (hospital) and was not incubating at the time of admission. personal protective equipment (ppe). a variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with infectious agents. ppe includes gloves, masks, respirators, goggles, face shields, and gowns. procedure mask. a covering for the nose and mouth that is intended for use in general patient care situations. these masks generally attach to the face with ear loops rather than ties or elastic. unlike surgical masks, procedure masks are not regulated by the food and drug administration. protective environment. a specialized patient care area, usually in a hospital, with a positive air flow relative to the corridor (ie, air flows from the room to the outside adjacent space). the combination of high-efficiency particulate air filtration, high numbers (.12) of air changes per hour, and minimal leakage of air into the room creates an environment that can safely accommodate patients with a severely compromised immune system (eg, those who have received allogeneic hemopoietic stem cell transplantation) and decrease the risk of exposure to spores produced by environmental fungi. other components include use of scrubbable surfaces instead of materials such as upholstery or carpeting, cleaning to prevent dust accumulation, and prohibition of fresh flowers or potted plants. quasi-experimental study. a study undertaken to evaluate interventions but do not use randomization as part of the study design. these studies are also referred to as nonrandomized, pre-/postintervention study designs. these studies aim to demonstrate causality between an intervention and an outcome but cannot achieve the level of confidence concerning an attributable benefit obtained through a randomized controlled trial. in hospitals and public health settings, randomized control trials often cannot be implemented due to ethical, practical, and urgency reasons; therefore, quasi-experimental design studies are commonly used. however, even if an intervention appears to be effective statistically, the question can be raised as to the possibility of alternative explanations for the result. such a study design is used when it is not logistically feasible or ethically possible to conduct a randomized controlled trial, (eg, during outbreaks). within the classification of quasi-experimental study designs, there is a hierarchy of design features that may contribute to validity of results (harris et al. cid 2004 :38: 1586 . residential care setting. a facility in which people live, minimal medical care is delivered, and the psychosocial needs of the residents are provided for. respirator. a personal protective device worn by health care personnel over the nose and mouth to protect them from acquiring airborne infectious diseases due to inhalation of infectious airborne particles , 5 mm in size. these include infectious droplet nuclei from patients with mycobacterium tuberculosis, variola virus [smallpox], or severe acute respiratory syndrome and dust particles that contain infectious particles, such as spores of environmental fungi (eg, aspergillus spp). the centers for disease control and prevention's national institute for occupational safety and health (niosh) certifies respirators used in health care settings (see http://www.cdc.gov/niosh/topics/respirators/). the n95 disposable particulate, air-purifying respirator is the type used most commonly by health care personnel. other respirators used include n-99 and n-100 particulate respirators, powered air-purifying respirators with high-efficiency filters, and nonpowered fullfacepiece elastomeric negative pressure respirators. a listing of niosh-approved respirators can be found at http://www.cdc.gov/niosh/npptl/respirators/disp_part/ particlist.html. respirators must be used in conjunction with a complete respiratory protection program, as required by the occupational safety and health administration, which includes fit testing, training, proper selection of respirators, medical clearance, and respirator maintenance. respiratory hygiene/cough etiquette. a combination of measures designed to minimize the transmission of respiratory pathogens through droplet or airborne routes in health care settings. the components of respiratory hygiene/cough etiquette are (1) covering the mouth and nose during coughing and sneezing, (2) using tissues to contain respiratory secretions with prompt disposal into a no-touch receptacle, (3) offering a surgical mask to persons who are coughing to decrease contamination of the surrounding environment, and (4) turning the head away from others and maintaining spatial separation (ideally .3 feet) when coughing. these measures are targeted to all patients with symptoms of respiratory infection and their accompanying family members or friends beginning at the point of initial encounter with a health care setting (eg, reception/triage in emergency departments, ambulatory clinics, health care provider offices). 126 (srinivasin a iche 2004; 25: 1020; http://www.cdc.gov/flu/ professionals/infectioncontrol/resphygiene.htm). safety culture. shared perceptions of workers and management regarding the level of safety in the work environment. a hospital safety climate includes the following organizational components: (1) senior management support for safety programs, (2) absence of workplace barriers to safe work practices, (3) cleanliness and orderliness of the worksite, (4) minimal conflict and good communication among staff members, (5) frequent safety-related feedback/training by supervisors, and (6) availability of ppe and engineering controls. 618 source control. the process of containing an infectious agent either at the portal of exit from the body or within a confined space. the term is applied most frequently to containment of infectious agents transmitted by the respiratory route but could apply to other routes of transmission, (eg, a draining wound, vesicular or bullous skin lesions). respiratory hygiene/cough etiquette that encourages individuals to ''cover your cough'' and/or wear a mask is a source control measure. the use of enclosing devices for local exhaust ventilation (eg, booths for sputum induction or administration of aerosolized medication) is another example of source control. standard precautions. a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed diagnosis or presumed infection status. standard precautions represents a combination and expansion of universal precautions 778 and body substance isolation. 1109 standard precautions are based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents. standard precautions include hand hygiene and, depending on the anticipated exposure, use of gloves, gown, mask, eye protection, or face shield. in addition, equipment or items in the patient environment likely to have been contaminated with infectious fluids must be handled in a manner to prevent transmission of infectious agents (eg, wear gloves for handling, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another patient). surgical mask. a device worn over the mouth and nose by operating room personnel during surgical procedures to protect both surgical patients and operating room personnel from transfer of microorganisms and body fluids. surgical masks also are used to protect health care personnel from contact with large infectious droplets (. 5 mm in size). according to draft guidance issued by the food and drug administration on may 15, 2003 , surgical masks are evaluated using standardized testing procedures for fluid resistance, bacterial filtration efficiency, differential pressure (air exchange), and flammability to mitigate the risks to health associated with the use of surgical masks. these specifications apply to any masks that are labeled surgical, laser, isolation, or dental or medical procedure (http://www.fda.gov/cdrh/ode/guidance/094.html#4). surgical masks do not protect against inhalation of small particles or droplet nuclei and should not be confused with particulate respirators that are recommended for protection against selected airborne infectious agents (eg, mycobacterium tuberculosis). other species s use contact precautions for diapered or incontinent persons for the duration of illness or to control institutional outbreaks. giardia lamblia s use contact precautions for diapered or incontinent persons for the duration of illness or to control institutional outbreaks. noroviruses s use contact precautions for diapered or incontinent persons for the duration of illness or to control institutional outbreaks. persons who clean areas heavily contaminated with feces or vomitus may benefit from wearing masks, because virus can be aerosolized from these body substances; 142,147,148 ensure consistent environmental cleaning and disinfection with focus on restrooms even when apparently unsoiled. 272, 1060 hypochlorite solutions may be required when there is continued transmission. [289] [290] [291] alcohol is less active, but there is no evidence that alcohol antiseptic handrubs are not effective for hand decontamination. 293 cohorting of affected patients to separate airs paces and toilet facilities may help interrupt transmission during outbreaks. rotavirus c di ensure consistent environmental cleaning and disinfection and frequent removal of soiled diapers. prolonged shedding may occur in both immunocompetent and immunocompromised children and the elderly. 930 also for asymptomatic, exposed infants delivered vaginally or by c-section and if mother has active infection and membranes have been ruptured for more than 4 to 6 hours until infant surface cultures obtained at 24 to 36 hours of age negative after 48 hours of incubation. 1065 susceptible hcws should not enter room if immune caregivers are available; no recommendation for face protection of immune hcws; no recommendation for type of protection (ie, surgical mask or respirator) for susceptible hcws. in an immunocompromised host with varicella pneumonia, prolong the duration of precautions for duration of illness. postexposure prophylaxis: provide postexposure vaccine as soon as possible but within 120 hours; for susceptible exposed persons for whom vaccine is contraindicated (immunocompromised persons, pregnant women, newborns whose mother's varicella onset is # 5 days before delivery or within 48 hours after delivery) provide vzig, when available, within 96 hours; if unavailable, use ivig. provide airborne precautions for exposed susceptible persons and exclude exposed susceptible health care workers beginning 8 days after first exposure until 21 days after last exposure or 28 if received vzig, regardless of postexposure vaccination. 1032 variola (see smallpox) vibrio parahaemolyticus (see gastroenteritis) vincent's angina (trench mouth) s viral hemorrhagic fevers due to lassa, ebola, marburg, crimean-congo fever viruses s, d, c di single-patient room preferred. emphasize: use of sharps safety devices and safe work practices, hand hygiene; barrier protection against blood and body fluids on entry into room (single gloves and fluid-resistant or impermeable gown, face/eye protection with masks, goggles or face shields), and appropriate waste handling. use n95 or higher-level respirator when performing aerosol-generating procedures. largest viral load in final stages of illness when hemorrhage may occur; additional ppe, including double gloves, leg and shoe coverings may be used, especially in resource-limited settings where options for cleaning and laundry are limited. notify public health officials immediately if ebola is suspected. 212, 313, 738, 770 also see table 3 *type of precautions: a, airborne precautions; c, contact; d, droplet; s, standard; when a, c, and d are specified, also use s. y duration of precautions: cn, until off antimicrobial treatment and culture-negative; di, duration of illness (with wound lesions, di means until wounds stop draining); de, until environment completely decontaminated; u, until time specified in hours (hrs) after initiation of effective therapy; unknown: criteria for establishing eradication of pathogen has not been determined guideline for isolation precautions in hospitals. the hospital infection control practices advisory committee. infect control the use and interpretation of quasi-experimental studies in infectious diseases effect of regression to the mean on decision making in health care randomized trials or observational tribulations? comparison of evidence of treatment effects in randomized and nonrandomized studies the use of systematic reviews and meta-analyses in infection control and hospital epidemiology a systematic review of quasi-experimental study designs in the fields of infection control and antibiotic resistance system-wide surveillance for clinical encounters by patients previously identified with mrsa and vre foundations of the severe acute respiratory syndrome preparedness and response plan for healthcare facilities guidelines for environmental infection control in health-care facilities. recommendations of cdc and the healthcare infection control practices advisory committee (hicpac) guidelines for preventing the transmission of mycobacterium tuberculosis in healthcare settings guidelines for design and construction of hospital and health care facilities recommendations of cdc and the healthcare infection control practices advisory committee guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. recommendations of cdc, the infectious disease society of america, and the american society of blood and marrow transplantation guideline for hand hygiene in health-care settings. recommendations of the healthcare infection control practices advisory committee and the hicpac/shea/apic/idsa hand hygiene task force, society for healthcare epidemiology of america/association for professionals in infection control/infectious diseases society of america guideline for infection control in healthcare personnel recommendations for preventing transmission of infections among chronic hemodialysis patients guidelines for infection control in dental health-care settings infection control recommendations for patients with cystic fibrosis: microbiology, important pathogens, and infection control practices to prevent patient-to-patient transmission investigation of a nosocomial outbreak of severe acute respiratory syndrome (sars) in toronto, canada eradication of endemic methicillin-resistant staphylococcus aureus infections from a neonatal intensive care unit transmission of influenza: implications for control in health care settings nosocomial respiratory syncytial virus infections: the ''cold war'' has not ended epidemiological analysis defining concurrent outbreaks of serratia marcescens and methicillin-resistant staphylococcus aureus in a neonatal intensivecare unit epidemiology and successful control of a large outbreak due to klebsiella pneumoniae producing extended-spectrum beta-lactamases the role of ''colonization pressure'' in the spread of vancomycin-resistant enterococci: an important infection control variable prolonged nosocomial outbreak of hepatitis a arising from an alcoholic with pneumonia an outbreak of pseudomonas aeruginosa pneumonia and bloodstream infection associated with intermittent otitis externa in a healthcare worker endemic pseudomonas aeruginosa infection in a neonatal intensive care unit outbreak of extended-spectrum beta-lactamase-producing klebsiella pneumoniae in a neonatal intensive care unit linked to artificial nails spread of methicillin-resistant staphylococcus aureus in a hospital after exposure to a health care worker with chronic sinusitis rubella outbreak in a prenatal clinic: management and prevention transmission of measles in medical settings, united states, 1985-1989 effects of influenza vaccination of health-care workers on mortality of elderly people in longterm care: a randomised controlled trial outbreaks of pertussis associated with hospitals pseudomonas surgical-site infections linked to a healthcare worker with onychomycosis excretion of serotype g1 rotavirus strains by asymptomatic staff: a possible source of nosocomial infection a hospital-acquired outbreak of methicillin-resistant staphylococcus aureus infection initiated by a surgeon carrier nosocomial pertussis: possible spread by a hospital visitor hutchinson nm. containment of pertussis in the regional pediatric hospital during the greater cincinnati epidemic of 1993 tuberculosis among adult visitors of children with suspected tuberculosis and employees at a children's hospital nosocomial respiratory syncytial virus infections: prevention and control in bone marrow transplant patients community respiratory virus infections among hospitalized adult bone marrow transplant recipients hospital transmission of community-acquired methicillin-resistant staphylococcus aureus among postpartum women external sources of vancomycin-resistant enterococci for intensive care units patients' endogenous flora as the source of ''nosocomial'' enterobacter in cardiac surgery epidemiology of endemic pseudomonas aeruginosa: why infection control efforts have failed intranasal mupirocin to prevent postoperative staphylococcus aureus infections factors that predict preexisting colonization with antibiotic-resistant gram-negative bacilli in patients admitted to a pediatric intensive care unit infection in prolonged pediatric critical illness: a prospective four-year study based on knowledge of the carrier state are most icu infections really nosocomial? a prospective observational cohort study in mechanically ventilated patients the epidemiology of methicillin-resistant staphylococcus aureus in a burn center the role of the intestinal tract as a reservoir and source for transmission of nosocomial pathogens principles and practice of infectious diseases risk of community-acquired pneumococcal bacteremia in patients with diabetes: a population-based casecontrol study diabetes mellitus and bacteraemia: a comparative study between diabetic and non-diabetic patients bacterial pneumonia in persons infected with the human immunodeficiency virus. pulmonary complications of hiv infection study group the importance of bacterial sepsis in intensive care unit patients with acquired immunodeficiency syndrome: implications for future care in the age of increasing antiretroviral resistance investigation of healthcare-associated transmission of mycobacterium tuberculosis among patients with malignancies at three hospitals and at a residential facility infection in organ transplant recipients a review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies nosocomial infections in pediatric patients rate, risk factors, and outcomes of nosocomial primary bloodstream infection in pediatric intensive care unit patients biofilms: microbial life on surfaces acquisition of hepatitis c by a conjunctival splash transmission of hiv and hepatitis c virus from a nursing home patient to a health care worker an outbreak of scabies in a teaching hospital: lessons learned outbreak of scabies in norwegian nursing homes and home care patients: control and prevention herpetic whitlow infection in a general pediatrician: an occupational hazard nosocomial herpetic infections in a pediatric intensive care unit acquisition of nosocomial pathogens on hands after contact with environmental surfaces near hospitalized patients transfer of vancomycin-resistant enterococci via health care worker hands reduction in the incidence of clostridium difficile-associated diarrhea in an acute care hospital and a skilled nursing facility following replacement of electronic thermometers with single-use disposables nosocomial hepatitis b virus infection associated with reusable fingerstick blood sampling devices hepatitis c in a ward for cystic fibrosis and diabetic patients: possible transmission by spring-loaded finger-stick devices for self-monitoring of capillary blood glucose transmission of hepatitis b virus among persons undergoing blood glucose monitoring in long-term care facilities, mississippi, north carolina, and los angeles county modes of transmission of respiratory syncytial virus possible transmission by fomites of respiratory syncytial virus multiresistant pseudomonas aeruginosa outbreak in a pediatric oncology ward related to bath toys transmission of a highly drug-resistant strain (strain w1) of mycobacterium tuberculosis: community outbreak and nosocomial transmission via a contaminated bronchoscope patient-to-patient transmission of hepatitis c virus during colonoscopy transmission of mycobacterium tuberculosis by a fiberoptic bronchoscope: identification by dna fingerprinting an outbreak of multidrug-resistant pseudomonas aeruginosa infection associated with contamination of bronchoscopes and an endoscope washer-disinfector lessons from outbreaks associated with bronchoscopy pseudomonas aeruginosa and serratia marcescens contamination associated with a manufacturing defect in bronchoscopes an outbreak of pseudomonas aeruginosa infections associated with flexible bronchoscopes environmental contamination due to methicillin-resistant staphylococcus aureus: possible infection control implications contamination of gowns, gloves, and stethoscopes with vancomycin-resistant enterococci bacterial contamination of uniforms the size distribution of droplets in the exhaled breath of healthy human subjects on airborne infection. study ii: droplets and droplet nuclei sars among critical care nurses transmission of severe acute respiratory syndrome during intubation and mechanical ventilation nosocomial meningococcemia in a physician illness in intensive-care staff after brief exposure to severe acute respiratory syndrome is burkholderia (pseudomonas) cepacia disseminated from cystic fibrosis patients during physiotherapy? possible sars coronavirus transmission during cardiopulmonary resuscitation transmission of ''toxic strep'' syndrome from an infected child to a firefighter during cpr nosocomial pertussis outbreak among adult patients and healthcare workers cluster of sars among medical students exposed to single patient influenza a among hospital personnel and patients: implications for recognition, prevention, and control epidemic meningococcal disease in an elementary school classroom aerosol transmission of rhinovirus colds the size and duration of air-carriage of respiratory droplets and droplet nucleii infectivity of respiratory syncytial virus by various routes of inoculation the recovery of smallpox virus from patients and their environment in a smallpox hospital the epidemiology of smallpox characterization of infectious aerosols in health care facilities: an aid to effective engineering controls and preventive strategies molecular heterogeneity of acinetobacter baumanii isolates during seasonal increase in prevalence how contagious are common respiratory tract infections? senterfit lb. ecology of mycoplasma pneumoniae infections in marine recruits at parris island, south carolina effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (sars) expulsion of group a haemolytic streptocicci in droplets and droplet nuclei by sneezing, coughing and talking prevention of nosocomial respiratory syncytial virus infections through compliance with glove and gown isolation precautions prospective controlled study of four infection-control procedures to prevent nosocomial infection with respiratory syncytial virus dispersal of staphylococcus aureus into the air associated with a rhinovirus infection the ''cloud baby'': an example of bacterial-viral interaction a cloud adult: the staphylococcus aureus-virus interaction revisited transmission of multidrug-resistant mycobacterium tuberculosis among persons with human immunodeficiency virus infection in an urban hospital: epidemiologic and restriction fragment length polymorphism analysis measles outbreak in a pediatric practice: airborne transmission in an office setting airborne transmission of chickenpox in a hospital aerial dissemination of pulmonary tuberculosis: a two-year study of contagion in a tuberculosis ward hospital outbreak of multidrug-resistant mycobacterium tuberculosis infections: factors in transmission to staff and hiv-infected patients guidelines for preventing the transmission of mycobacterium tuberculosis in healthcare facilities tuberculosis epidemic among hospital personnel an airborne outbreak of smallpox in a german hospital and its significance with respect to other recent outbreaks in europe the recent outbreak of smallpox in meschede, west germany an outbreak of influenza aboard a commercial airliner human influenza resulting from aerosol inhalation transmission of a small round structured virus by vomiting during a hospital outbreak of gastroenteritis aerosol transmission of experimental rotavirus infection the severe acute respiratory syndrome transmission of the severe acute respiratory syndrome on aircraft in-flight transmission of severe acute respiratory syndrome (sars): a case report detection of airborne severe acute respiratory syndrome (sars) coronavirus and environmental contamination in sars outbreak units evidence of airborne transmission of the severe acute respiratory syndrome virus update: outbreak of severe acute respiratory syndrome worldwide cluster of severe acute respiratory syndrome cases among protected health-care workers 25-to 30-nm virus particles associated with a hospital outbreak of acute gastroenteritis with evidence for airborne transmission evidence for airborne transmission of norwalk-like virus (nlv) in a hotel restaurant influenza in the acute hospital setting airborne infection general discussion widespread environmental contamination with norwalk-like viruses (nlv) detected in a prolonged hotel outbreak of gastroenteritis a school outbreak of norwalk-like virus: evidence for airborne transmission airborne transmission of communicable infection: the elusive pathway bacillus anthracis aerosolization associated with a contaminated mail-sorting machine secondary aerosolization of viable bacillus anthracis spores in a contaminated us senate office hospital epidemiologic surveillance for invasive aspergillosis: patient demographics and the utility of antigen detection pumonary aspergillosis during hospital renovation cluster of cases of invasive aspergillosis in a transplant intensive care unit: evidence of person-to-person airborne transmission investigation of an epidemic of invasive aspergillosis: utility of molecular typing with the use of random amplified polymorphic dna probes nosocomial fungal infection during hospital renovation positive-pressure isolation and the prevention of invasive aspergillosis: what is the evidence? refinements of environmental assessment during an outbreak investigation of invasive aspergillosis in a leukemia and bone marrow transplant unit pathogenic aspergillus species recovered from a hospital water system: a 3-year prospective study prevention of invasive group a streptococcal disease among household contacts of case patients and among postpartum and postsurgical patients: recommendations from the centers for disease control and prevention outbreak of group a streptococci in a burn center: use of pheno-and genotypic procedures for strain tracking cluster of deaths from group a streptococcus in a long-term care facility legionnaires' disease: update on epidemiology and management options changing face of health care-associated fungal infections intestinal flora in newborn infants with a description of a new pathogenic anaerobe, bacillus difficilis antimicrobial agent-induced diarrhea: a bacterial disease nosocomial acquisition of clostridium difficile infection clostridium difficile-associated diarrhea in a region of quebec from 1991 to 2003: a changing pattern of disease severity outbreak of clostridium difficile infection in a hospital in southeast england transmission of h7n7 avian influenza a virus to human beings during a large outbreak in commercial poultry farms in the netherlands an epidemic, toxin gene-variant strain of clostridium difficile a predominantly clonal multiinstitutional outbreak of clostridium difficile-associated diarrhea with high morbidity and mortality toxin production by an emerging strain of clostridium difficile associated with outbreaks of severe disease in north america and europe perceived increases in the incidence and severity of clostridium difficile disease: an emerging threat that continues to unfold. presented at the 15th annual scientific meeting of the society for healthcare epidemiology of america varying rates of clostridium difficile-associated diarrhea at prevention epicenter hospitals institute of medicine. antimicrobial resistance: issues and options society for healthcare epidemiology of america and infectious diseases society of america joint committee on the prevention of antimicrobial resistance guidelines for the prevention of antimicrobial resistance in hospitals vancomycin-resistant staphylococcus aureus in the absence of vancomycin exposure staphylococcus aureus with reduced susceptibility to vancomycin, united states centers for disease control and prevention. staphylococcus aureus resistant to vancomycin public health dispatch: vancomycin-resistant staphylococcus aureus vancomycin-resistant staphylococcus aureus infection with vancomycinresistant staphylococcus aureus containing the vana resistance gene epidemiological and microbiological characterization of infections caused by staphylococcus aureus with reduced susceptibility to vancomycin antimicrobial drug resistance vancomycin-intermediate staphylococcus aureus in a home health care patient the drug-resistant pneumococcus: clinical relevance, therapy, and prevention resistance patterns among nosocomial pathogens: trends over the past few years vancomycin-resistant enterococcal infections antibiotic resistance among gram-negative bacilli in us intensive care units: implications for fluoroquinolone use antimicrobial resistance with focus on beta-lactam resistance in gram-negative bacilli staphylococcus aureus with reduced susceptibility to vancomycin isolated from a patient with fatal bacteremia emergence of vancomycin resistance in staphylococcus aureus. glycopeptide-intermediate staphylococcus aureus working group vancomycin resistance in staphylococci risk factors for increasing multidrug resistance among extended-spectrum ã�-lactamase-producing escheria coli and klebsiella species streptococcus pneumoniae serotype 4 outbreak in a home for the aged: report and review of recent outbreaks persistence of fluoroquinolone-resistant, multidrug-resistant streptococcus pneumoniae in a long-term-care facility: efforts to reduce intrafacility transmission failure to control an outbreak of multidrug-resistant streptococcus pneumoniae in a longterm-care facility: emergence and ongoing transmission of a fluoroquinolone-resistant strain role of healthcare workers in outbreaks of methicillin-resistant staphylococcus aureus: a 10-year evaluation from a dutch university hospital shea guideline for preventing nosocomial transmission of multidrug-resistant strains of staphylococcus aureus and enterococcus nasal and hand carriage of staphylococcus aureus in staff at a department for thoracic and cardiovascular surgery: endogenous or exogenous source? ical terrorism: strategic plan for preparedness and response. recommendations of the cdc strategic planning workgroup anthrax as a biological weapon, 2002: updated recommendations for management smallpox as a biological weapon: medical and public health management. working group on civilian biodefense risk of person-to-person transmission of pneumonic plague plague as a biological weapon: medical and public health management. working group on civilian biodefense botulinum toxin as a biological weapon: medical and public health management tularemia as a biological weapon: medical and public health management notice to readers update: management of patients with suspected viral hemorrhagic fever, united states hemorrhagic fever viruses as biological weapons: medical and public health management contact vaccinia: transmission of vaccinia from smallpox vaccination how contagious is vaccinia? transmission of vaccinia virus and rationale for measures for prevention smallpox vaccination and adverse reactions: guidance for clinicians smallpox vaccination: a review. part ii: adverse events update: adverse events following civilian smallpox vaccination secondary and tertiary transfer of vaccinia virus among us military personnel, united states and worldwide risk of vaccinia transfer to the hands of vaccinated persons after smallpox immunization frequency of vaccinia virus isolation on semipermeable versus nonocclusive dressings covering smallpox vaccination sites in hospital personnel randomized trial comparing vaccinia on the external surfaces of 3 conventional bandages applied to smallpox vaccination sites in primary vaccinees quantitative vaccinia cultures and evolution of vaccinia-specific cd81 cytotoxic t-lymphocyte (ctl) responses in revaccinees recommendations for using smallpox vaccine in a pre-event vaccination program: supplemental recommendations of the advisory committee on immunization practices (acip) and the healthcare infection control practices advisory committee (hicpac) surveillance for creutzfeldt-jakob disease, united states creutzfeldt-jakob disease and related transmissible spongiform encephalopathies potential epidemic of creutzfeldt-jakob disease from human growth hormone therapy creutzfeldt-jakob disease in recipients of pituitary hormones update: creutzfeldt-jakob disease associated with cadaveric dura mater grafts creutzfeldt-jakob disease via dural and corneal transplants putative neurosurgical transmission of creutzfeldt-jakob disease with analysis of donor and recipient: agent strains evidence for case-to-case transmission of creutzfeldt-jakob disease danger of accidental person-to-person transmission of creutzfeldt-jakob disease by surgery creutzfeldt-jakob disease: recommendations for disinfection and sterilization chronic wasting disease and potential transmission to humans molecular analysis of prion strain variation and the aetiology of ''new variant'' cjd the public health impact of prion diseases variant creutzfeldt-jakob disease and bovine spongiform encephalopathy investigation of variant creutzfeldt-jakob disease and other human prion diseases with tonsil biopsy samples creutzfeldt-jakob disease and haemophilia: assessment of risk emerging infectious agents: do they pose a risk to the safety of transfused blood and blood products? available from. accessed possible transmission of variant creutzfeldt-jakob disease by blood transfusion preclinical vcjd after blood transfusion in a prnp codon 129 heterozygous patient guidelines for high-risk autopsy cases: special precautions for creutzfeldt-jakob disease identification of a novel coronavirus in patients with severe acute respiratory syndrome a novel coronavirus associated with severe acute respiratory syndrome epidemiologic linkage and public health implication of a cluster of severe acute respiratory syndrome in an extended family severe acute respiratory syndrome among children children hospitalized with severe acute respiratory syndrome-related illness in toronto outbreak of severe acute respiratory syndrome in a tertiary hospital in singapore, linked to an index patient with atypical presentation: epidemiological study super-spreading sars events protecting health care workers from sars and other respiratory pathogens: a review of the infection control literature protecting health care workers from sars and other respiratory pathogens: organizational and individual factors that affect adherence to infection control guidelines severe acute respiratory syndrome coronavirus on hospital surfaces public health guidance for community-level preparedness and response to severe acute respiratory syndrome (sars) lack of sars transmission among public hospital workers laboratory-acquired severe acute respiratory syndrome the detection of monkeypox in humans in the western hemisphere a case of severe monkeypox virus disease in an american child: emerging infections and changing professional values human monkey pox contagiousness of monkey pox for humans: results of an investigation of 2 outbreaks of the infection in zaire four generations of probable person-to-person transmission of human monkeypox extended interhuman transmission of monkeypox in a hospital community in the republic of the congo evaluation of human-tohuman transmission of monkeypox from infected patients to health care workers a tale of two clades: monkeypox viruses the transmission potential of monkeypox virus in human populations human monkeypox: disease pattern, incidence and attack rates in a rural area of northern zaire norwalk-like viruses: public health consequences and outbreak management an outbreak of viral gastroenteritis following environmental contamination at a concert hall a norovirus outbreak at a longterm-care facility: the role of environmental surface contamination laboratory efforts to cultivate noroviruses impact of an outbreak of norovirus infection on hospital resources. infect control shohat t. a large-scale gastroenteritis outbreak associated with norovirus in nursing homes an outbreak of acute gastroenteritis in a geriatric long-term-care facility: combined application of epidemiological and molecular diagnostic methods an outbreak of acute gastroenteritis caused by a small round structured virus in a geriatric convalescent facility a norovirus gastroenteritis epidemic in a long-term-care facility an outbreak of norovirus infection in a long-term-care facility a predominant role for norwalk-like viruses as agents of epidemic gastroenteritis in maryland nursing homes for the elderly outbreaks of acute gastroenteritis on cruise ships and on land: identification of a predominant circulating strain of norovirus, united states outbreaks of gastroenteritis associated with noroviruses on cruise ships centers for disease control and prevention. norovirus outbreak among evacuees from hurricane katrina evaluation of the impact of the source (patient versus staff) on nosocomial norovirus outbreak severity norovirus and child care: challenges in outbreak control philadelphia: lippincott-raven inactivation of caliciviruses inactivation of feline calicivirus, a norwalk virus surrogate effects of cleaning and disinfection in reducing the spread of norovirus contamination via environmental surfaces efficacy of commonly used disinfectants for the inactivation of calicivirus on strawberry, lettuce, and a food-contact surface inactivation of feline calicivirus, a surrogate of norovirus (formerly norwalk-like viruses), by different types of alcohol in vitro and in vivo norwalk virus infection and disease is associated with abo histo-blood group type division of viral and rickettsial diseases epidemiology of hemorrhagic fever viruses democratic republic of the congo, 1995: risk factors for patients without a reported exposure congo/crimean haemorrhagic fever in dubai: an outbreak at the rashid hospital a hospital epidemic of lassa fever in zorzor transmission of ebola hemorrhagic fever: a study of risk factors in family members marburg and ebola: arming ourselves against the deadly filoviruses ebola haemorrhagic fever in zaire a case of ebola virus infection a novel immunohistochemical assay for the detection of ebola virus in skin: implications for diagnosis, spread, and surveillance of ebola hemorrhagic fever. commission de lutte contre les epidemies a kikwit the reemergence of ebola hemorrhagic fever, democratic republic of the congo ebola outbreak in kikwit, democratic republic of the congo: discovery and control measures imported lassa fever in germany: surveillance and management of contact persons marburg agent disease in monkeys lethal experimental infection of rhesus monkeys with ebola-zaire (mayinga) virus by the oral and conjunctival route of exposure effect of environmental factors on aerosol-induced lassa virus infection lethal experimental infections of rhesus monkeys by aerosolized ebola virus transmission of ebola virus (zaire strain) to uninfected control monkeys in a biocontainment laboratory status of infection surveillance and control programs in the united states, 1992-1996. association for professionals in infection control and epidemiology characteristics of hospitals and infection control professionals participating in the national nosocomial infections surveillance system hospital-acquired infections in intensive care unit patients: an overview with emphasis on epidemics bloodstream infections due to candida species in the intensive care unit: identifying especially high-risk patients to determine prevention strategies secular trends of candidemia in a large tertiary-care hospital from 1988 to 2000: emergence of candida parapsilosis national nosocomial infections surveillance (nnis) system report, data summary from nosocomial infections in medical intensive care units in the united states. national nosocomial infections surveillance system nosocomial infections in combined medical-surgical intensive care units in the united states impact of ventilator-associated pneumonia on resource utilization and patient outcome nosocomial infections during extracorporeal membrane oxygenation acinetobacter outbreaks nosocomial bloodstream infections in patients with implantable left ventricular assist devices nosocomial cardiac infections increasing prevalence of antimicrobial resistance in intensive care units antibiotic resistance in the intensive care unit the effect of vancomycin and third-generation cephalosporins on prevalence of vancomycinresistant enterococci in 126 us adult intensive care units the role of the intensive care unit environment in the pathogenesis and prevention of ventilator-associated pneumonia variations in mortality and length of stay in intensive care units risk factors for epidemic xanthomonas maltophilia infection/colonization in intensive care unit patients nosocomial acquisition of candida parapsilosis: an epidemiologic study risk factors for an outbreak of multidrug-resistant acinetobacter nosocomial pneumonia among intubated patients outbreak of acinetobacter spp bloodstream infections in a nursery associated with contaminated aerosols and air conditioners outbreak of pseudomonas aeruginosa ventriculitis among patients in a neurosurgical intensive care unit respiratory syncytial virus infection among intubated adults in a university medical intensive care unit nosocomial infections in a burn intensive care unit predictors of infectious complications after burn injuries in children burn wound infections: current status epidemiology of infections and strategies for control in burn care and therapy alternate antimicrobial therapy for vancomycin-resistant enterococci burn wound infections control of methicillin-resistant staphylococcus aureus in a pediatric burn unit effective control of methicillin-resistant staphylococcus aureus in a burn unit profile of the first four years of the regional burn unit based at st. john's hospital, west lothian (1992-1996) candida infection with and without nystatin prophylaxis: an 11-year experience with patients with burn injury natural history of bloodstream infections in a burn patient population: the importance of candidemia an epidemiological profile and trend analysis of wound flora in burned children: 7 years' experience pseudomonas infections in the thermally injured patient containment of a multiresistant serratia marcescens outbreak an outbreak of methicillin-resistant staphylococcus aureus on a burn unit: potential role of contaminated hydrotherapy equipment a prolonged outbreak of methicillin-resistant staphylococcus aureus in the burn unit of a tertiary medical center methicillin-resistant staphylococcus aureus eradication in a burn center reduction of vancomycin-resistant enterococcal infections by limitation of broad-spectrum cephalosporin use in a trauma and burn intensive care unit candidemia in the pediatric patient with burns the epidemiology of burn wound infections: then and now a decade of reduced gram-negative infections and mortality associated with improved isolation of burned patients an outbreak of cutaneous aspergillosis in a tertiary care hospital preventing postoperative burn wound aspergillosis epidemiology of infections with pseudomonas aeruginosa in burn patients: the role of hydrotherapy risk factors for nosocomial bloodstream infections due to acinetobacter baumannii: a casecontrol study of adult burn patients effectiveness of bacteria-controlled nursing units in preventing cross-colonization with resistant bacteria in severely burned children implications for burn unit design following outbreak of multi-resistant acinetobacter infection in an icu and burn unit infection control in a burn center nosocomial infections in pediatric patients: a european, multicenter prospective study nosocomial infections in pediatric patients: a prevalence study in spanish hospitals. epine working group nosocomial infections in the pediatric patient: an update a national point-prevalence survey of pediatric intensive care unit-acquired infections in the united states prevalence of nosocomial infections in neonatal intensive care unit patients: results from the first national point-prevalence survey nosocomial infections among neonates in high-risk nurseries in the united states. national nosocomial infections surveillance system nosocomial infections in pediatric intensive care units in the united states. national nosocomial infections surveillance system nosocomial influenza in children outbreak of parainfluenza virus type 3 in an intermediate care neonatal nursery human metapneumovirus infection among children hospitalized with acute respiratory illness evolution of an adenovirus outbreak in a multidisciplinary children's hospital variation in risk for nosocomial chickenpox after inadvertent exposure nosocomial rotavirus in a pediatric hospital toys in a pediatric hospital: are they a bacterial source? co-bedding twins: a developmentally supportive care strategy comparison of skin-toskin (kangaroo) and traditional care: parenting outcomes and preterm infant development kangaroo mother care to reduce morbidity and mortality in low birthweight infants methicillin-resistant staphylococcus aureus in two child care centers methicillin-resistant staphylococcus aureus carriage in a child care center following a case of disease. toronto child care center study group emergence and control of methicillin-resistant staphylococcus aureus in a children's hospital and pediatric long-term care facility community-acquired methicillin-resistant staphylococcus aureus in children with no identified predisposing risk four pediatric deaths from community-acquired methicillin-resistant staphylococcus aureus, minnesota and north dakota, 1997-1999 clonal features of community-acquired methicillin-resistant staphylococcus aureus in children community-acquired methicillin-resistant staphylococcus aureus infections in south texas children prospective comparison of risk factors and demographic and clinical characteristics of communityacquired, methicillin-resistant versus methicillin-susceptible staphylococcus aureus infection in children three-year surveillance of community-acquired staphylococcus aureus infections in children infection control and changing health-care delivery systems residential care and the elderly: the burden of infection control of infections in nonacute care pediatric settings the burden of infection in long-term care healthcare industry market update nosocomial infection and antibiotic utilization in geriatric patients: a pilot prospective surveillance program in skilled nursing facilities regional data set of infection rates for long-term care facilities: description of a valuable benchmarking tool intensive surveillance for infections in a three-year study of nursing home patients two years of infection surveillance in a geriatric long-term care facility nosocomial infection rates during a one-year period in a nursing home care unit of a veterans administration hospital infection surveillance and control programs in the department of veterans affairs nursing home care units: a preliminary assessment everyday matters in the lives of nursing home residents: wish for and perception of choice and control care of the nursing home patient higher respiratory infection rates on an alzheimer's special care unit and successful intervention issues in the management of resistant bacteria in longterm-care facilities vancomycin-resistant enterococci in long-term-care facilities antimicrobial resistance in long-term-care facilities infections in long-term-care facilities: screen or clean? risk of acquiring influenza a in a nursing home from a culture-positive roommate viral respiratory infections in the institutionalized elderly: clinical and epidemiologic findings influenzaand respiratory syncytial virus-associated morbidity and mortality in the nursing home population rhinovirus outbreak in a longterm care facility for elderly persons associated with unusually high mortality direct costs associated with a nosocomial outbreak of adenoviral conjunctivitis infection in a long-term care institution a pertussis outbreak in a wisconsin nursing home outbreak of clostridium difficile infection in a long-term care facility: association with gatifloxacin use a new paradigm for clinical investigation of infectious syndromes in older adults: assessment of functional status as a risk factor and outcome measure risk factors for resistance to antimicrobial agents among nursing home residents pneumonia in longterm care: a prospective case-control study of risk factors and impact on survival risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities a longitudinal study of risk factors associated with the formation of pressure ulcers in nursing homes nutrition risk factors for survival in the elderly living in canadian long-term care facilities pulmonary aspiration in a long-term care setting: clinical and laboratory observations and an analysis of risk factors the chronic indwelling catheter and urinary infection in long-term care facility residents gastrostomy tube infections in a community hospital the nasogastric feeding tube as a risk factor for aspiration and aspiration pneumonia infections and functional impairment in nursing home residents: a reciprocal relationship methicillin-resistant staphylococcus aureus: colonization and infection in a long-term care facility incidence of methicillinresistant staphylococcus aureus (mrsa) isolation in a skilled nursing home: a third report on the risk factors for the occurrence of mrsa infection in the elderly colonization of skilled-care facility residents with antimicrobial-resistant pathogens infection control in long-term care facilities long-term care facilities as sources of antibioticresistant nosocomial pathogens infection prevention and control in the longterm-care facility. shea long-term-care committee and apic guidelines committee requirements for infrastructure and essential activities of infection control and epidemiology in out-of-hospital settings: a consensus panel report. association for professionals in infection control and epidemiology and society for healthcare epidemiology of america infection control in long-term care facilities methicillin-resistant staphylococcus aureus: long-term care concerns antibiotic-resistant organisms among long-term care facility residents on admission to an inpatient geriatrics unit: retrospective and prospective surveillance methicillin-resistant staphylococcus aureus in a nursing home and affiliated hospital: a four-year perspective multiple antibiotic-resistant klebsiella and escherichia coli in nursing homes the rising influx of multidrug-resistant gram-negative bacilli in tertiary care hospitals national hospital ambulatory medical care survey: 2000 outpatient department summary national ambulatory medical care survey: 2000 summary national surveillance of dialysis-associated diseases in the united states antimicrobial-resistant, gram-positive bacteria among patients undergoing chronic hemodialysis transmission of infectious diseases in outpatient health care settings infection control in ambulatory care infection control in the outpatient setting patient-to-patient transmission of hepatitis b in a dermatology practice endoscopic transmission of hepatitis b virus patient-to-patient transmission of hiv in private surgical consulting rooms investigation of possible patient-to-patient transmission of hepatitis c in a hospital transmission of hepatitis b and c viruses in outpatient settings viral hepatitis transmission in ambulatory health care settings nosocomial outbreak of tuberculosis in an outpatient hiv treatment room mycobacterium tuberculosis transmission in a health clinic mycobacterium tuberculosis transmission in a health clinic measles spread in medical settings: an important focus of disease transmission? infections due to adenovirus type 8 in the united states. i: an outbreak of epidemic keratoconjunctivitis originating in a physician's office epidemic keratoconjunctivitis outbreak at a tertiary referral eye care clinic adenovirus type 8 epidemic keratoconjunctivitis in an eye clinic: risk factors and control epidemic keratoconjunctivitis: report of an outbreak in an ophthalmology practice and recommendations for prevention community-associated methicillin resistant staphyloccoccus aureus skin infections among outpatient healthcare workers and its isolation in the clinic environment evidence of transmission of burkholderia cepacia, burkholderia multivorans, and burkholderia dolosa among persons with cystic fibrosis effects of segregation on an epidemic pseudomonas aeruginosa strain in a cystic fibrosis clinic bloodstream infections associated with a needleless intravenous infusion system in patients receiving home infusion therapy bloodstream infections in home infusion patients: the influence of race and needleless intravascular access devices bloodstream infection associated with needleless device use and the importance of infectioncontrol practices in the home health care setting prospective evaluation of risk factors for bloodstream infection in patients receiving home infusion therapy feasibility of national surveillance of health care-associated infections in home-care settings central venous catheter-associated bloodstream infections in pediatric oncology home care central venous access device outcomes in a homecare agency: a 7-year study infection surveillance in home care: device-related incidence rates surveillance of intravenous catheter-related infections among home care clients the nature and frequency of blood contacts among home healthcare workers draft definitions for surveillance of infections in home health care vancomycin and home health care multidrug-resistant organisms-vre and mrsa: practical home care tips improving infection control in home care: from ritual to science-based practice putting infection control principles into practice in home care evidence-based practice and the home care nurse's bag an exploratory study of nurse bag use by home visiting nurses nursing research in home health care: endangered species? identifying infectious diseases in prisons: surveillance, protection, and intervention update on public health in correctional facilities issues facing tb control (3.1) std testing policies and practices in us city and county jails preventable disease in correctional facilities: desmoteric foodborne outbreaks in the united states public health dispatch: tuberculosis outbreak in a homeless population public health dispatch: tuberculosis outbreak among homeless persons tuberculosis transmission in a homeless shelter population methicillin-resistant staphylococcus aureus infection in the texas prison system an epidemic of methicillin-resistant staphylococcus aureus soft tissue infections among medically underserved patients increasing prevalence of methicillin-resistant staphylococcus aureus infection in california jails centers for disease control and prevention. drug-susceptible tuberculosis outbreak in a state correctional facility housing hiv-infected inmates methicillin-resistant staphylococcus aureus skin or soft tissue infections in a state prison tuberculosis outbreak in a housing unit for human immunodeficiency virus-infected patients in a correctional facility: transmission risk factors and effective outbreak control prevention and control of tuberculosis in correctional racilities: recommendations of the advisory council for the elimination of tuberculosis community respiratory virus infections in immunocompromised patients with cancer molecular epidemiology of two consecutive outbreaks of parainfluenza 3 in a bone marrow transplant unit alpha-hemolytic streptococcal infection during intensive treatment for acute myeloid leukemia: a report from the children's cancer group study ccg-2891 immune reconstitution after childhood acute lymphoblastic leukemia is most severely affected in the high-risk group role of interleukin-1 (il-1) in the pathogenesis of systemic onset juvenile idiopathic arthritis and clinical response to il-1 blockade cyclosporine in addition to infliximab and methotrexate in refractory rheumatoid arthritis state of the art: ibd therapy and clinical trials in ibd guidelines for preventing opportunitic infections among hiv-infected persons infection control issues after solid organ transplantation a comparison of related donor peripheral blood and bone marrow transplants: importance of late-onset chronic graft-versus-host disease and infections pseudomonas species contamination of cystic fibrosis patients' home inhalation equipment an outbreak of burkholderia (formerly pseudomonas) cepacia respiratory tract colonization and infection associated with nebulized albuterol therapy home-use nebulizers: a potential primary source of burkholderia cepacia and other colistin-resistant, gram-negative bacteria in patients with cystic fibrosis low bacterial contamination of nebulizers in home treatment of cystic fibrosis patients cleaning home nebulizers used by patients with cystic fibrosis: is rinsing with tap water enough? infection control in cystic fibrosis: methicillin-resistant staphylococcus aureus, pseudomonas aeruginosa and the burkholderia cepacia complex changing epidemiology of pseudomonas aeruginosa infection in danish cystic fibrosis patients (1974-1995) pseudomonas cepacia infection in cystic fibrosis: an emerging problem burkholderia cepacia: management issues and new insights pseudomonas cepacia colonization in patients with cystic fibrosis: risk factors and clinical outcome prognostic implications of initial oropharyngeal bacterial flora in patients with cystic fibrosis diagnosed before the age of two years bronchopulmonary disease in children with cystic fibrosis after early or delayed diagnosis epidemic of pseudomonas cepacia in an adult cystic fibrosis unit: evidence of person-to-person transmission possible nosocomial transmission of pseudomonas cepacia in patients with cystic fibrosis evidence for transmission of pseudomonas cepacia by social contact in cystic fibrosis acquisition of pseudomonas cepacia at summer camps for patients with cystic fibrosis. summer camp study group colonization of the respiratory tract with pseudomonas cepacia in cystic fibrosis. risk factors and outcomes pseudomonas cepacia: decrease in colonization in patients with cystic fibrosis gene therapy: a new challenge for infection control infection control for gene therapy: a busy physician's primer gene therapy and infection control: more light on the way west nile virus infections in organ transplant recipients cytomegalovirus after kidney transplantation: a case review transmission of hepatitis c virus to several organ and tissue recipients from an antibody-negative donor clostridium infections associated with musculoskeletal tissue allografts centers for disease control and prevention. invasive streptococcus pyogenes after allograft implantation transfusiontransmitted malaria in the united states from 1963 through 1999 transfusion-associated babesiosis after heart transplant centers for disease control and prevention. chagas disease after organ transplantation lymphocytic choriomeningitis virus infection in organ transplant recipients, massachusetts and rhode island transmission of rabies virus from an organ donor to four transplant recipients transplanted infections: donor-to-host transmission with the allograft microbiological hazards related to xenotransplantation of porcine organs into man us public health service guideline on infectious disease issues in xenotransplantation to err is human: building a safer health system hospital-onset infections: a patient safety issue what practices will most improve safety? evidence-based medicine meets patient safety infection control: a problem for patient safety managing infection in the critical care unit: how can infection control make the icu safe? strategies to prevent and control the emergence and spread of antimicrobial-resistant microorganisms in hospitals: a challenge to hospital leadership requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: a consensus panel report. society for healthcare epidemiology of america nurse staffing and health care-associated infections: proceedings from a working group meeting staffing requirements for infection control programs in us health care facilities: delphi project role of clinical microbiology laboratories in the management and control of infectious diseases and the delivery of health care confronting bacterial resistance in healthcare settings: a crucial role for microbiologists available from. accessed intensive care unit quality improvement: a ''how-to'' guide for the interdisciplinary team how can clinicians measure safety and quality in acute care? practice analysis for infection control and epidemiology in the new millennium guideline for hand hygiene in health-care settings: recommendations of the healthcare infection control practices advisory committee and the hicpac/-shea/apic/idsa hand hygiene task force emerging issues in antibiotic resistant infections in long-term care facilities an organizational climate intervention associated with increased handwashing and decreased nosocomial infections effectiveness of a hospitalwide programme to improve compliance with hand hygiene. infection control programme implementation of strategies to control antimicrobial resistance organizational learning and continuous quality improvement: examining the impact on nursing home performance safety of patients isolated for infection control the efficacy of infection surveillance and control programs in preventing nosocomial infections in us hospitals a national task analysis of infection control practitioners, 1982. part one: methodology and demography a national task analysis of infection control practitioners part three: the relationship between hospital size and tasks performed validating the certification process for infection control practice job analysis 1992: infection control practitioner job analysis 1996: infection control professional. certification board in infection control and epidemiology inc development of a resource model for infection prevention and control programs in acute, long-term, and home care settings: conference proceedings of the infection prevention and control alliance a middle ground on public accountability assessing the status of infection control programs in small rural hospitals in the western united states detecting pediatric nosocomial infections: how do infection control and quality assurance personnel compare? the role of the infection control link nurse expanding the infection control team: development of the infection control liaison position for the neonatal intensive care unit the development of an infection control linknurse programme in a district general hospital evaluating the efficacy of the infection control liaison nurse in the hospital an infection control nurse-advisor program a program for infection surveillance utilizing an infection control liaison nurse nurse-staffing levels and the quality of care in hospitals effect of nurseto-patient ratio in the intensive care unit on pulmonary complications and resource use after hepatectomy enterobacter cloacae septicemia in a burn center: epidemiology and control of an outbreak nosocomial infections in a neonatal intensive care unit control of methicillin-resistant staphylococcus aureus in a burn unit: role of nurse staffing the role of understaffing and overcrowding in recurrent outbreaks of staphylococcal infection in a neonatal special-care unit the role of understaffing in central venous catheter-associated bloodstream infections the influence of the composition of the nursing staff on primary bloodstream infection rates in a surgical intensive care unit impact of institution size, staffing patterns, and infection control practices on communicable disease outbreaks in new york state nursing homes patient density, nurse-to-patient ratio and nosocomial infection risk in a pediatric cardiac intensive care unit outbreak of enterobacter cloacae related to understaffing, overcrowding, and poor hygiene practices nursing staff workload as a determinant of methicillin-resistant staphylococcus aureus spread in an adult intensive therapy unit the role of nurse understaffing in nosocomial viral gastrointestinal infections on a general pediatrics ward effect of nurse staffing and antimicrobial-impregnated central venous catheters on the risk for bloodstream infections in intensive care units prevalence of infected patients and understaffing have a role in hepatitis c virus transmission in dialysis the clinical microbiology laboratory and infection control: emerging pathogens, antimicrobial resistance, and new technology the role of the laboratory in infection prevention and control programs in long-term-care facilities for the elderly the role of the microbiology laboratory in surveillance and control of nosocomial infections interaction between the microbiology laboratory and clinician: what the microbiologist can provide role of nccls in antimicrobial susceptibility testing and monitoring performance standards for antimicrobial susceptibility testing: twelfth informational supplement. document m100-s12. wayne (pa): national committee for clinical laboratory standards analysis and presentation of cumulative antimicrobial susceptibility test data: approved guideline. document m39-a. wayne (pa): national committee for clinical laboratory standards reality of developing a community-wide antibiogram are united states hospitals following national guidelines for the analysis and presentation of cumulative antimicrobial susceptibility data? preventing antibiotic resistance through rapid genotypic identification of bacteria and of their antibiotic resistance genes in the clinical microbiology laboratory peterson lr. medical and economic benefit of a comprehensive infection control program that includes routine determination of microbial clonality evaluation of diagnostic tests for influenza in a pediatric practice centers for disease control and prevention. prevention and control of influenza: recommendations of the advisory committee on immunization practices (acip) influenza diagnosis and treatment in children: a review of studies on clinically useful tests and antiviral treatment for influenza the use of taqman pcr assay for detection of bordetella pertussis infection from clinical specimens clinical and financial benefits of rapid bacterial identification and antimicrobial susceptibility testing clinical and financial benefits of rapid detection of respiratory viruses: an outcomes study impact of a diagnostic cerebrospinal fluid enterovirus polymerase chain reaction test on patient management evaluation of an acute point-ofcare system screening for respiratory syncytial virus infection better control of antibiotic resistance the role of antimicrobial management programs in optimizing antibiotic prescribing within hospitals organizational and environmental factors that affect worker health and safety and patient outcomes organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery physician staffing patterns and clinical outcomes in critically ill patients: a systematic review evaluation of the culture of safety: survey of clinicians and managers in an academic medical center safety culture assessment: a tool for improving patient safety in healthcare organizations organizational climate, staffing, and safety equipment as predictors of needlestick injuries and near-misses in hospital nurses predictors of nurses' acceptance of an intravenous catheter safety device hospital safety climate and its relationship with safe work practices and workplace exposure incidents compliance with universal precautions among health care workers at three regional hospitals compliance with universal precautions among physicians factors promoting consistent adherence to safe needle precautions among hospital workers safety climate dimensions associated with occupational exposure to blood-borne pathogens in nurses the safety checklist program: creating a culture of safety in intensive care units developing a culture of safety in the veterans health administration developing a culture of patient safety at the va use and efficacy of tuberculosis infection control practices at hospitals with previous outbreaks of multidrug-resistant tuberculosis jarvis wr. efficacy of control measures in preventing nosocomial transmission of multidrug-resistant tuberculosis to patients and health care workers infection-control measures reduce transmission of vancomycin-resistant enterococci in an endemic setting education of physiciansin-training can decrease the risk for vascular catheter infection implementing and evaluating a system of generic infection precautions: body substance isolation adherence to universal (barrier) precautions during interventions on critically ill and injured emergency department patients universal precautions are not universally followed glove use by health care workers: results of a tristate investigation compliance with universal precautions in a medical practice with a high rate of hiv infection effect of educational program on compliance with glove use in a pediatric emergency department a comparison of observed and selfreported compliance with universal precautions among emergency department personnel at a minnesota public teaching hospital: implications for assessing infection control programs compliance with universal precautions and needle handling and disposal practices among emergency department staff at two community hospitals compliance with recommendations for universal precautions among prehospital providers barrier precautions in trauma resuscitation: real-time analysis utilizing videotape review handwashing and glove use in a long-term-care facility compliance with universal precautions: knowledge and behavior of residents and students in a department of obstetrics and gynecology compliance with universal precautions among pediatric residents use of personal protective equipment and operating room behaviors in four surgical subspecialties: personal protective equipment and behaviors in surgery education of the trauma team: video evaluation of the compliance with universal barrier precautions in resuscitation a comprehensive educational approach to improving patient isolation practice noncompliance of health care workers with universal precautions during trauma resuscitations barrier precautions in trauma: is knowledge enough? evaluation of a preclinical, educational and skills-training program to improve students' use of blood and body fluid precautions: one-year followup variables influencing worker compliance with universal precautions in the emergency department effect of an automated sink on handwashing practices and attitudes in high-risk units electronic monitoring and voice prompts improve hand hygiene and decrease nosocomial infections in an intermediate care unit behavioral interventions to improve infection control practices updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group die aetiologie, der begriff und die prophylaxis des kindbettfiebers antimicrobial prophylaxis for surgery: an advisory statement from the national surgical infection prevention project reducing acquired infections in the nicu: observing and implementing meaningful differences in process between high and low acquired infection rate centers preventing central venous catheter-associated primary bloodstream infections: characteristics of practices among hospitals participating in the evaluation of processes and indicators in infection control (epic) study. infect control process surveillance: an epidemiologic challenge for all health care organizations surveillance for outbreaks of respiratory tract infections in nursing homes preventing infections in non-hospital settings: long-term care basics of surveillance: an overview recommended practices for surveillance. association for professionals in infection control and epidemiology inc, surveillance initiative working group the scientific basis for using surveillance and risk factor data to reduce nosocomial infection rates statistical process control as a tool for research and healthcare improvement implementing and evaluating a rotating surveillance system and infection control guidelines in 4 intensive care units feeding back surveillance data to prevent hospital-acquired infections the changing face of surveillance for health care-associated infections detection of postoperative surgical-site infections: comparison of health plan-based surveillance with hospital-based programs standardized infection ratios for three general surgery procedures: a comparison between spanish hospitals and us centers participating in the national nosocomial infections surveillance system guidance on public reporting of healthcare-associated infections: recommendations of the healthcare infection control practices advisory committee the use of a ward-based educational teaching package to enhance nurses' compliance with infection control procedures intervention for medical students: effective infection control standardized management of patients and employees exposed to pertussis nosocomial respiratory syncytial virus infections: the cost-effectiveness and cost benefit of infection control hospital bloodborne pathogens programs: program characteristics and blood and body fluid exposure rates a training program in universal precautions for second-year medical students control of vancomycinresistant enterococcus in health care facilities in a region risk factors for ventilator-associated pneumonia: from epidemiology to patient management sars transmission among hospital workers in hong kong influenza vaccination of healthcare workers and vaccine allocation for healthcare workers during vaccine shortages influenza immunization: improving compliance of healthcare workers improving influenza immunization rates among healthcare workers caring for high-risk pediatric patients correlation between healthcare workers' knowledge of influenza vaccine and vaccine receipt learning styles and teaching/learning strategy preferences: implications for educating nurses in critical care, the operating room, and infection control impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? association for professionals in infection control and epidemiology planning programs for adult learners: a practical guide for educators, trainers, and staff developers. 2 nd ed interactive on-line continuing medical education: physicians' perceptions and experiences systems-based framework for continuing medical education and improvements in translating new knowledge into physicians' practices learning associated with participation in journal-based continuing medical education blood and body fluid exposures during clinical training: relation to knowledge of universal precautions universal precautions training of preclinical students: impact on knowledge, attitudes, and compliance an educational intervention to prevent catheter-associated bloodstream infections in a nonteaching, community medical center increasing icu staff handwashing: effects of education and group feedback handwashing practices in a tertiary-care, pediatric hospital and the effect on an educational program knowledge of the transmission of tuberculosis and infection control measures for tuberculosis among healthcare workers senior medical students' knowledge of universal precautions an educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects evaluation of a patient education model for increasing hand hygiene compliance in an inpatient rehabilitation unit patient-education handbook learning styles and teaching strategies: enhancing the patient education experience handwashing: the semmelweis lesson forgotten? handwashing: simple, but effective elimination of methicillin-resistant staphylococcus aureus from a neonatal intensive care unit after hand washing with triclosan use of 0.3% triclosan (bacti-stat) to eradicate an outbreak of methicillinresistant staphylococcus aureus in a neonatal nursery epidemiology and control of vancomycin-resistant enterococci in a regional neonatal intensive care unit hand hygiene and patient care: pursuing the semmelweis legacy a comparison of hand-washing techniques to remove escherichia coli and caliciviruses under natural or artificial fingernails impact of a 5-minute scrub on the microbial flora found on artificial, polished, or natural fingernails of operating room personnel bacterial carriage by artificial versus natural nails pathogenic organisms associated with artificial fingernails worn by healthcare workers postoperative serratia marcescens wound infections traced to an out-of-hospital source a prolonged outbreak of pseudomonas aeruginosa in a neonatal intensive care unit: did staff fingernails play a role in disease transmission? candida osteomyelitis and diskitis after spinal surgery: an outbreak that implicates artificial nail use outbreak of extended spectrum beta-lactamase-producing klebsiella pneumoniae infection in a neonatal intensive care unit related to onychomycosis in a health care worker impact of ring wearing on hand contamination and comparison of hand hygiene agents in a hospital bacterial contamination of the hands of hospital staff during routine patient care effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant enterococcus species by health care workers after patient care efficacy of gloves in reducing blood volumes transferred during simulated needlestick injury performance of latex and nonlatex medical examination gloves during simulated use latex allergy and gloving standards a review of natural-rubber latex allergy in health care workers barrier protection with examination gloves: double versus single leakage of latex and vinyl exam gloves in high-and low-risk clinical settings in-use barrier integrity of gloves: latex and nitrile superior to vinyl latex and vinyl examination gloves. quality control procedures and implications for health care workers integrity of vinyl and latex procedure gloves occupational exposure to bloodborne pathogens: final rule. 29 cfr part 1910: 1030 recommendations for preventing the spread of vancomycin resistance: recommendations of the hospital infection control practices advisory committee (hicpac) examination gloves as barriers to hand contamination in clinical practice removal of nosocomial pathogens from the contaminated glove: implications for glove reuse and handwashing a mrsa outbreak in an sicu during universal precautions: new epidemiology for nosocomial mrsa methicillin-resistant staphylococcus aureus (mrsa): a briefing for acute care hospitals and nursing facilities. the aha technical panel on infections within hospitals controlling vancomycin-resistant enterococci clostridium difficile-associated diarrhea and colitis overgrown use for infection control in nurseries and neonatal intensive care units gowning does not affect colonization or infection rates in a neonatal intensive care unit a comparison of the effect of universal use of gloves and gowns with that of glove use alone on acquisition of vancomycin-resistant enterococci in a medical intensive care unit the role of protective clothing in infection prevention in patients undergoing autologous bone marrow transplantation transmission of hepatitis c via blood splash into conjunctiva transmission of hepatitis c by blood splash into conjunctiva in a nurse update: human immunodeficiency virus infections in health care workers exposed to blood of infected patients unusual nosocomial transmission of mycobacterium tuberculosis value of the face mask and other measures droplet infection and its prevention by the face mask eye splashes during invasive vascular procedures guidance for industry and fda staff: surgical masks. premarket notification [510(k)] submissions; guidance for industry and fda national institute for occupational health and safety. eye protection for infection control the use of eye-nose goggles to control nosocomial respiratory syncytial virus infection respiratory syncytial virus (rsv) infection rate in personnel caring for children with rsv infections: routine isolation procedure versus routine procedure supplemented by use of masks and goggles rsv outbreak in a paediatric intensive care unit occupational safety and health administration. respiratory protection respiratory protection as a function of respirator fitting characteristics and fit-test accuracy respiratory protection against mycobacterium tuberculosis: quantitative fit test outcomes for five type n95 filtering-facepiece respirators simulated workplace performance of n95 respirators comparison of five methods for fit-testing n95 filtering-facepiece respirators nosocomial tuberculosis: new progress in control and prevention nosocomial transmission of multidrug-resistant mycobacterium tuberculosis lack of nosocomial spread of varicella in a pediatric hospital with negativepressure ventilated patient rooms varicella serological status of healthcare workers as a guide to whom to test or immunize persistence of immunity to varicella-zoster virus after vaccination of healthcare workers measles immunity in a population of healthcare workers measles immunity in employees of a multihospital healthcare provider updated us public health service guidelines for the management of occupational exposures to hbv, hcv, and hiv occupationally acquired human immunodeficiency virus (hiv) infection: national case surveillance data during 20 years of the hiv epidemic in the united states update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis b virus, and other bloodborne pathogens in healthcare settings occupational hazards of operating: opportunities for improvement procedure-specific infection control for preventing intraoperative blood exposures prevention of blood exposure: body and facial protection bloodborne pathogens and procedure safety in interventional radiology reducing percutaneous injuries in the or by educational methods national insititute for occupational health and safety. safer medical device implementation in health care facilities nosocomial tuberculosis isolation of patients in single rooms or cohorts to reduce spread of mrsa in intensivecare units: prospective two-centre study association of private isolation rooms with ventilator-associated acinetobacter baumanii pneumonia in a surgical intensive-care unit infection control of nosocomial respiratory viral disease in the immunocompromised host handwashing and cohorting in prevention of hospital acquired infections with respiratory syncytial virus the role of physical proximity in nosocomial diarrhea a hospital epidemic of vancomycin-resistant enterococcus: risk factors and control the implementation of a commode cleaning and identification system role of fecal incontinence in contamination of the environment with vancomycin-resistant enterococci clinical and molecular epidemiology of sporadic and clustered cases of nosocomial clostridium difficile diarrhea acquisition of clostridium difficile by hospitalized patients: evidence for colonized new admissions as a source of infection epidemiology of nosocomial clostridium difficile diarrhoea the prevalence of colonization with vancomycin-resistant enterococcus at a veterans' affairs institution nosocomial transmission of rotavirus infection risk of cryptosporidium parvum transmission between hospital roommates the incidence of viral-associated diarrhea after admission to a pediatric hospital control of epidemic methicillin-resistant staphylococcus aureus control of vancomycin-resistant enterococci at a community hospital: efficacy of patient and staff cohorting an outbreak of vancomycin-resistant enterococci in a hematology-oncology unit: control by patient cohorting and terminal cleaning of the environment eradication of multidrug-resistant acinetobacter from an intensive care unit epidemiology of methicillinsusceptible staphylococcus aureus in the neonatal intensive care unit cohorting of infants with respiratory syncytial virus control of nosocomial respiratory syncytial viral infections epidemic keratoconjunctivitis in a chronic care facility: risk factors and measures for control nosocomial rotavirus infections in neonates: means of prevention and control management of inpatients exposed to an outbreak of severe acute respiratory syndrome (sars) modelling the usefulness of a dedicated cohort facility to prevent the dissemination of mrsa an agent-based and spatially explicit model of pathogen dissemination in the intensive care unit vancomycin-resistant enterococci in intensive-care hospital settings: transmission dynamics, persistence, and the impact of infection control programs counting nurses: data show many nursing homes to be short-staffed staffing problems in long-term care: let's do something about it! stats & facts: nursing staff shortages in long-term care facilities human metapneumovirus: a not-so-new virus population-based surveillance for hospitalizations associated with respiratory syncytial virus, influenza virus, and parainfluenza viruses among young children a comparison of nested polymerase chain reaction and immunofluorescence for the diagnosis of respiratory infections in children with bronchiolitis, and the implications for a cohorting strategy human metapneumovirus and respiratory syncytial virus in hospitalized danish children with acute respiratory tract infection nosocomial pertussis in healthcare workers from a pediatric emergency unit in france an outbreak of multidrugresistant tuberculosis among hospitalized patients with the acquired immunodeficiency syndrome update: severe acute respiratory syndrome transmission of mycobacterium tuberculosis to and from children and adolescents infection control in cystic fibrosis: practical recommendations for the hospital, clinic, and social settings probable secondary infections in households of sars patients in hong kong contamination, disinfection, and cross-colonization: are hospital surfaces reservoirs for nosocomial infection? disinfection and sterilization in health care facilities: what clinicians need to know outbreak of multidrug-resistant enterococcus faecium with transferable vanb class vancomycin resistance pseudomonas aeruginosa outbreak in a haematology-oncology unit associated with contaminated surface cleaning equipment role of environmental cleaning in controlling an outbreak of acinetobacter baumannii on a neurosurgical intensive care unit pseudomonas aeruginosa wound infection associated with a nursing home's whirlpool bath use of audit tools to evaluate the efficacy of cleaning systems in hospitals survival and vehicular spread of human rotaviruses: possible relation to seasonality of outbreaks acquisition of clostridium difficile from the hospital environment environmental control to reduce transmission of clostridium difficile transmission of rotavirus and other enteric pathogens in the home rotavirus infections in infection control reference service comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of clostridium difficile infection healthcare infection control practices advisory committee committee (hicpac) persistent acinetobacter baumannii? look inside your medical equipment computer equipment used in patient care within a multihospital system: recommendations for cleaning and disinfection computer keyboards as reservoirs for acinetobacter baumannii in a burn hospital computer keyboards and faucet handles as reservoirs of nosocomial pathogens in the intensive care unit reduction in vancomycin-resistant enterococcus and clostridium difficile infections following change to tympanic thermometers a randomized crossover study of disposable thermometers for prevention of clostridium difficile and other nosocomial infections bacterial surface contamination of patients' linen: isolation precautions versus standard care isolating and double-bagging laundry: is it really necessary? available from tracking perinatal infection: is it safe to launder your scrubs at home? mcn home-versus hospital-laundered scrubs: a pilot study double-bagging of items from isolation rooms is unnecessary as an infection control measure: a comparative study of surface contamination with single-and double-bagging recommended antimicrobial agents for the treatment and postexposure prophylaxis of pertussis: 2005 cdc guidelines prevention and control of meningococcal disease: recommendations of the advisory committee on immunization practices (acip) notice to readers: additional options for preventive treatment for persons exposed to inhalational anthrax updated us public health service guidelines for the management of occupational exposures to hiv and recommendations for postexposure prophylaxis mrsa patients: proven methods to treat colonization and infection brief clinical and laboratory observations american academy of pediatrics and american academy of obstetricians and gynecologists. guidelines for perinatal care management of multidrug-resistant organisms in health care settings perioperative intranasal mupirocin for the prevention of surgical-site infections: systematic review of the literature and meta-analysis methicillin-resistant staphylococcus aureus infection in a cardiac surgical unit mupirocin prophylaxis to prevent staphylococcus aureus infection in patients undergoing dialysis: a meta-analysis immunization of health-care workers: recommendations of the advisory committee on immunization practices (acip) and the hospital infection control practices advisory committee (hicpac) progress toward the elimination of hepatitis b virus transmission among health care workers in the united states rubella exposure in an obstetric clinic effectiveness of influenza vaccine in health care professionals: a randomized trial influenza vaccination of health care workers in long-term care hospitals reduces the mortality of elderly patients influenza vaccination of healthcare personnel: recommendations of the healthcare infection control practices advisory committee (hicpac) and the advisory committee on immunization practices (acip) incidence of pertussis infection in healthcare workers nosocomial pertussis: costs of an outbreak and benefits of vaccinating health care workers recommendations are needed for adolescent and adult pertussis immunisation: rationale and strategies for consideration recommended childhood and adolescent immunization schedule recommended childhood and adolescent immunization schedule recommended adult immunization schedule, united states prevention of varicella: updated recommendations of the advisory committee on immunization practices (acip) broadly protective vaccine for staphylococcus aureus based on an in vivo-expressed antigen use of a staphylococcus aureus conjugate vaccine in patients receiving hemodialysis use of palivizumab to control an outbreak of syncytial respiratory virus in a neonatal intensive care unit an outbreak of tuberculosis in a children's hospital an outbreak due to multiresistant acinetobacter baumannii in a burn unit: risk factors for acquisition and management to gown or not to gown: the effect on acquisition of vancomycin-resistant enterococci management of an outbreak of vancomycin-resistant enterococci in the medical intensive care unit of a cancer center recommendations for preventing transmission of infection with human t-lymphotropic virus type iii/lymphadenopathy-associated virus in the workplace severe acute respiratory syndrome measures for the prevention and control of respiratory infections in military camps efficiency of surgical masks in use in hospital wards: report to the control of infection subcommittee wearing masks in a pediatric hospital: developing practical guidelines handwashing and respiratory illness among young adults in military training effect of infection control measures on the frequency of upper respiratory infection in child care: a randomized, controlled trial the effect of hand hygiene on illness rate among students in university residence halls what is the evidence for a causal link between hygiene and infections? american association of nurse anesthesists. reuse of needles and syringes by healthcare providers put patients at risk. available from www.aana.com/news.aspx?ucnavmenu_tsmenutargetid5171& ucnavmenu_tsmenutargettype54&ucnavmenu_tsmenuid56& id51613 streptococcus salivarius meningitis following myelography streptococcal meningitis complicating diagnostic myelography: three cases and review streptococcal meningitis after myelography iatrogenic meningitis: an increasing role for resistant viridans streptococci? case report and review of the last 20 years iatrogenic meningitis due to abiotrophia defectiva after myelography alpha-hemolytic streptococci: a major pathogen of iatrogenic meningitis following lumbar puncture. case reports and a review of the literature iatrogenic meningitis by streptococcus salivarius following lumbar puncture iatrogenic streptococcus salivarius meningitis after spinal anaesthesia: need for strict application of standard precautions iatrogenic meningitis due to streptococcus salivarius following a spinal tap three cases of bacterial meningitis after spinal and epidural anesthesia iatrogenic meningitis: the case for face masks the case for face masks: zorro or zero? surgical face masks are effective in reducing bacterial contamination caused by dispersal from the upper airway guidelines for the prevention of intravascular catheter-related infections anxiety and depression in hospitalized patients in resistant organism isolation methicillin-resistant staphylococcus aureus: psychological impact of hospitalization and isolation in an older adult population the experience of respiratory isolation for hiv-infected persons with tuberculosis the experience of infectious patients in isolation contact isolation in surgical patients: a barrier to care? adverse effects of contact isolation do physicians examine patients in contact isolation less frequently? a brief report management of multidrug-resistant organisms in healthcare settings respiratory syncytial viral infection in children with compromised immune function nosocomial outbreak of parvovirus b19 infection in a renal transplant unit prolonged shedding of multidrug-resistant influenza a virus in an immunocompromised patient adenovirus infection in children after allogeneic stem cell transplantation: diagnosis, treatment and immunity chronic enteric virus infection in two t-cell-immunodeficient children prolonged shedding of rotavirus in a geriatric inpatient staphylococcus aureus nasal colonization in a nursing home: eradication with mupirocin attempts to eradicate methicillin-resistant staphylococcus aureus from a long-term-care facility with the use of mupirocin ointment natural history of colonization with vancomycin-resistant enterococcus faecium high rate of false-negative results of the rectal swab culture method in detection of gastrointestinal colonization with vancomycin-resistant enterococci recurrence of vancomycin-resistant enterococcus stool colonization during antibiotic therapy duration of colonization by methicillin-resistant staphylococcus aureus after hospital discharge and risk factors for prolonged carriage persistent contamination of fabric-covered furniture by vancomycin-resistant enterococci: implications for upholstery selection in hospitals aspergillosis due to carpet contamination flower vases in hospitals as reservoirs of pathogens nosocomial aspergillosis: environmental microbiology, hospital epidemiology, diagnosis and treatment aspergillus terreus infections in haematological malignancies: molecular epidemiology suggests association with in-hospital plants masking of neutropenic patients on transport from hospital rooms is associated with a decrease in nosocomial aspergillosis during construction the infection control nurse in us hospitals, 1976-1977: characteristics of the position and its occupant are there regional variations in the diagnosis, surveillance, and control of methicillin-resistant staphylococcus aureus? results of a survey of work duties of 56 infection control professionals (icps): are new guidelines needed for the staffing of infection control (ic) programs? critical care unit bedside design and furnishing: impact on nosocomial infections the ability of hospital ventilation systems to filter aspergillus and other fungi following a building implosion increased catheter-related bloodstream infection rates after the introduction of a new mechanical valve intravenous access port joint commision on accreditation of healthcare organizations. comprehensive accredication manual for hospitals: the official handbook new technology for detecting multidrugresistant pathogens in the clinical microbiology laboratory employee health and infection control nosocomial outbreak of pseudomonas cepacia associated with contamination of reusable electronic ventilator temperature probes ventilator temperature sensors: an unusual source of pseudomonas cepacia in nosocomial infection centers for disease control and prevention. bronchoscopy-related infections and pseudoinfections decontaminated single-use devices: an oxymoron that may be placing patients at risk for cross-contamination centers for disease control and prevention. prevention and control of influenza: recommendations of the advisory committee on immunization practices (acip) control of influenza a on a bone marrow transplant unit impact of implementing a method of feedback and accountability related to contact precautions compliance evaluation of the contribution of isolation precautions in prevention and control of multi-resistant bacteria in a teaching hospital the text as an orientation tool surveillance for nosocomial infections monitoring hospitalacquired infections to promote patient safety controlling methicillin-resistant staphylococcus aureus: a feedback approach using annotated statistical process control charts spread of stenotrophomonas maltophilia colonization in a pediatric intensive care unit detected by monitoring tracheal bacterial carriage and molecular typing the impact of bedside behavior on catheter-related bacteremia in the intensive care unit epidemiology of invasive group a streptococcus disease in the united states regional dissemination and control of epidemic methicillin-resistant staphylococcus aureus. manitoba chapter of chica-canada emergence of community-associated methicillin-resistant staphylococcus aureus usa300 genotype as a major cause of health care-associated blood stream infections survival of hepatitis b virus after drying and storage for one week failure of bland soap handwash to prevent hand transfer of patient bacteria to urethral catheters skin tolerance and effectiveness of two hand decontamination procedures in everyday hospital use replace hand washing with use of a waterless alcohol hand rub? transmission of staphylococci between newborns: importance of the hands to personnel hands as route of transmission for klebsiella species effectiveness of hand washing and disinfection methods in removing transient bacteria after patient nursing extensive environmental contamination associated with patients with loose stools and mrsa colonization of the gastrointestinal tract efficacy of selected hand hygiene agents used to remove bacillus atrophaeus (a surrogate of bacillus anthracis) from contaminated hands banning artificial nails from health care settings prospective, controlled study of vinyl glove use to interrupt clostridium difficile nosocomial transmission latex glove penetration by pathogens: a review of the literature pcr-based method for detecting viral penetration of medical exam gloves association of contaminated gloves with transmission of acinetobacter calcoaceticus var. anitratus in an intensive care unit epidemiology and prevention of pediatric viral respiratory infections in health-care institutions nosocomial transmission of rotavirus from patients admitted with diarrhea safety and cleaning of medical materials and devices surface fixation of dried blood by glutaraldehyde and peracetic acid role of environmental contamination in the transmission of vancomycin-resistant enterococci disinfection of hospital rooms contaminated with vancomycin-resistant enterococcus faecium role of environmental contamination as a risk factor for acquisition of vancomycin-resistant enterococci in patients treated in a medical intensive care unit federal insecticide, fungicide, and rodenticidal act 7 usc 136 et seq is methicillin-resistant staphylococcus aureus (mrsa) contamination of ward-based computer terminals a surrogate marker for nosocomial mrsa transmission and handwashing compliance? transfer of bacteria from fabrics to hands and other fabrics: development and application of a quantitative method using staphylococcus aureus as a model evaluation of bedmaking-related airborne and surface methicillin-resistant staphylococcus aureus contamination bacterial contamination on the surface of hospital linen chutes designing linen chutes to reduce spread of infectious organisms iatrogenic contamination of multidose vials in simulated use: a reassessment of current patient injection technique a large outbreak of hepatitis b virus infections associated with frequent injections at a physician's office a large nosocomial outbreak of hepatitis c and hepatitis b among patients receiving pain remediation treatments patient-to-patient transmission of hepatitis c virus through the use of multidose vials during general anesthesia an outbreak of hepatitis c virus infections among outpatients at a hematology/oncology clinic streptococcal meningitis following myelogram procedures a prospective study to determine whether cover gowns in addition to gloves decrease nosocomial transmission of vancomycin-resistant enterococci in an intensive care unit parainfluenza virus infections after hematopoietic stem cell transplantation: risk factors, response to antiviral therapy, and effect on transplant outcome parainfluenza virus 3 infection after stem cell transplant: relevance to outcome of rapid diagnosis and ribavirin treatment serial observations of chronic rotavirus infection in an immunodeficient child an outbreak of imipenem-resistant acinetobacter baumannii in critically ill surgical patients epidemiology of methicillin-resistant staphylococcus aureus at a university hospital in the canary islands nosocomial acquisition of methicillin-resistant staphylococcus aureus during an outbreak of severe acute respiratory syndrome increase in methicillin-resistant staphylococcus aureus acquisition rate and change in pathogen pattern associated with an outbreak of severe acute respiratory syndrome an outbreak of mupirocin-resistant staphylococcus aureus on a dermatology ward associated with an environmental reservoir risk of secondary meningococcal disease in health-care workers an outbreak of measles at an international sporting event with airborne transmission in a domed stadium an outbreak of airborne nosocomial varicella herpes zoster causing varicella (chickenpox) in hospital employees: cost of a casual attitude identification of factors that disrupt negative air pressurization of respiratory isolation rooms an evaluation of hospital special ventilation room pressures nosocomial transmission of tuberculosis associated with a draining abscess an outbreak of tuberculosis among hospital personnel caring for a patient with a skin ulcer secondary measles vaccine failure in healthcare workers exposed to infected patients a cluster of primary varicella cases among healthcare workers with false-positive varicella zoster virus titers airborne transmission of nosocomial varicella from localized zoster zoster-causing varicella: current dangers of contagion without isolation detection of aerosolized varicella-zoster virus dna in patients with localized herpes zoster measles vaccination after exposure to natural measles use of live measles virus vaccine to abort an expected outbreak of measles within a closed population measles, mumps, and rubella vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the advisory committee on immunization practices (acip) general recommendations on immunization: recommendations of the advisory committee on immunization practices (acip) postexposure effectiveness of varicella vaccine postexposure varicella vaccination in siblings of children with active varicella centers for disease control and preverntion. vaccinia (smallpox) vaccine: recommendations of the advisory committee on immunization practices (acip) smallpox vaccination: a review. part i: background, vaccination technique, normal vaccination and revaccination, and expected normal reactions smallpox in tripolitania, 1946: an epidemiological and clinical study of 500 cases, including trials of penicillin treatment ventilation for protection of immune-compromised patients efficacy of portable filtration units in reducing aerosolized particles in the size range of mycobacterium tuberculosis dolin r, editors. mandell, douglas and bennett's principles and practice of infectious diseases control of communicable diseases manual outbreak of amebiasis in a family in the netherlands parasitic disease control in a residential facility for the mentally retarded: failure of selected isolation procedures west nile virus: epidemiology, clinical presentation, diagnosis, and prevention person-to-person transmission of brucella melitensis isolation of brucella melitensis from human sperm prevention of laboratoryacquired brucellosis chlamydia pneumoniae as a new source of infectious outbreaks in nursing homes an epidemic of infections due to chlamydia pneumoniae in military conscripts an outbreak of surgical wound infections due to clostridium perfringens acquisition of coccidioidomycosis at necropsy by inhalation of coccidioidal endospores donor-related coccidioidomycosis in organ transplant recipients centers for disease control and prevention. acute hemorrhagic conjunctivitis outbreak caused by coxsackievirus a24 outbreak of adenovirus type 30 in a neonatal intensive care unit an outbreak of epidemic keratoconjunctivtis in a pediatric unit due to adenovirus type 8 a large outbreak of epidemic keratoconjunctivitis: problems in controlling nosocomial spread nosocomial transmission of cryptococcosis cryptococcal endophthalmitis after corneal transplantation probable transmission of norovirus on an airplane centers for disease control and prevention. prevention of hepatitis a through active or passive immunization: recommendations of the advisory committee on immunization practices (acip) hepatitis a outbreak in a neonatal intensive care unit: risk factors for transmission and evidence of prolonged viral excretion among preterm infants excretion of hepatitis a virus in the stools of hospitalized hepatitis patients hospital outbreak of hepatitis e herpes simplex virus infections neonatal herpes infection: diagnosis, treatment and prevention human metapneumovirus infection in the united states: clinical manifestations associated with a newly emerging respiratory infection in children listeria moncytogenes cross-contamination in a nursery neonatal listeriosis due to cross-infection confirmed by isoenzyme typing and dna fingerprinting outbreak of neonatal listeriosis associated with mineral oil neonatal cross-infection with listeria monocytogenes nosocomial malaria and saline flush plasmodium falciparum malaria transmitted in hospital through heparin locks nosocomial malaria from contamination of a multidose heparin container with blood hospital-acquired malaria transmitted by contaminated gloves clustering of necrotizing enterocolitis: interruption by infection-control measures how contagious is necrotizing enterocolitis? an outbreak of rotavirus-associated neonatal necrotizing enterocolitis increased risk of illness among nursery staff caring for neonates with necrotizing enterocolitis outbreak of adenovirus 35 pneumonia among adult residents and staff of a chronic care psychiatric facility nosocomial adenovirus infection: molecular epidemiology of an outbreak a recent outbreak of adenovirus type 7 infection in a chronic inpatient facility for the severely handicapped an outbreak of multidrugresistant pneumococcal pneumonia and bacteremia among unvaccinated nursing home residents human-to-human transmission of rabies virus by corneal transplant human rabies prevention, united states, 1999: recommendations of the advisory committee on immunization practices (acip) rhinovirus and the lower respiratory tract concurrent outbreaks of rhinovirus and respiratory syncytial virus in an intensive care nursery: epidemiology and associated risk factors rhinovirus infection associated with serious lower respiratory illness in patients with bronchopulmonary dysplasia nosocomial ringworm in a neonatal intensive care unit: a nurse and her cat nosocomial transmission of trichophyton tonsurans tinea corporis in a rehabilitation hospital molecular epidemiology of staphylococcal scalded skin syndrome in premature infants an outbreak of fatal nosocomial infections due to group a streptococcus on a medical ward an outbreak of group a streptococcal infection among health care workers clusters of invasive group a streptococcal infections in family, hospital, and nursing home settings isolation techniques for use in hospitals us government printing office rethinking the role of isolation practices in the prevention of nosocomial infections the authors and hicpac gratefully acknowledge dr larry strausbaugh for his many contributions and valued guidance in the preparation of this guideline. the mode(s) and risk of transmission for each specific disease agent listed in this appendix were reviewed. principle sources consulted for the development of disease-specific recommendations for the appendix included infectious disease manuals and textbooks. 831, 1039, 1040 the published literature was searched for evidence of person-to-person transmission in health care and non-health care settings with a focus on reported outbreaks that would assist in developing recommendations for all settings where health care is delivered. the following criteria were used to assign transmission-based precautions categories: d a transmission-based precautions category was assigned if there was strong evidence for person-to-person transmission via droplet, contact, or airborne routes in health care or non-health care settings and/or if patient factors (eg, diapered infants, diarrhea, draining wounds) increased the risk of transmission. d transmission-based precautions category assignments reflect the predominant mode(s) of transmission. d if there was no evidence for person-to-person transmission by droplet, contact or airborne routes, then standard precautions were assigned. d if there was a low risk for person-to-person transmission and no evidence of health care-associated transmission, then standard precautions were assigned. d standard precautions were assigned for bloodborne pathogens (eg, hbv, hcv, hiv) in accordance with cdc recommendations for universal precautions issued in 1988. 778 subsequent experience has confirmed the efficacy of standard precautions to prevent exposure to infected blood and body fluid. 776, 777, 863 additional information relevant to use of precautions was added in the comments column to assist the caregiver in decision-making. citations were added as needed to support a change in or provide additional evidence for recommendations for a specific disease and for new infectious agents (eg, sars-cov, avian influenza) that have been added to appendix a. the reader may refer to more detailed discussion concerning modes of transmission and emerging pathogens in the background text and for mdro control in the mdro guideline. key: cord-294557-4h0sybiy authors: stogiannos, n.; fotopoulos, d.; woznitza, n.; malamateniou, c. title: coronavirus disease 2019 (covid-19) in the radiology department: what radiographers need to know date: 2020-06-04 journal: radiography (lond) doi: 10.1016/j.radi.2020.05.012 sha: doc_id: 294557 cord_uid: 4h0sybiy objectives: the aim is to review current literature related to the diagnosis, management, and follow-up of suspected and confirmed covid-19 cases. key findings: medical imaging plays an important auxiliary role in the diagnosis of covid-19 patients, mainly those most seriously affected. practice differs widely among different countries, mainly due to the variability of access to resources (viral testing and imaging equipment, specialised staff, protective equipment). it has been now well-documented that chest radiographs should be the first-line imaging tool and chest ct should only be reserved for critically ill patients, or when chest radiograph and clinical presentation may be inconclusive. conclusion: as radiographers work on the frontline, they should be aware of the potential risks associated with covid-19 and engage in optimal strategies to reduce these. their role in vetting, conducting and often reporting the imaging examinations is vital as well as their contribution in patient safety and care. medical imaging should be limited to critically ill patients, and where it may have an impact on the patient management plan. implications for practice: at the time of publication, this review offers the most up-to-date recommendations for clinical practitioners in radiology departments, including radiographers. radiography practice has to significantly adjust to these new requirements to support optimal and safe imaging practices for the diagnosis of covid-19. the adoption of low dose ct, rigorous infection control protocols and optimal use of personal protective equipment may reduce the potential risks of radiation exposure and infection, respectively, within radiology departments. since the outbreak of the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) pandemic a few months ago, more than 4,731,000 laboratory-confirmed cases of the new virus have been reported, with over 316,000 confirmed deaths, as per may 19 , 2020. 1 the coronavirus disease 2019 (covid-19) resulting after infection from sars-cov-2 has already affected 210 countries and territories globally. 2 this virus was first recorded in china's hubei province, where the cause of the disease was initially unknown. hence, it was first classified as unknown pneumonia. 3 new information about covid-19 emerges every day as more diagnostic tests are being carried out. medical imaging has a unique place in this new evidence-base and radiographers are working on the frontline to deliver care for some of the most seriously affected patients, often facing challenging situations with staff and resource shortages. 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 the aim is to review current literature related to the diagnosis, management, and follow-up of suspected and confirmed covid-19 cases. objectives include to: i) outline pathophysiology and basic epidemiology useful for radiographers, ii) discuss the role of medical imaging in the diagnosis of covid-19, iii) summarise national and international guidelines of imaging covid-19, iv) present main clinical and imaging findings and v) summarise current safety recommendations for medical imaging practice. the search methods and keywords for this review are appended on table 1 below for clarity. it has to be noted that in this review all available information at the time of publication was included, however we appreciate this is a fast developing area of study. coronaviruses belong to a large family of single-stranded rna viruses. although they are thought to cause mainly mild symptoms, the middle east respiratory syndrome (mers-cov) and the severe acute respiratory syndrome (sars-cov) recently, caused many fatalities. 4 in 2002, the sars-cov originating in china had a 11% mortality rate, while in 2012 the mers-cov in saudi arabia had a mortality rate of 34%. both viruses originated from wild animals. 4 sars-cov-2 targets the respiratory system. after the infection there is a variable incubation period ranging between 1 and 14 days. in some studies, average incubation periods of 3 days have been reported. 5 it has been found that the majority of covid-19 patients are asymptomatic or with mild symptoms. however, for a significant minority of cases, covid-19 can present as, or progress to, severe respiratory distress. 6 the typical clinical symptoms associated with the covid-19 disease include cough, fever, fatigue and dyspnea. 7 however, many patients can initially develop nausea and diarrhea, as well as generalised muscular pain and lack of sense of smell or taste. 8e10 haemoptysis has also been reported on a less frequent basis. 7 less common non-respiratory symptoms have also been described such as headache, urticaria, or presentation of neurological clinical features prior to or following the onset of covid-19related symptoms. 7, 11, 12 at the time of writing, the united states of america have reported the highest number of confirmed covid-19 cases, as well as the highest number of deaths, followed by spain, italy, france and the uk. mortality rate is measured using the case fatality rate (cfr), a measure describing the proportion of deaths within a defined population, and this rate varies considerably among different countries and is challenging to accurately calculate, as the number of asymptomatic or mild cases may be under-reported. 13 according to the world health organization around 5% of confirmed cases are severe and require intensive care. 14 acute respiratory distress syndrome, organ failure, septic shock and severe pneumonia are the main causes of mortality. covid-19 patients with one or more comorbidities, including hypertension, diabetes, cardiovascular diseases, cerebrovascular disease, chronic obstructive pulmonary disease (copd), malignancies, chronic kidney disease and smoking, are associated with poorer clinical outcomes and higher mortality rates. 15e18 severe asthma is also listed as a risk factor for hospitalisation. 19, 20 in addition, mortality rates have been found to dramatically increase with age. a recent uk study estimates an overall covid-19 mortality rate of 0.66%, increasing to 7.8% for people over 80. 21 a study from italy reports that 83% of the deaths were people over 70 years old. 22 similarly, there is a sharp decline of death rate in children. 21 recent data shows that children with covid-19 might be largely asymptomatic (90%) or demonstrate milder clinical manifestations and lower cfr compared to adults, while only younger than 1-year of age are more susceptible to severe disease. 23e25 there are also disproportionately more deaths in men than women, with similar cases between the two genders. this was attributed to sex-based immunological differences, or sex-based behavioral differences such as prevalence of smoking. 26, 27 diagnostic investigations for covid-19 accurate detection of an active covid-19 infection is vital for case identification, disease containment and optimal management of patients. molecular techniques are the first-line method of diagnosing covid-19. most commonly they use respiratory samples, such as nasopharyngeal swabs 28 with reverse-transcription polymerase chain reaction (rt-pcr), real-time rt-pcr (rrt-pcr) and reverse transcription loop-mediated isothermal amplification (rt-lamp) being the most common methods employed. 29 viral tests are used to detect the presence of an antigen, e.g. the virus's rna, in a patient, rather than antibodies, which affirm an immune response. however, antigen tests have limitations, including the time to obtain results, the relatively high false negative and false positive rates and the intermittent shortage of test kits during the outbreak. 29e31 there is ongoing debate about the optimal testing for coronavirus, with antibody testing gaining momentum, but equally more time is required until these tests become widely available. 32 laboratory tests are widely available and cost effective, and are used in the diagnosis and management of covid-19 patients, including differentiated white cell count, c reactive protein (crp), d-dimer and erythrocyte sedimentation rate (esr). 33 lymphopenia and mildly elevated crp have been widely reported, with the degree of lymphopenia proposed as a risk factor for more severe disease. 34 the role of imaging medical imaging plays an important role in supporting clinical decision making in the diagnosis, management and treatment of covid-19 patients. medical imaging may be useful for differential diagnosis between covid-19 and other viral respiratory illnesses with similar symptoms. 35e37 chest radiographs, chest ct, lung ultrasound, as well as mri are included in the arsenal of medical imaging, each one with advantages and limitations. chest radiographs (cxr) are the most widely used imaging modality for suspected and confirmed covid-19 cases. 38 mobile radiographs are being used with increasing frequency to avoid possible transmission during patient transfer to imaging departments, as well as the traditional role in imaging critically unwell patients. 39 classical cxr patterns of covid-19 include ground-glass opacities, consolidation and bilateral interstitial opacification associated with atypical or organizing pneumonia. 39e42 pneumothorax or lung cavitation are uncommon complications. 38, 43 imaging appearances may vary with stage of the disease (days from first symptoms) and with disease severity (fig. 1 ). 44 cxrs may be normal in cases of confirmed covid-19, both in early infection and in mild disease. in severe covid-19 there is a proportionately greater lung involvement which tends to be denser peripherally and in the lower zones. 38 the role of cxrs as the initial radiological assessment of patients presenting with respiratory distress and possible covid-19 is established. however, the available data on the accuracy of cxr in covid-19 is limited, with smaller case numbers compared to chest ct research and often without the inclusion of normal or non-covid-19 cases. for example, all patients within the analysis of zhao et al. 45 had a cxr performed but the findings have not been included. sensitivity of chest radiographs is dependent on the extent of covid-19 infection. in a cohort study (n ¼ 64 patients), cxr imaging of mild to moderate covid-19 patients was found to have a sensitivity of 69% 40 and lomoro et al. 42 found cxr sensitivity of 84% (27 of 32) . of the 170 non-hospitalised patients with mild symptoms, bandirali et al. 46 found 100 (58.8%) abnormal cxrs suggestive of covid-19, however rt-pcr confirmation was not performed. a small case series with rt-pcr confirmed covid-19 (n ¼ 9 patients) reported 50% sensitivity (true positive n ¼ 3) and specificity 33% (true negative n ¼ 1) for cxr, with two false positive cxrs (breast tissue mimicking ground glass opacification and atelectasis) without ct correlation. 47 paucity of reported specificity, small sample sizes, lack of normal and non covid-19 cases emphasises the requirement for imaging to be used as part of clinical decision making rather than in isolation. these findings can be summarised in table 2 . chest computed tomography (chest ct) has a limited but important role in clinical management of covid-19 patients. ct should be reserved for seriously ill patients, with emerging awareness of high prevalence of pulmonary thrombosis. 48 in addition, it can be used in the case of inconclusive chest radiographs 49 or unavailability of pcr tests. in the case of follow-up imaging where ct is required for clinical decision making, lowdose chest ct may be considered, as it can offer up to an 8-fold dose reduction. 50 systematic reviews and meta-analyses found that the most common imaging manifestations of the disease at ct were: bilateral, basal, ground glass opacities (ggos), crazy-paving, peripheral consolidations, reverse halo ("atoll" sign) and peri-lobular patterns (fig. 2) . 51, 52 bilateral pneumonia was predominant compared to unilateral, while most patients had more than two lobes involved, more often affecting the bases of the lungs than the apices. pericardial effusion, pleural thickening or hydrothorax were uncommon ct findings. 52e54 though viral pneumonias generally show similar imaging features, there are some characteristic ct findings which may help differentiating covid-19 from influenza-related pneumonia. 55 asymptomatic patients demonstrate single or multiple groundglass opacities, air bronchogram and nodules encircled by groundglass opacities. these are the main patterns also for early symptomatic patients, with the extra possible finding of interlobular septal thickening. 36, 44 when imaging patients between 3 and 7 days after the onset of clinical symptoms, ct demonstrated fused consolidations with air bronchogram, which tended to slightly decrease in range and density when imaging was performed between 7 and 14 days after the full clinical manifestation of the disease has taken place. 56 finally, imaging in the dissipation period 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 yradi1913_proof ■ 3 june 2020 ■ 3/10 (2e3 weeks after the onset of symptoms) revealed further decrease in lesions and thickening of bronchial wall and interlobular septum. however, even though the majority of patients developed improvement after 14 days, some studies have shown increased consolidations and development of pleural effusion on follow-up cts during the latter stages of the disease. 44 finally, a significant proportion of critically unwell patients with covid-19 have pulmonary embolic disease ranging from 23 to 30% and the role of ct pulmonary angiography (ctpa) is being established. 57, 58 despite paediatric patients having less severe symptoms than elderly cases, the ct findings in each age range are similar, most frequently bilateral sub-pleural ground-glass opacities and consolidation. 59 although, when compared to adults, the ggos in children are more localised and of lower attenuation. 60 therefore, these findings were characterised as atypical. furthermore, there is higher prevalence of peri-bronchial infiltrates and bronchial wall thickening in children compared to adults. this could be related to differences in distribution of the coronavirus infection along the respiratory epithelium between the two groups or to occurrence of co-infection. 61 similarly, chest ct performed in pregnant women diagnosed with covid-19 disease, showed that the consolidation lesions were more prevalent than in the rest of the patients. 62 low-dose protocols were implemented for these patients, minimising the risks of radiation exposure. 62 imaging of pregnant women should always be performed with extreme caution, after a thorough risk-benefit analysis for mother and fetus. relative to cxr, chest ct has higher contrast resolution without superimposed anatomy, which facilitates identification of radiographically occult abnormalities, in particular early ground glass opacification. however, many diseases manifest with similar ct findings, which may explain the relatively low specificity and risk of false positive diagnoses. 63 this is not coming as a surprise as in ct the three-dimensional nature of data acquisition and presentation ensures that superimposition of anatomy and pathology is minimised and any lesions can therefore be more easily identified and characterised. these findings suggest that ct should not be used alone as a diagnostic tool, and that swab tests must always be performed for these patients. although some studies conducted in china suggested chest ct as a first-line tool, 37, 64, 65 it must be noted that chest ct should only be reserved for the critically ill patients with unexplained deterioration. in the early stages of the covid-19 pandemic, characteristic ct appearances were seen in asymptomatic patients undergoing imaging for other reasons. 66, 67 hence, radiographers working in any healthcare setting must be aware and familiar with covid-19 findings in order to eliminate the potential risks of further transmission and improve patient management. reporting radiographers in particular are expected to be familiar with covid-19 imaging findings and preliminary clinical evaluation by radiographers is an expected competency in different countries, including the united kingdom. 39 point-of-care lung ultrasound (lus) the use of lung ultrasound (lus) in covid-19 is contentious and the evidence base is still evolving. point-of-care lus may have a 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 yradi1913_proof 68, 69 some early studies show that lus has a high sensitivity (93e98%) in imaging of acute respiratory distress syndrome (ards), as well as in cases of viral infections, such as the influenza pandemic in 2009. 70 in addition, lus reported a 93% sensitivity and 95% specificity when imaging critically ill patients with pneumonia. 71 a summary of all reported diagnostic accuracy values can be found in table 3 . although its full diagnostic value in patient management is yet to be established for covid-19 patients in larger studies, lus can depict signs suggestive of alveoral damage, subpleural consolidations, white lung regions, as well as irregular b-lines. 68, 70 a recent study reported a strong correlation with chest ct findings, and lus was recommended for imaging acute respiratory failure and lung inflammation. 76 more research with larger sample sizes would be needed to establish its added value, particularly for children or pregnant patients. however high operator dependency will remain its weak point. lastly, magnetic resonance imaging (mri), although not relevant for the evaluation of lung disease, it can contribute to the diagnostic pathway of patients with symptoms from the central nervous system. these may include various neurological manifestations, such as acute stroke, skeletal muscle injuries, consciousness impairment, or acute necrotizing hemorrhagic encephalopathy. 77, 78 the role of mri currently in the diagnosis of further secondary to covid19 complications, such as cardiac complications or persistent myositis, is still being explored and it is likely the application of mri in this area will expand as we understand more about this disease. cxr imaging of suspected or confirmed covid-19 cases should be performed with portable equipment within specifically designated isolated rooms for eliminating the risks of cross-infection within the radiology department. 79 an anterioposterior (ap) chest radiograph is performed on the patient's bed, despite known limitations of this technique, such as sub-optimal evaluation of the cardiothoracic ratio. in contrast, when cxr is performed within radiology, a posterioanterior (pa) standard technique must be used, as indicated. due to known risks of cross-infection, extreme care must be taken in relation to the optimal use of personal protective equipment (ppe) and decontamination of surfaces. 79 the technical quality of chest radiographs impacts diagnosis; mobile radiographs are performed on critically unwell patients and as a mechanism to reduce possible transmission. suboptimal image quality may occur due to rotation, incorrect exposure and reduced inspiration. it is therefore always important for the radiographer to check that all the technical and image quality criteria are fulfilled for every examination, where possible, and that neither patients' nor radiographers' safety is compromised. a plethora of guidelines on radiographic imaging considerations during the covid-19 pandemic, including a 10-point check list and other helpful evaluation tools, have been produced by the international society of radiographers and radiological technologists (isrrt). 80 regarding chest ct imaging, a standard unenhanced ct protocol 81 and multidetector (mdct) ct scanners can be used; the examination is carried out during the end-inspiration phase, when patients can follow breathing instructions. reconstruction to 1.25 mm slice thickness and multi-planar reconstruction is suggested. 82, 83 in case of clinical indications of pulmonary embolism and elevated d-dimers levels, a contrast-enhanced ct should be performed. 84 low dose ct should be used in paediatric and pregnant patients, to minimise radiation. the advantages of cxr include portability, which prevents cross-infection within radiology, cost-effectiveness, and wider availability. however, the sensitivity of the method is relatively low. on the contrary, chest ct has higher sensitivity (97e98%) 73,74 but lacks specificity, it is not widely available, has a higher radiation dose compared to cxr and its use requires thorough decontamination of the scanner room impacting workflows. lus offers the advantage of portability in the intensive care units or in a prehospital setting. 70 however, its diagnostic role has yet to be established. the role of mri is only ancillary in the case of neurological complications and its use should be strongly weighted against the impact on workflows, subject to the delays caused by decontamination. after the outbreak of the covid-19 pandemic, many professional bodies and learned societies have been quick to issue official guidelines on how medical imaging should optimally be performed for early diagnosis and related management of these patients, but also how staff should be protected from cross-infection. proportionate recommendations are offered for the protection of radiographers, as frontline staff. this knowledge is necessary for any medical imaging professional. subtle differences have been noted on the suggested imaging pathways among different countries (table 4 ). this could be mainly attributed to differences on the availability of antigen testing or of imaging equipment, the variability of diagnostic methods and techniques used. there may also be disproportionate lack of the required specialised staff (i.e. radiographers) to operate the equipment, and also dissimilar policies for the management of the pandemic. however a common denominator is that in most guidelines and recommendations medical imaging investigations are reserved for those patients who are critically ill, for those with inconclusive or insufficient prior diagnostic tests but with persistent symptoms, consistent with covid-19, and for those patients where clinical management decisions need to be imminently considered. most of the societies and professional bodies suggest that chest x-ray should be reserved for critically ill patients; the bsti identifies as such those who demonstrate oxygen saturation values below 94% (90% for patients with known copd). 49 however, they conclude that chest radiographs should not be used as a first-line tool due to low sensitivity, and that they must be restricted to imaging for intensive care unit patients. 35 similarly, the professional bodies suggest that ct imaging is indicated for those patients with clinical symptoms and inconclusive or normal imaging features on cxr and that the use of ct imaging for covid-19 should be based on clinical need and the possibility to change the management plan. 85 furthermore, the table 3 summary of sensitivity and specificity of cxr, ct and lus for the diagnosis of covid-19. chest radiograph 50e84% 40, 42, 46, 47 inadequate information, see 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 intercollegiate general surgery guidance 86 proposes for ct chest to be performed alongside abdominal imaging, especially to those patients requiring emergency surgery. this may have occurred as a consequence of the many incidental findings in asymptomatic cases. in addition, gastrointestinal may be the only presenting symptoms, hence rigorous infection control protocols must be employed regardless of the lack of respiratory-related symptoms, and radiographers must be prepared to manage these patients. 87 it is also reported that ct findings are not specific enough, and they can mimic other infections. 88 hence, ct imaging is recommended only if the clinical teams decide that it will have an impact on the management of the patient. the european bodies (esr and esti) concur with the limited use of chest ct, underlining the potential risks of infection during patient transportation. in line with the above and perhaps more conservatively to their european counterparts, north american professional bodies underline that no imaging, either cxr or ct, are recommended for the diagnosis of covid-19, and that viral testing should be the first-line method for diagnosis of the disease. 89 the european societies suggest that lung ultrasound should be used at the bedside, when needed, to eliminate the risks of further infection. 35 the fleischner society, an international consortium of worldrenowned experts in lung imaging, including radiologists and pulmonologists, states that imaging is not suggested for suspected covid-19 patients with mild symptoms, but it is recommended for patients with severe symptoms and worsening respiratory status. 90 in addition, they underline that cxr is less sensitive in the early/ mild infection in contrast with chest ct, which offers much more information at this stage. however, the final decision is left to the clinicians, as the availability of these methods, expertise and resources have to be considered. consequently, there is a consensus that imaging these patients must be generally limited to those critically ill, and that the clinicians at the point-of-care must always make a thoughtful risk-benefit analysis for these procedures, taking into account the stage of the disease and patient's clinical condition. some variability exists among countries regarding the use of medical imaging, mainly due to availability of resources and equipment, but also due to new scientific data about disease progression, which become available with time. however, radiographers should always consider these guidelines to avoid unnecessary staff and patient infection and to minimise radiation dose to patients by vetting the requested examinations or minimising radiation dose accordingly. optimal infection control procedures must take place within the radiology department, to minimise the potential risks of transmission of the virus to radiographers and other healthcare staff. decontamination of the imaging equipment is vital, and it has been widely discussed within the literature. 79,80,91e93 a recent study within radiology departments suggested that imaging equipment such as ct scanner components must be disinfected every time after contamination with 2,000 mg/l chlorine-containing disinfectant and the ct gantry must be fully wiped with 75% ethanol. 94 also, after decontamination the ct room must be closed for 1 h for ventilation and air circulation. 92 these studies are in line with the recommendations issued by the car and cstr, who also suggest standardized disinfection protocols after imaging of all suspected 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 or confirmed covid-19 patients, as well as unavailability of the equipment for a period of time. 89 keyboards, viewing stations, ultrasound probes, are also suggested to be disinfected after exposure, with alcohol-containing disinfectants (fig. 3) . 92, 95 radiology departments are encouraged to contact their vendors in order to specify the optimal disinfectants for every piece of equipment. in addition, all healthcare staff associated with cleaning, must be trained in optimal decontamination strategies, and radiology managers must develop specific infection control protocols to enhance safety within the departments. 96e98 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 radiology departments must also re-organise their facilities and staff in order to enhance safety and minimise the risks of infection. a recent study suggested some effective ways to achieve this, such as segregating radiographers into teams. furthermore, additional isolation rooms need to be created near the emergency department, where mobile radiography units can be deployed to minimise transferring patients. a two-radiographer team was found to effectively reduce the potential risks of cross-infection. 99 when non-urgent imaging is reintroduced, where possible, patients should be cohorted, outpatients screened at first presentation and possible covid-19 patients imaged using dedicated equipment, appropriate radiographer ppe and decontamination procedures. 100 however, it is crucial that asymptomatic transmission is recognised early; radiographers working on the frontline could conduct a preliminary clinical evaluation, as one method to facilitate rapid identification of unsuspected covid-19. 39 personal protective equipment (ppe) personal protective equipment (ppe) is vital for radiographers and other frontline healthcare professionals, as they can help minimise the likelihood of infection. a shortage of ppe has been reported globally given the high demand. the use of ppe must be proportional to risk of exposure. 101 a typical set of ppe for healthcare professionals consists of a long-sleeved gown, gloves, eye protection and a fluid repellent surgical mask or disposable respirator (n95, ffp2 or ffp3). this is the full ppe suggested by the european centre for disease prevention and control. 102 however, the uk government suggests the use of aprons instead of a gown for non-aerosol generating procedures (fig. 4) . 103, 104 in addition, the sessional use of ppe, or reuse have been also recommended in case of extreme shortages, while the use of double gloves is not suggested. the society of radiographers (sor) suggests that no radiographer should treat a patient without the ppe identified in the protocols. 105 more guidance is also available on the isrrt website 80 in relation to this. the covid-19 pandemic is rapidly and continually evolving. what is certain is that medical imaging will continue to play a key role in supporting clinical decision-making. further research is however needed to verify the added value of the different medical imaging modalities in diagnosis and patient management. moreover, the epidemiology of the disease is constantly changing, often impacting on the imaging findings and imaging techniques required to delineate these. what is certain is that there is more to learn in the coming months, but the authors hope that this paper will be a first tool, useful to summarise current knowledge for the radiography workforce at the frontline. medical imaging has a pivotal role in the covid-19 pandemic, offering the advantage of supplementary diagnosis and follow-up of the critically ill patients. radiographers, as frontline staff, should be familiar with the main challenges and controversies related to imaging patients with covid-19 so they can fulfill their role in safeguarding patient safety, patient care, optimise image quality as a tool for more accurate diagnosis, but also to engage in their reporting roles. most importantly, they should be aware of ways to keep themselves safe and well during this unprecedented situation by correctly using the right ppe and ensuring all their workspaces are adequately decontaminated to minimise the risk of further infection . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 world health organization. coronavirus disease 2019 (covid-19) situation report-120 reported cases and deaths by country, territory, or conveyance di napoli r. features, evaluation and treatment coronavirus covid-19): a review of clinical features, diagnosis, and treatment covid-19: what has been learned and to be learned about the novel coronavirus disease world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19) clinical features of patients infected with 2019 novel coronavirus in wuhan, china coronavirus disease 2019 (covid-19): a perspective from china olfactory and gustatory dysfunctions as a clinical presentation of mildto-moderate forms of the coronavirus disease (covid-19): a multicenter european study don't overlook digestive symptoms in patients with 2019 novel coronavirus disease (covid-2019) alert for non-respiratory symptoms of coronavirus disease 2019 (covid-19) patients in epidemic period: a case report of familial cluster with three asymptomatic covid-19 patients nervous system involvement after infection with covid-19 and other coronaviruses cross-country comparison of case fatality rates of covid-19/sars-cov-2 unknown unknows-covid-19 and potential global morality comorbidity and its impact on 1590 patients with covid-19 in china: a nationwide analysis does comorbidity increase the risk of patients with covid-19: evidence from meta-analysis prevalence of comorbidities in the novel wuhan coronavirus (covid-19) infection: a systematic review and meta-analysis prevalence of underlying diseases in hospitalized patients with covid-19: a systematic review and meta-analysis covid-19 rapid guideline: managing symptoms (including at the end of life) in the community people with moderate to severe asthma estimates of the severity of coronavirus disease 2019: a model-based analysis covid-19 spiraling of frailty in older italian patients sars-cov-2 infection in children cdc covid-19 response team. coronavirus disease 2019 in children-united states radiography xxx (xxxx) xxx novel coronavirus disease (covid-19) in children covid-19: the gendered impacts of the outbreak provisional death counts for coronavirus disease (covid-19) diagnosing covid-19: the disease and tools for detection the epidemiology, diagnosis and treatment of covid-19 stability issues of rt-pcr testing of sars-cov-2 for hospitalized patients clinically diagnosed with covid-19 dynamic profile of rt-pcr findings from 301 covid-19 patients in wuhan, china: a descriptive study antibody tests in detecting sars-cov-2 infection: a meta-analysis the critical role of laboratory medicine during coronavirus disease 2019 (covid-19) and other viral outbreaks lymphopenia predicts disease severity of covid-19: a descriptive and predictive study covid-19 patients and the radiology department-advice from the european society of radiology (esr) and the european society of thoracic imaging (esti) the role of imaging in 2019 novel coronavirus pneumonia (covid-19) ct imaging and differential diagnosis of covid-19 portable chest x-ray in coronavirus disease-19 (covid-19): a pictorial review covid-19: a case series to support radiographer preliminary clinical evaluation. radiography frequency and distribution of chest radiographic findings in covid-19 positive patients clinical, laboratory and imaging features of covid-19: a systematic review and meta-analysis covid-19 pneumonia manifestations at the admission on chest ultrasound, radiographs and ct: single-center study and comprehensive radiologic literature review progress and prospect on imaging diagnosis of covid-19 coronavirus disease 2019 (covid-19): a systematic review of imaging findings in 919 patients a comparative study on the clinical features of covid-19 pneumonia to other pneumonias chest radiograph findings in asymptomatic and minimally symptomatic quarantined patients in codogno, italy during covid-19 pandemic chest radiographic and ct findings of the 2019 novel coronavirus disease (covid-19): analysis of nine patients treated in korea covid-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up radiology decision tool for suspected covid-19 recommendation of low-dose ct in the detection and management of covid-19 guidance for the reporting radiologist ct imaging changes of corona virus disease 2019 (covid-19): a multi-center study in southwest china coronavirus disease 2019 (covid-19) ct findings: a systematic review and meta-analysis imaging and clinical features of patients with 2019 novel coronavirus sars-cov-2: a systematic review and meta-analysis characteristic ct findings distinguishing 2019 novel coronavirus disease (covid-19) from influenza pneumonia a rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-ncov) infected pneumonia (standard version) acute pulmonary embolism associated with covid-19 pneumonia detected by pulmonary ct angiography acute pulmonary embolism in covid-19 patients on ct angiography and relationship with d-dimer levels clinical and ct features in pediatric patients with covid-19 infection: different points of adults ct features of novel coronavirus pneumonia (covid-19) in children differences in clinical and imaging presentation of pediatric patients with covid-19 in comparison to adults clinical and ct imaging features of the covid-19 pneumonia: focus on pregnant women and children the role of ct for covid-19 patient's management remains poorly defined initial ct findings and temporal changes in patients with the novel coronavirus pneumonia (2019-ncov): a study of 63 patients in wuhan, china chest ct findings of covid-19 pneumonia by duration of symptoms covid-19 pneumonia in asymptomatic trauma patients; report of 8 cases incidental findings suggestive of covid-19 in asymptomatic patients undergoing nuclear medicine procedures in a high prevalence region point-of-care lung ultrasound findings in novel coronavirus disease-19 pnemoniae: a case report and potential applications during covid-19 outbreak point of care and intensive care lung ultrasound: a reference guide for practitioners during covid-19 is there a role for lung ultrasound during the covid-19 pandemic? role of thoracic ultrasound in diagnosis of pulmonary and pleural diseases in critically ill patients ct on the diamond princess: what might this tell us about sensitivity for covid-19? correlation of chest ct and rt-pcr testing in coronavirus disease 2019 (covid-19) in china: a report of 1014 cases sensitivity of chest ct for covid-19: comparison to rt-pcr chest ct features of covid-19 in rome can lung us help critical care clinicians in the early diagnosis of novel coronavirus (covid-19) pneumonia? radiology 2020 neurological complications of coronavirus disease (covid-19): encephalopathy covid-19-associated acute necrotizing hemorrhagic encephalopathy: ct and mri features british society of thoracic imaging. example covid-19 action card. radiology portable cxr's-'at risk' patients in ed or wards international covid-19 support for radiographers and radiologic technologists an update on covid-19 for the radiologist-a british society of thoracic imaging statement coronavirus disease 2019 (covid-19): role of chest ct in diagnosis and management ct features of coronavirus disease 2019 (covid-19) pneumonia in 62 patients in wuhan, china pulmonary embolism in patients with covid-19: time to change the paradigm of computed tomography rcr position on the role of ct in patients suspected with covid-19 infection intercollegiate general surgery guidance on covid-19 update potential implications of novel coronavirus disease (covid-19) related gastrointestinal symptoms for abdominal imaging acr recommendations for the use of chest radiography and computed tomography (ct) for suspected covid-19 infection the canadian association of radiologists (car) and the canadian society on thoracic radiology recommendations on covid-19 management in imaging departments the role of chest imaging in patient management during the covid-19 pandemic: a multinational consensus statement from the fleischner society covid-19 pneumonia: infection control protocol inside computed tomography suites covid-19) outbreak: what the department of radiology should know microbiology for radiologists: how to minimize infection transmission in the radiology department the battle against coronavirus disease 2019 (covid-19): emergency management and infection control in a radiology department management of patients with suspected or confirmed covid-19, in the radiology department covid-19 preparedness for portable xrays in an indian hospital-safety of the radiographers, the frontline warriors infection control against covid-19 in departments of radiology corona virus international public health emergencies: implications for radiology management how to safely and sustainably reorganise a large general radiography service facing the covid-19 pandemic rsna covid-19 task force: post-covid surge radiology preparedness rational use of personal protective equipment (ppe) for coronavirus disease (covid-19) european centre for disease prevention and control. guidance for wearing and removing personal protective equipment in healthcare settings for the care of patients with suspected or confirmed covid-19 covid-19: personal protective equipment (ppe) plan personal protective equipment advice for imaging departments and teams covid-19: personal protective equipment (ppe) none