Transmission of COVID-19 to Health Care Personnel During Exposures to a Hospitalized Patient - Solano County, California, February 2020

Guidance on Mitigating the Risk of Transmitting Respiratory Infections During Nebulization by the COPD Foundation Nebulizer Consortium

BACKGROUND

Nebulizers are used commonly for inhaled drug delivery. Because they deliver medication through aerosol generation, clarification is needed on what constitutes safe aerosol delivery in infectious respiratory disease settings. The COVID-19 pandemic highlighted the importance of understanding the safety and potential risks of aerosol-generating procedures. However, evidence supporting the increased risk of disease transmission with nebulized treatments is inconclusive, and inconsistent guidelines and differing opinions have left uncertainty regarding their use. Many clinicians opt for alternative devices, but this practice could impact outcomes negatively, especially for patients who may not derive full treatment benefit from handheld inhalers. Therefore, it is prudent to develop strategies that can be used during nebulized treatment to minimize the emission of fugitive aerosols, these comprising bioaerosols exhaled by infected individuals and medical aerosols generated by the device that also may be contaminated. This is particularly relevant for patient care in the context of a highly transmissible virus.

RESEARCH QUESTION

How can potential risks of infections during nebulization be mitigated?

STUDY DESIGN AND METHODS

The COPD Foundation Nebulizer Consortium (CNC) was formed in 2020 to address uncertainties surrounding administration of nebulized medication. The CNC is an international, multidisciplinary collaboration of patient advocates, pulmonary physicians, critical care physicians, respiratory therapists, clinical scientists, and pharmacists from research centers, medical centers, professional societies, industry, and government agencies. The CNC developed this expert guidance to inform the safe use of nebulized therapies for patients and providers and to answer key questions surrounding medication delivery with nebulizers during pandemics or when exposure to common respiratory pathogens is anticipated.

RESULTS

CNC members reviewed literature and guidelines regarding nebulization and developed two sets of guidance statements: one for the health care setting and one for the home environment.

INTERPRETATION

Future studies need to explore the risk of disease transmission with fugitive aerosols associated with different nebulizer types in real patient care situations and to evaluate the effectiveness of mitigation strategies.

Personal protective measures and settings on the risk of SARS-COV-2 community transmission: a case-control study

Background

During the SARS-CoV-2 pandemic, nurses of primary health care has been an important role in Spain. Even so, the data obtained in the tracing have been scarcely used to investigate the possible mechanisms of transmission. Few studies focused on community transmission, evaluating the effectiveness of individual protective measures and exposure environment. The main aim of the study was to evaluate the association between individual protective measures and SARS-CoV-2 transmission in the community and to compare secondary attack rates in different exposure settings.

Methods

A case-control study from contact tracing of SARS-CoV-2 index patients. COVID-19 contact tracing was led by nurses at the COVID-19 Coordinating Centre in Majorca (Spain). During the systematic tracing, additional information for this study was collected from the index patient (social-demographic variables, symptoms, the number of close contacts). And also, the following variables from their close contacts: contact place, ventilation characteristics mask-wearing, type of mask, duration of contact, shortest distance, case-contact relationship, household members, and handwashing, the test result for SARS-CoV-2 diagnostic. Close contacts with a positive test for SARS-CoV-2 were classified as "cases" and those negative as "controls."

Results

A total of 1,778 close contacts from 463 index patients were identified. No significant differences were observed between the sexes but between age groups. Overall Secondary Attack Rate (SAR) was 24.0% (95% CI: 22.0-26.0%), 36.9% (95% CI: 33.2-40.6%) in closed spaces without ventilation and 50.7% (95% CI: 45.6-55.8%) in exposure time > 24 h. A total of 49.2% of infections occurred among household members. Multivariate logistic regression analysis showed that open-air setting (OR 0.43, 95% CI: 0.27-0.71), exposure for less than 1 h (OR 0.19, 95% CI: 0.11-0.32), and wearing a mask (OR 0.49, 95% CI: 0.28-0.85) had a protective effect transmission of SARS-CoV-2 in the community.

Conclusion

Ventilation of the space, mask-wearing and shorter exposure time were associated with a lower risk of transmission in the community. The data obtained allowed an assessment of community transmission mechanisms and could have helped to improve and streamline tracing by identifying close contacts at higher risk.

Effectiveness of wearing masks during the COVID-19 outbreak in cohort and case-control studies: a systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy of wearing a mask to prevent COVID-19 infection.

METHODS

This was a systematic review and meta-analysis of cohort and case-control studies, considering the best level of evidence available. Electronic databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Clinical Trials.gov) were searched to identify studies that evaluated the effectiveness of wearing masks compared with that of not wearing them during the COVID-19 pandemic. Risk of bias and quality of evidence were assessed using the Cochrane risk of bias tool and the Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

Of the 1,028 studies identified, 9 met the inclusion criteria (2 cohort studies and 7 case-control studies) and were included in the analysis. The meta-analysis using cohort studies alone showed statistically significant differences, wearing a cloth mask decreased by 21% [RD = -0.21 (95% CI, -0.34 to -0.07); I2 = 0%; p = 0,002] the risk of COVID-19 infection, but the quality of evidence was low. Regarding case-control studies, wearing a surgical mask reduced the chance of COVID-19 infection [OR = 0.51 (95% CI, 0.37-0.70); I2 = 47%; p = 0.0001], as did wearing an N95 respirator mask [OR = 0.31 (95% CI, 0.20-0.49); I2 = 0%; p = 0.00001], both with low quality of evidence.

CONCLUSIONS

In this systematic review with meta-analysis, we showed the effectiveness of wearing masks in the prevention of SARS-CoV-2 infection regardless of the type of mask (disposable surgical mask, common masks, including cloth masks, or N95 respirators), although the studies evaluated presented with low quality of evidence and important biases.

A systematic review and meta-analysis of the efficacy of N95 respirators and surgical masks for protection against COVID-19

Former meta-analyses concluded that there was not sufficient evidence to determine the effect of surgical masks and N95 respirators. We collected randomized controlled trials (RCTs) and conducted a systematic review and meta-analysis to evaluate the efficacy of N95 respirators and surgical masks for protection against COVID-19. We retrieved relevant RCTs published between January 2019 and January 2023 by searching the PubMed, EMBASE, and Cochrane CENTRAL. Study quality was evaluated using the Cochrane Risk of Bias tool with the RevMan 5.4 software. Meta-analyses were conducted to calculate pooled estimates using the RevMan 5.4 software. A total of six RCTs were finally included. The findings revealed that wearing a mark made little difference in preventing COVID-19 [odds ratio (OR) = 0.10; 95% confidence interval (CI): 0.01-0.93; P = 0.04]. Subgroup analysis showed that the heterogeneity of data was I2 = 64% (OR = 0.32; 95% CI: 0.06-1.77; P = 0.19) for surgical mask use and I2 = 0% (OR = 0.03; 95 %CI: 0.01-0.15; P < 0.01) for N95 respirator use. The heterogeneity of data for medical staff was I2 = 0% (OR = 0.03; 95 %CI: 0.01-0.12; P < 0.01). Meta-analysis indicated a protective effect of N95 respirators against COVID-19, particularly for medical staff. The use of surgical masks is not associated with a lower risk of COVID-19. However, the subgroup using N95 respirators, particularly medical staff, showed a significant protective. These findings suggest that N95 respirators should be reserved for high-risk medical staff in the absence of sufficient resources during an epidemic. But the number of included studies was small, more studies in future analyses is required to reduce the risk of distribution bias.

Impact of Epidemic Intelligence Service Training in Occupational Respiratory Epidemiology

The Centers for Disease Control and Prevention's Epidemic Intelligence Service (EIS) is a fellowship in applied epidemiology for physicians, veterinarians, nurses, scientists, and other health professionals. Each EIS fellow is assigned to a position at a federal, state, or local site for 2 years of on-the-job training in outbreak investigation, epidemiologic research, surveillance system evaluation, and scientific communication. Although the original focus of the program on the control of infectious diseases remains salient, positions are available for training in other areas of public health, including occupational respiratory disease. In this Perspective, we describe the EIS program, highlight three positions (one federal and two state-based) that provide training in occupational respiratory epidemiology, and summarize trainees' experiences in these positions over a 30-year period. For early-career health professionals interested in understanding and preventing occupational respiratory hazards and diseases, EIS offers a unique career development opportunity.

There Is a Risk of Spread During a Nebulization Session in a Patient with COVID-19

Introduction: A hypothetical risk of SARS-CoV-2 airborne transmission through nebulization was suggested based on a potential environmental contamination by the fugitive aerosol emitted in the environment during the procedure. The aim of this study was to verify this risk from the fugitive aerosol emitted by COVID-19 patients during one nebulization session. Methods: In this cohort study, COVID-19 patients treated with nebulization were recruited at their admission to the hospital. Patients had to perform a nebulization session while a BioSampler® and a pump were used to vacuum the fugitive aerosol and collect it for SARS-CoV-2 RNA detection. Results: Ten consecutive patients hospitalized with COVID-19 were recruited. The median viral load was 6.5 × 106 copies/mL. Two out of the 10 samples from the fugitive aerosol collected were positive to SARS-CoV-2. Conclusion: The risk of fugitive aerosol contamination with SARS-CoV-2 during nebulization has now been verified.

[Risk management system to reduce COVID-19 infection in health personnelSistema de gestão de riscos para reduzir o contágio de COVID-19 em profissionais de saúde]

Objective

To assess the occupational factors associated with the occurrence of COVID-19 in health personnel who were exposed to different magnitudes of risk and who followed the United Nations crisis management policy for COVID-19.

Methods

Cross-sectional survey conducted between April and May 2021. The low-risk group (LRG) were considered to be those who had minimal contact with patients; the medium-risk group (MRG) had contact with non-COVID-19 patients and did not perform instrumental airway intervention; and the high-risk group (HRG) were those who cared for COVID-19 patients and performed instrumental intervention with aerosol generation. Diagnosed COVID-19 disease and the presence of positive IgG antibodies for SARS-CoV-2 measured with Elecsys® anti-SARS-CoV-2 were considered as outcomes.

Results

Outcome recorded in 43.8% of the LRG, versus 46.7% in the MRG (odds ratio [OR]: 1.125; 95% confidence interval [CI 95% ]: 0.896-1.414; p = 0.311), and 48.6% in the HRG (OR: 1,214; CI 95%: 0.964-1.530; p= 0.10).

Conclusion

Belonging to the high-risk group and the medium-risk group, based on the degree of exposure to confirmed COVID-19 patients in the work area, was not associated with a higher occurrence of disease or seroconversion.

Nosocomial SARS-COVID-19 Outbreak During the Third Wave of COVID-19 in an Oncology Facility at a Tertiary Care Hospital in Kashmir, India

BACKGROUND

Coronavirus disease 2019 (COVID-19) emerged as a life-threatening respiratory condition, especially in immunocompromised patients, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Initially detected in China in December 2019, the first case in India was diagnosed on January 30, 2020. Here we report a nosocomial COVID-19 outbreak among cancer patients and healthcare workers (HCWs) in a medical oncology unit of a tertiary care hospital from our region.

MATERIALS AND METHODS

This was a descriptive study of the nosocomial COVID-19 outbreak and was conducted in the month of January 2022 at the medical oncology unit of a tertiary care hospital in Srinagar, Jammu and Kashmir (J&K), India. The study included 25 COVID-19 cases, including patients and HC/non-HCWs (NHCWs). The confirmation of diagnosis was done through real-time polymerase chain reaction (RT-PCR) using nasopharyngeal/oropharyngeal swabs as the test sample.

RESULTS

Twenty-five COVID-19 cases, including 14 admitted patients, nine HCWs, and two NHCWs were confirmed by COVID-19 RT-PCR in a span of 11 days. The first case was a positive HCW. The patients were admitted for management of various hematological as well as solid organ malignancies. Of the 14 patients, eight were in the pediatric age group with a mean age of 6.9 years, and six were adults with a mean age of 55.2 years. Thirteen patients were on different chemotherapy protocols, and one was undergoing an autologous stem cell transplant. Of the 14 patients, four were asymptomatic for COVID-19 symptoms, eight had mild disease, and two had severe disease with respiratory failure. Two patients with severe diseases needed COVID-19-designated high-dependency unit (HDU) admission. There was one COVID-19-related death. Among the healthcare workers, the mean age was 33.8 years, of which six were males and three were females. All the HCWs and NHCWs had mild disease, and all of them recovered completely.

CONCLUSION

Nosocomial COVID-19 illness is a new entity and is preventable. COVID-19 illness will remain in society after the pandemic is over, like the influenza B viral illness, and there can be seasonal flares in the future. Proper measures should be taken to prevent its clustering in hospital settings.

Emerging Roles of Malaysian Pharmacists in Asthma Management Amidst the COVID-19 Pandemic: A Narrative Review

The arrival of COVID-19 pandemic in March 2020 adversely affected every aspect of human life, including the management of asthma. The pandemic has forced clinicians to revisit the application of high-risk aerosol-generating procedures in asthma management, including spirometry and nebuliser therapy. The use of commercial spacers with pressurised metered-dose inhalers to replace nebulisation is limited by the high cost and pandemic-induced stock unavailability of these inhalers. The need for social distancing, healthcare reserves reallocation, and scarce personal protective equipment has promote increased telemedicine uptake for patients' asthma control and monitoring. Malaysian pharmacists have been providing long-term care of asthma through the introduction of the respiratory Medication Therapy Adherence Clinic (MTAC) to empower patients' general health literacy, train and regularly evaluate their inhalation technique, and reinforce the importance of medication compliance. To minimise the use of unplanned healthcare resources and avoidable COVID-19 infection exposure, Malaysian pharmacists need to better support asthma self-management via increased uptake of written Asthma Action Plans (AAPs). Pharmacist-led asthma treatment step-down to attain the lowest effective dose of inhaled corticosteroids (ICS) has become increasingly relevant during the pandemic, as its prolonged use carries risk of numerous side effects and possible hospitalisation. Telepharmacy offers a promising model for exploration and an alternative to the traditional service delivery of asthma education. Despite not being authorised as vaccinators, Malaysian pharmacists hold strong positions in COVID-19 immunisation programmes for pharmacovigilance and advocacy. The pandemic demands an increased role for pharmacists within medication management to prevent patients from the stockpiling that can cause adverse effects on pharmaceutical supply chain. This review intends to summarise the impact of COVID-19 on asthma management, with a focus on the transitional roles of Malaysian pharmacists before and after the pandemic era.

Influencing factors of hospital-acquired COVID-19 prevention and control status among emergency support frontline healthcare workers under closed-loop management: a cross-sectional study

Background

This study aimed to understand the hospital-acquired COVID-19 infection rate and infection prevention and control status of emergency support frontline healthcare workers (ESFHCWs) under closed-loop management, and to explore the related factors affecting hospital-acquired COVID-19 prevention and control status.

Methods

The study site was a provincial-level tertiary hospital in the Xinjiang Uygur Autonomous Region specializing in treating COVID-19 patients. ESFHCWs were assigned from different hospitals in Zhejiang Province to provide emergency medical support in this specialized hospital. All ESFHCWs were managed using a closed loop. A self-designed questionnaire was used to estimate basic information, work experience, and the status of infection prevention and control (SIPC). A total of 269 ESFHCWs responded to the questionnaire. A generalized linear regression model was used to estimate the factors influencing SIPC.

Results

There were six hospital-acquired COVID-19 cases, with an infection rate of 2.23%. The independent risk factors influencing COVID-19 prevention and control status were work seniority, anxiety disorder, and consumption of gastrointestinal, anti-inflammatory and anti-asthmatic, and hypnotic sedative drugs. Compared with ESFHCWs with more than 10 years of work seniority, ESFHCWs with less than 5 years of work seniority and 5-10 years of work seniority had lower COVID-19 SIPC scores. Among ESFHCWs with anxiety disorder, the SIPC score was significantly lower than that of ESFHCWs without anxiety disorder. The SIPC scores of ESFHCWs taking other medications (gastrointestinal, anti-inflammatory and anti-asthmatic, and hypnotic sedative drugs) were lower than those of ESFHCWs who did not.

Conclusion

The closed-loop management method may be effective in reducing the infection rate of hospital-acquired COVID-19 among ESFHCWs. HCWs with less than 10 years of work seniority, anxiety disorder, and other medications (gastrointestinal, anti-inflammatory and anti-asthmatic, and hypnotic sedative drugs) were probably not suitable for participating in emergency assistant actions because of their poor SIPC scores. Further studies are needed to develop the selection criteria for ESFHCWs.

Occupational COVID-19 Exposures and Illnesses among Workers in California-Analysis of a New Occupational COVID-19 Surveillance System

Little is known about occupational SARS-CoV-2 exposures and COVID-19 outcomes. We established a Doctor's First Reports of Occupational Injury or Illness (DFR)-based surveillance system to study cases of work-related COVID-19 exposures and disease. The surveillance data included demographics, occupation, industry, exposure, and illness, details including hospitalization and lost work. We classified workers into 'healthcare', non-healthcare 'public-facing', or 'other' worker groups, and rural-urban commuting areas (RUCAs). We describe worker exposures and outcomes overall by worker group and RUCA. We analyzed 2848 COVID-19 DFRs representing workers in 22 detailed occupation groups and 19 industry groups. Most DFRs were for workers in metropolitan RUCAs (89%) and those in healthcare (42%) and public-facing (24%) worker groups. While DFRs were from 382 unique worksites, 52% were from four hospitals and one prison. Among 1063 DFRs with a suspected exposure, 73% suspected exposure to a patient or client. Few DFRs indicated hospitalization (3.9%); however, the proportion hospitalized was higher among nonmetropolitan (7.4%) and public-facing (6.7%) workers. While 56% of DFRs indicated some lost work time, the proportion was highest among public-facing (80%) workers. Healthcare and prison workers were the majority of reported occupational COVID-19 exposures and illnesses. The risk of COVID-19 hospitalization and lost work may be highest among nonmetropolitan and public-facing workers.

DNA amplification tests at universal pre-admission screening with enhanced precaution strategies for asymptomatic patients with COVID-19

Objective

To analyse the effect of hospital pre-admission screening and enhanced precaution strategies on the transmission of severe acute respiratory syndrome coronavirus-2.

Methods

This retrospective cohort study was conducted over 17 months from 11 May 2020 to 30 September 2021 at a large hospital in Tokyo. Universal DNA amplification tests were conducted during pre-admission screening, and enhanced precaution strategies were implemented for all patients with negative admission tests. The primary outcome was the occurrence of symptomatic coronavirus disease 2019 (COVID-19) in patients after admission. The secondary outcomes were time-series analyses of monthly positive admission test numbers, positive rates, clinical features in positive cases, and clinically confirmed nosocomial transmission.

Results

In total, 32,081 patients were screened pre-admission (29,556 asymptomatic patients and 2525 symptomatic patients). Of the asymptomatic patients, 0.11% (n=32) tested positive and were admitted to a designated COVID-19 ward or were not admitted. Among the five inpatients who developed symptomatic COVID-19 during hospitalization, only two cases were related to a single nosocomial transmission.

Conclusion

Pre-admission test screening was effective in identifying asymptomatic cases of COVID-19. This allowed administrators to quarantine patients or delay hospital admission. The combination of testing and enhanced precaution strategies for asymptomatic cases of COVID-19 may minimize nosocomial transmission.

Major Update: Masks for Prevention of SARS-CoV-2 in Health Care and Community Settings-Final Update of a Living, Rapid Review

BACKGROUND

Optimal use of masks for preventing COVID-19 is unclear.

PURPOSE

To update an evidence synthesis on N95, surgical, and cloth mask effectiveness in community and health care settings for preventing SARS-CoV-2 infection.

DATA SOURCES

MEDLINE, EMBASE, medRxiv (3 June 2022 to 2 January 2023), and reference lists.

STUDY SELECTION

Randomized trials of interventions to increase mask use and risk for SARS-CoV-2 infection and observational studies of mask use that controlled for potential confounders.

DATA EXTRACTION

Two investigators sequentially abstracted study data and rated quality.

DATA SYNTHESIS

Three randomized trials and 21 observational studies were included. In community settings, mask use may be associated with a small reduced risk for SARS-CoV-2 infection versus no mask use, on the basis of 2 randomized trials and 7 observational studies. In routine patient care settings, surgical masks and N95 respirators may be associated with similar risk for SARS-CoV-2 infection, on the basis of 1 new randomized trial with some imprecision and 4 observational studies. Evidence from observational studies was insufficient to evaluate other mask comparisons due to methodological limitations and inconsistency.

LIMITATION

Few randomized trials, studies had methodological limitations and some imprecision, suboptimal adherence and pragmatic aspects of randomized trials potentially attenuated benefits, very limited evidence on harms, uncertain applicability to Omicron variant predominant era, meta-analysis not done due to heterogeneity, unable to formally assess for publication bias, and restricted to English-language articles.

CONCLUSION

Updated evidence suggests that masks may be associated with a small reduction in risk for SARS-CoV-2 infection in community settings. Surgical masks and N95 respirators may be associated with similar infection risk in routine patient care settings, but a beneficial effect of N95 respirators cannot be ruled out.

PRIMARY FUNDING SOURCE

None.

Excess risk of SARS-CoV-2 infection among in-person nonhealthcare workers in six states, September 2020-June 2021

BACKGROUND

While the occupational risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection for healthcare personnel in the United States has been relatively well characterized, less information is available on the occupational risk for workers employed in other settings. Even fewer studies have attempted to compare risks across occupations and industries. Using differential proportionate distribution as an approximation, we evaluated excess risk of SARS-CoV-2 infection by occupation and industry among non-healthcare workers in six states.

METHODS

We analyzed data on occupation and industry of employment from a six-state callback survey of adult non-healthcare workers with confirmed SARS-CoV-2 infection and population-based reference data on employment patterns, adjusted for the effect of telework, from the U.S. Bureau of Labor Statistics. We estimated the differential proportionate distribution of SARS-CoV-2 infection by occupation and industry using the proportionate morbidity ratio (PMR).

RESULTS

Among a sample of 1111 workers with confirmed SARS-CoV-2 infection, significantly higher-than-expected proportions of workers were employed in service occupations (PMR 1.3, 99% confidence interval [CI] 1.1-1.5) and in the transportation and utilities (PMR 1.4, 99% CI 1.1-1.8) and leisure and hospitality industries (PMR 1.5, 99% CI 1.2-1.9).

CONCLUSIONS

We found evidence of significant differences in the proportionate distribution of SARS-CoV-2 infection by occupation and industry among respondents in a multistate, population-based survey, highlighting the excess risk of SARS-CoV-2 infection borne by some worker populations, particularly those whose jobs require frequent or prolonged close contact with other people.

Size distribution and relationship of airborne SARS-CoV-2 RNA to indoor aerosol in hospital ward environments

Aerosol particles proved to play a key role in airborne transmission of SARS-CoV-2 viruses. Therefore, their size-fractionated collection and analysis is invaluable. However, aerosol sampling in COVID departments is not straightforward, especially in the sub-500-nm size range. In this study, particle number concentrations were measured with high temporal resolution using an optical particle counter, and several 8 h daytime sample sets were collected simultaneously on gelatin filters with cascade impactors in two different hospital wards during both alpha and delta variants of concern periods. Due to the large number (152) of size-fractionated samples, SARS-CoV-2 RNA copies could be statistically analyzed over a wide range of aerosol particle diameters (70-10 µm). Our results revealed that SARS-CoV-2 RNA is most likely to exist in particles with 0.5-4 µm aerodynamic diameter, but also in ultrafine particles. Correlation analysis of particulate matter (PM) and RNA copies highlighted the importance of indoor medical activity. It was found that the daily maximum increment of PM mass concentration correlated the most with the number concentration of SARS-CoV-2 RNA in the corresponding size fractions. Our results suggest that particle resuspension from surrounding surfaces is an important source of SARS-CoV-2 RNA present in the air of hospital rooms.

Transmission risk of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) to healthcare personnel following unanticipated exposure to aerosol-generating procedures: Experience from epidemiologic investigations at an academic medical center

Healthcare personnel (HCP) with unprotected exposures to aerosol-generating procedures (AGPs) on patients with coronavirus disease 2019 (COVID-19) are at risk of infection with severe acute respiratory coronavirus virus 2 (SARS-CoV-2). A retrospective review at an academic medical center demonstrated an infection rate of <1% among HCP involved in AGPs without a respirator and/or eye protection.

Aerosol containment device design considerations and performance evaluation metrics

BACKGROUND

Spurred by the Coronavirus infectious disease 2019 pandemic, aerosol containment devices (ACDs) were developed to capture infectious respiratory aerosols generated by patients at their source. Prior reviews indicated that such devices had low evidence of effectiveness, but did not address how ACDs should be evaluated, how well they should perform, nor have clearly defined performance standards. Towards developing design criteria for ACDs, two questions were posed: 1) What characteristics have guided the design of ACDs? 2) How have these characteristics been evaluated?

METHODS

A scoping review was performed consistent with PRISMA guidelines. Data were extracted with respect to general study information, intended use of the device, device design characteristics and evaluation.

RESULTS

Fifty-four articles were included. Evaluation was most commonly performed with respect to device aerosol containment (n = 31, 61%), with only 5 (9%), 3 (6%) and 8 (15%) formally assessing providing experience, patient experience and procedure impact, respectively. Nearly all of the studies that explored provider experience and procedure impact studied intubation. Few studies provided a priori performance criteria for any evaluation metric, or referenced any external guidelines by which to bench mark performance.

CONCLUSION

With respect to aerosol containment, ACDs should reduce exposure among HCP with the device compared with the absence of the device, and provide ≥90% reduction in respirable aerosols, equivalent in performance to N95 filtering facepiece respirators, if the goal is to reduce reliance on personal protective equipment. The ACD should not increase awkward or uncomfortable postures, or adversely impact biomechanics of the procedure itself as this could have implications for procedure outcomes. A variety of standardized instruments exist to assess the experience of patients and healthcare personnel. Integration of ACDs into routine clinical practice requires rigorous studies of aerosol containment and the user experience.

Out-of-Hospital Cardiac Arrest during the COVID-19 Pandemic: A Systematic Review

Objective: Out-of-hospital cardiac arrest (OHCA) is a prominent cause of death worldwide. As indicated by the high proportion of COVID-19 suspicion or diagnosis among patients who had OHCA, this issue could have resulted in multiple fatalities from coronavirus disease 2019 (COVID-19) occurring at home and being counted as OHCA. Methods: We used the MeSH term "heart arrest" as well as non-MeSH terms "out-of-hospital cardiac arrest, sudden cardiac death, OHCA, cardiac arrest, coronavirus pandemic, COVID-19, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)." We conducted a literature search using these search keywords in the Science Direct and PubMed databases and Google Scholar until 25 April 2022. Results: A systematic review of observational studies revealed OHCA and mortality rates increased considerably during the COVID-19 pandemic compared to the same period of the previous year. A temporary two-fold rise in OHCA incidence was detected along with a drop in survival. During the pandemic, the community's response to OHCA changed, with fewer bystander cardiopulmonary resuscitations (CPRs), longer emergency medical service (EMS) response times, and worse OHCA survival rates. Conclusions: This study's limitations include a lack of a centralised data-gathering method and OHCA registry system. If the chain of survival is maintained and effective emergency ambulance services with a qualified emergency medical team are given, the outcome for OHCA survivors can be improved even more.

Exposure risk management: Personal protective equipment and the risk of accidents occurring during aerosol generating procedures applied to COVID-19 patients

BACKGROUND

COVID-19 is considered to be very contagious as it can be spread through multiple ways. Therefore, exposure risk of healthcare workers (HCWs) treating COVID-19 patients is a highly salient topic in exposure risk management. From a managerial perspective, wearing personal protective equipment and the risk of accidents occurring during aerosol generating procedures applied to COVID-19 patients are two interconnected issues encountered in all COVID-19 hospitals.

OBJECTIVE

The study was conducted to understand the realistic impact of exposure risk management on HCWs exposed to risks of SARS-CoV-2 virus infection in a healthcare unit. In particular, this study discusses the role of personal protective equipment (PPEs) used in aerosol generating procedures (AGPs) to protect HCWs, and the related risk of accidents occurring when performing AGPs.

METHODOLOGY

This is a cross-sectional single-hospital study conducted at the "Sf. Ioan cel Nou" Hospital in Suceava, Romania, that had to ensure safety of healthcare workers (HCWs) getting in contact with COVID-19 cases. Data used in the study were collected between 10.12.2020-19.03.2021 by means of a questionnaire that collected information on risk assessment and healthcare workers' exposure management, and which was translated and adapted from the World Health Organization (WHO) and applied to respondents online. For this purpose, ethical approval was obtained, doctors and nurses from all hospital departments being invited to complete the questionnaire. Data processing, as well as descriptive, correlation and regression analyses have been done by using the 21.0 version of the Statistical Package for Social Sciences software.

RESULTS

Most of the 312 HCWs reported having always used disposable gloves (98.13%), medical masks N95 (or equivalent) (92.86%), visors or googles (91.19%), disposable coverall (91.25%) and footwear protection (95.00%) during AGPs. The waterproof apron had always been worn only by 40% of the respondents, and almost 30% of staff had not used it at all during AGPs. Over the last three months, the period when the questionnaire was completed, 28 accidents were reported while performing AGPs: 11 accidents with splashing of biological fluids/ respiratory secretions in the eyes, 11 with splashing of biological fluids/ respiratory secretions on the non-idemn skin, 3 with splashing of biological fluids/ respiratory secretions in the oral/ nasal mucosa and 3 with puncture/ sting with any material contaminated with biological fluids/ respiratory secretions. Also, 84.29% of respondents declared having changed their routine, at least, moderately due to COVID-19.

CONCLUSION

An effective risk exposure management is based on wearing protective equipment. The only protection offered by the disposable coverall, as it results from our analysis, is related to splashing of biological fluids/ respiratory secretions on the non-idemn skin. In addition, the results show that the number of accidents should decrease due to the fact that disposable gloves and footwear protection are used while performing AGPs on patients with COVID-19 and hand hygiene is practised before and after touching a patient with COVID-19 (regardless of glove wearing).

Risk of COVID-19 infection among mobile extracorporeal membrane oxygenation team

Background and Aim

The transport of coronavirus-2019 (COVID-19) patients on extracorporeal membrane oxygenation (ECMO) is a challenging situation, especially for healthcare workers (HCWs), due to the risk of cross-infection. Hence, certain precautions are needed for their safety. The study aims to evaluate the risk of COVID-19 transmission to HCWs who transport COVID-19 patients on ECMO device.

Methods

A retrospective review of adult patients with COVID-19 infection supported with ECMO and transported by ground route to the Medical Intensive Care Unit (MICU) at Hamad General Hospital (HGH) and a survey of HCWs involved in those cases.

Results

A total of 63 HCWs of the mobile ECMO team were exposed to COVID-19-positive patients on 199 occasions. HCWs exposure time was nearly 110 h, and the total transport distance was 1018 km. During the study period, only two of the mobile ECMO HCWs tested positive for COVID-19. There was zero incidence of transfer-associated injuries or accidents to HCWs.

Conclusions

The risk of COVID-19 cross-infection to the mobile ECMO team seems to be very low, provided that strict infection prevention and control measures are applied.

The inactivation and destruction of viruses by reactive oxygen species generated through physical and cold atmospheric plasma techniques: Current status and perspectives

BACKGROUND

Outbreaks of airborne viral infections, such as COVID-19, can cause panic regarding other severe respiratory syndrome diseases that may develop and affect public health. It is therefore necessary to develop control methods that offer protection against such viruses.

AIM OF REVIEW

To identify a feasible solution for virus deactivation, we critically reviewed methods of generating reactive oxygen species (ROS), which can attack a wide range of molecular targets to induce antiviral activity, accounting for their flexibility in facilitating host defense mechanisms against a comprehensive range of pathogens. Recently, the role of ROS in microbial decontamination has been critically investigated as a major topic in infectious diseases. ROS can eradicate pathogens directly by inducing oxidative stress or indirectly by promoting pathogen removal through numerous non-oxidative mechanisms, including autophagy, T-cell responses, and pattern recognition receptor signaling.

KEY SCIENTIFIC CONCEPTS OF REVIEW

In this article, we reviewed possible methods for the in vitro generation of ROS with antiviral activity. Furthermore, we discuss, in detail, the novel and environmentally friendly cold plasma delivery system in the destruction of viruses. This review highlights the potential of ROS as therapeutic mediators to modernize current techniques and improvement on the efficiency of inactivating SARS-CoV2 and other viruses.

Efficacy of personal protective equipment to prevent environmental infection of COVID-19 among healthcare workers: a systematic review

BACKGROUND

Healthcare workers (HCWs) employed personal protective equipment (PPE) during the COVID-19 pandemic, crucial to protecting themselves from infection. To highlight the efficacy of PPE in preventing environmental infection among HCWs, a systematic review was conducted in line with PRISMA guidance.

METHODS

A search of the PubMed and Web of Science databases was conducted from January 2019 to April 2021 using pre-defined search terms. Articles were screened by three researchers. The approved papers were read in full and included in this review if relevance was mutually agreed upon. Data were extracted by study design and types of PPEs.

RESULTS

47 of 108 identified studies met the inclusion criteria, with seven reviews and meta-analyses, seven cohort, nine case-control, fifteen cross-sectional studies, four before and after, four case series, and one modeling studies. Wearing PPE offered COVID-19 protection in HCWs but required adequate training. Wearing surgical masks provided improved protection over cloth masks, while the benefit of powered air-purifying respirators is less clear, as are individual gowns, gloves, and/or face shields.

CONCLUSIONS

Wearing PPE, especially facial masks, is necessary among HCWs, while training in proper use of PPE is also important to prevent COVID-19 infection.

Hospital-acquired coronavirus disease 2019 (COVID-19) among patients of two acute-care hospitals: Implications for surveillance

OBJECTIVES

We quantified hospital-acquired coronavirus disease 2019 (COVID-19) during the early phases of the pandemic, and we evaluated solely temporal determinations of hospital acquisition.

DESIGN

Retrospective observational study during early phases of the COVID-19 pandemic, March 1-November 30, 2020. We identified laboratory-detected severe acute respiratory coronavirus virus 2 (SARS-CoV-2) from 30 days before admission through discharge. All cases detected after hospital day 5 were categorized by chart review as community or unlikely hospital-acquired cases, or possible or probable hospital-acquired cases.

SETTING

The study was conducted in 2 acute-care hospitals in Chicago, Illinois.

PATIENTS

The study included all hospitalized patients including an inpatient rehabilitation unit.

INTERVENTIONS

Each hospital implemented infection-control precautions soon after identifying COVID-19 cases, including patient and staff cohort protocols, universal masking, and restricted visitation policies.

RESULTS

Among 2,667 patients with SARS-CoV-2, detection before hospital day 6 was most common (n = 2,612; 98%); detection during hospital days 6-14 was uncommon (n = 43; 1.6%); and detection after hospital day 14 was rare (n = 16; 0.6%). By chart review, most cases after day 5 were categorized as community acquired, usually because SARS-CoV-2 had been detected at a prior healthcare facility (68% of cases on days 6-14 and 53% of cases after day 14). The incidence rates of possible and probable hospital-acquired cases per 10,000 patient days were similar for ICU- and non-ICU patients at hospital A (1.2 vs 1.3 difference, 0.1; 95% CI, -2.8 to 3.0) and hospital B (2.8 vs 1.2 difference, 1.6; 95% CI, -0.1 to 4.0).

CONCLUSIONS

Most patients were protected by early and sustained application of infection-control precautions modified to reduce SARS-CoV-2 transmission. Using solely temporal criteria to discriminate hospital versus community acquisition would have misclassified many "late onset" SARS-CoV-2-positive cases.

Characteristics of COVID-19 infection clusters occurring among workers in several Asia-Pacific countries

The types of workplaces and occupations with coronavirus 2019 (COVID-19) clusters vary between countries and periods. We aimed to characterize major occupational groups with mass outbreaks of COVID-19 infections in several Asia-Pacific countries. Data on the major occupations or workplaces reporting COVID-19 cases in workplaces from January 2020 to July 2021 was collected from industrial hygiene professionals in nine countries. The proportion of workers accounted for 39.1 to 56.6% of the population in each country. The number of workers covered in the national statistics varies among nations based on their definition of a worker. None of the countries examined here have systematically collected occupational data on COVID-19 illnesses and deaths classified by type of industry, occupation, or job. Most countries experienced COVID-19 clusters among health and social care workers (HSCW) in hospitals or long-term care facilities. The types of occupations or workplaces with virus clusters in some participating countries included prisons, call centers, workplaces employing immigrants, garment facilities, grocery stores, and the military, which differed among countries, except for a few common occupations such as HSCW and those populated by immigrants. Further study is necessary in order to seek ways to control infection risks, including revisions to industrial-health-related laws.

A domain-knowledge modeling of hospital-acquired infection risk in Healthcare personnel from retrospective observational data: A case study for COVID-19

INTRODUCTION

Hospital-acquired infections of communicable viral diseases (CVDs) have been posing a tremendous challenge to healthcare workers globally. Healthcare personnel (HCP) is facing a consistent risk of viral infections, and subsequently higher rates of morbidity and mortality.

MATERIALS AND METHODS

We proposed a domain-knowledge-driven infection risk model to quantify the individual HCP and the population-level risks. For individual-level risk estimation, a time-variant infection risk model is proposed to capture the transmission dynamics of CVDs. At the population-level, the infection risk is estimated using a Bayesian network model constructed from three feature sets, including individual-level factors, engineering control factors, and administrative control factors. For model validation, we investigated the case study of the Coronavirus disease, in which the individual-level and population-level infection risk models were applied. The data were collected from various sources such as COVID-19 transmission databases, health surveys/questionaries from medical centers, U.S. Department of Labor databases, and cross-sectional studies.

RESULTS

Regarding the individual-level risk model, the variance-based sensitivity analysis indicated that the uncertainty in the estimated risk was attributed to two variables: the number of close contacts and the viral transmission probability. Next, the disease transmission probability was computed using a multivariate logistic regression applied for a cross-sectional HCP data in the UK, with the 10-fold cross-validation accuracy of 78.23%. Combined with the previous result, we further validated the individual infection risk model by considering six occupations in the U.S. Department of Labor O*Net database. The occupation-specific risk evaluation suggested that the registered nurses, medical assistants, and respiratory therapists were the highest-risk occupations. For the population-level risk model validation, the infection risk in Texas and California was estimated, in which the infection risk in Texas was lower than that in California. This can be explained by California's higher patient load for each HCP per day and lower personal protective equipment (PPE) sufficiency level.

CONCLUSION

The accurate estimation of infection risk at both individual level and population levels using our domain-knowledge-driven infection risk model will significantly enhance the PPE allocation, safety plans for HCP, and hospital staffing strategies.

The proportion and determinants of COVID-19 infection among medical doctors in Sudan, 2020: A cross-sectional survey

Globally, frontline health care providers are among the most affected population group by the COVID-19 pandemic. Knowing the factors contributing to the transmission of COVID-19 infection among frontline health care providers is essential for implementing tailored control measures and protecting this vital population group. This study aimed to estimate the proportion and to identify factors associated with COVID-19 infection among medical doctors in Sudan. A web-based survey was used to collect data from medical doctors who were working in Sudan during the study period. Data were analyzed using SPSS^® version 25; Descriptive analysis in terms of means (SD) for continuous variables, frequencies, and percentages with 95% CI for the categorical variable was conducted. Chi-square test and binary logistic regression for associations between the outcome variables (risk of exposure to COVID-19 infection and ever tested positive for COVID-19 infection) and independent variables (socio-demographic and infection control standards) were also performed. Out of 352 valid responses, 13.6% had tested positive for COVID-19 infection at least once during the pandemic. More than one-third have identified colleagues as the main sources of infection compared to 21% of patients (p-value < 0.04). Doctors who received training on COVID-19 were 60% less likely to have positive tests for COVID-19 (p-value <0.03), while lack of PPE and hand hygiene utilities had no statistically significant associations with testing positive for COVID-19 infection. In conclusion, a significant proportion of doctors have contracted COVID-19 infection from their colleagues. This calls for restricting infection control practices at hospitals, doctor’s doormats, and any other shared places that allow day-to-day interaction between doctors and their colleagues. Also, urgent need for training doctors on COVID-19 infection control practices as it has been identified as the key protective factor.

Missing science: A scoping study of COVID-19 epidemiological data in the United States

Systematic approaches to epidemiologic data collection are critical for informing pandemic responses, providing information for the targeting and timing of mitigations, for judging the efficacy and efficiency of alternative response strategies, and for conducting real-world impact assessments. Here, we report on a scoping study to assess the completeness of epidemiological data available for COVID-19 pandemic management in the United States, enumerating authoritative US government estimates of parameters of infectious transmission, infection severity, and disease burden and characterizing the extent and scope of US public health affiliated epidemiological investigations published through November 2021. While we found authoritative estimates for most expected transmission and disease severity parameters, some were lacking, and others had significant uncertainties. Moreover, most transmission parameters were not validated domestically or re-assessed over the course of the pandemic. Publicly available disease surveillance measures did grow appreciably in scope and resolution over time; however, their resolution with regards to specific populations and exposure settings remained limited. We identified 283 published epidemiological reports authored by investigators affiliated with U.S. governmental public health entities. Most reported on descriptive studies. Published analytic studies did not appear to fully respond to knowledge gaps or to provide systematic evidence to support, evaluate or tailor community mitigation strategies. The existence of epidemiological data gaps 18 months after the declaration of the COVID-19 pandemic underscores the need for more timely standardization of data collection practices and for anticipatory research priorities and protocols for emerging infectious disease epidemics.

Investigation of healthcare-associated COVID-19 in a large French hospital group by whole-genome sequencing

OBJECTIVES

Despite the quick implementation of infection prevention and control procedures and the use of personal protective equipment within healthcare facilities, many cases of nosocomial COVID-19 transmission have been reported. We aimed to estimate the frequency and impact of healthcare-associated COVID-19 (HA-COVID-19) and evaluate the contribution of whole-genome sequencing (WGS) in cluster investigation.

METHODS

We estimated the frequency and mortality of HA-COVID-19 infections from September 1 to November 30, 2020, with a focus on the evolution of hospitalized community-associated COVID-19 (CA-COVID-19) cases and cases detected among healthcare workers (HCWs) within the Sorbonne University Hospital Group (Paris, France). We thoroughly examined 12 clusters through epidemiological investigations and WGS.

RESULTS

Overall, 209 cases of HA-COVID-19 were reported. Evolution of HA-COVID-19 incidence closely correlated with the incidence of CA-COVID-19 and COVID-19 among HCWs. During the study period, 13.9 % of hospitalized patients with COVID-19 were infected in the hospital and the 30-day mortality rate of HA-COVID-19 was 31.5 %. Nosocomial transmission of SARS-CoV-2 led to clusters involving both patients and HCWs. WGS allowed the exclusion of one-third of cases initially assigned to a cluster.

CONCLUSIONS

WGS analysis combined with comprehensive epidemiological investigations is essential to understand transmission routes and adapt the IPC response to protect both patients and HCWs.

The COVID-19 pandemic and its impact on esthetic dermatology

In general, the world population interest has increased for maintaining youthfulness and having better appearance since this leads to a better mental wellbeing and self-estimate. The coronavirus disease 2019 (COVID-19) pandemic has revolutionized every field of medicine. As every specialty has been affected by limitations caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), this branch of medicine has also needed certain precautions for safer practice in the COVID era. With the global vaccination program against COVID-19, reports of some cutaneous reactions in patients have been undergone various esthetic procedures including filler or botox injection would be increasingly demonstrated. Although the end of pandemic was announced, the necessity of continuing COVID vaccination in future mandates gathering data regarding safety of vaccines. Herein, we presented a comprehensive review on various aspects of association between esthetic medicine or cosmetic dermatology and COVID-19.

Cases of dental clinic visit by COVID-19 confirmed patients

Objectives

This study aims to review cases of dental visits by patients who had confirmed COVID‐19 infection in Seoul and Gyeonggi‐do. It analyses the patterns of infection transmission among dental healthcare professionals and dental clinic visitors.

Methods

This study obtained data from reports on disease trends and press releases published by the Korea Centers for Disease Control and Prevention (KCDC) on its COVID‐19 website.

Results

After examining cases of patients with a confirmed COVID‐19 infection, 24 people (10 in Seoul and 14 in Gyeonggi‐do) visited the dental office 1–13 days prior to their case confirmation; however, the spread of the virus in the dental office was not confirmed.

Conclusion

The WHO and KCDC guidelines must be followed to curb transmission of the SARS‐CoV‐2 virus among dental patients and professionals.

Human Responses in Public Health Emergencies for Infectious Disease Control: An Overview of Controlled Topologies for Biomedical Applications

COVID-19 originated in Wuhan city of Hubei Province in China in December three years ago. Since then, it has spread to more than 210 countries and territories. This disease is caused by Severe Acute Respiratory Syndrome Coronavirus 2. The virus has a size of one to two nanometers and a single-stranded positive RNA. Droplets spread the virus from coughing and sneezing. This condition causes coughing, fever, acute respiratory problems, and even death. According to the WHO, the virus can survive outside the body for several hours. This research aimed to determine how environmental factors influenced the COVID-19 virus's survival and behavior, as well as its transmission, in a complex environment. Based on the results, virus transmissions are influenced by various human and environmental factors such as population distribution, travel, social behavior, and climate change. Environmental factors have not been adequately examined concerning the transmission of this epidemic. Thus, it is necessary to examine various aspects of prevention and control of this disease, including its effects on climate and other environmental factors.

Early-stage COVID-19 pandemic observations on pulmonary embolism using nationwide multi-institutional data harvesting

We introduce a multi-institutional data harvesting (MIDH) method for longitudinal observation of medical imaging utilization and reporting. By tracking both large-scale utilization and clinical imaging results data, the MIDH approach is targeted at measuring surrogates for important disease-related observational quantities over time. To quantitatively investigate its clinical applicability, we performed a retrospective multi-institutional study encompassing 13 healthcare systems throughout the United States before and after the 2020 COVID-19 pandemic. Using repurposed software infrastructure of a commercial AI-based image analysis service, we harvested data on medical imaging service requests and radiology reports for 40,037 computed tomography pulmonary angiograms (CTPA) to evaluate for pulmonary embolism (PE). Specifically, we compared two 70-day observational periods, namely (i) a pre-pandemic control period from 11/25/2019 through 2/2/2020, and (ii) a period during the early COVID-19 pandemic from 3/8/2020 through 5/16/2020. Natural language processing (NLP) on final radiology reports served as the ground truth for identifying positive PE cases, where we found an NLP accuracy of 98% for classifying radiology reports as positive or negative for PE based on a manual review of 2,400 radiology reports. Fewer CTPA exams were performed during the early COVID-19 pandemic than during the pre-pandemic period (9806 vs. 12,106). However, the PE positivity rate was significantly higher (11.6 vs. 9.9%, p < 10^-4) with an excess of 92 PE cases during the early COVID-19 outbreak, i.e., ~1.3 daily PE cases more than statistically expected. Our results suggest that MIDH can contribute value as an exploratory tool, aiming at a better understanding of pandemic-related effects on healthcare.

Risk of transmission of respiratory viruses during aerosol-generating medical procedures (AGMPs) revisited in the COVID-19 pandemic: a systematic review

Background

In many jurisdictions healthcare workers (HCWs) are using respirators for aerosol-generating medical procedures (AGMPs) performed on adult and pediatric populations with all suspect/confirmed viral respiratory infections (VRIs). This systematic review assessed the risk of VRIs to HCWs in the presence of AGMPs, the role respirators versus medical/surgical masks have on reducing that risk, and if the risk to HCWs during AGMPs differed when caring for adult or pediatric patient populations.

Main text

We searched MEDLINE, EMBASE, Cochrane Central, Cochrane SR, CINAHL, COVID-19 specific resources, and MedRxiv for English and French articles from database inception to September 9, 2021. Independent reviewers screened abstracts using pre-defined criteria, reviewed full-text articles, selected relevant studies, abstracted data, and conducted quality assessments of all studies using the ROBINS-I risk of bias tool. Disagreements were resolved by consensus. Thirty-eight studies were included; 23 studies on COVID-19, 10 on SARS, and 5 on MERS/ influenza/other respiratory viruses. Two of the 16 studies which assessed associations found that HCWs were 1.7 to 2.5 times more likely to contract COVID-19 after exposure to AGMPs vs. not exposed to AGMPs. Eight studies reported statistically significant associations for nine specific AGMPs and transmission of SARS to HCWS. Intubation was consistently associated with an increased risk of SARS. HCWs were more likely (OR 2.05, 95% CI 1.2–3.4) to contract human coronaviruses when exposed to an AGMP in one study. There were no reported associations between AGMP exposure and transmission of influenza or in a single study on MERS. There was limited evidence supporting the use of a respirator over a medical/surgical mask during an AGMP to reduce the risk of viral transmission. One study described outcomes of HCWs exposed to a pediatric patient during intubation.

Conclusion

Exposure to an AGMP may increase the risk of transmission of COVID-19, SARS, and human coronaviruses to HCWs, however the evidence base is heterogenous and prone to confounding, particularly related to COVID-19. There continues to be a significant research gap in the epidemiology of the risk of VRIs among HCWs during AGMPs, particularly for pediatric patients. Further evidence is needed regarding what constitutes an AGMP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01133-8.

Prevention of SARS-CoV-2 and respiratory viral infections in healthcare settings: current and emerging concepts

PURPOSE OF REVIEW

COVID-19 has catalyzed a wealth of new data on the science of respiratory pathogen transmission and revealed opportunities to enhance infection prevention practices in healthcare settings.

RECENT FINDINGS

New data refute the traditional division between droplet vs airborne transmission and clarify the central role of aerosols in spreading all respiratory viruses, including Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), even in the absence of so-called 'aerosol-generating procedures' (AGPs). Indeed, most AGPs generate fewer aerosols than talking, labored breathing, or coughing. Risk factors for transmission include high viral loads, symptoms, proximity, prolonged exposure, lack of masking, and poor ventilation. Testing all patients on admission and thereafter can identify early occult infections and prevent hospital-based clusters. Additional prevention strategies include universal masking, encouraging universal vaccination, preferential use of N95 respirators when community rates are high, improving native ventilation, utilizing portable high-efficiency particulate air filters when ventilation is limited, and minimizing room sharing when possible.

SUMMARY

Multifaceted infection prevention programs that include universal testing, masking, vaccination, and enhanced ventilation can minimize nosocomial SARS-CoV-2 infections in patients and workplace infections in healthcare personnel. Extending these insights to other respiratory viruses may further increase the safety of healthcare and ready hospitals for novel respiratory viruses that may emerge in the future.

Aerosol-Generating Procedures and Virus Transmission

During the early phase of the COVID-19 pandemic, many respiratory therapies were classified as aerosol-generating procedures. This categorization resulted in a broad range of clinical concerns and a shortage of essential medical resources for some patients. In the past 2 years, many studies have assessed the transmission risk posed by various respiratory care procedures. These studies are discussed in this narrative review, with recommendations for mitigating transmission risk based on the current evidence.

A rapid assessment of health system preparedness and response to the COVID-19 pandemic in Guinea

Epidemic-prone diseases have high adverse impacts and pose important threats to global health security. This study aimed to assess levels of health facility preparedness and response to the COVID-19 pandemic in Guinea. This was a cross-sectional study in public and private health facilities/services across 13 Guinean health districts. Managers and healthcare workers (HCWs) from departments in each facility/service were interviewed. Descriptive statistics and comparisons were presented using Pearson’s Chi-Squared Test or Fischer exact test. Totally, 197 managers and 1020 HCWs participated in the study. Guidance documents and dedicated spaces for management/isolation of suspected COVID-19 cases were available only in 29% and 26% of facilities, respectively. Capacities to collect (9%) and safely transport (14%) samples were low. Intensive care units (5%), dedicated patient beds (3%), oxygenators (2%), and respirators (0.6%) were almost lacking. While 36% of facilities/services had received infection prevention and control supplies, only 20% had supplies sufficient for 30 days. Moreover, only 9% of HCWs had received formal training on COVID-19. The main sources of information for HCWs were the media (90%) and the internet (58%). Only 30% of HCWs had received personal protective equipment, more in the public sector (p<0.001) and in Conakry (p=0.022). This study showed low levels of preparedness of health facilities/services in Guinea and highlighted a lack of confidence among HCWs who felt unsafe at their workplace. Better governance to improve and maintain the capacity of the Guinean health system to respond to current and future epidemics is needed.

Indian Guidelines on Nebulization Therapy

Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.

Recommendation of the German Society of Hospital Hygiene (DGKH): Prevention of COVID-19 by virucidal gargling and virucidal nasal spray - updated version April 2022

The German Society of Hospital Hygiene develops guidelines, recommendations and standard operation procedures on a voluntary basis, published on the DGKH-website (https://www.krankenhaushygiene.de/). The original German version of this recommendation was published in April 2022 and has now been made available to the international professional public in English. Evaluating the current data on the efficacy of virucidal gargle/mouthwash solutions and nasal sprays against SARS-CoV-2 in vitro and in clinical trials, conducted with preventive or therapeutic objectives, recommendations are given for the prevention of COVID-19. The following areas are considered: Protection of the community when regional clusters or high incidences of infection become knownProtection of the community at low risk of infectionPre-exposure prophylaxis for the protection of healthcare workersPost-exposure prophylaxis.

COVID-19 Booster Uptake among First Responders and Their Household Members May Be Lower than Anticipated

(1) Background: COVID-19 vaccination status varies widely among law enforcement and emergency medical services professionals. Though at high risk of exposure, these first responders have demonstrated significant vaccine hesitancy, with only 70% reportedly vaccinated. We sought to understand whether similar vaccine hesitancy exists for first responders and their household contacts around COVID-19 boosters. (2) Methods: In a prospective longitudinal cohort of first responders and their household contacts, survey data was collected, including demographics, medical history, COVID-19 exposure risks, and vaccination and/or booster status. The statistical analysis focused on primary vaccination and booster rates of both the first responders and their household contacts. (3) Results: Across 119 study participants, 73% reported having received some combination of vaccine and/or booster, and 26% were unvaccinated. Vaccinated individuals were older, reported less prior exposure to COVID-19 and had more comorbidities. Only 23% reported having received a COVID-19 booster. Pairing of the data for household contacts demonstrated a 60% agreement to receive primary vaccination but only a 20% agreement for boosters within households. (4) Conclusions: This study provides insight into the vaccination and booster rates of first responders and household contacts. Focused efforts to enhance vaccinations is essential for the protection and maintenance of this critical workforce.

Supercritical CO2 sterilization: An effective treatment to reprocess FFP3 face masks and to reduce waste during COVID-19 pandemic

The outbreak of COVID-19 pandemic unveiled an unprecedented scarcity of personal protective equipment (PPE) available in sanitary premises and for the population worldwide. This situation fostered the development of new strategies to reuse PPE that would ensure sterility and, simultaneously, preserve the filtering properties of the materials. In addition, the reuse of PPEs by reprocessing could reduce the environmental impact of the massive single-use and disposal of these materials. Conventional sterilization techniques such as steam or dry heat, ethylene oxide, and gamma irradiation may alter the functional properties of the PPEs and/or leave toxic residues. Supercritical CO₂ (scCO₂)-based sterilization is herein proposed as a safe, sustainable, and rapid sterilization method for contaminated face masks while preserving their performance. The functional (bacterial filtration efficiency, breathability, splash resistance, straps elasticity) properties of the processed FFP3 face masks were evaluated after 1 and 10 cycles of sterilization. Log-6 sterilization reduction levels were obtained for face masks contaminated with Bacillus pumilus endospores at mild operating conditions (CO₂ at 39 °C and 100 bar for 30 min) and with low contents of H₂O₂ (150 ppm). Physicochemical properties of the FFP3 face masks remained unchanged after reprocessing and differences in efficacy were not observed neither in the filtration tests, following UNE-EN 14683, nor in the integrity of FFP3 filtration after the sterilization process. The herein presented method based on scCO₂ technology is the first reported protocol achieving the reprocessing of FFP3 masks up to 10 cycles while preserving their functional properties.

Reported Exposures Among In-Person Workers With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in 6 States, September 2020-June 2021

BACKGROUND

Surveillance systems lack detailed occupational exposure information from workers with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The National Institute for Occupational Safety and Health partnered with 6 states to collect information from adults diagnosed with SARS-CoV-2 infection who worked in person (outside the home) in non-healthcare settings during the 2 weeks prior to illness onset.

METHODS

The survey captured demographic, medical, and occupational characteristics and work- and non-work-related risk factors for SARS-CoV-2 infection. Reported close contact with a person known or suspected to have SARS-CoV-2 infection was categorized by setting as exposure at work, exposure outside of work only, or no known exposure/did not know. Frequencies and percentages of exposure types are compared by respondent characteristics and risk factors.

RESULTS

Of 1111 respondents, 19.4% reported exposure at work, 23.4% reported exposure outside of work only, and 57.2% reported no known exposure/did not know. Workers in protective service occupations (48.8%) and public administration industries (35.6%) reported exposure at work most often. More than one third (33.7%) of respondents who experienced close contact with ≥10 coworkers per day and 28.8% of respondents who experienced close contact with ≥10 customers/clients per day reported exposures at work.

CONCLUSIONS

Exposure to occupational SARS-CoV-2 was common among respondents. Examining differences in exposures among different worker groups can help identify populations with the greatest need for prevention interventions. The benefits of recording employment characteristics as standard demographic information will remain relevant as new and reemerging public health issues occur.

Rapid review and meta-analysis of the effectiveness of personal protective equipment for healthcare workers during the COVID-19 pandemic

Objectives

Healthcare workers (HCWs) worldwide have and are using personal protective equipment (PPE) as COVID-19 prevention measures, including gloves, gowns, goggles, masks and hand hygiene. Although several reviews have been published on the effectiveness of PPE, these often include studies on other inflectional diseases. This is problematic, because these diseases differ with regard to, e.g. the transmissibility and viral loads in the days after infection. Therefore, we assessed the effectiveness of PPE to protect HCWs from COVID-19 infections.

Design

Rapid review of literature.

Methods

We followed a practical guide to conduct the rapid review based on a protocol established by the Cochrane Rapid Reviews Methods Group. Meta-analyses have been conducted to synthesize the results. The confidence in the evidence was determined using the GRADE method.

Results

We found 461 reviews and 208 primary studies, of which 16 systematic reviews included 11 observational studies of interest. Wearing PPE conferred significant protection against infection with COVID-19 as opposed to not wearing adequate PPE. Overall, the review results show that wearing face masks can significantly protect HCWs from infection. We found no effects for wearing gloves and gowns. Practicing thorough hand hygiene and having proper PPE, as compared to lacking proper PPE, showed a protective but not statistically significant effect. No studies reported the side effects of wearing PPE or acceptance rates.

Conclusion

This evidence supports PPE use by HCW, and especially N95 masks, to reduce the risk of a COVID-19 infection.

Hospital-Wide SARS-CoV-2 seroprevalence in health care workers in a Spanish teaching hospital

Introduction

Methods

Results

Conclusions

Moderate forms of COVID-19 among healthcare workers in a Belgian hospital and their immune response

INTRODUCTION

Healthcare professionals have been treating patients with COVID-19 since the pandemic started in early 2020 while also trying to limit disease spread among their coworkers and communities. This study aimed to identify and follow potentially infected healthcare workers in one hospital in order to develop an epidemiological baseline for COVID-19 infection and spread rates in this population.

MATERIALS AND METHODS

This prospective study was conducted between 1 April and 30 June 2020 at a single Belgian hospital. Healthcare workers with symptoms consistent with COVID-19 were included. Participants underwent testing for SARS-CoV-2 infection by nasopharyngeal (NP) swab and analysis of blood samples for antibody response at different timepoints (day 0, 7, 14 and day 30 or 60). Patient exposures, symptoms, and disease progression were collected.

RESULTS

Of a total of 150 healthcare workers with symptoms compatible with SARS-CoV-2 infection, 31% (47) tested positive for the virus by NP swab. Of the 47 participants with positive NP swabs, 66% also had positive IgG serology. Of the 99 participants with negative NP swabs who underwent blood sample collection, 5% had positive IgG serology results. Of the 29 participants who presented with at least 3 major symptoms, 15 (52%) had positive NP swabs and 14 (48%) had positive serology.

CONCLUSIONS

This study demonstrates that evidence of symptoms, even when major, is a poor predictor for SARS-CoV-2 positivity in health care workers and raises the question of the best way to efficiently screen this population especially during the upcoming flu period.

Novel Negative Pressure Procedural Tent Reduces Aerosolized Particles in a Simulated Prehospital Setting

BACKGROUND/OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has challenged the ability of Emergency Medical Services (EMS) providers to maintain personal safety during the treatment and transport of patients potentially infected. Increased rates of COVID-19 infection in EMS providers after patient care exposure, and notably after performing aerosol-generating procedures (AGPs), have been reported. With an already strained workforce seeing rising call volumes and increased risk for AGP-requiring patient presentations, development of novel devices for the protection of EMS providers is of great importance.Based on the concept of a negative pressure room, the AerosolVE BioDome is designed to encapsulate the patient and contain aerosolized infectious particles produced during AGPs, making the cabin of an EMS vehicle safer for providers. The objective of this study was to determine the efficacy and safety of the tent in mitigating simulated infectious particle spread in varied EMS transport platforms during AGP utilization.

METHODS

Fifteen healthy volunteers were enrolled and distributed amongst three EMS vehicles: a ground ambulance, an aeromedical-configured helicopter, and an aeromedical-configured jet. Sodium chloride particles were used to simulate infectious particles and particle counts were obtained in numerous locations close to the tent and around the patient compartment. Counts near the tent were compared to ambient air with and without use of AGPs (non-rebreather mask, continuous positive airway pressure [CPAP] mask, and high-flow nasal cannula [HFNC]).

RESULTS

For all transport platforms, with the tent fan off, the particle generator alone, and with all AGPs produced particle counts inside the tent significantly higher than ambient particle counts (P <.0001). With the tent fan powered on, particle counts near the tent, where EMS providers are expected to be located, showed no significant elevation compared to baseline ambient particle counts during the use of the particle generator alone or with use of any of the AGPs across all transport platforms.

CONCLUSION

Development of devices to improve safety for EMS providers to allow for use of all available therapies to treat patients while reducing risk of communicable respiratory disease transmission is of paramount importance. The AerosolVE BioDome demonstrated efficacy in creating a negative pressure environment and workspace around the patient and provided significant filtration of simulated respiratory droplets, thus making the confined space of transport vehicles potentially safer for EMS personnel.

SIMEU position paper on non-invasive respiratory support in COVID-19 pneumonia

The rapid worldwide spread of the Coronavirus disease (COVID-19) crisis has put health systems under pressure to a level never experienced before, putting intensive care units in a position to fail to meet an exponentially growing demand. The main clinical feature of the disease is a progressive arterial hypoxemia which rapidly leads to ARDS which makes the use of intensive care and mechanical ventilation almost inevitable. The difficulty of health systems to guarantee a corresponding supply of resources in intensive care, together with the uncertain results reported in the literature with respect to patients who undergo early conventional ventilation, make the search for alternative methods of oxygenation and ventilation and potentially preventive of the need for tracheal intubation, such as non-invasive respiratory support techniques particularly valuable. In this context, the Emergency Department, located between the area outside the hospital and hospital ward and ICU, assumes the role of a crucial junction, due to the possibility of applying these techniques at a sufficiently early stage and being able to rapidly evaluate their effectiveness. This position paper describes the indications for the use of non-invasive respiratory support techniques in respiratory failure secondary to COVID-19-related pneumonia, formulated by the Non-invasive Ventilation Faculty of the Italian Society of Emergency Medicine (SIMEU) on the base of what is available in the literature and on the authors' direct experience. Rationale, literature, tips & tricks, resources, risks and expected results, and patient interaction will be discussed for each one of the escalating non-invasive respiratory techniques: standard oxygen, HFNCO, CPAP, NIPPV, and awake self-repositioning. The final chapter describes our suggested approach to the failing patient.

Infection Prevention and Control of Severe Acute Respiratory Syndrome Coronavirus 2 in Health Care Settings

The authors describe infection prevention and control approaches to severe acute respiratory syndrome coronavirus 2 in the health care setting, including a review of the chain of transmission and the hierarchy of controls, which are cornerstones of infection control and prevention. The authors also discuss lessons learned from nosocomial transmission events.