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Biney IN, Ari A, Barjaktarevic IZ, Carlin B, Christiani DC, Cochran L, Drummond MB, Johnson K, Kealing D, Kuehl PJ, Li J, Mahler DA, Martinez S, Ohar J, Radonovich LJ, Sood A, Suggett J, Tal-Singer R, Tashkin D, Yates J, Cambridge L, Dailey PA, Mannino DM, Dhand R. Guidance on Mitigating the Risk of Transmitting Respiratory Infections During Nebulization by the COPD Foundation Nebulizer Consortium. Chest 2024; 165:653-668. [PMID: 37977263 DOI: 10.1016/j.chest.2023.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/06/2023] [Accepted: 11/08/2023] [Indexed: 11/19/2023] Open
Abstract
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.
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Affiliation(s)
- Isaac N Biney
- University Pulmonary and Critical Care, The University of Tennessee Graduate School of Medicine, Knoxville, TN.
| | - Arzu Ari
- Department of Respiratory Care and Texas State Sleep Center, Texas State University, Round Rock, TX
| | - Igor Z Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California Los Angeles Health Sciences, Los Angeles, CA; Division of Liver and Pancreas Transplantation, David Geffen School of Medicine, University of California Los Angeles Health Sciences, Los Angeles, CA
| | - Brian Carlin
- Sleep Medicine and Lung Health Consultants LLC, Pittsburgh, PA
| | - David C Christiani
- Harvard T.H. Chan School of Public Health, Harvard Medical School, Cambridge, MA; Pulmonary and Critical Care Division, Massachusetts General Hospital, Boston, MA
| | | | - M Bradley Drummond
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | - Jie Li
- Rush University, Chicago, IL
| | - Donald A Mahler
- Geisel School of Medicine at Dartmouth, Hanover, NH; Valley Regional Hospital, Claremont, NH
| | | | - Jill Ohar
- Bowman Gray Center for Medical Education, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Lewis J Radonovich
- Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV
| | - Akshay Sood
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | | | | | - Donald Tashkin
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California Los Angeles Health Sciences, Los Angeles, CA
| | | | - Lisa Cambridge
- Medical Science & Pharmaceutical Alliances, PARI, Inc., Midlothian, VA
| | | | | | - Rajiv Dhand
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The University of Tennessee Graduate School of Medicine, Knoxville, TN
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Siwal SS, Chaudhary G, Saini AK, Kaur H, Saini V, Mokhta SK, Chand R, Chandel UK, Christie G, Thakur VK. Key ingredients and recycling strategy of personal protective equipment (PPE): Towards sustainable solution for the COVID-19 like pandemics. JOURNAL OF ENVIRONMENTAL CHEMICAL ENGINEERING 2021; 9:106284. [PMID: 34485055 PMCID: PMC8404393 DOI: 10.1016/j.jece.2021.106284] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/26/2021] [Accepted: 08/25/2021] [Indexed: 05/24/2023]
Abstract
The COVID-19 pandemic has intensified the complications of plastic trash management and disposal. The current situation of living in fear of transmission of the COVID-19 virus has further transformed our behavioural models, such as regularly using personal protective equipment (PPE) kits and single-use applications for day to day needs etc. It has been estimated that with the passage of the coronavirus epidemic every month, there is expected use of 200 billion pieces of single-use facemasks and gloves. PPE are well established now as life-saving items for medicinal specialists to stay safe through the COVID-19 pandemic. Different processes such as glycolysis, hydrogenation, aminolysis, hydrolysis, pyrolysis, and gasification are now working on finding advanced technologies to transfer waste PPE into value-added products. Here, in this article, we have discussed the recycling strategies of PPE, important components (such as medical gloves, gowns, masks & respirators and other face and eye protection) and the raw materials used in PPE kits. Further, the value addition methods to recycling the PPE kits, chemical & apparatus used in recycling and recycling components into value-added products. Finally, the biorenewable materials in PPE for textiles components have been discussed along with concluded remarks.
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Affiliation(s)
- Samarjeet Singh Siwal
- Department of Chemistry, M.M. Engineering College, Maharishi Markandeshwar (Deemed to be University), Mullana, Ambala, Haryana 133207, India
| | - Gauri Chaudhary
- Department of Chemistry, M.M. Engineering College, Maharishi Markandeshwar (Deemed to be University), Mullana, Ambala, Haryana 133207, India
| | - Adesh Kumar Saini
- Department of Biotechnology, Maharishi Markandeshwar (Deemed to be University), Mullana, Ambala, Haryana 133207, India
| | - Harjot Kaur
- Department of Chemistry, M.M. Engineering College, Maharishi Markandeshwar (Deemed to be University), Mullana, Ambala, Haryana 133207, India
| | - Vipin Saini
- Department of Pharmacy, Maharishi Markandeshwar University, Kumarhatti, Solan, Himachal Pradesh, 173229, India
| | - Sudesh Kumar Mokhta
- Department of Environment, Science & Technology, Government of Himachal Pradesh, 171001, India
| | - Ramesh Chand
- Department of Health and Family Welfare, Government of Himachal Pradesh, 171001, India
| | - U K Chandel
- Department of surgery, Indira Gandhi Medical College and Hospital (IGMC), Shimla, Himachal Pradesh 171001, India
| | - Graham Christie
- Institute of Biotechnology, Department of Chemical Engineering and Biotechnology, University of Cambridge, Cambridge CB2 1QT, UK
| | - Vijay Kumar Thakur
- Biorefining and Advanced Materials Research Center, SRUC, Kings Buildings, Edinburgh EH9 3JG, UK
- Enhanced Composites and Structures Center, School of Aerospace, Transport and Manufacturing, Cranfield University, Bedfordshire MK43 0AL, UK
- Faculty of Materials Science and Applied Chemistry Institute of Polymer Materials, Riga Technical University, P.Valdena 3/7, LV, 1048 Riga, Latvia
- Department of Mechanical Engineering, School of Engineering, Shiv Nadar University, Uttar Pradesh 201314, India
- School of Engineering, University of Petroleum & Energy Studies (UPES), Dehradun, Uttarakhand, India
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Li J, Qiu Y, Zhang Y, Gong X, He Y, Yue P, Zheng X, Liu L, Liao H, Zhou K, Hua Y, Li Y. Protective efficient comparisons among all kinds of respirators and masks for health-care workers against respiratory viruses: A PRISMA-compliant network meta-analysis. Medicine (Baltimore) 2021; 100:e27026. [PMID: 34449478 PMCID: PMC8389967 DOI: 10.1097/md.0000000000027026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 07/06/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND There is no definite conclusion about comparison of better effectiveness between N95 respirators and medical masks in preventing health-care workers (HCWs) from respiratory infectious diseases, so that conflicting results and recommendations regarding the protective effects may cause difficulties for selection and compliance of respiratory personal protective equipment use for HCWs, especially facing with pandemics of corona virus disease 2019. METHODS We systematically searched MEDLINE, Embase, PubMed, China National Knowledge Infrastructure, Wanfang, medRxiv, and Google Scholar from initiation to November 10, 2020 for randomized controlled trials, case-control studies, cohort studies, and cross-sectional studies that reported protective effects of masks or respirators for HCWs against respiratory infectious diseases. We gathered data and pooled differences in protective effects according to different types of masks, pathogens, occupations, concurrent measures, and clinical settings. The study protocol is registered with PROSPERO (registration number: 42020173279). RESULTS We identified 4165 articles, reviewed the full text of 66 articles selected by abstracts. Six randomized clinical trials and 26 observational studies were included finally. By 2 separate conventional meta-analyses of randomized clinical trials of common respiratory viruses and observational studies of pandemic H1N1, pooled effects show no significant difference between N95 respirators and medical masks against common respiratory viruses for laboratory-confirmed respiratory virus infection (risk ratio 0.99, 95% confidence interval [CI] 0.86-1.13, I2 = 0.0%), clinical respiratory illness (risk ratio 0.89, 95% CI 0.45-1.09, I2 = 83.7%, P = .002), influenza-like illness (risk ratio 0.75, 95% CI 0.54-1.05, I2 = 0.0%), and pandemic H1N1 for laboratory-confirmed respiratory virus infection (odds ratio 0.92, 95% CI 0.49-1.70, I2 = 0.0%, P = .967). But by network meta-analysis, N95 respirators has a significantly stronger protection for HCWs from betacoronaviruses of severe acute respiratory syndrome, middle east respiratory syndrome, and corona virus disease 2019 (odds ratio 0.43, 95% CI 0.20-0.94). CONCLUSIONS Our results provide moderate and very-low quality evidence of no significant difference between N95 respirators and medical masks for common respiratory viruses and pandemic H1N1, respectively. And we found low quality evidence that N95 respirators had a stronger protective effectiveness for HCWs against betacoronaviruses causative diseases compared to medical masks. The evidence of comparison between N95 respirators and medical masks for corona virus disease 2019 is open to question and needs further study.
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Schmid A, Downey D. Implementing a Novel Nursing Site Manager Role in the Pediatric Emergency Department for Patient and Staff Safety During the COVID-19 Pandemic. J Emerg Nurs 2021; 48:13-21. [PMID: 34674878 PMCID: PMC8318683 DOI: 10.1016/j.jen.2021.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 07/06/2021] [Accepted: 07/25/2021] [Indexed: 11/09/2022]
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Coltart CEM, Wells D, Sutherland E, Fowler A. National cross-sectional survey of 1.14 million NHS staff SARS-CoV-2 serology tests: a comparison of NHS staff with regional community seroconversion rates. BMJ Open 2021; 11:e049703. [PMID: 34257096 PMCID: PMC8282419 DOI: 10.1136/bmjopen-2021-049703] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES An initial report of findings from 1.14 million SARS CoV-2 serology tests in National Health Service (NHS) staff to compare NHS staff seroconversion with community seroconversion rates at a regional level. DESIGN A national cross-sectional survey. SETTING A SARS-CoV-2 antibody testing programme offered across all NHS Trusts. PARTICIPANTS 1.14 million NHS staff. INTERVENTION SARS-CoV-2 antibody testing. PRIMARY AND SECONDARY OUTCOME MEASURES SARS-CoV-2 antibody testing was used to estimate the seroprevalence of SARS-CoV-2 in NHS staff by region, compared with community seroprevalence as determined by the COVID-19 Infection Survey (Office for National Statistics). We also explored seroprevalence trends by regional COVID-19 activity, using regional death rates as a proxy for COVID-19 'activity'. RESULTS 1 146 310 tests were undertaken on NHS staff between 26 May and 31 August 2020. 186 897 NHS tests were positive giving a seroconversion rate of 16.3% (95% CI 16.2% to 16.4%), in contrast to the national community seroconversion rate of 5.9% (95% CI 5.3% to 6.6%). There was significant geographical regional variation, which mirrored the trends seen in community prevalence rates. NHS staff were infected at a higher rate than the general population (OR 3.1, 95% CI 2.8 to 3.5). NHS seroconversion by regional death rate suggested a trend towards higher seroconversion rates in the areas with higher COVID-19 'activity'. CONCLUSIONS This is the first cross-sectional survey assessing the risk of COVID-19 disease in healthcare workers at a national level. It is the largest study of its kind. It suggests that NHS staff have a significantly higher rate of COVID-19 seroconversion compared with the general population in England, with regional variation across the country which matches the background population prevalence trends. There was also a trend towards higher seroconversion rates in areas which had experienced high COVID-19 clinical activity. This work has global significance in terms of the value of such a testing programme and contributing to the understanding of healthcare worker seroconversion at a national level.
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Affiliation(s)
- Cordelia E M Coltart
- Institute for Global Health, University College London, London, UK
- Chief Medical Officer's Office, Department of Health and Social Care, London, UK
| | - David Wells
- COVID-19 Testing cell, NHS England and NHS Improvement, London, UK
| | - Esther Sutherland
- COVID-19 Infection Survey, Office for National Statistics, Newport, UK
| | - Aidan Fowler
- Chief Medical Officer's Office, Department of Health and Social Care, London, UK
- COVID-19 Testing cell, NHS England and NHS Improvement, London, UK
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Transmission of Severe Acute Respiratory Syndrome Coronavirus 1 and Severe Acute Respiratory Syndrome Coronavirus 2 During Aerosol-Generating Procedures in Critical Care: A Systematic Review and Meta-Analysis of Observational Studies. Crit Care Med 2021; 49:1159-1168. [PMID: 33749225 DOI: 10.1097/ccm.0000000000004965] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To assess the risk of coronavirus transmission to healthcare workers performing aerosol-generating procedures and the potential benefits of personal protective equipment during these procedures. DATA SOURCES MEDLINE, EMBASE, and Cochrane CENTRAL were searched using a combination of related MeSH terms and keywords. STUDY SELECTION Cohort studies and case controls investigating common anesthetic and critical care aerosol-generating procedures and transmission of severe acute respiratory syndrome coronavirus 1, Middle East respiratory syndrome coronavirus, and severe acute respiratory syndrome coronavirus 2 to healthcare workers were included for quantitative analysis. DATA EXTRACTION Qualitative and quantitative data on the transmission of severe acute respiratory syndrome coronavirus 1, severe acute respiratory syndrome coronavirus 2, and Middle East respiratory syndrome coronavirus to healthcare workers via aerosol-generating procedures in anesthesia and critical care were collected independently. The Risk Of Bias In Non-randomized Studies - of Interventions tool was used to assess the risk of bias of included studies. DATA SYNTHESIS Seventeen studies out of 2,676 yielded records were included for meta-analyses. Endotracheal intubation (odds ratio, 6.69, 95% CI, 3.81-11.72; p < 0.001), noninvasive ventilation (odds ratio, 3.65; 95% CI, 1.86-7.19; p < 0.001), and administration of nebulized medications (odds ratio, 10.03; 95% CI, 1.98-50.69; p = 0.005) were found to increase the odds of healthcare workers contracting severe acute respiratory syndrome coronavirus 1 or severe acute respiratory syndrome coronavirus 2. The use of N95 masks (odds ratio, 0.11; 95% CI, 0.03-0.39; p < 0.001), gowns (odds ratio, 0.59; 95% CI, 0.48-0.73; p < 0.001), and gloves (odds ratio, 0.39; 95% CI, 0.29-0.53; p < 0.001) were found to be significantly protective of healthcare workers from contracting severe acute respiratory syndrome coronavirus 1 or severe acute respiratory syndrome coronavirus 2. CONCLUSIONS Specific aerosol-generating procedures are high risk for the transmission of severe acute respiratory syndrome coronavirus 1 and severe acute respiratory syndrome coronavirus 2 from patients to healthcare workers. Personal protective equipment reduce the odds of contracting severe acute respiratory syndrome coronavirus 1 and severe acute respiratory syndrome coronavirus 2.
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7
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Li Y, Hu T, Gai X, Zhang Y, Zhou X. Transmission Dynamics, Heterogeneity and Controllability of SARS-CoV-2: A Rural-Urban Comparison. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:5221. [PMID: 34068947 PMCID: PMC8156721 DOI: 10.3390/ijerph18105221] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/09/2021] [Accepted: 05/12/2021] [Indexed: 01/12/2023]
Abstract
Few studies have examined the transmission dynamics of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in rural areas and clarified rural-urban differences. Moreover, the effectiveness of non-pharmaceutical interventions (NPIs) relative to vaccination in rural areas is uncertain. We addressed this knowledge gap through using an improved statistical stochastic method based on the Galton-Watson branching process, considering both symptomatic and asymptomatic cases. Data included 1136 SARS-2-CoV infections of the rural outbreak in Hebei, China, and 135 infections of the urban outbreak in Tianjin, China. We reconstructed SARS-CoV-2 transmission chains and analyzed the effectiveness of vaccination and NPIs by simulation studies. The transmission of SARS-CoV-2 showed strong heterogeneity in urban and rural areas, with the dispersion parameters k = 0.14 and 0.35, respectively (k < 1 indicating strong heterogeneity). Although age group and contact-type distributions significantly differed between urban and rural areas, the average reproductive number (R) and k did not. Further, simulation results based on pre-control parameters (R = 0.81, k = 0.27) showed that in the vaccination scenario (80% efficacy and 55% coverage), the cumulative secondary infections will be reduced by more than half; however, NPIs are more effective than vaccinating 65% of the population. These findings could inform government policies regarding vaccination and NPIs in rural and urban areas.
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Affiliation(s)
- Yuying Li
- Department of Biostatistics, School of Public Health, Peking University, Beijing 100191, China; (Y.L.); (T.H.); (X.G.); (Y.Z.)
| | - Taojun Hu
- Department of Biostatistics, School of Public Health, Peking University, Beijing 100191, China; (Y.L.); (T.H.); (X.G.); (Y.Z.)
| | - Xin Gai
- Department of Biostatistics, School of Public Health, Peking University, Beijing 100191, China; (Y.L.); (T.H.); (X.G.); (Y.Z.)
| | - Yunjun Zhang
- Department of Biostatistics, School of Public Health, Peking University, Beijing 100191, China; (Y.L.); (T.H.); (X.G.); (Y.Z.)
| | - Xiaohua Zhou
- Department of Biostatistics, School of Public Health, Peking University, Beijing 100191, China; (Y.L.); (T.H.); (X.G.); (Y.Z.)
- Beijing International Center for Mathematical Research, Peking University, Beijing 100871, China
- Center for Statistical Sciences, Peking University, Beijing 100871, China
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Marra AR, Edmond MB, Popescu SV, Perencevich EN. Examining the need for eye protection for coronavirus disease 2019 (COVID-19) prevention in the community. Infect Control Hosp Epidemiol 2021; 42:646-647. [PMID: 32576322 PMCID: PMC7338438 DOI: 10.1017/ice.2020.314] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/20/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Alexandre R. Marra
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, United States
- Department of Internal Medicine, University of Iowa Hospital & Clinics, Iowa City, Iowa, United States
- Albert Einstein Jewish Institute for Education and Research, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Michael B. Edmond
- Department of Internal Medicine, University of Iowa Hospital & Clinics, Iowa City, Iowa, United States
| | | | - Eli N. Perencevich
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, United States
- Department of Internal Medicine, University of Iowa Hospital & Clinics, Iowa City, Iowa, United States
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Goldstein KM, Ghadimi K, Mystakelis H, Kong Y, Meng T, Cantrell S, Von Isenburg M, Gordon A, Ear B, Gierisch JM, Williams JW. Risk of Transmitting Coronavirus Disease 2019 During Nebulizer Treatment: A Systematic Review. J Aerosol Med Pulm Drug Deliv 2021; 34:155-170. [PMID: 33887156 DOI: 10.1089/jamp.2020.1659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Rationale: There is an urgent need to understand the risk of viral transmission during nebulizer treatment of patients with coronavirus disease 2019 (COVID-19). Objectives: To assess the risk of transmitting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), SARS, Middle East respiratory syndrome (MERS), and influenza with administration of drugs via nebulizer. Methods: We searched multiple electronic databases, including PubMed®, China National Knowledge Infrastructure, Wanfang, preprint databases, and clinicaltrials.gov through December 1, 2020. Any study design in any language describing the risk of viral transmission with nebulizer treatment was eligible. Data were abstracted by one investigator and verified by a second. Results: We identified 22 articles: 1 systematic review, 7 cohort/case-control studies, 7 case series, and 7 simulation-based studies. Eight individual studies involved patients with SARS, five involved MERS, and one involved SARS-CoV-2. The seven cohort/case-control studies (four high risk of bias [ROB], three unclear ROB) found mixed results (median odds ratio 3.91, range 0.08-20.67) based on very weak data among a small number of health care workers (HCWs) with variable use of personal protective equipment (PPE). Case series had multiple potential contributors to transmission. Simulation studies found evidence for droplet dispersion after saline nebulization and measureable influenza viral particles up to 1.7 m from the source after 10 minutes of nebulization with a patient simulator. Study heterogeneity prevented meta-analysis. Conclusions: Case series raise concern of transmission risk, and simulation studies demonstrate droplet dispersion with virus recovery, but specific evidence that exposure to nebulizer treatment increases transmission of coronaviruses similar to COVID-19 is inconclusive. Tradeoffs balancing HCW safety and patient appropriateness can potentially minimize risk, including choice of delivery method for inhaled medications (e.g., nebulizer vs. metered dose inhaler) and PPE (e.g., N95 vs. surgical mask).
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Affiliation(s)
- Karen M Goldstein
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kamrouz Ghadimi
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA.,Division of Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Yuanyuan Kong
- Clinical Epidemiology and EBM Unit, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Tongtong Meng
- Clinical Epidemiology and EBM Unit, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Sarah Cantrell
- Duke University Medical Center Library & Archives, Durham, North Carolina, USA
| | - Megan Von Isenburg
- Duke University Medical Center Library & Archives, Durham, North Carolina, USA
| | - Adelaide Gordon
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Belinda Ear
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Jennifer M Gierisch
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - John W Williams
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Xu N, Lv A, Li T, Li X, Huang M, Su Y. Experiences of healthcare providers during the coronavirus pandemic and its impact on them: protocol for a mixed-methods systematic review. BMJ Open 2021; 11:e043686. [PMID: 33637546 PMCID: PMC7918807 DOI: 10.1136/bmjopen-2020-043686] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Frontline healthcare providers are redeployed to areas outside their clinical expertise and assigned high-loading workload to address the surge of patients with each coronavirus outbreak. Their importance in crisis is not in doubt. However, they experienced considerable physical distress and psychological stressors, even leading to psychological illness and infection in this environment. There is an urgent need to accurately, comprehensively and objectively understand their experiences, perceptions and current situation of burnout, post-traumatic stress disorder (PTSD), anxiety, depression, insomnia and coronavirus infection. Therefore, this protocol is to conduct a mixed-methods systematic review to summarise the evidence on the experiences of healthcare providers and impacts of the coronavirus on their psychological status and infection during the pandemics. METHODS Published studies on experience, perspective, impact, burnout, PTSD, anxiety, depression, insomnia, and infection of healthcare providers with SARS, Middle East respiratory syndrome and COVID-19, and written in English and Chinese will be accepted. Databases (MEDLINE, EMBASE, CENTRAL, Web of Science, PubMed, Psychology Information, WanFang and SinoMed) from inception until 30 July 2020 will be searched. Two reviewers will select, screen, extract data and assess the risk of bias independently. Risk of bias of results will be using the Mixed-Methods Appraisal Tool. Using a convergent integrated approach on qualitative/quantitative studies, we will synthesise qualitative and quantitative data separately. The incidence and number of cases about burnout, PTSD, anxiety, depression, insomnia and coronavirus infection among medical staff will be extracted. Then we will transform quantitative data to synthesise narrative findings. This protocol will be reported per the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. ETHICS AND DISSEMINATION Ethical assessment is not required due to the nature of the proposed systematic review. Findings of our research will be disseminated at conferences related to this field and through publication in peer-reviewed journals. PROSPERO REGISTRATION NUMBER CRD42020198506.
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Affiliation(s)
- Na Xu
- Health Science Center, Xi'an Jiaotong University, Xi'an, China
| | - AiLi Lv
- Health Science Center, Xi'an Jiaotong University, Xi'an, China
| | - TianZi Li
- Health Science Center, Xi'an Jiaotong University, Xi'an, China
| | - XiaoFeng Li
- Tongji University Tenth People's Hospital, Shanghai, China
| | - Mei Huang
- Department of Nursing, Air Force Medical University, Xi' an, ShaanXi, China
| | - Yan Su
- Health Science Center, Xi'an Jiaotong University, Xi'an, China
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Scaggs Huang F, Schaffzin JK. Rewriting the playbook: infection prevention practices to mitigate nosocomial severe acute respiratory syndrome coronavirus 2 transmission. Curr Opin Pediatr 2021; 33:136-143. [PMID: 33315687 DOI: 10.1097/mop.0000000000000973] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Given the limited evidence and experience with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), this novel pathogen has challenged the field of infection prevention. Despite uncertainty, infection prevention principles and experience with similar diseases have helped guide how to best protect providers and patients against disease acquisition. RECENT FINDINGS Guidance to date has relied on data from SARS-CoV-1 and MERS-CoV to guide practices on patient isolation and personal protective equipment (PPE) use. Although a face mask and eye protection are likely adequate for most clinical scenarios, published guidelines for PPE can be confusing and conflicting. Consensus for what constitutes a high-risk aerosol-generating procedure (AGP) is lacking, but most agree providers performing procedures such as bronchoscopy, intubation, and cardiopulmonary resuscitation would likely benefit from the use of an N95 respirator and eye protection. SUMMARY Needed research to elucidate the predominant SARS-CoV-2 mode of transmission is not likely to be completed in the immediate future. Recommendations for PPE to mitigate procedure-associated risk remain controversial. Nonetheless, implementation of existing measures based on basic infection prevention principles is likely to prevent transmission significantly.
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Affiliation(s)
- Felicia Scaggs Huang
- Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Joshua K Schaffzin
- Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
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Zhang XS, Duchaine C. 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. Clin Microbiol Rev 2020; 34:e00184-20. [PMID: 33115724 PMCID: PMC7605309 DOI: 10.1128/cmr.00184-20] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- X Sophie Zhang
- Department of General Medicine, CIUSSS Centre-Sud-de-l'Île-de-Montréal, Montreal, Canada
- CHSLD Bruchési and CHSLD Jean De La Lande, Montreal, Canada
- GMF-U Faubourgs, Montreal, Canada
- Centre de Recherche et d'Aide aux Narcomanes, Montreal, Canada
| | - Caroline Duchaine
- Department of Biochemistry, Microbiology, and Bioinformatics, Université Laval, Quebec City, Canada
- Quebec Heart and Lung Institute-Université Laval (CRIUCPQ), Quebec City, Canada
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13
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Abboah-Offei M, Salifu Y, Adewale B, Bayuo J, Ofosu-Poku R, Opare-Lokko EBA. A rapid review of the use of face mask in preventing the spread of COVID-19. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2020; 3:100013. [PMID: 33313575 PMCID: PMC7718106 DOI: 10.1016/j.ijnsa.2020.100013] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/21/2020] [Accepted: 11/19/2020] [Indexed: 12/21/2022] Open
Abstract
Introduction The original use of face masks was to help protect surgical wounds from staff-generated nasal and oral bacteria. Currently governments across the world have instituted the mandatory use of masks and other face coverings so that face masks now find much broader usage in situations where close contact of people is frequent and inevitable, particularly inside public transport facilities, shopping malls and workplaces in response to the COVID-19. Objective We conducted a rapid review to investigate the impact face mask use has had in controlling transmission of respiratory viral infections. Method A rapid review was conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. Five electronic databases (CINAHL, Embase, Medline, PsycINFO and Global Health) were searched from database inception to date, using pre-defined search terms. We included all studies of any design and used descriptive analysis to report summary statistics of search results. Data were extracted including sample characteristics, study design, respiratory virus being controlled, type of face masks used and their effectiveness. Results 58 out of 84 studies met the inclusion criteria, of which 13 were classified as systematic reviews and 45 were quantitative studies (comprising randomised controlled trials, retrospective cohort studies, case control, cross-sectional, surveys, observational and descriptive studies). N = 27 studies were conducted amongst healthcare workers wearing face masks, n = 19 studies among the general population, n = 9 studies among healthcare workers the general population and patients wearing masks, and n = 3 among only patients. Face masks use have shown a great potential for preventing respiratory virus transmission including COVID-19. Conclusion Regardless of the type, setting, or who wears the face mask, it serves primarily a dual preventive purpose; protecting oneself from getting viral infection and protecting others. Therefore, if everyone wears a face mask in public, it offers a double barrier against COVID-19 transmission.
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Affiliation(s)
- Mary Abboah-Offei
- Department of Health Sciences, University of York, Heslington York Y10 5DD, United Kingdom
| | - Yakubu Salifu
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom
| | - Bisi Adewale
- Faculty of Nursing, University of Alberta, Canada
| | - Jonathan Bayuo
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong Special Administrative Region
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Kritselis M, Remick DG. Universal Precautions Provide Appropriate Protection during Autopsies of Patients with Infectious Diseases. THE AMERICAN JOURNAL OF PATHOLOGY 2020; 190:2180-2184. [PMID: 32827462 PMCID: PMC7437536 DOI: 10.1016/j.ajpath.2020.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 12/14/2022]
Abstract
The current coronavirus disease 2019 (COVID-19) pandemic has raised concerns about the safety of laboratory personnel who handle tissue samples that harbor pathogens, including those performing autopsies. While pathologists have performed autopsies on infected decedents for centuries, universal precaution protocols for limiting exposure to pathogens were not developed until the 20th century. This article reviews the history and effectiveness of universal precautions, with an emphasis on performing autopsies on COVID-19 decedents.
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Affiliation(s)
- Michael Kritselis
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Daniel G Remick
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts.
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Cournoyer A, Grand'Maison S, Lonergan AM, Lessard J, Chauny JM, Castonguay V, Marquis M, Frégeau A, Huard V, Garceau-Tremblay Z, Turcotte AS, Piette É, Paquet J, Cossette S, Féral-Pierssens AL, Leblanc RX, Martel V, Daoust R. Oxygen Therapy and Risk of Infection for Health Care Workers Caring for Patients With Viral Severe Acute Respiratory Infection: A Systematic Review and Meta-analysis. Ann Emerg Med 2020; 77:19-31. [PMID: 32788066 PMCID: PMC7415416 DOI: 10.1016/j.annemergmed.2020.06.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/09/2020] [Accepted: 06/17/2020] [Indexed: 01/08/2023]
Abstract
Study objective To synthesize the evidence regarding the infection risk associated with different modalities of oxygen therapy used in treating patients with severe acute respiratory infection. Health care workers face significant risk of infection when treating patients with a viral severe acute respiratory infection. To ensure health care worker safety and limit nosocomial transmission of such infection, it is crucial to synthesize the evidence regarding the infection risk associated with different modalities of oxygen therapy used in treating patients with severe acute respiratory infection. Methods MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2000, to April 1, 2020, for studies describing the risk of infection associated with the modalities of oxygen therapy used for patients with severe acute respiratory infection. The study selection, data extraction, and quality assessment were performed by independent reviewers. The primary outcome measure was the infection of health care workers with a severe acute respiratory infection. Random-effect models were used to synthesize the extracted data. Results Of 22,123 citations, 50 studies were eligible for qualitative synthesis and 16 for meta-analysis. Globally, the quality of the included studies provided a very low certainty of evidence. Being exposed or performing an intubation (odds ratio 6.48; 95% confidence interval 2.90 to 14.44), bag-valve-mask ventilation (odds ratio 2.70; 95% confidence interval 1.31 to 5.36), and noninvasive ventilation (odds ratio 3.96; 95% confidence interval 2.12 to 7.40) were associated with an increased risk of infection. All modalities of oxygen therapy generate air dispersion. Conclusion Most modalities of oxygen therapy are associated with an increased risk of infection and none have been demonstrated as safe. The lowest flow of oxygen should be used to maintain an adequate oxygen saturation for patients with severe acute respiratory infection, and manipulation of oxygen delivery equipment should be minimized.
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Affiliation(s)
- Alexis Cournoyer
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada; Department of Emergency Medicine, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada; Department of Emergency Medicine, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Corporation d'Urgences-santé, Montreal, Quebec, Canada.
| | - Sophie Grand'Maison
- Department of Medicine, Université de Montréal, Montreal, Quebec, Canada; Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Ann-Marie Lonergan
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada; Department of Emergency Medicine, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Justine Lessard
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada; Department of Emergency Medicine, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Jean-Marc Chauny
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada; Department of Emergency Medicine, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Véronique Castonguay
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada; Department of Emergency Medicine, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Martin Marquis
- Department of Emergency Medicine, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Amélie Frégeau
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada; Department of Emergency Medicine, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Vérilibe Huard
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada; Department of Emergency Medicine, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Zoé Garceau-Tremblay
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada; Department of Emergency Medicine, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Ann-Sophie Turcotte
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada; Department of Emergency Medicine, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Éric Piette
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada; Department of Emergency Medicine, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Jean Paquet
- Department of Emergency Medicine, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Sylvie Cossette
- Faculty of Nursing, Université de Montréal, Montreal, Quebec, Canada; Research Center, Institut de Cardiologie de Montréal, Montreal, Quebec, Canada
| | - Anne-Laure Féral-Pierssens
- Charles Lemoyne-Saguenay-Lac-Saint-Jean Research Center on Health Innovations, Université de Sherbrooke, Longueuil, Quebec, Canada; Department of Emergency Medicine, Hôpital Européen Georges Pompidou, Paris, France
| | - Renaud-Xavier Leblanc
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada; Department of Emergency Medicine, Centre intégré de santé et de services sociaux de Laval, Hôpital Cité de la Santé, Laval, Quebec, Canada
| | - Valéry Martel
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada; Department of Emergency Medicine, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Raoul Daoust
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada; Department of Emergency Medicine, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
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Chu DK, Akl EA, Duda S, Solo K, Yaacoub S, Schünemann HJ. 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. Lancet 2020; 395:1973-1987. [PMID: 32497510 PMCID: PMC7263814 DOI: 10.1016/s0140-6736(20)31142-9] [Citation(s) in RCA: 2245] [Impact Index Per Article: 561.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/07/2020] [Accepted: 05/07/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes COVID-19 and is spread person-to-person through close contact. We aimed to investigate the effects of physical distance, face masks, and eye protection on virus transmission in health-care and non-health-care (eg, community) settings. METHODS We did a systematic review and meta-analysis to investigate the optimum distance for avoiding person-to-person virus transmission and to assess the use of face masks and eye protection to prevent transmission of viruses. We obtained data for SARS-CoV-2 and the betacoronaviruses that cause severe acute respiratory syndrome, and Middle East respiratory syndrome from 21 standard WHO-specific and COVID-19-specific sources. We searched these data sources from database inception to May 3, 2020, with no restriction by language, for comparative studies and for contextual factors of acceptability, feasibility, resource use, and equity. We screened records, extracted data, and assessed risk of bias in duplicate. We did frequentist and Bayesian meta-analyses and random-effects meta-regressions. We rated the certainty of evidence according to Cochrane methods and the GRADE approach. This study is registered with PROSPERO, CRD42020177047. FINDINGS Our search identified 172 observational studies across 16 countries and six continents, with no randomised controlled trials and 44 relevant comparative studies in health-care and non-health-care settings (n=25 697 patients). Transmission of viruses was lower with physical distancing of 1 m or more, compared with a distance of less than 1 m (n=10 736, pooled adjusted odds ratio [aOR] 0·18, 95% CI 0·09 to 0·38; risk difference [RD] -10·2%, 95% CI -11·5 to -7·5; moderate certainty); protection was increased as distance was lengthened (change in relative risk [RR] 2·02 per m; pinteraction=0·041; moderate certainty). Face mask use could result in a large reduction in risk of infection (n=2647; aOR 0·15, 95% CI 0·07 to 0·34, RD -14·3%, -15·9 to -10·7; low certainty), with stronger associations with N95 or similar respirators compared with disposable surgical masks or similar (eg, reusable 12-16-layer cotton masks; pinteraction=0·090; posterior probability >95%, low certainty). Eye protection also was associated with less infection (n=3713; aOR 0·22, 95% CI 0·12 to 0·39, RD -10·6%, 95% CI -12·5 to -7·7; low certainty). Unadjusted studies and subgroup and sensitivity analyses showed similar findings. INTERPRETATION The findings of this systematic review and meta-analysis support physical distancing of 1 m or more and provide quantitative estimates for models and contact tracing to inform policy. Optimum use of face masks, respirators, and eye protection in public and health-care settings should be informed by these findings and contextual factors. Robust randomised trials are needed to better inform the evidence for these interventions, but this systematic appraisal of currently best available evidence might inform interim guidance. FUNDING World Health Organization.
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Affiliation(s)
- Derek K Chu
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; The Research Institute of St Joe's Hamilton, Hamilton, ON, Canada
| | - Elie A Akl
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Internal Medicine, American University of Beirut, Beirut, Lebanon; Clinical Research Institute, American University of Beirut, Beirut, Lebanon
| | - Stephanie Duda
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Karla Solo
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Sally Yaacoub
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Michael G DeGroote Cochrane Canada and GRADE Centres, Hamilton, ON, Canada.
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Chu DK, Akl EA, Duda S, Solo K, Yaacoub S, Schünemann HJ. 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. Lancet 2020. [PMID: 32497510 DOI: 10.1016/s0140-6736(20)31142-31149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes COVID-19 and is spread person-to-person through close contact. We aimed to investigate the effects of physical distance, face masks, and eye protection on virus transmission in health-care and non-health-care (eg, community) settings. METHODS We did a systematic review and meta-analysis to investigate the optimum distance for avoiding person-to-person virus transmission and to assess the use of face masks and eye protection to prevent transmission of viruses. We obtained data for SARS-CoV-2 and the betacoronaviruses that cause severe acute respiratory syndrome, and Middle East respiratory syndrome from 21 standard WHO-specific and COVID-19-specific sources. We searched these data sources from database inception to May 3, 2020, with no restriction by language, for comparative studies and for contextual factors of acceptability, feasibility, resource use, and equity. We screened records, extracted data, and assessed risk of bias in duplicate. We did frequentist and Bayesian meta-analyses and random-effects meta-regressions. We rated the certainty of evidence according to Cochrane methods and the GRADE approach. This study is registered with PROSPERO, CRD42020177047. FINDINGS Our search identified 172 observational studies across 16 countries and six continents, with no randomised controlled trials and 44 relevant comparative studies in health-care and non-health-care settings (n=25 697 patients). Transmission of viruses was lower with physical distancing of 1 m or more, compared with a distance of less than 1 m (n=10 736, pooled adjusted odds ratio [aOR] 0·18, 95% CI 0·09 to 0·38; risk difference [RD] -10·2%, 95% CI -11·5 to -7·5; moderate certainty); protection was increased as distance was lengthened (change in relative risk [RR] 2·02 per m; pinteraction=0·041; moderate certainty). Face mask use could result in a large reduction in risk of infection (n=2647; aOR 0·15, 95% CI 0·07 to 0·34, RD -14·3%, -15·9 to -10·7; low certainty), with stronger associations with N95 or similar respirators compared with disposable surgical masks or similar (eg, reusable 12-16-layer cotton masks; pinteraction=0·090; posterior probability >95%, low certainty). Eye protection also was associated with less infection (n=3713; aOR 0·22, 95% CI 0·12 to 0·39, RD -10·6%, 95% CI -12·5 to -7·7; low certainty). Unadjusted studies and subgroup and sensitivity analyses showed similar findings. INTERPRETATION The findings of this systematic review and meta-analysis support physical distancing of 1 m or more and provide quantitative estimates for models and contact tracing to inform policy. Optimum use of face masks, respirators, and eye protection in public and health-care settings should be informed by these findings and contextual factors. Robust randomised trials are needed to better inform the evidence for these interventions, but this systematic appraisal of currently best available evidence might inform interim guidance. FUNDING World Health Organization.
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Affiliation(s)
- Derek K Chu
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; The Research Institute of St Joe's Hamilton, Hamilton, ON, Canada
| | - Elie A Akl
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Internal Medicine, American University of Beirut, Beirut, Lebanon; Clinical Research Institute, American University of Beirut, Beirut, Lebanon
| | - Stephanie Duda
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Karla Solo
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Sally Yaacoub
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Michael G DeGroote Cochrane Canada and GRADE Centres, Hamilton, ON, Canada.
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18
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Verbeek JH, Rajamaki B, Ijaz S, Sauni R, Toomey E, Blackwood B, Tikka C, Ruotsalainen JH, Kilinc Balci FS. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. Cochrane Database Syst Rev 2020; 5:CD011621. [PMID: 32412096 PMCID: PMC8785899 DOI: 10.1002/14651858.cd011621.pub5] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND In epidemics of highly infectious diseases, such as Ebola, severe acute respiratory syndrome (SARS), or coronavirus (COVID-19), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Personal protective equipment (PPE) can reduce the risk by covering exposed body parts. It is unclear which type of PPE protects best, what is the best way to put PPE on (i.e. donning) or to remove PPE (i.e. doffing), and how to train HCWs to use PPE as instructed. OBJECTIVES To evaluate which type of full-body PPE and which method of donning or doffing PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and CINAHL to 20 March 2020. SELECTION CRITERIA We included all controlled studies that evaluated the effect of full-body PPE used by HCW exposed to highly infectious diseases, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training on the same outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, extracted data and assessed the risk of bias in included trials. We conducted random-effects meta-analyses were appropriate. MAIN RESULTS Earlier versions of this review were published in 2016 and 2019. In this update, we included 24 studies with 2278 participants, of which 14 were randomised controlled trials (RCT), one was a quasi-RCT and nine had a non-randomised design. Eight studies compared types of PPE. Six studies evaluated adapted PPE. Eight studies compared donning and doffing processes and three studies evaluated types of training. Eighteen studies used simulated exposure with fluorescent markers or harmless microbes. In simulation studies, median contamination rates were 25% for the intervention and 67% for the control groups. Evidence for all outcomes is of very low certainty unless otherwise stated because it is based on one or two studies, the indirectness of the evidence in simulation studies and because of risk of bias. Types of PPE The use of a powered, air-purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.17 to 0.43) but was more difficult to don (non-compliance: RR 7.5, 95% CI 1.81 to 31.1). In one RCT (59 participants) coveralls were more difficult to doff than isolation gowns (very low-certainty evidence). Gowns may protect better against contamination than aprons (small patches: mean difference (MD) -10.28, 95% CI -14.77 to -5.79). PPE made of more breathable material may lead to a similar number of spots on the trunk (MD 1.60, 95% CI -0.15 to 3.35) compared to more water-repellent material but may have greater user satisfaction (MD -0.46, 95% CI -0.84 to -0.08, scale of 1 to 5). According to three studies that tested more recently introduced full-body PPE ensembles, there may be no difference in contamination. Modified PPE versus standard PPE The following modifications to PPE design may lead to less contamination compared to standard PPE: sealed gown and glove combination (RR 0.27, 95% CI 0.09 to 0.78), a better fitting gown around the neck, wrists and hands (RR 0.08, 95% CI 0.01 to 0.55), a better cover of the gown-wrist interface (RR 0.45, 95% CI 0.26 to 0.78, low-certainty evidence), added tabs to grab to facilitate doffing of masks (RR 0.33, 95% CI 0.14 to 0.80) or gloves (RR 0.22, 95% CI 0.15 to 0.31). Donning and doffing Using Centers for Disease Control and Prevention (CDC) recommendations for doffing may lead to less contamination compared to no guidance (small patches: MD -5.44, 95% CI -7.43 to -3.45). One-step removal of gloves and gown may lead to less bacterial contamination (RR 0.20, 95% CI 0.05 to 0.77) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28) than separate removal. Double-gloving may lead to less viral or bacterial contamination compared to single gloving (RR 0.34, 95% CI 0.17 to 0.66) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28). Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4) and to fewer contamination spots (MD -5, 95% CI -8.08 to -1.92). Extra sanitation of gloves before doffing with quaternary ammonium or bleach may decrease contamination, but not alcohol-based hand rub. Training The use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7). A video lecture on donning PPE may lead to better skills scores (MD 30.70, 95% CI 20.14 to 41.26) than a traditional lecture. Face-to-face instruction may reduce noncompliance with doffing guidance more (odds ratio 0.45, 95% CI 0.21 to 0.98) than providing folders or videos only. AUTHORS' CONCLUSIONS We found low- to very low-certainty evidence that covering more parts of the body leads to better protection but usually comes at the cost of more difficult donning or doffing and less user comfort. More breathable types of PPE may lead to similar contamination but may have greater user satisfaction. Modifications to PPE design, such as tabs to grab, may decrease the risk of contamination. For donning and doffing procedures, following CDC doffing guidance, a one-step glove and gown removal, double-gloving, spoken instructions during doffing, and using glove disinfection may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than folder-based training. We still need RCTs of training with long-term follow-up. We need simulation studies with more participants to find out which combinations of PPE and which doffing procedure protects best. Consensus on simulation of exposure and assessment of outcome is urgently needed. We also need more real-life evidence. Therefore, the use of PPE of HCW exposed to highly infectious diseases should be registered and the HCW should be prospectively followed for their risk of infection.
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Affiliation(s)
- Jos H Verbeek
- Cochrane Work Review Group, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Blair Rajamaki
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Sharea Ijaz
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Bronagh Blackwood
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Christina Tikka
- Finnish Institute of Occupational Health, TYÖTERVEYSLAITOS, Finland
| | | | - F Selcen Kilinc Balci
- National Personal Protective Technology Laboratory (NPPTL), National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Pittsburgh, PA, USA
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Wilson NM, Norton A, Young FP, Collins DW. Airborne transmission of severe acute respiratory syndrome coronavirus-2 to healthcare workers: a narrative review. Anaesthesia 2020; 75:1086-1095. [PMID: 32311771 PMCID: PMC7264768 DOI: 10.1111/anae.15093] [Citation(s) in RCA: 219] [Impact Index Per Article: 54.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2020] [Indexed: 12/12/2022]
Abstract
Healthcare workers are at risk of infection during the severe acute respiratory syndrome coronavirus‐2 pandemic. International guidance suggests direct droplet transmission is likely and airborne transmission occurs only with aerosol‐generating procedures. Recommendations determining infection control measures to ensure healthcare worker safety follow these presumptions. Three mechanisms have been described for the production of smaller sized respiratory particles (‘aerosols’) that, if inhaled, can deposit in the distal airways. These include: laryngeal activity such as talking and coughing; high velocity gas flow; and cyclical opening and closure of terminal airways. Sneezing and coughing are effective aerosol generators, but all forms of expiration produce particles across a range of sizes. The 5‐μm diameter threshold used to differentiate droplet from airborne is an over‐simplification of multiple complex, poorly understood biological and physical variables. The evidence defining aerosol‐generating procedures comes largely from low‐quality case and cohort studies where the exact mode of transmission is unknown as aerosol production was never quantified. We propose that transmission is associated with time in proximity to severe acute respiratory syndrome coronavirus‐1 patients with respiratory symptoms, rather than the procedures per se. There is no proven relation between any aerosol‐generating procedure with airborne viral content with the exception of bronchoscopy and suctioning. The mechanism for severe acute respiratory syndrome coronavirus‐2 transmission is unknown but the evidence suggestive of airborne spread is growing. We speculate that infected patients who cough, have high work of breathing, increased closing capacity and altered respiratory tract lining fluid will be significant producers of pathogenic aerosols. We suggest several aerosol‐generating procedures may in fact result in less pathogen aerosolisation than a dyspnoeic and coughing patient. Healthcare workers should appraise the current evidence regarding transmission and apply this to the local infection prevalence. Measures to mitigate airborne transmission should be employed at times of risk. However, the mechanisms and risk factors for transmission are largely unconfirmed. Whilst awaiting robust evidence, a precautionary approach should be considered to assure healthcare worker safety.
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Affiliation(s)
- N M Wilson
- Department of Intensive Care Medicine, Prince of Wales Hospital, Sydney, NSW, Australia
| | - A Norton
- Emergency Department, Oamaru Hospital, New Zealand
| | - F P Young
- Department of Intensive Care Medicine, Prince of Wales Hospital, Sydney, NSW, Australia
| | - D W Collins
- Department of Intensive Care Medicine, Prince of Wales Hospital, Sydney, NSW, Australia
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20
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Verbeek JH, Rajamaki B, Ijaz S, Sauni R, Toomey E, Blackwood B, Tikka C, Ruotsalainen JH, Kilinc Balci FS. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. Cochrane Database Syst Rev 2020; 4:CD011621. [PMID: 32293717 PMCID: PMC7158881 DOI: 10.1002/14651858.cd011621.pub4] [Citation(s) in RCA: 161] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND In epidemics of highly infectious diseases, such as Ebola, severe acute respiratory syndrome (SARS), or coronavirus (COVID-19), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Personal protective equipment (PPE) can reduce the risk by covering exposed body parts. It is unclear which type of PPE protects best, what is the best way to put PPE on (i.e. donning) or to remove PPE (i.e. doffing), and how to train HCWs to use PPE as instructed. OBJECTIVES To evaluate which type of full-body PPE and which method of donning or doffing PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and CINAHL to 20 March 2020. SELECTION CRITERIA We included all controlled studies that evaluated the effect of full-body PPE used by HCW exposed to highly infectious diseases, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training on the same outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, extracted data and assessed the risk of bias in included trials. We conducted random-effects meta-analyses were appropriate. MAIN RESULTS Earlier versions of this review were published in 2016 and 2019. In this update, we included 24 studies with 2278 participants, of which 14 were randomised controlled trials (RCT), one was a quasi-RCT and nine had a non-randomised design. Eight studies compared types of PPE. Six studies evaluated adapted PPE. Eight studies compared donning and doffing processes and three studies evaluated types of training. Eighteen studies used simulated exposure with fluorescent markers or harmless microbes. In simulation studies, median contamination rates were 25% for the intervention and 67% for the control groups. Evidence for all outcomes is of very low certainty unless otherwise stated because it is based on one or two studies, the indirectness of the evidence in simulation studies and because of risk of bias. Types of PPE The use of a powered, air-purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.17 to 0.43) but was more difficult to don (non-compliance: RR 7.5, 95% CI 1.81 to 31.1). In one RCT (59 participants), people with a long gown had less contamination than those with a coverall, and coveralls were more difficult to doff (low-certainty evidence). Gowns may protect better against contamination than aprons (small patches: mean difference (MD) -10.28, 95% CI -14.77 to -5.79). PPE made of more breathable material may lead to a similar number of spots on the trunk (MD 1.60, 95% CI -0.15 to 3.35) compared to more water-repellent material but may have greater user satisfaction (MD -0.46, 95% CI -0.84 to -0.08, scale of 1 to 5). Modified PPE versus standard PPE The following modifications to PPE design may lead to less contamination compared to standard PPE: sealed gown and glove combination (RR 0.27, 95% CI 0.09 to 0.78), a better fitting gown around the neck, wrists and hands (RR 0.08, 95% CI 0.01 to 0.55), a better cover of the gown-wrist interface (RR 0.45, 95% CI 0.26 to 0.78, low-certainty evidence), added tabs to grab to facilitate doffing of masks (RR 0.33, 95% CI 0.14 to 0.80) or gloves (RR 0.22, 95% CI 0.15 to 0.31). Donning and doffing Using Centers for Disease Control and Prevention (CDC) recommendations for doffing may lead to less contamination compared to no guidance (small patches: MD -5.44, 95% CI -7.43 to -3.45). One-step removal of gloves and gown may lead to less bacterial contamination (RR 0.20, 95% CI 0.05 to 0.77) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28) than separate removal. Double-gloving may lead to less viral or bacterial contamination compared to single gloving (RR 0.34, 95% CI 0.17 to 0.66) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28). Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4) and to fewer contamination spots (MD -5, 95% CI -8.08 to -1.92). Extra sanitation of gloves before doffing with quaternary ammonium or bleach may decrease contamination, but not alcohol-based hand rub. Training The use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7). A video lecture on donning PPE may lead to better skills scores (MD 30.70, 95% CI 20.14 to 41.26) than a traditional lecture. Face-to-face instruction may reduce noncompliance with doffing guidance more (odds ratio 0.45, 95% CI 0.21 to 0.98) than providing folders or videos only. AUTHORS' CONCLUSIONS We found low- to very low-certainty evidence that covering more parts of the body leads to better protection but usually comes at the cost of more difficult donning or doffing and less user comfort, and may therefore even lead to more contamination. More breathable types of PPE may lead to similar contamination but may have greater user satisfaction. Modifications to PPE design, such as tabs to grab, may decrease the risk of contamination. For donning and doffing procedures, following CDC doffing guidance, a one-step glove and gown removal, double-gloving, spoken instructions during doffing, and using glove disinfection may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than folder-based training. We still need RCTs of training with long-term follow-up. We need simulation studies with more participants to find out which combinations of PPE and which doffing procedure protects best. Consensus on simulation of exposure and assessment of outcome is urgently needed. We also need more real-life evidence. Therefore, the use of PPE of HCW exposed to highly infectious diseases should be registered and the HCW should be prospectively followed for their risk of infection.
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Affiliation(s)
- Jos H Verbeek
- Academic Medical Center, University of Amsterdam, Cochrane Work Review Group, Amsterdam, Netherlands, 1105AZ
| | - Blair Rajamaki
- University of Eastern Finland, School of Pharmacy, Kuopio, Finland
| | - Sharea Ijaz
- University of Bristol, Population Health Sciences, Bristol Medical School, Bristol, UK, BS1 2NT
| | | | | | - Bronagh Blackwood
- Queen's University Belfast, Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Wellcome-Wolfson Building, 97 Lisburn Road, Belfast, Northern Ireland, UK, BT9 7LB
| | - Christina Tikka
- Finnish Institute of Occupational Health, TYÖTERVEYSLAITOS, Finland, FI-70032
| | - Jani H Ruotsalainen
- Finnish Medicines Agency, Assessment of Pharmacotherapies, Microkatu 1, Kuopio, Finland, FI-70210
| | - F Selcen Kilinc Balci
- Centers for Disease Control and Prevention (CDC), National Personal Protective Technology Laboratory (NPPTL), National Institute for Occupational Safety and Health (NIOSH), 626 Cochrans Mill Road, Pittsburgh, PA, USA, 15236
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Shah A, Kashyap R, Tosh P, Sampathkumar P, O'Horo JC. Guide to Understanding the 2019 Novel Coronavirus. Mayo Clin Proc 2020; 95:646-652. [PMID: 32122636 PMCID: PMC7094318 DOI: 10.1016/j.mayocp.2020.02.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 02/06/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Aditya Shah
- Division of Infectious Diseases, Mayo Clinic, Mayo Clinic, Rochester, MN.
| | - Rahul Kashyap
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Mayo Clinic, Rochester, MN
| | - Pritish Tosh
- Division of Infectious Diseases, Mayo Clinic, Mayo Clinic, Rochester, MN
| | - Priya Sampathkumar
- Division of Infectious Diseases, Mayo Clinic, Mayo Clinic, Rochester, MN
| | - John C O'Horo
- Division of Infectious Diseases, Mayo Clinic, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Mayo Clinic, Rochester, MN
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22
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An update on US Ebola treatment center personnel management and training. Am J Infect Control 2020; 48:375-379. [PMID: 32035689 DOI: 10.1016/j.ajic.2019.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/05/2019] [Accepted: 12/06/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND In 2014, 56 US hospitals were designated as Ebola treatment centers (ETCs). ETCs had minimum augmented capability requirements for Ebola virus disease care, including for staffing and training. We sought to identify current ETC staffing challenges and frequency of staff retraining. METHODS In May 2019, an electronic survey was distributed to representatives of the 56 ETCs. RESULTS Sixty-six percent (37/56) of ETCs responded. Registered nurses comprised the majority of ETC staff. All responding units required orientation training (average = 15.21 hours) and all but one required retraining. Among the top challenges that ETCs reported to maintaining high-level isolation capabilities were staff training time, staff recruitment, staff retention, and training costs. DISCUSSION Five years after ETC designation, units face staffing challenges. Research is lacking on the effective number of hours and optimal frequency of staff training. ETCs reported smaller staffing teams compared to our 2016 assessment, but team composition remains similar. As units continue to maintain capabilities with decreasing external support and attention, the need for retraining must be balanced with logistical constraints and competing demands for staff time. CONCLUSIONS Our study shows that US preparedness capabilities are reduced. More research, support, and funding are needed to sustain the unique knowledge and proficiency acquired by ETC teams to ensure domestic preparedness for highly hazardous communicable diseases.
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Adhikari U, Chabrelie A, Weir M, Boehnke K, McKenzie E, Ikner L, Wang M, Wang Q, Young K, Haas CN, Rose J, Mitchell J. A Case Study Evaluating the Risk of Infection from Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV) in a Hospital Setting Through Bioaerosols. RISK ANALYSIS : AN OFFICIAL PUBLICATION OF THE SOCIETY FOR RISK ANALYSIS 2019; 39:2608-2624. [PMID: 31524301 PMCID: PMC7169172 DOI: 10.1111/risa.13389] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 05/15/2019] [Accepted: 06/24/2019] [Indexed: 05/03/2023]
Abstract
Middle Eastern respiratory syndrome, an emerging viral infection with a global case fatality rate of 35.5%, caused major outbreaks first in 2012 and 2015, though new cases are continuously reported around the world. Transmission is believed to mainly occur in healthcare settings through aerosolized particles. This study uses Quantitative Microbial Risk Assessment to develop a generalizable model that can assist with interpreting reported outbreak data or predict risk of infection with or without the recommended strategies. The exposure scenario includes a single index patient emitting virus-containing aerosols into the air by coughing, leading to short- and long-range airborne exposures for other patients in the same room, nurses, healthcare workers, and family visitors. Aerosol transport modeling was coupled with Monte Carlo simulation to evaluate the risk of MERS illness for the exposed population. Results from a typical scenario show the daily mean risk of infection to be the highest for the nurses and healthcare workers (8.49 × 10-4 and 7.91 × 10-4 , respectively), and the lowest for family visitors and patients staying in the same room (3.12 × 10-4 and 1.29 × 10-4 , respectively). Sensitivity analysis indicates that more than 90% of the uncertainty in the risk characterization is due to the viral concentration in saliva. Assessment of risk interventions showed that respiratory masks were found to have a greater effect in reducing the risks for all the groups evaluated (>90% risk reduction), while increasing the air exchange was effective for the other patients in the same room only (up to 58% risk reduction).
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Affiliation(s)
- Umesh Adhikari
- Department of Biosystems and Agricultural EngineeringMichigan State UniversityEast LansingMIUSA
| | - Alexandre Chabrelie
- Department of Biosystems and Agricultural EngineeringMichigan State UniversityEast LansingMIUSA
| | - Mark Weir
- Division of Environmental Health Sciences, College of Public HealthThe Ohio State UniversityColumbusOHUSA
| | - Kevin Boehnke
- Department of Anesthesiology & the Chronic Pain and Fatigue Research CenterUniversity of MichiganAnn ArborMIUSA
| | - Erica McKenzie
- Department of Civil and Environmental EngineeringTemple UniversityPhiladelphiaPAUSA
| | - Luisa Ikner
- Department of Soil, Water and Environmental ScienceUniversity of ArizonaTucsonAZUSA
| | - Meng Wang
- Department of Civil & Environmental EngineeringUniversity of South FloridaTampaFLUSA
| | - Qing Wang
- Department of Animal and Food SciencesUniversity of DelawareNewarkDEUSA
| | - Kyana Young
- Department of Fisheries and WildlifeMichigan State UniversityEast LansingMIUSA
| | - Charles N. Haas
- Department of Civil, Architectural and Environmental EngineeringDrexel UniversityPhiladelphiaPAUSA
| | - Joan Rose
- Department of Fisheries and WildlifeMichigan State UniversityEast LansingMIUSA
| | - Jade Mitchell
- Department of Biosystems and Agricultural EngineeringMichigan State UniversityEast LansingMIUSA
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Verbeek JH, Rajamaki B, Ijaz S, Tikka C, Ruotsalainen JH, Edmond MB, Sauni R, Kilinc Balci FS. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. Cochrane Database Syst Rev 2019; 7:CD011621. [PMID: 31259389 PMCID: PMC6601138 DOI: 10.1002/14651858.cd011621.pub3] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND In epidemics of highly infectious diseases, such as Ebola Virus Disease (EVD) or Severe Acute Respiratory Syndrome (SARS), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Contact precautions by means of personal protective equipment (PPE) can reduce the risk. It is unclear which type of PPE protects best, what is the best way to remove PPE, and how to make sure HCW use PPE as instructed. OBJECTIVES To evaluate which type of full body PPE and which method of donning or doffing PPE have the least risk of self-contamination or infection for HCW, and which training methods increase compliance with PPE protocols. SEARCH METHODS We searched MEDLINE (PubMed up to 15 July 2018), Cochrane Central Register of Trials (CENTRAL up to 18 June 2019), Scopus (Scopus 18 June 2019), CINAHL (EBSCOhost 31 July 2018), and OSH-Update (up to 31 December 2018). We also screened reference lists of included trials and relevant reviews, and contacted NGOs and manufacturers of PPE. SELECTION CRITERIA We included all controlled studies that compared the effects of PPE used by HCW exposed to highly infectious diseases with serious consequences, such as Ebola or SARS, on the risk of infection, contamination, or noncompliance with protocols. This included studies that used simulated contamination with fluorescent markers or a non-pathogenic virus.We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training in PPE use on the same outcomes. DATA COLLECTION AND ANALYSIS Two authors independently selected studies, extracted data and assessed risk of bias in included trials. We planned to perform meta-analyses but did not find sufficiently similar studies to combine their results. MAIN RESULTS We included 17 studies with 1950 participants evaluating 21 interventions. Ten studies are Randomised Controlled Trials (RCTs), one is a quasi RCT and six have a non-randomised controlled design. Two studies are awaiting assessment.Ten studies compared types of PPE but only six of these reported sufficient data. Six studies compared different types of donning and doffing and three studies evaluated different types of training. Fifteen studies used simulated exposure with fluorescent markers or harmless viruses. In simulation studies, contamination rates varied from 10% to 100% of participants for all types of PPE. In one study HCW were exposed to Ebola and in another to SARS.Evidence for all outcomes is based on single studies and is very low quality.Different types of PPEPPE made of more breathable material may not lead to more contamination spots on the trunk (Mean Difference (MD) 1.60 (95% Confidence Interval (CI) -0.15 to 3.35) than more water repellent material but may have greater user satisfaction (MD -0.46; 95% CI -0.84 to -0.08, scale of 1 to 5).Gowns may protect better against contamination than aprons (MD large patches -1.36 95% CI -1.78 to -0.94).The use of a powered air-purifying respirator may protect better than a simple ensemble of PPE without such respirator (Relative Risk (RR) 0.27; 95% CI 0.17 to 0.43).Five different PPE ensembles (such as gown vs. coverall, boots with or without covers, hood vs. cap, length and number of gloves) were evaluated in one study, but there were no event data available for compared groups.Alterations to PPE design may lead to less contamination such as added tabs to grab masks (RR 0.33; 95% CI 0.14 to 0.80) or gloves (RR 0.22 95% CI 0.15 to 0.31), a sealed gown and glove combination (RR 0.27; 95% CI 0.09 to 0.78), or a better fitting gown around the neck, wrists and hands (RR 0.08; 95% CI 0.01 to 0.55) compared to standard PPE.Different methods of donning and doffing proceduresDouble gloving may lead to less contamination compared to single gloving (RR 0.36; 95% CI 0.16 to 0.78).Following CDC recommendations for doffing may lead to less contamination compared to no guidance (MD small patches -5.44; 95% CI -7.43 to -3.45).Alcohol-based hand rub used during the doffing process may not lead to less contamination than the use of a hypochlorite based solution (MD 4.00; 95% CI 0.47 to 34.24).Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4).Different types of trainingThe use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7).A video lecture on donning PPE may lead to better skills scores (MD 30.70; 95% CI 20.14,41.26) than a traditional lecture.Face to face instruction may reduce noncompliance with doffing guidance more (OR 0.45; 95% CI 0.21 to 0.98) than providing folders or videos only.There were no studies on effects of training in the long term or on resource use.The quality of the evidence is very low for all comparisons because of high risk of bias in all studies, indirectness of evidence, and small numbers of participants. AUTHORS' CONCLUSIONS We found very low quality evidence that more breathable types of PPE may not lead to more contamination, but may have greater user satisfaction. Alterations to PPE, such as tabs to grab may decrease contamination. Double gloving, following CDC doffing guidance, and spoken instructions during doffing may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than video or folder based training. Because data come from single small studies with high risk of bias, we are uncertain about the estimates of effects.We still need randomised controlled trials to find out which training works best in the long term. We need better simulation studies conducted with several dozen participants to find out which PPE protects best, and what is the safest way to remove PPE. Consensus on the best way to conduct simulation of exposure and assessment of outcome is urgently needed. HCW exposed to highly infectious diseases should have their use of PPE registered and should be prospectively followed for their risk of infection in the field.
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Affiliation(s)
- Jos H Verbeek
- University of Eastern FinlandCochrane Work Review GroupKuopioFinland70201
| | - Blair Rajamaki
- University of Eastern FinlandInstitute of Public Health and Clinical Nutrition, Occupational Health UnitKuopioFinland
| | - Sharea Ijaz
- University of BristolPopulation Health Sciences, Bristol Medical SchoolBristolUKBS1 2NT
| | - Christina Tikka
- Finnish Institute of Occupational HealthCochrane Work Review GroupTYÖTERVEYSLAITOSFinlandFI‐70032
| | - Jani H Ruotsalainen
- Coronel Institute of Occupational HealthCochrane Work Review GroupAcademic Medical Center, University of AmsterdamPO Box 22700AmsterdamNetherlands1100 DE
| | - Michael B Edmond
- University of Iowa Hospitals and ClinicsC512 GH, 200 Hawkins DriveIowa CityIAUSA52241
| | - Riitta Sauni
- Finnish Institute of Occupational HealthP.O.Box 486TampereFinlandFI‐33101
| | - F Selcen Kilinc Balci
- Centers for Disease Control and Prevention (CDC)National Personal Protective Technology Laboratory (NPPTL), National Institute for Occupational Safety and Health (NIOSH)626 Cochrans Mill RoadPittsburghPAUSA15236
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Öncü E, Vayısoğlu SK, Lafcı D, Yıldız E. An evaluation of the effectiveness of nursing students' hand hygiene compliance: A cross-sectional study. NURSE EDUCATION TODAY 2018; 65:218-224. [PMID: 29604605 PMCID: PMC7115509 DOI: 10.1016/j.nedt.2018.02.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 02/04/2018] [Accepted: 02/20/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Emine Öncü
- Community Health Nursing Department, Faculty of Nursing, Mersin University, Mersin, Turkey.
| | | | - Diğdem Lafcı
- Fundementals of Nursing Department, Faculty of Nursing, Mersin University, Mersin, Turkey
| | - Ebru Yıldız
- Fundementals of Nursing Department, Faculty of Nursing, Mersin University, Mersin, Turkey
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Abstract
In the U.S., migration has been documented to affect the prevalence of infectious disease. As a mitigation entity, border security has been recorded by numerous scholarly works as being essential to the support of the health of the U.S. population. Consequently, the lack of current health care monitoring of the permeable U.S. border places the U.S. population at risk in the broad sectors of infectious disease and interpersonal violence. Visualizing border security in the context of public health mitigation has significant potential to protect migrant health as well as that of all populations on both sides of the border. Examples of how commonly this philosophy is held can be found in the expansive use of security-focused terms regarding public health. Using tools such as GIS to screen for disease in people before their entrance into a nation would be more efficient and ethical than treating patients once they have entered a population and increased the impact on the healthcare system. (Disaster Med Public Health Preparedness. 2018;12:554-562).
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LaVela SL, Kostovich C, Locatelli S, Gosch M, Eagan A, Radonovich L. Development and initial validation of the Respirator Comfort, Wearing Experience, and Function Instrument [R-COMFI]. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2017; 14:135-147. [PMID: 27636378 DOI: 10.1080/15459624.2016.1237025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Filtering face-piece respirators (FFRs) are worn to protect health care personnel from airborne particles; however, clinical studies have demonstrated that FFR adherence is relatively low in some settings, in part, due to discomfort and intolerance. The objective of this study was to develop and initially evaluate the psychometric properties of an instrument designed to measure the comfort and tolerability of FFRs. Instrument items were developed through literature reviews, focus groups, and several iterations of ranking and refining by experts. Psychometric evaluation of the instrument was conducted using Rasch partial credit model (PCM) analysis. Pivot anchoring was used to specify the threshold defining item difficulty; in our analyses, this was the point that participants moved from possessing none of the trait to some of the trait. The final instrument was completed by 165 health care personnel from 3 Veterans Health Administration facilities, and data were analyzed using Rasch PCM. Seven items were removed because they: (1) violated the assumption of independence; (2) were mis-fitting; and/or (3) were deemed not relevant. Category function analysis demonstrated that all categories progressed monotonically. Principal components analysis demonstrated the existence of three subscales (Discomfort, General Wearing Experience, and Function). Final reliability analyses showed that the scale had moderate to high person reliability and high item reliability. The final instrument contained 21 items. Until now, to our knowledge no instrument with evidence supporting its reliability and validity to assess discomfort and tolerance of FFRs among health care personnel has been published. A 21-item psychometrically sound measure of comfort and tolerability of FFRs, Respirator Comfort, Wearing Experience, and Function Instrument (R-COMFI), was developed. The significance of developing such an instrument is that it will help identify respirators that are likely to have better adherence in practice settings. The R-COMFI may be used within and beyond the VA healthcare system as a psychometrically sound instrument to evaluate the comfort and tolerability of respirators, including developmental prototypes.
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Affiliation(s)
- Sherri L LaVela
- a Department of Veterans Affairs , VA Health Services Research and Development , Hines , Illinois
- b Department of Physical Medicine and Rehabilitation , Feinberg School of Medicine, Northwestern University , Chicago , Illinois
| | - Carol Kostovich
- a Department of Veterans Affairs , VA Health Services Research and Development , Hines , Illinois
- c Marcella Niehoff School of Nursing , Loyola University Chicago , Chicago , Illinois
| | - Sara Locatelli
- a Department of Veterans Affairs , VA Health Services Research and Development , Hines , Illinois
| | - Megan Gosch
- d National Center for Occupational Health and Infection Control, Office of Public Health, Veterans Health Administration , Department of Veterans Affairs , Washington , DC
| | - Aaron Eagan
- d National Center for Occupational Health and Infection Control, Office of Public Health, Veterans Health Administration , Department of Veterans Affairs , Washington , DC
| | - Lewis Radonovich
- d National Center for Occupational Health and Infection Control, Office of Public Health, Veterans Health Administration , Department of Veterans Affairs , Washington , DC
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Verbeek JH, Ijaz S, Mischke C, Ruotsalainen JH, Mäkelä E, Neuvonen K, Edmond MB, Sauni R, Balci FSK, Mihalache RC. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. Cochrane Database Syst Rev 2016; 4:CD011621. [PMID: 27093058 PMCID: PMC10068873 DOI: 10.1002/14651858.cd011621.pub2] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In epidemics of highly infectious diseases, such as Ebola Virus Disease (EVD) or SARS, healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Contact precautions by means of personal protective equipment (PPE) can reduce the risk. It is unclear which type of PPE protects best, what is the best way to remove PPE, and how to make sure HCWs use PPE as instructed. OBJECTIVES To evaluate which type or component of full-body PPE and which method of donning or removing (doffing) PPE have the least risk of self-contamination or infection for HCWs, and which training methods most increase compliance with PPE protocols. SEARCH METHODS We searched MEDLINE (PubMed up to 8 January 2016), Cochrane Central Register of Trials (CENTRAL up to 20 January 2016), EMBASE (embase.com up to 8 January 2016), CINAHL (EBSCOhost up to 20 January 2016), and OSH-Update up to 8 January 2016. We also screened reference lists of included trials and relevant reviews, and contacted NGOs and manufacturers of PPE. SELECTION CRITERIA We included all eligible controlled studies that compared the effect of types or components of PPE in HCWs exposed to highly infectious diseases with serious consequences, such as EVD and SARS, on the risk of infection, contamination, or noncompliance with protocols. This included studies that simulated contamination with fluorescent markers or a non-pathogenic virus.We also included studies that compared the effect of various ways of donning or removing PPE, and the effects of various types of training in PPE use on the same outcomes. DATA COLLECTION AND ANALYSIS Two authors independently selected studies, extracted data and assessed risk of bias in included trials. We intended to perform meta-analyses but we did not find sufficiently similar studies to combine their results. MAIN RESULTS We included nine studies with 1200 participants evaluating ten interventions. Of these, eight trials simulated the exposure with a fluorescent marker or virus or bacteria containing fluids. Five studies evaluated different types of PPE against each other but two did not report sufficient data. Another two studies compared different types of donning and doffing and three studies evaluated the effect of different types of training.None of the included studies reported a standardised classification of the protective properties against viral penetration of the PPE, and only one reported the brand of PPE used. None of the studies were conducted with HCWs exposed to EVD but in one study participants were exposed to SARS. Different types of PPE versus each otherIn simulation studies, contamination rates varied from 25% to 100% of participants for all types of PPE. In one study, PPE made of more breathable material did not lead to a statistically significantly different number of spots with contamination but did have greater user satisfaction (Mean Difference (MD) -0.46 (95% Confidence Interval (CI) -0.84 to -0.08, range 1 to 5, very low quality evidence). In another study, gowns protected better than aprons. In yet another study, the use of a powered air-purifying respirator protected better than a now outdated form of PPE. There were no studies on goggles versus face shields, on long- versus short-sleeved gloves, or on the use of taping PPE parts together. Different methods of donning and doffing procedures versus each otherTwo cross-over simulation studies (one RCT, one CCT) compared different methods for donning and doffing against each other. Double gloving led to less contamination compared to single gloving (Relative Risk (RR) 0.36; 95% CI 0.16 to 0.78, very low quality evidence) in one simulation study, but not to more noncompliance with guidance (RR 1.08; 95% CI 0.70 to 1.67, very low quality evidence). Following CDC recommendations for doffing led to less contamination in another study (very low quality evidence). There were no studies on the use of disinfectants while doffing. Different types of training versus each otherIn one study, the use of additional computer simulation led to less errors in doffing (MD -1.2, 95% CI -1.6 to -0.7) and in another study additional spoken instruction led to less errors (MD -0.9, 95% CI -1.4 to -0.4). One retrospective cohort study assessed the effect of active training - defined as face-to-face instruction - versus passive training - defined as folders or videos - on noncompliance with PPE use and on noncompliance with doffing guidance. Active training did not considerably reduce noncompliance in PPE use (Odds Ratio (OR) 0.63; 95% CI 0.31 to 1.30) but reduced noncompliance with doffing procedures (OR 0.45; 95% CI 0.21 to 0.98, very low quality evidence). There were no studies on how to retain the results of training in the long term or on resource use.The quality of the evidence was very low for all comparisons because of high risk of bias in studies, indirectness of evidence, and small numbers of participants. This means that it is likely that the true effect can be substantially different from the one reported here. AUTHORS' CONCLUSIONS We found very low quality evidence that more breathable types of PPE may not lead to more contamination, but may have greater user satisfaction. We also found very low quality evidence that double gloving and CDC doffing guidance appear to decrease the risk of contamination and that more active training in PPE use may reduce PPE and doffing errors more than passive training. However, the data all come from single studies with high risk of bias and we are uncertain about the estimates of effects.We need simulation studies conducted with several dozens of participants, preferably using a non-pathogenic virus, to find out which type and combination of PPE protects best, and what is the best way to remove PPE. We also need randomised controlled studies of the effects of one type of training versus another to find out which training works best in the long term. HCWs exposed to highly infectious diseases should have their use of PPE registered and should be prospectively followed for their risk of infection.
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Affiliation(s)
- Jos H Verbeek
- Cochrane Work Review Group, Finnish Institute of Occupational Health, Kuopio, Finland
| | - Sharea Ijaz
- Cochrane Work Review Group, Finnish Institute of Occupational Health, Kuopio, Finland
| | - Christina Mischke
- Cochrane Work Review Group, Finnish Institute of Occupational Health, Kuopio, Finland
| | - Jani H Ruotsalainen
- Cochrane Work Review Group, Finnish Institute of Occupational Health, Kuopio, Finland
| | - Erja Mäkelä
- Finnish Institute of Occupational Health, Helsinki, Finland
| | - Kaisa Neuvonen
- Cochrane Work Review Group, Finnish Institute of Occupational Health, Helsinki, Finland
| | | | - Riitta Sauni
- Finnish Institute of Occupational Health, Tampere, Finland
| | - F Selcen Kilinc Balci
- National Personal Protective Technology Laboratory (NPPTL), National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Pittsburgh, PA, USA
| | - Raluca C Mihalache
- Cochrane Work Review Group, Finnish Institute of Occupational Health, Kuopio, Finland
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Chughtai AA, Seale H, Dung TC, Hayen A, Rahman B, Raina MacIntyre C. Compliance with the Use of Medical and Cloth Masks Among Healthcare Workers in Vietnam. ANNALS OF OCCUPATIONAL HYGIENE 2016; 60:619-30. [PMID: 26980847 DOI: 10.1093/annhyg/mew008] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 01/19/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Masks are often worn in healthcare settings to prevent the spread of infection from healthcare workers (HCWs) to patients. Masks are also used to protect the employee from patient-generated infectious organisms but poor compliance can reduce efficacy. The aim of this study was to examine the factors influencing compliance with the use of medical and cloth masks amongst hospital HCWs. METHODS HCWs compliance with the use of medical and cloth masks was measured over a 4-week period in a randomized controlled trial in Vietnam. HCWs were instructed to record their daily activities in diary cards. Demographic, clinical, and diary card data were used to determine the predictors of compliance and the relationship of compliance with infection outcomes. RESULTS Compliance rates for both medical and cloth masks decreased during the 4 weeks: medical mask use decreased from 77 to 68% (P < 0.001) and cloth masks from 78 to 69% (P < 0.001). The presence of adverse events (adjusted RR 0.90, 95% CI 0.85-0.95), and performing aerosol-generating procedures (adjusted RR 0.78, 95% CI 0.73-0.82) were negatively associated with compliance, while contact with febrile respiratory illness patients was positively associated (adjusted RR 1.14, 95% CI 1.07-1.20). Being compliant with medical or cloth masks use (average use ≥70% of working time) was not associated with clinical respiratory illness, influenza-like illness, and laboratory-confirmed viral infection. CONCLUSION Understanding the factors that affect compliance is important for the occupational health and safety of HCWs. New strategies and tools should be developed to increase compliance of HCWs. The presence of adverse events such as discomfort and breathing problems may be the main reasons for the low compliance with mask use and further studies should be conducted to improve the design/material of masks to improve comfort for the wearer.
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Affiliation(s)
- Abrar Ahmad Chughtai
- 1.School of Public Health and Community Medicine, UNSW Medicine, University of New South Wales, Sydney, Australia;
| | - Holly Seale
- 1.School of Public Health and Community Medicine, UNSW Medicine, University of New South Wales, Sydney, Australia
| | - Tham Chi Dung
- 2.National Institute of Hygiene and Epidemiology (NIHE), Hanoi, Vietnam
| | - Andrew Hayen
- 1.School of Public Health and Community Medicine, UNSW Medicine, University of New South Wales, Sydney, Australia
| | - Bayzidur Rahman
- 1.School of Public Health and Community Medicine, UNSW Medicine, University of New South Wales, Sydney, Australia
| | - C Raina MacIntyre
- 1.School of Public Health and Community Medicine, UNSW Medicine, University of New South Wales, Sydney, Australia
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Comparative Epidemiology of Human Infections with Middle East Respiratory Syndrome and Severe Acute Respiratory Syndrome Coronaviruses among Healthcare Personnel. PLoS One 2016; 11:e0149988. [PMID: 26930074 PMCID: PMC4773072 DOI: 10.1371/journal.pone.0149988] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 02/07/2016] [Indexed: 01/14/2023] Open
Abstract
The largest nosocomial outbreak of Middle East respiratory syndrome (MERS) occurred in South Korea in 2015. Health Care Personnel (HCP) are at high risk of acquiring MERS-Coronavirus (MERS-CoV) infections, similar to the severe acute respiratory syndrome (SARS)-Coronavirus (SARS-CoV) infections first identified in 2003. This study described the similarities and differences in epidemiological and clinical characteristics of 183 confirmed global MERS cases and 98 SARS cases in Taiwan associated with HCP. The epidemiological findings showed that the mean age of MERS-HCP and total MERS cases were 40 (24~74) and 49 (2~90) years, respectively, much older than those in SARS [SARS-HCP: 35 (21~68) years, p = 0.006; total SARS: 42 (0~94) years, p = 0.0002]. The case fatality rates (CFR) was much lower in MERS-HCP [7.03% (9/128)] or SARS-HCP [12.24% (12/98)] than the MERS-non-HCP [36.96% (34/92), p<0.001] or SARS-non-HCP [24.50% (61/249), p<0.001], however, no difference was found between MERS-HCP and SARS-HCP [p = 0.181]. In terms of clinical period, the days from onset to death [13 (4~17) vs 14.5 (0~52), p = 0.045] and to discharge [11 (5~24) vs 24 (0~74), p = 0.010] and be hospitalized days [9.5 (3~22) vs 22 (0~69), p = 0.040] were much shorter in MERS-HCP than SARS-HCP. Similarly, days from onset to confirmation were shorter in MERS-HCP than MERS-non-HCP [6 (1~14) vs 10 (1~21), p = 0.044]. In conclusion, the severity of MERS-HCP and SARS-HCP was lower than that of MERS-non-HCP and SARS-non-HCP due to younger age and early confirmation in HCP groups. However, no statistical difference was found in MERS-HCP and SARS-HCP. Thus, prevention of nosocomial infections involving both novel Coronavirus is crucially important to protect HCP.
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Evaluation of respiratory protection programs and practices in California hospitals during the 2009-2010 H1N1 influenza pandemic. Am J Infect Control 2013; 41:1024-31. [PMID: 23932825 PMCID: PMC4615716 DOI: 10.1016/j.ajic.2013.05.006] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Revised: 04/28/2013] [Accepted: 05/01/2013] [Indexed: 11/29/2022]
Abstract
Background Emergence of the novel 2009 influenza A H1N1 virus in California led to an evaluation of hospital respiratory protection programs (RPPs) and practices by the California Department of Public Health during the 2009-2010 influenza season. Methods Onsite evaluation of 16 hospitals consisted of interviews with managers and health care workers about RPPs and practices, review of written RPPs, and limited observations of personnel using respirators. Data were analyzed using descriptive statistics. Results All hospitals had implemented policies requiring the minimum use of N95 filtering facepiece respirators when working with patients with H1N1 virus infection; 95.5% of health care workers (n = 199) reported they would wear at least this level of protection when in close contact with a patient with confirmed or suspected H1N1 virus infection. However, evaluation of written RPPs indicated deficiencies in required areas, most commonly in recordkeeping, designation of a program administrator, program evaluation, employee training, and fit testing procedures. Conclusions Health care workers were aware of respiratory protection required when providing care for patients with confirmed or suspected H1N1 virus infection. Hospitals should improve written RPPs, fully implement written procedures, and conduct periodic program evaluation to ensure effectiveness of respirator use for health care worker protection. Increased accessibility of resources tailored for hospital respirator program administrators may be helpful.
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Nichol K, McGeer A, Bigelow P, O'Brien-Pallas L, Scott J, Holness DL. Behind the mask: Determinants of nurse's adherence to facial protective equipment. Am J Infect Control 2013; 41:8-13. [PMID: 22475568 PMCID: PMC7132700 DOI: 10.1016/j.ajic.2011.12.018] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Revised: 12/22/2011] [Accepted: 12/23/2011] [Indexed: 11/14/2022]
Abstract
BACKGROUND As the predominant occupation in the health sector and as the health worker with the most patient interaction, nurses are at high risk for occupational transmission of communicable respiratory illness. The use of facial protective equipment (FPE) is an important strategy to prevent occupational transmission. METHODS A 2-phased study was conducted to examine nurse's adherence to recommended use of FPE. Phase 1 was a cross-sectional survey of nurses in selected units of 6 acute care hospitals in Toronto, Canada. Phase 2 was a direct observational study of critical care nurses. RESULTS Of the 1,074 nurses who completed surveys (82% response rate), 44% reported adherence to recommended use of FPE. Multivariable analysis revealed 6 predictors of adherence: unit type, frequency of equipment use, equipment availability, training, organizational support, and communication. Following the survey, 100 observations in 14 intensive care units were conducted that revealed a 44% competence rate with proper use of N95 respirators and knowledge as a significant predictor of competence. CONCLUSION Whereas increasing knowledge should enhance competence, strategies to improve adherence to recommended use of FPE in a busy and complex health care setting should focus on ready availability of equipment, training and fit testing, organizational support for worker health and safety, and good communication practices.
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Affiliation(s)
- Kathryn Nichol
- Occupational Health Services Program, St Michael's Hospital, Toronto, ON, Canada.
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H1N1 infection and acute respiratory failure: Can we give non-invasive ventilation a chance? REVISTA PORTUGUESA DE PNEUMOLOGIA 2011; 16:907-911. [PMID: 32288976 PMCID: PMC7129842 DOI: 10.1016/s2173-5115(10)70008-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Accepted: 06/28/2010] [Indexed: 11/20/2022] Open
Abstract
In 2009, a novel H1N1 Influenza virus has emerged and on June 11 the World Health Organization declared it as pandemic. It may cause acute respiratory failure ranging from severe Acute Respiratory Distress Syndrome to exacerbations of airflow limitation. Non-invasive ventilation is now considered first-line intervention for different causes of acute respiratory failure and may be considered in the context of H1N1 pandemic. Although infection control issues have been arisen, non-invasive ventilation was effective and safe during the Severe Acute Respiratory Syndrome in Asia. It is reasonable to recommend non-invasive ventilation in H1N1-related exacerbations of chronic respiratory diseases, especially in negative-pressure wards. Treatment of early Acute Respiratory Distress Syndrome associated with H1N1 using non-invasive ventilation could be tried rapidly identifying those who fail without delaying endotracheal intubation. Considering the high demand for critical care beds during the pandemic, non-invasive ventilation may have a role in reducing the estimated load.
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Severe acute respiratory syndrome: What have we learned two years later? CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2011; 15:309-12. [PMID: 18159508 DOI: 10.1155/2004/964258] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2004] [Accepted: 11/08/2004] [Indexed: 12/12/2022]
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H1N1 infection and acute respiratory failure: can we give non-invasive ventilation a chance? REVISTA PORTUGUESA DE PNEUMOLOGIA 2011; 16:907-11. [PMID: 21067697 PMCID: PMC7135749 DOI: 10.1016/s0873-2159(15)31253-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
In 2009, a novel H1N1 Influenza virus has emerged and on June 11 the World Health Organization declared it as pandemic. It may cause acute respiratory failure ranging from severe Acute Respiratory Distress Syndrome to exacerbations of airflow limitation. Non-invasive ventilation is now considered first-line intervention for different causes of acute respiratory failure and may be considered in the context of H1N1 pandemic. Although infection control issues have been arisen, non-invasive ventilation was effective and safe during the Severe Acute Respiratory Syndrome in Asia. It is reasonable to recommend non-invasive ventilation in H1N1-related exacerbations of chronic respiratory diseases, especially in negative-pressure wards. Treatment of early Acute Respiratory Distress Syndrome associated with H1N1 using non-invasive ventilation could be tried rapidly identifying those who fail without delaying endotracheal intubation. Considering the high demand for critical care beds during the pandemic, non-invasive ventilation may have a role in reducing the estimated load.
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Nichol K, Bigelow P, O'Brien-Pallas L, McGeer A, Manno M, Holness DL. 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. Am J Infect Control 2008; 36:481-7. [PMID: 18786451 PMCID: PMC7132646 DOI: 10.1016/j.ajic.2007.12.004] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Revised: 12/05/2007] [Accepted: 12/10/2007] [Indexed: 11/16/2022]
Abstract
BACKGROUND Communicable respiratory illness is an important cause of morbidity among nurses. One of the key reasons for occupational transmission of this illness is the failure to implement appropriate barrier precautions, particularly facial protection. The objectives of this study were to describe the factors that influence nurses' decisions to use facial protection and to determine their relative importance in predicting compliance. METHODS This cross-sectional survey was conducted in 9 units of 2 urban hospitals in which nursing staff regularly use facial protection. RESULTS A total of 400 self-administered questionnaires were provided to nurses, and 177 were returned (44% response rate). Less than half of respondents reported compliance with the recommended use of facial protection (eye/face protection, respirators, and surgical masks) to prevent occupational transmission of communicable respiratory disease. Multivariate analysis showed 5 factors to be key predictors of nurses' compliance with the recommended use of facial protection. These factors include full-time work status, greater than 5 years tenure as a nurse, at least monthly use of facial protection, a belief that media coverage of infectious diseases impacts risk perception and work practices, and organizational support for health and safety. CONCLUSION Strategies and interventions based on these findings should result in enhanced compliance with facial protection and, ultimately, a reduction in occupational transmission of communicable respiratory illness.
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Affiliation(s)
- Kathryn Nichol
- Centre for Research Expertise in Occupational Disease, University of Toronto and St. Michael's Hospital, Toronto, Canada.
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Addressing gaps in health care sector legal preparedness for public health emergencies. Disaster Med Public Health Prep 2008; 2:50-6. [PMID: 18388658 DOI: 10.1097/dmp.0b013e3181587cff] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Health care providers and their legal counsel play pivotal roles in preparing for and responding to public health emergencies. Lawyers representing hospitals, health systems, and other health care provider components are being called upon to answer complex legal questions regarding public health preparedness issues that most providers have not previously faced. Many of these issues are legal issues with which public health officials should be familiar, and that can serve as a starting point for cross-sector legal preparedness planning involving both the public health and health care communities. This article examines legal issues that health care providers face in preparing for public health emergencies, and steps that providers, their legal counsel, and others can take to address those issues and to strengthen community preparedness.
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Carrico RM, Coty MB, Goss LK, Lajoie AS. Changing health care worker behavior in relation to respiratory disease transmission with a novel training approach that uses biosimulation. Am J Infect Control 2007; 35:14-9. [PMID: 17276786 PMCID: PMC7115298 DOI: 10.1016/j.ajic.2005.12.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2005] [Revised: 12/02/2005] [Accepted: 12/02/2005] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Ruth M Carrico
- School of Public Health and Information Sciences, Department of Health Knowledge and Cognitive Sciences, University of Louisville, Louisville, KY, USA
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Abstract
This review examines the literature, including literature in Chinese, on the effectiveness of handwashing as an intervention against severe acute respiratory syndrome (SARS) transmission. Nine of 10 epidemiological studies reviewed showed that handwashing was protective against SARS when comparing infected cases and non‐infected controls in univariate analysis, but only in three studies was this result statistically significant in multivariate analysis. There is reason to believe that this is because most of the studies were too small. The evidence for the effectiveness of handwashing as a measure against SARS transmission in health care and community settings is suggestive, but not conclusive.
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Aquino M, Raboud JM, McGeer A, Green K, Chow R, Dimoulas P, Loeb M, Scales D. Accuracy of healthcare worker recall and medical record review for identifying infectious exposures to hospitalized patients. Infect Control Hosp Epidemiol 2006; 27:722-8. [PMID: 16807848 DOI: 10.1086/504355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2004] [Accepted: 06/01/2005] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the validity of using healthcare worker (HCW) recall of patient interactions and medical record review for contact tracing in a critical care setting. DESIGN Trained observers recorded the interactions of nurses, respiratory therapists, and service assistants with study patients in a medical-surgical intensive care unit. These observers' records were used as the reference standard to test the criterion validity of using HCW recall data or medical record review data to identify exposure characteristics. We assessed the effects of previous quarantine of the HCW (because of possible exposure) and the availability of patients' medical records for use as memory aids on the accuracy of HCW recall. SETTING A 10-bed medical-surgical intensive care unit at Mount Sinai Hospital in Toronto, Ontario. PATIENTS Thirty-six HCWs observed caring for 16 patients, for a total of 55 healthcare worker shifts. RESULTS Recall accuracy was better among HCWs who were provided with patient medical records as memory aids (P<.01). However, HCWs tended to overestimate exposures when they used patient medical records as memory aids. For 6 of 26 procedures or care activities, this tendency to overestimate was statistically significant (P<.05). Most HCWs with true exposures were identified by means of this technique, despite the overestimations. Documentation of the activities of the 4 service assistants could not be found in any of the patients' medical records. Similarly, the interactions between 6 (19%) of 32 other patient-HCW pairs were not recorded in patients' medical records. CONCLUSIONS Data collected from follow-up interviews with HCWs in which they are provided with patient medical records as memory aids should be adequate for contact tracing and for determining exposure histories. Neither follow-up interviews nor medical record review alone provide sufficient data for these purposes.
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Affiliation(s)
- M Aquino
- Department of Microbiology, Mount Sinai Hospital, Toronto, Ontario, Canada
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Chen MIC, Loon SC, Leong HN, Leo YS. Understanding the Super-spreading Events of SARS in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2006. [DOI: 10.47102/annals-acadmedsg.v35n6p390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Introduction: It has been noted that SARS transmission is characterised by a few super-spreading events (SSEs) giving rise to a disproportionate number of secondary cases. Clinical and environmental features surrounding the index cases involved were compared with cases in non-SSEs.
Materials and Methods: Data on 231 cases of probable SARS admitted to Tan Tock Seng Hospital (TTSH) were used. Index cases directly causing 10 or more secondary cases were classified as having been involved in SSEs; all others were defined as non-SSEs.
Results: Only 5 cases were involved in SSEs; all 5 were isolated on day 5 of illness or later, and spent at least a brief period in a non-isolation ward; in contrast, amongst the 226 non-SSE cases, only 40.7% and 4.0% were isolated late and admitted to non-isolation wards respectively, and only 3.1% had both these environmental features present; the differences were highly significant (P = 0.012, P <0.001 and P <0.001 by Fisher’s Exact test). When compared to 7 non-SSE cases with delayed isolation and an admission to non-isolation wards, SSEs were more likely to have co-morbid disease or require ICU care at time of isolation (P = 0.045 for both factors).
Conclusion: SSEs were likely due to a conglomeration of environmental factors of delayed isolation and admission to a non-isolation ward, coupled with severe disease stage at time of isolation.
Key words: Communicable diseases, emerging; Cross infection; Disease outbreaks; Infection control
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Lloyd-Smith JO, Schreiber SJ, Kopp PE, Getz WM. Superspreading and the effect of individual variation on disease emergence. Nature 2005; 438:355-9. [PMID: 16292310 PMCID: PMC7094981 DOI: 10.1038/nature04153] [Citation(s) in RCA: 1539] [Impact Index Per Article: 81.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2005] [Accepted: 08/22/2005] [Indexed: 01/10/2023]
Abstract
From Typhoid Mary to SARS, it has long been known that some people spread disease more than others. But for diseases transmitted via casual contact, contagiousness arises from a plethora of social and physiological factors, so epidemiologists have tended to rely on population averages to assess a disease's potential to spread. A new analysis of outbreak data shows that individual differences in infectiousness exert powerful influences on the epidemiology of ten deadly diseases. SARS and measles (and perhaps avian influenza) show strong tendencies towards ‘superspreading events’ that can ignite explosive epidemics — but this same volatility makes outbreaks more likely to fizzle out. Smallpox and pneumonic plague, two potential bioterrorism agents, show steadier growth but still differ markedly from the traditional average-based view. These findings are relevant to how emerging diseases are detected and controlled. Population-level analyses often use average quantities to describe heterogeneous systems, particularly when variation does not arise from identifiable groups1,2. A prominent example, central to our current understanding of epidemic spread, is the basic reproductive number, R0, which is defined as the mean number of infections caused by an infected individual in a susceptible population3,4. Population estimates of R0 can obscure considerable individual variation in infectiousness, as highlighted during the global emergence of severe acute respiratory syndrome (SARS) by numerous ‘superspreading events’ in which certain individuals infected unusually large numbers of secondary cases5,6,7,8,9,10. For diseases transmitted by non-sexual direct contacts, such as SARS or smallpox, individual variation is difficult to measure empirically, and thus its importance for outbreak dynamics has been unclear2,10,11. Here we present an integrated theoretical and statistical analysis of the influence of individual variation in infectiousness on disease emergence. Using contact tracing data from eight directly transmitted diseases, we show that the distribution of individual infectiousness around R0 is often highly skewed. Model predictions accounting for this variation differ sharply from average-based approaches, with disease extinction more likely and outbreaks rarer but more explosive. Using these models, we explore implications for outbreak control, showing that individual-specific control measures outperform population-wide measures. Moreover, the dramatic improvements achieved through targeted control policies emphasize the need to identify predictive correlates of higher infectiousness. Our findings indicate that superspreading is a normal feature of disease spread, and to frame ongoing discussion we propose a rigorous definition for superspreading events and a method to predict their frequency.
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Affiliation(s)
- J O Lloyd-Smith
- Department of Environmental Science, Policy and Management, 140 Mulford Hall, University of California, Berkeley, California 94720-3114, USA.
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Abstract
Severe Acute Respiratory Syndrome (SARS) emerged recently as a new infectious disease that was transmitted efficiently in the healthcare setting and particularly affected healthcare workers (HCWs), patients and visitors. The efficiency of transmission within healthcare facilities was recognised following significant hospital outbreaks of SARS in Canada, China, Hong Kong, Singapore, Taiwan and Vietnam. The causative agent of SARS was identified as a novel coronavirus, the SARS coronavirus. This was largely spread by direct or indirect contact with large respiratory droplets, although airborne transmission has also been reported. High infection rates among HCWs led initially to the theory that SARS was highly contagious and the concept of 'super-spreading events'. Such events illustrated that lack of infection control (IC) measures or failure to comply with IC precautions could lead to large-scale hospital outbreaks. SARS was eventually contained by the stringent application of IC measures that limited exposure of HCWs to potentially infectious individuals. As the 'global village' becomes smaller and other microbial threats to health emerge, or re-emerge, there is an urgent need to develop a global strategy for infection control in hospitals. This paper provides an overview of the main IC practices employed during the 2003 SARS outbreak, including management measures, dedicated SARS hospitals, personal protective equipment, isolation, handwashing, environmental decontamination, education and training. The psychological and psychosocial impact on HCWs during the outbreak are also discussed. Requirements for IC programmes in the post-SARS period are proposed based on the major lessons learnt from the SARS outbreak.
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Affiliation(s)
- Karen Shaw
- Health Protection Agency, South East Regional Office, 6th Floor New Court, 48 Carey Street, London WC2A 2JE, UK.
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Gamage B, Moore D, Copes R, Yassi A, Bryce E. Protecting health care workers from SARS and other respiratory pathogens: a review of the infection control literature. Am J Infect Control 2005; 33:114-21. [PMID: 15761412 PMCID: PMC7132691 DOI: 10.1016/j.ajic.2004.12.002] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Severe Acute Respiratory Syndrome (SARS) was responsible for outbreaks in Canada, China, Hong Kong, Vietnam, and Singapore. SARS focused attention on the adequacy of and compliance with infection control practices in preventing airborne and droplet-spread transmission of infectious agents. Methods This paper presents a review of the current scientific knowledge with respect to the efficacy of personal protective equipment in preventing the transmission of respiratory infections. The effectiveness of infection control polices and procedures used in clinical practice is examined. Results Literature searches were conducted in several databases for articles published in the last 15 years that related to infection control practices, occupational health and safety issues, environmental factors, and other issues of importance in protecting workers against respiratory infections in health care settings. Conclusion Failure to implement appropriate barrier precautions is responsible for most nosocomial transmissions. However, the possibility of a gradation of infectious particles generated by aerosolizing procedures suggests that traditional droplet transmission prevention measures may be inadequate in some settings. Further research is needed in this area.
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Affiliation(s)
- Bruce Gamage
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.
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Jarvis WR. The state of the science of health care epidemiology, infection control, and patient safety, 2004. Am J Infect Control 2004; 32:496-503. [PMID: 15573058 PMCID: PMC7124206 DOI: 10.1016/j.ajic.2004.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Being aware and implementing the latest and best scientific evidence in infection control and health care epidemiology is critical to enhancing patient outcomes. In this review, the latest published scientific data in health care epidemiology and patient safety were reviewed for the period May 2003-May 2004. Medline reviews and reviews of infection control and infectious diseases journals were used for this period. The latest guidelines and publications on antimicrobial resistance, nursing or infection control professional staffing, West Nile virus, and Severe Acute Respiratory Syndrome (SARS) are included. Awareness of these and other important infection control publications is essential if the latest measures are to be implemented to prevent and control health care-associated infections.
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McDonald LC, Simor AE, Su IJ, Maloney S, Ofner M, Chen KT, Lando JF, McGeer A, Lee ML, Jernigan DB. SARS in healthcare facilities, Toronto and Taiwan. Emerg Infect Dis 2004; 10:777-81. [PMID: 15200808 PMCID: PMC3323242 DOI: 10.3201/eid1005.030791] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The healthcare setting was important in the early spread of severe acute respiratory syndrome (SARS) in both Toronto and Taiwan. Healthcare workers, patients, and visitors were at increased risk for infection. Nonetheless, the ability of individual SARS patients to transmit disease was quite variable. Unrecognized SARS case-patients were a primary source of transmission and early detection and intervention were important to limit spread. Strict adherence to infection control precautions was essential in containing outbreaks. In addition, grouping patients into cohorts and limiting access to SARS patients minimized exposure opportunities. Given the difficulty in implementing several of these measures, controls were frequently adapted to the acuity of SARS care and level of transmission within facilities. Although these conclusions are based only on a retrospective analysis of events, applying the experiences of Toronto and Taiwan to SARS preparedness planning efforts will likely minimize future transmission within healthcare facilities.
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Abstract
Severe acute respiratory syndrome (SARS) was first recognized in China in November 2002 and was subsequently associated with a worldwide outbreak involving 8098 people, 774 of whom died. The outbreak was declared contained on July 5, 2003, after the last human chain of transmission of SARS had been broken. Whether outbreaks of SARS will return is debatable, but no one disagrees that it is important to be prepared for this possibility. This article presents an overview of the transmission and control of SARS based on the current state of knowledge derived from published studies of the outbreak and on our own personal experience.
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Affiliation(s)
- Susan M. Poutanen
- Department of Microbiology, Toronto Medical Laboratories and Mount Sinai Hospital, 600 University Avenue, Room 1470, M5G 1X5 Toronto, Ontario Canada
| | - Allison J. McGeer
- Department of Microbiology, Toronto Medical Laboratories and Mount Sinai Hospital, 600 University Avenue, Room 1470, M5G 1X5 Toronto, Ontario Canada
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Affiliation(s)
| | | | - Patricia Simone
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Umesh Parashar
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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