Infectious Diseases Society of America Guidelines on Infection Prevention for Health Care Personnel Caring for Patients with Suspected or Known COVID-19

Characterizing intubation practices in response to the COVID-19 pandemic: a survey of the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) sites

OBJECTIVE

The risk of occupational exposure during endotracheal intubation has required the global Emergency Medicine (EM), Anesthesia, and Critical Care communities to institute new COVID- protected intubation guidelines, checklists, and protocols. This survey aimed to deepen the understanding of the changes in intubation practices across Canada by evaluating the pre-COVID-19, early-COVID-19, and present-day periods, elucidating facilitators and barriers to implementation, and understanding provider impressions of the effectiveness and safety of the changes made.

METHODS

We conducted an electronic, self-administered, cross-sectional survey of EM physician site leads within the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) to characterize and compare airway management practices in the pre-COVID-19, early-COVID-19, and present-day periods. Ethics approval for this study was obtained from the University of Manitoba Health Research Ethics Board. The electronic platform SurveyMonkey ( www.surveymonkey.com ) was used to collect and store survey tool responses. Categorical item responses, including the primary outcome, are reported as numbers and proportions. Variations in intubation practices over time were evaluated through mixed-effects logistic regression models.

RESULTS

Invitations were sent to 33 emergency department (ED) physician site leads in the CCEDRRN. We collected 27 survey responses, 4 were excluded, and 23 analysed. Responses were collected in English (87%) and French (13%), from across Canada and included mainly physicians practicing in mainly Academic and tertiary sites (83%). All respondents reported that the intubation protocols used in their EDs changed in response to the COVID-19 pandemic (100%, n = 23, 95% CI 0.86-1.00).

CONCLUSIONS

This study provides a novel summary of changes to airway management practices in response to the evolving COVID-19 pandemic in Canada. Information from this study could help inform a consensus on safe and effective emergent intubation of persons with communicable respiratory infections in the future.

Perceptions, Knowledge, and Experiences of Using Face Masks among Egyptian Healthcare Workers during the COVID-19 Pandemic: A Cross-Sectional Study

Using face masks appropriately is important for preventing the community spread of respiratory infections. A cross-sectional study was conducted to evaluate the knowledge level and experience of using face masks between healthcare teams to protect them and limit the spread of COVID-19 infection. A structured questionnaire was distributed to 228 healthcare members in July–December 2021. It was divided into two sections and consisted of 29 questions for a total possible score of 0 to 29. The first section was related to perceptions and knowledge about face masks (13 items); the second was related to the experience of using face masks (16 items). The average score of this questionnaire was 23.21/29 with respect to the knowledge about face masks and their proper use techniques. The healthcare team studied had satisfactory knowledge about face mask use techniques, and the study shed light on their unsatisfactory practices. Following instructions is very vital to protecting the person wearing the mask and preventing the spread of infection during health care by blocking droplets produced by speaking or coughing. Providing the healthcare teams with knowledge and experience about how to use face masks during the pandemic is critical to increase their awareness and practice in using face masks and prevent the infection from spreading.

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

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

Evolution and Control of COVID-19 Epidemic in Hong Kong

Hong Kong SAR has adopted universal masking, social distancing, testing of all symptomatic and high-risk groups for isolation of confirmed cases in healthcare facilities, and quarantine of contacts as epidemiological control measures without city lockdown or border closure. These measures successfully suppressed the community transmission of pre-Omicron SARS-CoV-2 variants or lineages during the first to the fourth wave. No nosocomial SARS-CoV-2 infection was documented among healthcare workers in the first 300 days. The strategy of COVID-19 containment was adopted to provide additional time to achieve population immunity by vaccination. The near-zero COVID-19 situation for about 8 months in 2021 did not enable adequate immunization of the eligible population. A combination of factors was identified, especially population complacency associated with the low local COVID-19 activity, together with vaccine hesitancy. The importation of the highly transmissible Omicron variant kickstarted the fifth wave of COVID-19, which could no longer be controlled by our initial measures. The explosive fifth wave, which was partially contributed by vertical airborne transmission in high-rise residential buildings, resulted in over one million cases of infection. In this review, we summarize the epidemiology of COVID-19 and the infection control and public health measures against the importation and dissemination of SARS-CoV-2 until day 1000.

Pattern of Perioperative Surgical Patient Care, Equipment Handling and Operating Room Management During COVID-19 Pandemic at Jimma Medical Center

BACKGROUND

The nature of COVID-19 transmission creates significant risks in surgical departments owing to the close contact of medical staff with patients, the limited physical environment of the operating room and recovery room, the possibility of shared surgical equipment and challenges in the delivery of surgical care in all surgical departments. Globally, studies have reported that the effects of the pandemic on surgical departments are profound, potentially long-lasting and extensive. To manage these effects, different local guidelines and recommendations have been developed, with potential differences in their effectiveness and implementation. Therefore, harmonized and effective national/international guidelines for specific surgical departments during perioperative periods are pertinent to curtail the infection, and will inevitably need to be adapted for consistent and sustainable implementation by all medical staff. The pattern of surgical patient care during the COVID-19 pandemic at Jimma Medical Center (JMC), Ethiopia, has not been explored yet. The present study aimed to describe the pattern of perioperative surgical patient care, equipment handling and operating room management during the COVID-19 pandemic at JMC.

METHODS

A cross-sectional study was conducted to describe the pattern of perioperative surgical patient care, equipment handling and operating room management during the COVID-19 pandemic at JMC, using five-point Likert scales (0, not at all; 1, rarely; 2, sometimes; 3, most of the time; 4, frequently). A total of 90 respondents [35 patients (five patients from each of seven surgical departments) and 55 healthcare providers (six professionals from each of nine units, including the center of sterility room and anesthesia)] who were available during the study period, selected by a convenience sampling technique with multistage clustering, participated in the study. Data were collected using a structured questionnaire via direct observation and face-to-face interviews with patients undergoing surgery, healthcare providers and hospital administrators, against the standard surgical patient care guidelines. The collected data were manually checked for missing values and outliers, cleared, entered into EpiData (v4.3.1) and exported to SPSS (v22) for analysis. The mean score of practice was compared among different disciplines by applying the unpaired t-test. The findings of the study were reported using tables and narration. A p-value of less than 0.05 was declared as statistically significant.

RESULTS

Despite the surgical care practice having changed during the COVID-19 pandemic in all service domains, it is not implemented consistently among different surgical departments owing to different barriers (lack of training on the updated guidelines and financial constraints). The majority of surgical staff were implementing the use of preventive measures against COVID-19, while they were practiced less among patients. The guidelines for surgical practice during the preoperative phase were well applied, especially screening patients by different methods and the application of telemedicine to reduce physical contacts. But, against guidelines, elective patients were planned and underwent surgery, especially in the general surgery department. The implementation of recommended guidelines in the center of sterility room in handling surgical equipment was not very different before and during the pandemic. The extent of practice for anesthesia care, operating room management and postoperative care in the recovery room also changed, and the guidelines were sometimes applied.

CONCLUSION AND RECOMMENDATIONS

Although perioperative surgical care practice differed before and during the pandemic, the standard guidelines were inconsistently implemented among surgical departments. The implementation of recommended guidelines in the center of sterility room in handling surgical equipment was not very different before and during the pandemic. Thus, the authors developed safe surgical care guidelines throughout the different domains (infection prevention and PPE use; preoperative care, intraoperative care, operating room management, anesthesia care, equipment handling process and postoperative care) for all disciplines and shared them with all staff. We recommend that all surgical staff should access these guidelines and strictly adhere to them for surgical service during the pandemic.

Prevalence and factors associated with COVID-19 among healthcare workers at a university hospital in Thailand

Globally, healthcare workers (HCWs) have a high risk of SARS-CoV-2 infection, but less is known about healthcare workers in Thailand. We estimated the prevalence and risk factors for COVID-19 among HCWs in Bangkok, Thailand. A retrospective cohort study was conducted at a large tertiary care academic hospital in Thailand from May 2020 to May 2021. HCWs that presented with fever and/or acute respiratory tract symptoms who tested with RT-PCR were identified, and their clinical data were collected. There were 1432 HCWs with fever and/or acute respiratory tract symptoms during May 2020 and May 2021. A total of 167 patients were front-line HCWs and 1265 were non-front-line HCWs. Sixty HCWs (4.2%) developed COVID-19; 2 were front-line and 58 were non-front-line HCWs. The prevalence of COVID-19 in front-line HCWs was 1.7% (2/167), and 4.6% (58/1265) in non-front-line HCWs (P = .04). In addition, non-front-line HCWs, non-medical staffs, history of contact with a confirmed COVID-19 case at home/family, unvaccinated status, fair compliance to personal protective equipment (PPE) standard, and initial presentation with pneumonia were significantly more common in HCWs with COVID-19 than those without COVID-19 (P < .05). Front-line HCWs, history of contact with a confirmed COVID-19 case at the clinical care areas in the hospital, vaccinated status, good compliance to PPE standards, and initial presentation with upper respiratory infection were significantly more common in HCWs without COVID-19 than those with COVID-19 (P < .05). Multivariate analysis revealed history of exposure with confirmed COVID-19 case at home or in family, unvaccinated status, non-frontline-HCWs, non-medical staffs, and fair compliance to PPE standard to be independent factors associated with COVID-19 in HCWs. COVID-19 was more common in non-front-line HCWs at this tertiary hospital. Thai guidelines on infection prevention and control for COVID-19 seem to be effective in preventing SARS-CoV-2 transmission. Therefore, the adherence to these recommendations should be encouraged.

A full-face mask for protection against respiratory infections

BACKGROUND

Aerosols and droplets are the transmission routes of many respiratory infectious diseases. The COVID-19 management guidance recommends against the use of nebulized inhalation therapy directly in the emergency room or in an ambulance to prevent possible viral transmission. The three-dimensional printing method was used to develop an aerosol inhalation treatment mask that can potentially prevent aerosol dispersion. We conducted this utility validation study to understand the practicability of this new nebulizer mask system.

RESULTS

The fit test confirmed that the filter can efficiently remove small particles. The different locations of the mask had an excellent fit with a high pressure making a proper face seal usability. The full-face mask appeared to optimize filtration with pressure and is an example of materials that perform well for improvised respiratory protection using this design. The filtering effect test confirmed that the contamination of designated locations could be protected when using the mask with filters. As in the clinical safety test, a total of 18 participants (10 [55.6%] females; aged 33.1 ± 0.6 years) were included in the final analysis. There were no significant changes in SPO₂, EtCO₂, HR, SBP, DBP, and RR at the beginning, 20th, 40th, or 60th minutes of the test (all p >.05). The discomfort of wearing a mask increased slightly after time but remained within the tolerable range. The vision clarity score did not significantly change during the test. The mask also passed the breathability test.

CONCLUSION

The results of our study showed that this mask performed adequately in the fit test, the filtering test, and the clinical safety test. The application of a full-face mask with antiviral properties, together with the newly designed shape of a respirator that respects the natural curves of a human face, will facilitate the production of personal protective equipment with a highly efficient filtration system.

METHODS

We conducted three independent tests in this validation study: (1) a fit test to calculate the particle number concentration and its association with potential leakage; (2) a filtering effect test to verify the mask's ability to contain aerosol spread; and (3) a clinical safety test to examine the clinical safety, comfortableness, and visual clarity of the mask.

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

Background

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

Main text

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

Conclusion

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

Supplementary Information

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

Respirators in Healthcare: Material, Design, Regulatory, Environmental, and Economic Considerations for Clinical Efficacy

Maintaining an ample supply of personal protective equipment continues to be a challenge for the healthcare industry, especially during emergency situations and times of strain on the supply chain. Most critically, healthcare workers exposed to potential airborne hazards require sufficient respiratory protection. Respirators are the only type of personal protective equipment able to provide adequate respiratory protection. However, their ability to shield hazards depends on design, material, proper fit, and environmental conditions. As a result, not all respirators may be adequate for all scenarios. Additionally, factors including user comfort, ease of use, and cost contribute to respirator effectiveness. Therefore, a careful consideration of these parameters is essential for ensuring respiratory protection for those working in the healthcare industry. Here respirator design and material characteristics are reviewed, as well as properties of airborne hazards and potential filtration mechanisms, regulatory standards of governmental agencies, respirator efficacy in the clinical setting, attitude of healthcare personnel toward respiratory protection, and environmental and economic considerations of respirator manufacturing and distribution.

Stigma toward healthcare providers from patients during COVID-19 era in Jordan

AIM

This study aimed to explore healthcare providers' (HCP) stigmatization from patients during the COVID-19 outbreak in Jordan.

METHOD

A cross-sectional design was used. Data collection was conducted between May and July 2021. The research questionnaire included demographic information about participants and multiple statements that reflect stigma of participants toward HCPs. Regression analysis was conducted to assess the association between stigma and explanatory variables.

RESULTS

A total of 777 surveys were included in the study. Many people show high stigma toward HCPs during COVID-19 pandemic. Various factors including hearing news all time (p<.001), having children (p<.024), and smoking (p<.001) were significant in prediction stigma toward HCPs.

CONCLUSION

This one of few studies conducted in Jordan regarding the stigma toward HCP from other people with chronic diseases. Our study found that many people showed some stigma toward HCP during COVID-19. Stigmatization of HCP related to a pandemic is a lesson most people have not learned. It is not enough to cheer HCPs. A clear, sensible public education campaign about the public's risks by interacting with HCP is necessary.

Infection Prevention during the Coronavirus Disease 2019 Pandemic

COVID-19 is a nonspecific viral illness caused by a novel coronavirus, SARS-CoV-2, and led to an ongoing global pandemic. Transmission is primarily human-to-human via contact with respiratory particles containing infectious virus. The risk of transmission to health care personnel is low with proper use of personal protective equipment, including gowns, gloves, N95 or surgical mask, and eye protection. Additional measures affecting the risk of transmission include physical distancing, hand hygiene, routine cleaning and disinfection, appropriate air handling and ventilation, and public health interventions such as universal masking and stay-at-home orders.

Impact of respirator versus surgical masks on SARS-CoV-2 acquisition in healthcare workers: a prospective multicentre cohort

Background

There is insufficient evidence regarding the role of respirators in the prevention of SARS-CoV-2 infection. We analysed the impact of filtering facepiece class 2 (FFP2) versus surgical masks on the risk of SARS-CoV-2 acquisition among Swiss healthcare workers (HCW).

Methods

Our prospective multicentre cohort enrolled HCW from June to August 2020. Participants were asked about COVID-19 risk exposures/behaviours, including preferentially worn mask type when caring for COVID-19 patients outside of aerosol-generating procedures. The impact of FFP2 on (1) self-reported SARS-CoV-2-positive nasopharyngeal PCR/rapid antigen tests captured during weekly surveys, and (2) SARS-CoV-2 seroconversion between baseline and January/February 2021 was assessed.

Results

We enrolled 3259 participants from nine healthcare institutions, whereof 716 (22%) preferentially used FFP2. Among these, 81/716 (11%) reported a SARS-CoV-2-positive swab, compared to 352/2543 (14%) surgical mask users; seroconversion was documented in 85/656 (13%) FFP2 and 426/2255 (19%) surgical mask users. Adjusted for baseline characteristics, COVID-19 exposure, and risk behaviour, FFP2 use was non-significantly associated with decreased risk for SARS-CoV-2-positive swab (adjusted hazard ratio [aHR] 0.8, 95% CI 0.6–1.0) and seroconversion (adjusted odds ratio [aOR] 0.7, 95% CI 0.5–1.0); household exposure was the strongest risk factor (aHR 10.1, 95% CI 7.5–13.5; aOR 5.0, 95% CI 3.9–6.5). In subgroup analysis, FFP2 use was clearly protective among those with frequent (> 20 patients) COVID-19 exposure (aHR 0.7 for positive swab, 95% CI 0.5–0.8; aOR 0.6 for seroconversion, 95% CI 0.4–1.0).

Conclusions

Respirators compared to surgical masks may convey additional protection from SARS-CoV-2 for HCW with frequent exposure to COVID-19 patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01070-6.

Renoprotective effect of N-acetylcystein and vitamin E in bisphenol A-induced rat nephrotoxicity; Modulators of Nrf2/ NF-κB and ROS signaling pathway

BACKGROUND AND AIM OF THE WORK

Bisphenol A (BPA) is a chemical product that is widely used as a plastic precursor. It acts directly on the kidney mitochondria, causing renal dysfunction. N-acetylcysteine is effective in protecting the kidneys from chemical-induced damage. Vitamin E is an antioxidant that protects cells from the damaging effects of free radicals. The aim of this study is to further evaluate and compare NAC and vitamin E to oppose the nephrotoxicity caused by BPA.

RESEARCH DESIGN AND METHODS

Forty-two adult male rats were divided into 7 groups:  control, BPA, NAC, vitamin E, BPA plus NAC, BPA plus vitamin E, and combined BPA, NAC and vitamin E. BPA, NAC, vitamin E were given orally at doses of 50 mg/kg, 200 mg/kg, and 1000 mg/kg respectively, for 5 weeks.

RESULTS

NAC and vitamin E groups showed improved kidney function tests and alleviated BPA-induced oxidative stress; increased GSH and decreased MDA, NO and iNOS levels. NAC and vitamin E significantly attenuated inflammation; decreased NF-κB and increased IL-4, and Nrf2, in addition there was alleviation of renal histopathology. To some extent, vitamin E administration showed significant improvement. Moreover, combined NAC and vitamin E treatment showed more significance than either NAC or vitamin E separate groups.

CONCLUSIONS

This study determined the substantial protective effects of NAC and/or vitamin E in BPA-induced nephrotoxicity through modulation of Nrf2 with subsequent improvement of oxidative stress and inflammation. The alleviation was more significant in combined NAC and vitamin E treatment mainly through their synergistic effect on Nrf2.

Can a combination of vaccination and face mask wearing contain the COVID-19 pandemic?

The COVID‐19 pandemic is going into its third year with Europe again being the focus of major epidemic activity. The present review tries to answer the question whether one can come to grip with the pandemic by a combination of vaccinations and non‐pharmaceutical interventions (NPIs). Several COVID‐19 vaccines are of remarkable efficacy and achieve high protection rates against symptomatic disease, especially severe disease, but mathematical models suggest that the current vaccination coverage in many countries is insufficient to achieve pandemic control. NPIs are needed as complementary measures because recent research has also revealed the limits of vaccination alone. Here, we review the evidence for efficacy of face mask wearing in various settings. Overall pooled analysis showed significant reduction in COVID‐19 incidence with mask wearing, although heterogeneity between studies was substantial. Controlled trials of mask wearing are difficult to conduct, separating mask wearing effects in population studies from the impact of other NPIs is challenging and the efficacy of masks depend on mask material and mask fit. The combination of vaccination and mask wearing is potentially synergistic since vaccination protects so far well from disease development (the omicron variant is currently an unknown) but immunity from infection wanes over few months after vaccination. In comparison, masks interfere with the virus transmission process at a level of a physical barrier independent of coronavirus variant. Vaccination and masks are much less costly to apply than other NPI measures which are associated with high economic and social costs, but paradoxically both measures are the target of a vocal opposition by a sizable minority of the society. In parallel with biomedical research, we need more social science research into this opposition to guide political decisions on how to end the pandemic.

The present review tries to answer the question whether one can control the pandemic by a combination of vaccinations and non‐pharmaceutical interventions. The combination of vaccination and mask wearing is potentially synergistic since vaccination protects so far well from disease while masks interfere with the virus transmission process as a physical barrier against any type of coronavirus variant.

Lessons learned 1 year after SARS-CoV-2 emergence leading to COVID-19 pandemic

Without modern medical management and vaccines, the severity of the Coronavirus Disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome (SARS) coronavirus 2 (SARS-CoV-2) might approach the magnitude of 1894-plague (12 million deaths) and 1918-A(H1N1) influenza (50 million deaths) pandemics. The COVID-19 pandemic was heralded by the 2003 SARS epidemic which led to the discovery of human and civet SARS-CoV-1, bat SARS-related-CoVs, Middle East respiratory syndrome (MERS)-related bat CoV HKU4 and HKU5, and other novel animal coronaviruses. The suspected animal-to-human jumping of 4 betacoronaviruses including the human coronaviruses OC43(1890), SARS-CoV-1(2003), MERS-CoV(2012), and SARS-CoV-2(2019) indicates their significant pandemic potential. The presence of a large reservoir of coronaviruses in bats and other wild mammals, culture of mixing and selling them in urban markets with suboptimal hygiene, habit of eating exotic mammals in highly populated areas, and the rapid and frequent air travels from these areas are perfect ingredients for brewing rapidly exploding epidemics. The possibility of emergence of a hypothetical SARS-CoV-3 or other novel viruses from animals or laboratories, and therefore needs for global preparedness should not be ignored. We reviewed representative publications on the epidemiology, virology, clinical manifestations, pathology, laboratory diagnostics, treatment, vaccination, and infection control of COVID-19 as of 20 January 2021, which is 1 year after person-to-person transmission of SARS-CoV-2 was announced. The difficulties of mass testing, labour-intensive contact tracing, importance of compliance to universal masking, low efficacy of antiviral treatment for severe disease, possibilities of vaccine or antiviral-resistant virus variants and SARS-CoV-2 becoming another common cold coronavirus are discussed.

Factors affecting decontamination of N95 masks for reuse: Feasibility & practicality of various methods

The SARS-CoV-2 pandemic has led to an enormous increase in cases worldwide in a short time. The potential shortage might call for the reuse of personal protective equipment especially N95 masks. In this review, the methods available for decontamination of N95 masks have been compared to highlight the advantages and efficacies of different methods. Studies conducted to evaluate the biocidal efficacy, effect on filtration efficacy of the decontamination method, and maintenance of structural integrity of masks, were reviewed. Ultraviolet germicidal irradiation (UVGI) and hydrogen peroxide (H2O2) vapour were the most commonly evaluated interventions and showed good germicidal activity without significant deleterious effects on mask performance. Vapourous H2O2 was the best method as it maintained NIOSH (The National Institute for Occupational Safety and Health) recommendations of the mask on re-use and additionally, one mask could be decontaminated and reused 30 times. Ethylene oxide (EtO) preserved the maximum filtration efficacy and flow resistance. Chemical and heat-based methods had the advantages of being cost-effective and feasible but affected the structural integrity and fit of the masks. For the decontamination of N95 masks, among the heat-based methods steam was found to be the best for low middle-income countries setting. H2O2-based methods, UVGI, and EtO all exhibited both adequate biocidal efficacies and functionality (fit testing and structural integrity). Further studies on logistics, healthcare worker acceptability of reuse, and actual efficacy of protection against SARS-CoV-2 infection should be carried out to validate the use of decontamination in the real-life settings.

Assessment of Perceived Compliance and Barriers to Personal Protective Equipment Use Among Healthcare Workers During the COVID-19 Pandemic's Second Wave Surge: "Walk to Talk" Cross-Sectional Correlational Study

OBJECTIVE

This study aimed at investigating HCWs' perceptions of PPE compliance and barriers, as well as influencing factors, in order to develop methods to combat the rise in their infection rates.

METHODS

During the 'second wave' surge, a cross-sectional correlational analysis was conducted over a 1-month period. It consists of HCWs from various hospital sectors that admit COVID-19 patients using an online self-administered predesigned tool.

RESULTS

Out of the 285 recruited participants, 36.1% had previously been diagnosed with COVID-19. Around 71% received training on PPE use. The perceived compliance was good for (PPE) usage (mean 2.60 ± 1.10). A significant higher compliance level was correlated with previous diagnosis with COVID-19, working with patients diagnosed with COVID-19, and having a direct contact with a family member older than 45 years old (P < 0.01). The main perceived barriers to the use of PPEs were unavailability of full PPEs (35%), interference with their ability to provide patient care (29%), not enough time to comply with the rigors of PPEs (23.2%) and working in emergency situations (22.5%). With regards to perceived barriers, those working with patients diagnosed with COVID-19 and those who reported having a direct contact with a family member older than 45 years old showed significantly higher level of barriers.

CONCLUSION

A series of measures, including prioritization of PPE acquisition, training, and monitoring to guarantee appropriate resources for IPC, are necessary to reduce transmission.

Research on Dry Microwave Heating Infectious Aerosols or Droplets on Respirators

Dramatic shortages of filtering facepiece respirator supplies generally occur following the outbreak of a pandemic such as COVID-19. Here, the decontamination and reuse of respirators are considered. Among decontamination methods, microwave irradiation has great potential because of easy access of microwave ovens. However, can a respirator be heated in a microwave oven for a certain time and then be reused? Herein, we demonstrate that dry microwave irradiation cannot heat infectious aerosols or droplets up to their deactivation temperature. The microwave absorption performance of a single aerosol or droplet was analyzed theoretically. The multiphysics simulation results indicate that a single aerosol or droplet can be barely heated under dry microwave irradiation. Experiments were carried out using a traveling wave system to verify the simulation. Following this, we simulated multiple aerosols and droplets on a respirator material, with the results indicating that the aerosols and droplets were at the same temperature as that of the respirator. Experimental measurements using a microwave oven demonstrated that the temperature increase of an N95 respirator under dry heating is less than 10 °C, which is far less than the temperature required to deactivate the COVID-19 virus. Although dry microwave heating cannot be used to heat the aerosols or droplets, microwave-generated steam has proved effective in deactivating infectious biological organisms. Therefore, to successfully decontaminate a used respirator in a microwave oven, a reservoir with a small amount of water beneath the respirator (or a steam bag to accommodate it) is essential to the decontamination process.

Effectiveness and safety of noninvasive positive pressure ventilation in the treatment of COVID-19-associated acute hypoxemic respiratory failure: a single center, non-ICU setting experience

The role of noninvasive positive pressure ventilation (NIPPV) in COVID-19 patients with acute hypoxemic respiratory failure (AHRF) is uncertain, as no direct evidence exists to support NIPPV use in such patients. We retrospectively assessed the effectiveness and safety of NIPPV in a cohort of COVID-19 patients consecutively admitted to the COVID-19 general wards of a medium-size Italian hospital, from March 6 to May 7, 2020. Healthcare workers (HCWs) caring for COVID-19 patients were monitored, undergoing nasopharyngeal swab for SARS-CoV-2 in case of onset of COVID-19 symptoms, and periodic SARS-CoV-2 screening serology. Overall, 50 patients (mean age 74.6 years) received NIPPV, of which 22 (44%) were successfully weaned, avoiding endotracheal intubation (ETI) and AHRF-related death. Due to limited life expectancy, 25 (50%) of 50 NIPPV-treated patients received a "do not intubate" (DNI) order. Among these, only 6 (24%) were weaned from NIPPV. Of the remaining 25 NIPPV-treated patients without treatment limitations, 16 (64%) were successfully weaned, 9 (36%) underwent delayed ETI and, of these, 3 (33.3%) died. NIPPV success was predicted by the use of corticosteroids (OR 15.4, CI 1.79-132.57, p 0.013) and the increase in the PaO₂/FiO₂ ratio measured 24-48 h after NIPPV initiation (OR 1.02, CI 1-1.03, p 0.015), while it was inversely correlated with the presence of a DNI order (OR 0.03, CI 0.001-0.57, p 0.020). During the study period, 2 of 124 (1.6%) HCWs caring for COVID-19 patients were diagnosed with SARS-CoV-2 infection. Apart from patients with limited life expectancy, NIPPV was effective in a substantially high percentage of patients with COVID-19-associated AHRF. The risk of SARS-CoV-2 infection among HCWs was low.

Commonly available but highly effective protection against SARS-CoV-2 during gastrointestinal endoscopies

BACKGROUND AND AIMS

SARS-CoV-2 is a worldwide serious health problem. The aim of this study was to demonstrate the number of potentially infectious particles present during endoscopic procedures and find effective tools to eliminate the risks of SARS-CoV-2 infection while performing them.

METHODS

An experimental model which focused on aerosol problematics was made in a specialized laboratory. This model simulated conditions present during endoscopic procedures and monitored the formation of potentially infectious fluid particles from the patient's body, which pass through the endoscope and are then released into the environment. For this reason, we designed and tested a prototype of a protective cover for the endoscope's control body to prevent the release and spread of these fluid particles from its working channel. We performed measurements with and without the protective cover of the endoscope's control body.

RESULTS

It was found that liquid coming through the working channel of the endoscope with forceps or other instruments inside generates droplets with a diameter in the range of 0.1-1.1 mm and an initial velocity of up to 0.9 m/s. The average number of particles per measurement per whole measured area without a protective cover on the endoscope control body was 51.1; with this protective cover on, the measurement was 0.0, p<0.0001.

CONCLUSIONS

Our measurements proved that fluid particles are released from the working channel of an endoscope when forceps are inserted. A special protective cover for the endoscope control body, made out of breathable material (surgical cap) and designed by our team, was found to eliminate this release of potentially infectious fluid particles.

Analysis of the Impact of the Coronavirus Disease Epidemic on the Emergency Medical System in South Korea Using the Korean Triage and Acuity Scale

PURPOSE

Severe acute respiratory syndrome coronavirus 2, which causes coronavirus disease 2019 (COVID-19), has spread worldwide. Global health systems, including emergency medical systems, are suffering from a lack of medical resources. Using a method for classifying patients visiting the emergency department (ED), we aimed to investigate trends in emergency medical system usage during the COVID-19 epidemic in Korea.

MATERIALS AND METHODS

This retrospective observational study included patients who visited emergency medical institutions registered with the National Emergency Department Information System database from January 1, 2017 to May 31, 2020. The primary outcome was identification of changes in the distribution of patients visiting the ED according to the type of emergency medical institution. The secondary outcome was a detailed comparison of Korean Triage and Acuity Scale (KTAS) levels and patient distributions before and during the infectious disaster crisis period.

RESULTS

Severe patients visited regional emergency centers (RECs) and local emergency centers (LECs) more frequently during the COVID-19 period, and disposition status warranting admission to the intensive care unit or resulting in death was more common in RECs and LECs during the COVID-19 period [RECs, before COVID-19: 300686 (6.3%), during COVID-19: 33548 (8.0%) (p<0.001); LECs, before COVID-19: 373593 (3.7%), during COVID-19: 38873 (4.5%) (p<0.001)].

CONCLUSION

During the COVID-19 period, severe patients were shifted to advanced emergency medical institutions, and the KTAS better reflected severe patients. Patient distribution according to the stage of emergency medical institution improved, and validation of the KTAS triage increased more in RECs.

COVID-19-Lessons Learned and Questions Remaining

In this article, the editors of Clinical Infectious Diseases review some of the most important lessons they have learned about the epidemiology, clinical features, diagnosis, treatment and prevention of SARS-CoV-2 infection and identify essential questions about COVID-19 that remain to be answered.

Continuum of care for patients with obstructive sleep apnea after one year from the COVID-19 pandemic onset: no time for further delays: practical issues for a safe and effective management

Since the SARS-CoV-2 pandemic onset, many routine medical activities have been put on hold and this has deeply affected the management of patients with chronic diseases such as obstructive sleep apnea. Untreated OSA is associated with increased mortality and difficulties in social functioning. A delay in initiating treatment may therefore have harmful consequences. Between February and April 2020, the so-called first wave of the pandemic, the overall activity of sleep centers in Europe was reduced by 80%. As the international infection control authorities released guidelines for SARS-CoV-2 outbreak control, many of the national sleep societies provided strategies for a gradual re-opening of sleep facilities. Most of these strategies were not evidences-based and, in a climate of general concern, worldwide it was strongly advised to post-pone any non-urgent sleep-related procedure. Despite the initial idea that the outbreak could be transient, after one year it is still ongoing and the price we are paying, not only includes deaths caused by COVID-19, but also deaths caused by missed or late diagnosis. As further delays in diagnosing and treating patients with sleep apnea are no more acceptable, a new arrangement of sleep facilities and resources, in order to operate safely and effectively, is now mandatory. In this article, we review most recent literature and guidelines in order to provide practical advice for a new arrangement of sleep laboratories and the care of patients with obstructive sleep apnea after one year from the onset of the COVID-19 pandemic.

COVID-19 Infection, Reinfection, and Vaccine Effectiveness in a Prospective Cohort of Arizona Frontline/Essential Workers: The AZ HEROES Research Protocol

BACKGROUND

The Arizona Healthcare, Emergency Response, and Other Essential workers Study (AZ HEROES) aims to examine the epidemiology of SARS-CoV-2 infection and COVID-19 illness among adults with high occupational exposure risk.

OBJECTIVE

Study objectives include estimating incidence of SARS-CoV-2 infection in essential workers by symptom presentation and demographic factors, determining independent effects of occupational and community exposures on incidence of SARS-CoV-2 infection, establishing molecular and immunologic characteristics of SARS-CoV-2 infection in essential workers, describing the duration and patterns of rRT-PCR-positivity, and examining post-vaccine immunologic response.

METHODS

Eligible participants include Arizona residents aged 18-85 years who work at least 20 hours per week in an occupation involving regular direct contact (within three feet) with others. Recruitment goals are stratified by demographic characteristics (50% aged 40 or older, 50% women, and 50% Hispanic or American Indian), by occupation (40% healthcare personnel, 30% first responders, and 30% other essential workers), and by prior SARS-CoV-2 infection (with up to 50% seropositive at baseline). Information on sociodemographics, health and medical history, vaccination status, exposures to individuals with suspected or confirmed SARS-CoV-2 infection, use of personal protective equipment, and perceived risks are collected at enrollment and updated through quarterly surveys. Every week, participants complete active surveillance for COVID-19-like illness (CLI) and self-collect nasal swabs. Additional self-collected nasal swab and saliva specimens are collected in the event of CLI onset. Respiratory specimens are sent to Marshfield Laboratories and tested for SARS-CoV-2 by real-time reverse transcription polymerase chain reaction (rRT-PCR) assay. CLI symptoms and impact on work and productivity are followed through illness resolution. Serum specimens are collected every 3 months and additional sera are collected following incident rRT-PCR positivity and after each COVID-19 vaccine dose. Incidence of SARS-CoV-2 infections will be calculated by person-weeks at risk and compared by occupation and demographic characteristics and by seropositivity status and infection and vaccination history.

RESULTS

The AZ HEROES study was funded by the Centers for Disease Control and Prevention. Enrollment began July 27, 2020 and as of May 1, 2021 a total of 3,165 participants have been enrolled in the study.

CONCLUSIONS

AZ HEROES is unique in aiming to recruit a diverse sample of essential workers and prospectively following strata of SARS-CoV-2 seronegative and seropositive adults. Survey results combined with active surveillance data on exposure, CLI, weekly molecular diagnostic testing, and periodic serology will be used to estimate the incidence of symptomatic and asymptomatic SARS-CoV-2 infection, assess the intensity and durability of immune responses to natural infection and COVID-19 vaccination, and contribute to the evaluation of COVID-19 vaccine effectiveness.

CLINICALTRIAL

INTERNATIONAL REGISTERED REPORT

DERR1-10.2196/28925.

Response to COVID-19 Pandemic: Managing Inpatient Pharmacy Services at King Abdulaziz Medical City - Jeddah

Since early December 2019, the coronavirus disease 2019 (COVID-19) has been relentlessly spread worldwide and has hit the healthcare systems with terrible force. Pharmacists play a vital role in the healthcare system in providing medicines, therapeutics, vaccines, clinical services, and other pharmaceutical care services to patients. Therefore, to ensure all these services continued at King Abdulaziz Medical City - Jeddah during the COVID-19 pandemic, the Department of Pharmaceutical Care initiated a departmental crisis preparedness plan, as a part of general hospital preparedness plan. It started with adjusting medication dosing time, instituting a daily medication refill process, working remotely, expanding the use of automation, and modifying employee schedules. Other actions included the following: handling drug shortages, placing restrictions on some medications, using personal protective equipment, changing routine practices of pharmacy aides, revising the medication delivery process, starting a contingency training program, and restricting pneumatic tube operation. We took guidance from the Ministry of Health, our own institute's experience, World Health Organization recommendations, updated scientific research, and the American Society of Health-System Pharmacists regulatory updates. This article aims to describe how health services, policies, and systems were applied and adapted to address a specific problem while maintaining all pharmacy employees' safety. This article reviews the inpatient pharmacy's particular needs and responses to these needs to meet the COVID-19 pandemic challenges.

Novel coronavirus seropositivity and related factors among healthcare workers at a university hospital during the prevaccination period: a cross-sectional study

BACKGROUND

This study aimed to investigate the specific risk factors for the transmission of novel coronavirus (SARS-CoV-2) among healthcare workers in different campuses of a university hospital and to reveal the risk factors for antibody positivity.

METHODS

In this retrospective cross-sectional study, 2988 (82%) of 3620 healthcare workers in a university hospital participated. The coronavirus disease 2019 (COVID-19) antibody was investigated using serum from healthcare workers who underwent COVID-19 antibody testing. The antibody test results of the participants were evaluated based on their work campus, their profession and their workplace. The statistical significance level was p < 0.05 in all analyses.

RESULTS

Of the participants in this study, 108 (3.6%) were antibody positive, and 2880 (96.4%) were negative. Antibody positivity rates were greater in nurses compared with other healthcare workers (p < 0.001). Regarding workplace, antibody positivity was greater in those working in intensive care compared to those working in other locations (p < 0.001).

CONCLUSIONS

Healthcare workers are at the highest risk of being infected with COVID-19. Those who have a higher risk of infection among healthcare workers and those working in high-risk areas should be vaccinated early and use personal protective equipment during the pandemic.

TRIAL REGISTRATION

Retrospective permission was obtained from both the local ethics committee and the Turkish Ministry of Health for this study (IRB No:71522473/050.01.04/370, Date: 05.20.2020).

Multipronged infection control strategy to achieve zero nosocomial coronavirus disease 2019 (COVID-19) cases among Hong Kong healthcare workers in the first 300 days of the pandemic

Background:

Nosocomial outbreaks leading to healthcare worker (HCW) infection and death have been increasingly reported during the coronavirus disease 2019 (COVID-19) pandemic.

Objective:

We implemented a strategy to reduce nosocomial acquisition.

Methods:

We summarized our experience in implementing a multipronged infection control strategy in the first 300 days (December 31, 2019, to October 25, 2020) of the COVID-19 pandemic under the governance of Hospital Authority in Hong Kong.

Results:

Of 5,296 COVID-19 patients, 4,808 (90.8%) were diagnosed in the first pandemic wave (142 cases), second wave (896 cases), and third wave (3,770 cases) in Hong Kong. With the exception of 1 patient who died before admission, all COVID-19 patients were admitted to the public healthcare system for a total of 78,834 COVID-19 patient days. The median length of stay was 13 days (range, 1–128). Of 81,955 HCWs, 38 HCWs (0.05%; 2 doctors and 11 nurses and 25 nonprofessional staff) acquired COVID-19. With the exception of 5 of 38 HCWs (13.2%) infected by HCW-to-HCW transmission in the nonclinical settings, no HCW had documented transmission from COVID-19 patients in the hospitals. The incidence of COVID-19 among HCWs was significantly lower than that of our general population (0.46 per 1,000 HCWs vs 0.71 per 1,000 population; P = .008). The incidence of COVID-19 among professional staff was significantly lower than that of nonprofessional staff (0.30 vs 0.66 per 1,000 full-time equivalent; P = .022).

Conclusions:

A hospital-based approach spared our healthcare service from being overloaded. With our multipronged infection control strategy, no nosocomial COVID-19 in was identified among HCWs in the first 300 days of the COVID-19 pandemic in Hong Kong.

Management of infants born to mothers with suspected or confirmed SARS-CoV-2 infection in the delivery room: A tentative proposal 2020

Coronavirus disease 2019 (COVID-19) has spread worldwide within a short period, and there is still no sign of an end to the pandemic. Management of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected pregnant women at the time of delivery presents a unique challenge. To fulfill the goal of providing adequate management of such women and their infants, and to decrease the risk of exposure of the healthcare providers, tentative guidelines are needed until more evidence is collected. Practical preventative action is required that takes into account the following infection routes: (i) aerosol transmission from mothers to healthcare providers, (ii) horizontal transmission to healthcare providers from infants infected by their mothers, and (iii) horizontal transmission from mothers to infants. To develop standard operating procedures, briefings/training simulations should be carried out, taking into account the latest information. Briefings should be carefully conducted to clarify the role and procedures. Healthcare providers should wear personal protective equipment. If it is physically possible, neonatal resuscitation should be performed in a separate area next to the delivery room. If a separate area is not available, the infant warmer should be placed at least 2 m away from the delivery table, or partitioned off in the same room. A minimum number of skilled personnel should participate in resuscitation using the latest neonatal resuscitation algorithms.

A Nurse's Guide to COVID-19

ABSTRACT

To assist nurses caring for hospitalized adults with coronavirus disease 2019 (COVID-19), the authors synthesize evidence-based information on the disease, providing background on the epidemiology and history of severe acute respiratory syndrome coronavirus 2, the causative virus. They also discuss the risks for severe effects of the illness, the multiple signs and symptoms hospitalized adults with COVID-19 may manifest, and the precautions hospitals should take to keep health care providers and patients safe during the course of this pandemic.

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

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.

Filtration Efficiency of Hospital Face Mask Alternatives Available for Use During the COVID-19 Pandemic

IMPORTANCE

Procuring respiratory protection for clinicians and other health care workers has become a major challenge of the coronavirus disease 2019 (COVID-19) pandemic and has resulted in nonstandard practices such as the use of expired respirators and various decontamination processes to prolong the useful life of respirators in health care settings. In addition, imported, non-National Institute for Occupational Safety and Health (NIOSH)-approved respirators have been donated or acquired by hospitals as a potential replacement for limited NIOSH-approved N95 respirators.

OBJECTIVE

To assess fitted filtration efficiencies (FFEs) for face mask alternatives used during the COVID-19 pandemic.

DESIGN, SETTING, AND PARTICIPANTS

For this quality-improvement study conducted between April and June 2020, we used the Occupational Safety and Health Administration's Quantitative Fit Testing Protocol for Filtering Facepiece Respirators in a laboratory atmosphere supplemented with sodium chloride particles to assess the FFEs of a variety of respirators worn by a male volunteer and female volunteer.

MAIN OUTCOMES AND MEASURES

The FFEs of respirators commonly worn by clinicians and other health care workers and available respirator alternatives during the COVID-19 pandemic.

RESULTS

Of the 29 different fitted face mask alternatives tested on 1 man and 1 woman, expired N95 respirators with intact elastic straps and respirators subjected to ethylene oxide and hydrogen peroxide sterilization had unchanged FFE (>95%). The performance of N95 respirators in the wrong size had slightly decreased performance (90%-95% FFE). All of the respirators not listed as approved in this evaluation (n = 6) failed to achieve 95% FFE. Neither of the 2 imported respirators authorized for use by the Centers for Disease Control and Prevention that were not NIOSH-approved tested in this study achieved 95% FFE, and the more effective of the 2 functioned at approximately 80% FFE. Surgical and procedural face masks had filtering performance that was lower relative to that of N95 respirators (98.5% overall FFE), with procedural face masks secured with elastic ear loops showing the lowest efficiency (38.1% overall FFE).

CONCLUSIONS AND RELEVANCE

This quality-improvement study evaluating 29 face mask alternatives for use by clinicians interacting with patients during the COVID-19 pandemic found that expired N95 respirators and sterilized, used N95 respirators can be used when new N95 respirators are not available. Other alternatives may provide less effective filtration.

Decontamination and reuse of N95 filtering facemask respirators: A systematic review of the literature

INTRODUCTION

As has happened in other emerging respiratory pandemics, demand for N95 filtering facemask respirators (FFRs) has far exceeded their manufacturing production and availability in the context of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. One of the proposed strategies for mitigating the massive demand for N95 FFRs is their reuse after a process of decontamination that allows the inactivation of any potentially infectious material on their surfaces. This article aims to summarize all of the available evidence on the different decontamination methods that might allow disposable N95 FFRs to be reused, with emphasis on decontamination from SARS-CoV-2.

METHODS

We performed a systematic review of the literature in order to identify studies reporting outcomes of at least 1 decontamination method for inactivating or removing any potentially infectious material from the surface of N95 FFRs, specifically addressing issues related to reduction of the microbial threat (including SARS-CoV-2 when available), maintaining the function of N95 FFRs and a lack of residual toxicity.

RESULTS

We identified a total of 15 studies reporting on the different decontamination methods that might allow disposable N95 FFRs to be reused, including small-scale energetic methods and disinfecting solutions/spray/wipes. Among these decontamination methods, ultraviolet germicidal irradiation and vaporized hydrogen peroxide seem to be the most promising decontamination methods for N95 FFRs, based on their biocidal efficacy, filtration performance, fitting characteristics, and residual chemical toxicity, as well as other practical aspects such as the equipment required for their implementation and the maximum number of decontamination cycles.

CONCLUSIONS

Although all the methods for the decontamination and reuse of N95 FFRs have advantages and disadvantages, ultraviolet germicidal irradiation and vaporized hydrogen peroxide seem to be the most promising methods.

Decontamination and Reuse of N95 Masks: A Narrative Review

BACKGROUND

The COVID-19 pandemic has presented an unprecedented strain on healthcare supplies. Currently there is a global shortage of personal protective equipment (PPE), especially N95 masks. In order to safeguard healthcare personnel in this critical time and to mitigate shortages of N95 respirators, reuse of N95 respirators has to be considered.

METHODS

Using PubMed and Science Direct, a literature search was conducted to find and synthesize relevant literature on decontamination of N95 respirators for their subsequent reuse. Peer-reviewed publications related to methods of decontamination from January 2007 to April 2020 in the English language are included in this narrative review. Bibliographies of articles for relevant literature were also scrutinized. Findings. A total of 19 studies are included in this narrative review. The appraised methods include ultraviolet germicidal irradiation (UVGI), moist heat incubation (MHI), ethylene oxide (EtO), hydrogen peroxide vapor (HPV), microwave steam bags (MSB), microwave-generated steam (MGS), dry microwave oven irradiation, hydrogen peroxide gas plasma (HPGP), dry heat, liquid hydrogen peroxide, and bleach and alcohol.

CONCLUSION

In light of the COVID-19 pandemic, reuse of N95 respirators, although suboptimal, can be considered. Evidence reveals that UVGI, MHI, and HPV are amongst the safest and efficacious methods for decontamination of N95 masks. More research is needed to establish the safety and effectiveness of MGS, MSB, dry heat, EtO, liquid hydrogen peroxide, and HPGP. Alcohol, microwave irradiation, and bleach are not recommended because they damage N95 respirators.

A novel aerosolisation mitigation device for endoscopic sinus and skull base surgery in the COVID-19 era

Purpose

To provide a novel solution to reduce aerosol exposure in the operating room during endoscopic sinus and skull base procedures in the COVID-19 era.

Methods

We have designed a 3D printable midfacial mask that partially seals the nose, while allowing instrumentation during endoscopic transnasal surgery. The mask when connected to a vacuum system creates a constant negative pressure inside it, sucking out aerosols and gases generated during surgical procedures. Its effectiveness was tested using vapour exhalations by a human volunteer and drilling bone in a head model. The physical barrier effect was measured using fluorescein atomization in a head model.

Results

The pressure and airflow measured remained negative inside it in all the different situations tested. The mask was capable of completely evacuating human adult exhalation, and was more effective than the hand suction instrument. However, it was as effective as hand suction instrument at preventing aerosol spread from bone drilling. The physical barrier effect achieved a 72% reduction in the splatter created from the fluorescein atomization.

Conclusions

The mask effectively prevented the spread of aerosols and reduced droplet spread during simulated transnasal endoscopic skull base surgery in laboratory conditions. This device has potential benefits in protecting surgical personnel against airborne transmission of COVID-19 and could be useful in reducing chronic exposure to the hazard of surgical smoke.

Electronic supplementary material

The online version of this article (10.1007/s00405-020-06462-1) contains supplementary material, which is available to authorized users.

Impact of an e-learning module on personal protective equipment knowledge in student paramedics: a randomized controlled trial

BACKGROUND

Prehospital professionals such as emergency physicians or paramedics must be able to choose and adequately don and doff personal protective equipment (PPE) in order to avoid COVID-19 infection. Our aim was to evaluate the impact of a gamified e-learning module on adequacy of PPE in student paramedics.

METHODS

This was a web-based, randomized 1:1, parallel-group, triple-blind controlled trial. Student paramedics from three Swiss schools were invited to participate. They were informed they would be presented with both an e-learning module and an abridged version of the current regional prehospital COVID-19 guidelines, albeit not in which order. After a set of 22 questions designed to assess baseline knowledge, the control group was shown the guidelines before answering a set of 14 post-intervention questions. The e-learning group was shown the gamified e-learning module right after the guidelines, and before answering post-intervention questions. The primary outcome was the difference in the percentage of adequate choices of PPE before and after the intervention.

RESULTS

The participation rate was of 71% (98/138). A total of 90 answer sets was analyzed. Adequate choice of PPE increased significantly both in the control (50% [33;83] vs 25% [25;50], P = .013) and in the e-learning group (67% [50;83] vs 25% [25;50], P = .001) following the intervention. Though the median of the difference was higher in the e-learning group, there was no statistically significant superiority over the control (33% [0;58] vs 17% [- 17;42], P = .087). The e-learning module was of greatest benefit in the subgroup of student paramedics who were actively working in an ambulance company (42% [8;58] vs 25% [- 17;42], P = 0.021). There was no significant effect in student paramedics who were not actively working in an ambulance service (0% [- 25;33] vs 17% [- 8;50], P = .584).

CONCLUSIONS

The use of a gamified e-learning module increases the rate of adequate choice of PPE only among student paramedics actively working in an ambulance service. In this subgroup, combining this teaching modality with other interventions might help spare PPE and efficiently protect against COVID-19 infection.

Infection prevention and control for labor and delivery, well baby nurseries, and neonatal intensive care units

During the early months of the COVID-19 pandemic, infection prevention and control (IP&C) for women in labor and mothers and newborns during delivery and receiving post-partum care was quite challenging for staff, patients, and support persons due to a relative lack of evidence-based practices, high rates of community transmission, and shortages of personal protective equipment (PPE). We present our IP&C policies and procedures for the obstetrical population developed from mid-March to mid-May 2020 when New York City served as the epicenter of the pandemic in the U.S. For patients, we describe screening for COVID-19, testing for SARS-CoV-2, and clearing patients from COVID-19 precautions. For staff, we address self-monitoring for symptoms, PPE in different clinical scenarios, and reducing staff exposures to SARS-CoV-2. For visitors/support persons, we address limiting them in labor and delivery, the postpartum units, and the NICU to promote staff and patient safety. We describe management of SARS-CoV-2-positive mothers and their newborns in both the well-baby nursery and in the neonatal ICU. Notably, in the well-baby nursery we do not separate SARS-CoV-2-positive mothers from their newborns, but emphasize maternal mask use and social distancing by placing newborns in isolates and asking mothers to remain 6 feet away unless feeding or changing their newborn. We also encourage direct breastfeeding and do not advocate early bathing. Newborns of SARS-CoV-2-positive mothers are considered persons under investigation (PUIs) until 14 days of life, the duration of the incubation period for SARS-CoV-2. We share two models of community-based care for PUI neonates. Finally, we provide our strategies for enhancing communication and education during the early months of the pandemic.

[Challenges in visceral medicine during COVID-19]

Hintergrund

Die sich weltweit ausbreitende COVID-19(„coronavirus disease 2019“)-Pandemie hat sich innerhalb weniger Wochen auch in Deutschland zu einem zunehmenden Problem im Gesundheitssystem und in der gesamten Gesellschaft entwickelt. Da auch die Viszeralmedizin im Fokus steht, sind deutliche Veränderungen im Vorgehen notwendig.

Material und Methode

Erforderliche Strukturen und Herausforderungen der Viszeralmedizin werden für notwendige Eingriffe nach Screening und bei SARS(„severe acute respiratory syndrome“)-CoV(„coronavirus“)-2-infizierten Patienten beschrieben und die Anforderungen an die Viszeralchirurgie dargestellt. Hierfür erfolgten eine Analyse der aktuellen und themenbezogenen Literatur und die Erläuterung des Vorgehens im Krankenhaus der Grund- und Regelversorgung am Niederrhein.

Ergebnisse

Bei der Anpassung an die Krisensituation kann die Etablierung eines Systems für ein Krankenhaus in Deutschland dargestellt werden. Hierfür erfolgten unter anderem die Schaffung eines Corona-Screening-Centers am Haupteingang der Klinik und die Etablierung eines Krisenstabs für COVID-19. Spezifische interne Leitlinien wurden für das Vorgehen erstellt, erläutert, durch internationale Studien belegt und mehrfach den jeweiligen Anforderungen der Situation angepasst.

Diskussion

Die Krise ist mit deutlicher Verzögerung im Vergleich zu anderen Ländern in Deutschland milde verlaufen. Entsprechende Vorbereitungen konnten in vielen Krankenhäusern getroffen werden, um möglichst gut vorbereitet zu sein auf schwerkranke SARS-CoV-2-infizierte Patienten auf den Intensivstationen, auf der Isolierstation, im Operationsbereich und in der Endoskopie. Der Schutz der Mitarbeiter und der Patienten ist dabei oberstes Ziel. Letztlich werden wir durch Aufarbeitung der Pandemie auch medizinische Rituale und Angewohnheiten überdenken müssen.

Rationale for American Society of Retina Specialists Best Practice Recommendations for Conducting Vitreoretinal Surgery during the COVID-19 Era

PURPOSE

To detail the rationale behind recommendations recently published by the American Society of Retina Specialists (ASRS) outlining best practices for safety of vitreoretinal surgeons and staff while performing vitreoretinal surgery during the coronavirus disease (COVID)-19 pandemic.

METHODS

The committee for ASRS Best Practices for Retinal Surgery during the COVID-19 Pandemic reviewed existing evidence and information on SARS-CoV-2 transmission, and risk factors during vitreoretinal surgery. Recommendations were based on best available published data, cumulative clinical experiences, and recommendations and policies from other organizations. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the strength of recommendations and confidence in the evidence. These serve as interim recommendations which are routinely updated given gaps of knowledge and lack of high-quality data on this evolving subject.

RESULTS

Relevant existing literature related to methods of transmission, and ocular manifestations of SARS-CoV-2 are summarized. The data and clinical experiences driving recommendations for pre-operative, intraoperative and post-operative surgical considerations, anesthesia choice, as well as considerations for intravitreal injections are provided.

CONCLUSION

Recommendations are provided with the goal of protecting vitreoretinal surgeons and associated personnel from exposure to SARS-CoV-2 during interventional vitreoretinal procedures. This is a rapidly evolving topic with numerous remaining gaps in our current knowledge. As such, recommendations will evolve and the current manuscript is intended to serve as a foundation for continued dialogue on best practices.

[SARS-CoV-2-How can and must medical personnel protect themselves?]

The SARS-CoV‑2 pandemic represents a great challenge worldwide not only under the aspect of treatment but also of prevention. The infection curve could be flattened by the rapid implementation of simple distance and hygiene measures. In order to ensure current and future patient care in conjunction with protection of medical personnel working in the healthcare system during this pandemic, adequate protective equipment is essential. Routine care can only be resumed if there is sufficient and adequate personal protective equipment (PPE). If recommended hygiene protective measures including the necessary PPE are seriously taken into account both elective interventions and emergency care can be carried out without an increased risk of infection. This is very important in vascular surgery with a high proportion of urgent and emergency disease management.