communities, remains imperative. Safe locations and staffing
plans that separate vulnerable patients from COVID-19
activities have been carefully considered.”
Protecting healthcare personnel who are on the front
lines of COVID-19 is essential. The evidence as it stands
now indicates that the disease spreads primarily via droplet
transmission and direct contact; however, as we will see on
page 25, airborne transmission is being evaluated.
“With the appropriate precautions, nosocomial
transmission can be mitigated,” say Chopra, et al. (2020).
“Healthcare personnel should receive training on proper
donning and doffing of personal protective equipment,
including fit testing of N95 masks and use of powered
air-purifying respirators, as well as basic infection prevention
tenets, such as hand hygiene. Hospitals should monitor rates
of equipment use to ensure an adequate supply of personal
protective equipment for those on the front lines and may
need to engage hospital security to avoid theft or hoarding
of such equipment. Extended use or limited reuse of N95
respirators may become necessary, and communication
about preservation is important.”
To limit the total number of personnel engaged in patient
care, hospitals should institute overtime and extended hours
with appropriate compensation strategies, the researchers
advocate: “Clear exposure criteria with
detailed plans outlining management of
in regard to work restrictions
Hospitals and personnel
or other quarantine requirements must
health systems be developed,” say Chopra, et al.
“Hospitals must also safeguard
must set aside a (2020).
their own by keeping logs of staff who
“business as usual” care for patients and monitoring them
mentality and for signs or symptoms of infection.
Finally, even if care of patients with
focus on how best COVID-19 will be provided by a subset
to accommodate of providers, it is important not to
lose sight of the needs of their family
the patients likely members and other staff. Support is
to benefit the most important to the morale and well-being
workforce.”
from care.” of the
Another imperative, according to
the experts, is to allocate resources in an ethical, rational and
structured way to benefit the greatest number of patients.
As Chopra, et al. (2020) explain, “Hospitals and health
systems must set aside a “business as usual” mentality and
focus on how best to accommodate the patients likely to
benefit the most from care. Specifically, a plan that outlines
what services and types of procedures will be provided (for
example, extracorporeal membrane oxygenation) and what
will not (for example, elective cases) must be developed.
Accordingly, clinical guidelines for use (or denial) of scarce
services, such as mechanical ventilation and critical care,
should be outlined, in consultation with ethics and medical
staff. A protocol that defines how patients will be triaged
for admission, observation, early discharge, and quarantine
is important. Hospitals should anticipate that normal
staffing ratios and some standards of care are unlikely to
be maintained; plans for contingency and crisis standards
that lay out a legal and ethical framework for care decisions,
including who will make decisions, how, and under what
20
circumstances, must be readied. At Michigan Medicine,
scarce resource guidelines have not only been developed,
but portions have been revised and circulated to staff to
ensure agreement and buy-in for execution.”
COVID-19 a Reminder of the Challenge of Emerging
Infectious Diseases
In recent decades, several highly transmissible respiratory
viruses with epidemic potential have emerged. Experts point
to the most significant pandemics of the 20th century, which
were influenza viruses in 1918, 1957 and 1968. In 2003,
severe acute respiratory syndrome (SARS) caused by a novel
coronavirus (SARSCoV) resulted in roughly 8,000 cases and
800 deaths in 30-plus countries. In subsequent years, Middle
East respiratory syndrome coronavirus (MERS-CoV) emerged,
as did adenovirus-14, and virulent strains of influenza viruses.
As Kock, et al. (2020) acknowledge, “The emergence of
a new coronavirus (2019-nCoV) in Wuhan creates a sense of
déjà vu with the SARS-CoV epidemic in 2003. Coronaviruses
are enveloped, positive-stranded RNA viruses of mammals
and birds. These viruses have high mutation and gene recom-
bination rates, making them ideal for pathogen evolution. In
humans, coronavirus is usually associated with mild disease,
the common cold. Previous emerging novel coronaviruses,
such as SARS-CoV and MERS-CoV) were associated with
severe and sometimes fatal disease. MERS-CoV was less
pathogenic than SARS-CoV, with the most severe infections
mainly in individuals with underlying illnesses.”
The researchers continue, “Clinically and epidemio-
logically, the contemporary 2019-nCoV in China seems
to resemble SARS-CoV. The genome of 2019-nCoV also
appears most closely related to SARS-CoV and related bat
coronaviruses. The infection has now spread widely, with
phylogenetic analysis of the emerging viruses suggesting
an initial single-locus zoonotic spillover event in November
2019, and subsequent human-to-human transmission. The
SARS epidemic in 2003 was followed soon after by avian
influenza H5N1 in 2006, centered on the Asian continent
and Middle East. Other surprising viral zoonoses that have
caused serious disease include Nipah encephalitic virus in pigs
and humans in southeast and south Asia in 1999-2014, and
large-scale Ebola virus epidemics in 2014-16 and 2018-19
in west and central Africa. Taken together, these events ring
alarm bells about disease emergence in the 21st century,
and the importance of human diseases originating from
indiscriminate contacts with infected animals.”
Experts say the healthcare sector is primarily reactive
to these events, acting to save lives as well as undertake
surveillance and control, but complacency can set in after the
outbreaks end. As Kock, et al. (2020) confirm, “The drama
and panic typically fade into history with the substantial costs
being absorbed by ordinary people, international financial
systems, and tax bases, making life go on as normal, but not
quite. The frequency, severity, and financial impacts of these
events are growing, and the world can no longer afford to
just wait and see, especially because prevention of these
threats is in theory relatively simple and where addressed
has resulted in a cessation of risk.”
Public health experts say that lessons learned from past
global pandemics is a mixed bag: “These events are of global
public health and economic importance and need collective
april 2020 • www.healthcarehygienemagazine.com