Healthcare Hygiene magazine September 2020 September 2020 | Page 16

TRANSMISSION DYNAMICS AND COVID-19
surfaces and objects in all parts of the facility,”
emphasize Dooley and Frieden (2020).
These manual practices must also be supplemented
by implementation and enforcement of IP&C policies
and procedures. To be effective, the authors say
administrative controls must include:
● training of all healthcare workers at all levels with
role-specific practical instruction
● reinforcement of training to provide frequent
reminders of key points
● quality control to assess adherence to policies and
procedures
● strict enforcement
As we will see, PPE may be the most problematic
control in the hierarchy in the age of COVID-19.
The Centers for Disease Prevention and Control
(CDC) recommends that, when available, respirators
are preferred over facemasks for all healthcare workers
entering areas where patients with known or suspected
COVID-19 receive care, and eye protection should also
be used in such situations. As Dooley and Frieden
(2020) observe, “Respirators should be prioritized for
persons present during aerosol-generating procedures
if supplies are restricted; otherwise respirators should
be used by all providing care to patients with known
or suspected COVID-19. Use of reusable elastomeric
half-facepiece N95 respirators or PAPRs could resolve
supply issues, and these products can be safely cleaned
by either wiping, or, after temporary removal of the
filter, immersion.”
Because many persons with asymptomatic
COVID-19 are contagious, Dooley and Frieden (2020)
emphasize the widely accepted instruction that all
healthcare personnel should wear masks at all times in
all areas of healthcare facilities, explaining that, “Doing
so may protect HCWs from being infected by patients
or other HCWs with asymptomatic COVID-19; and
mask wearing may prevent HCWs with asymptomatic
COVID-19 from infecting patients or other HCWs,
including in non-clinical staff areas.”
Recently, Weber, et al. (2020) suggested the adoption
of what they call Universal Pandemic Precautions,
likened to the creation of Universal Precautions (now
called Standard Precautions) which was a response
to the HIV epidemic-driven threat of bloodborne
pathogens. Standard Precautions recommend that
healthcare personnel (HCP) wear gloves for anticipated
contact with all body fluids except sweat.
The researchers remind us that, “Although there
was some initial pushback with the implementation
of Standard Precautions due to concern that routine
wearing of gloves would be poorly received by patients
and impair the ability to perform procedures such
as placing intravenous catheters, they are routinely
practiced and accepted today.”
They add, “Similarly, the threat proffered by the
sudden appearance of COVID-19 in the healthcare
workplace resulted in the implementation of risk
mitigation strategies that may also produce permanent
behavioral modification in the healthcare setting.
As happened during the 1980s with the HIV/AIDS
epidemic, the introduction of a new disease and
new risks into the healthcare setting should result
in long-lasting changes in patient care that at least
offer potential for increased patient and staff safety.”
The measures to prevent SARS-CoV-2 transmission
are by now well-known and include: screening
patients, visitors and HCP for COVID-19 symptoms
prior to entry; routine use of source control masks by
patients, visitors and HCP; frequent hand hygiene and
surface disinfection of shared equipment and devices;
enhanced PPE for HCP performing aerosol-generating
procedures and during care of known or suspected
patients with COVID-19; and prompt testing of persons
with signs/symptoms of COVID-19 and appropriate
isolation precautions.
Implementation of Universal Pandemic Precautions
(UPPs) – use of a mask and eye protection for all direct
patient contacts or at a minimum, use of a mask
and eye protection for direct patient contact when
the patient is unable or unwilling to wear a mask.
The researchers say this is necessary due to several
factors: transmission from pre-symptomatic and/or
asymptomatic COVID-19 patients; use of masks and
eye protection by HCP protects against acquisition
of SARS and SARS-CoV-2; and use of UPPs would
prevent HCP from having an exposure that per the
CDC would lead to exclusion from work for 14 days.
They add that UPPS will “likely also offer a potential
beneficial effect on the prevention of transmission
of other droplet-spread respiratory pathogens in the
healthcare setting (e.g., influenza A and B, respiratory
syncytial virus, seasonal coronaviruses, etc.), especially
during seasons in which these and other respiratory
viruses are circulating.”
In their pitch, Weber, et al. (2020) acknowledge,
“We understand that implementation of UPPs will
require careful messaging for our colleagues and
patients. We expect that the rationale … will be persuasive
for our colleagues to accept UPPs. Messaging
to patients should focus on describing the rationale
for UPPs including noting that use of UPPs is one of
several precautions that protect patients. In addition,
patients should be informed that this is routine practice
not specifically focused on them individually. Finally,
we realize that institution and discontinuation of UPPs
should be based on current local case numbers (or
rates or burden) and local prevalence of infection in
asymptomatic populations (e.g., pre-procedural test
positivity rates, as symptom screening cannot detect
these potentially infectious patients. We realize that
paradigm shifts are difficult and as demonstrated by
Semmelweis may not be accepted. However, ultimately
the use of hand hygiene as advocated by Semmelweis
became a keystone of infection prevention. We believe
•
Because many
persons with
asymptomatic
COVID-19 are
contagious,
Dooley and
Frieden (2020)
emphasize the
widely accepted
instruction that
all healthcare
personnel should
wear masks at all
times in all areas
of healthcare
facilities,
explaining
that, “Doing so
may protect
HCWs from
being infected
by patients or
other HCWs with
asymptomatic
COVID-19; and
(2) mask wearing
may prevent
HCWs with
asymptomatic
COVID-19 from
infecting patients
or other HCWs,
including in
non-clinical staff
areas.”
16 september 2020 • www.healthcarehygienemagazine.com