As many countries across the world have imposed lockdowns, asking residents to stay home and self-isolate in an attempt to break the chain of transmission of the coronavirus, healthcare workers are at the frontlines of battling the pandemic.
In February, Li Wenliang, a Chinese doctor who warned about the outbreak of the coronavirus, died from the disease. According to the medical journal Lancet, over 3300 healthcare workers have been infected by coronavirus in China as of early March and over 22 have died. In Italy, on the other hand, the country with the highest number of cases after US and China, over 20 percent of the responding healthcare workers contracted the disease and some even died from it.
These figures raise concerns about the steps healthcare workers need to take to protect themselves from the virus. Apart from healthcare workers, deathcare workers including coroners, medical examiners, funeral directors, airline staff and waste management staff are also at increased risk of exposure to the infection.
An editorial in Lancet highlighted the importance of healthcare workers at this time, calling them “every country’s most valuable resource”, urging governments to ensure healthcare workers have access to personal protective equipment (PPE) that are worn to protect themselves from serious workplace injuries and illnesses, and also provide them with food, rest, and psychological support.
What is the risk of exposure for healthcare workers?
A report published in the Annals of Internal Medicine said that the effectiveness of using PPEs in protecting against infection from SARS-CoV-2 is relatively unknown. The study that analysed healthcare workers dealing with a COVID-19 patient with severe pneumonia found that when 41 workers who were dealing with the patient were exposed during an aerosol-generating procedure, 85 percent of them were wearing surgical masks and the remaining were wearing N95 masks.
None of the healthcare workers involved in the study contracted infection even though the aerosol-generating procedures such as endotracheal intubation, extubation, noninvasive ventilation were performed and the workers were at a distance of less than 2 meters from the patient for at least a period of 10 minutes. The conclusion derived from this study is that the use of surgical masks, hand hygiene and other standard procedures prevented them from getting infected.
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In China on the other hand, where more than 3,000 healthcare workers were infected, the possible reasons that they contracted infection were highlighted in a report in The Journal of Hospital Infection. These include not having adequate personal protection gear for the workers at the beginning of the outbreak, long exposure to a large-scale of infected patients, pressure of treatment, work intensity, lack of rest, shortage of PPE, inadequate training received by healthcare workers for infection prevention and control (IPC).
So how do healthcare workers protect themselves?
Hospital-associated transmission of COVID-19 is a significant route for the spread of the disease and requires that healthcare workers are prepared and trained on precautions that need to be taken with regards to handling patients, conducting procedures, while also taking care that they themselves don’t contract the infection. In an address to the editor of Infection Control and Hospital Epidemiology, the authors note that due to shortage of PPEs, tertiary and secondary hospitals in China had to call for donations and the workers there had to make do with daily plastic products such as photographic films, plastic wrap, file bag and so on to make “simple PPE”.
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“More PPE should be produced or imported, and delivered to hospitals quickly. Training of HCWs to identify suspicious cases and use PPE properly is in urgent need, especially for HCWs in departments other than infectious diseases. Concealing medical history should have legal consequences,” the authors said.
Apart from PPEs, it is imperative that healthcare workers have access to N95 masks, goggles and protective gowns. Additionally, they also need to be trained for IPC.
Guidelines for healthcare workers in India
The Ministry of Health and Family Welfare has issued guidelines for healthcare workers, which includes steps and precautions they must take to protect themselves from infection. For instance, before entering isolation wards, the medical staff needs to ensure that they have collected all required equipment, have performed hand-hygiene and have put on the PPE. Preferably, this should be done in the following order, performing hand hygiene, donning the gown, mask or respirator, eye protection and gloves.
On the other hand, before exiting from an isolation ward, PPEs should be removed in a manner that prevents self-contamination. Ideally, this can be done by removing the most contaminated PPE items first, performing hand hygiene immediately after removing gloves, removing the mask or particulate respirator, discarding disposable items in a closed rubbish bin, putting reusable items in a dry closed bin. In case the gown is disposable, the ministry advises removing the gloves together with the gown upon removal, followed by hand hygiene, removing eye protection, mask or respirator, followed by hand hygiene again.
Setting up an isolation ward in India
Ideally, COVID-19 patients should be housed in single rooms, but due to limited resources, they can be housed together in common wards with a distance of one metre between adjacent beds. For a ten-bed facility, a space of 2000 sq. feet is required.
All isolation wards should have separate entry and exit and they should not be co-located with post-surgical wards or dialysis units and labour rooms. “It should be in a segregated area which is not frequented by outsiders,” the ministry has said. Such rooms also need to have a double-door entry with a changing room and nursing station, along with adequate room ventilation. In case the room is air-conditioned, it needs to be ensured that there are 12 air changes per hour and that exhaust air is filtered.
Further, for patients that require aerosolization procedures such as intubation, suction nebulisation, a negative pressure is desirable and such rooms should also not be connected with centralised air-conditioning. In case air-conditioning is not available, negative pressure in the room should be created by using three-four exhaust fans that drive air out of the room. Significantly, medical staff designated to the isolation wards should not be allowed to work in other wards.
The checklist for an isolation ward includes eye protection gear, face shield, gloves, reusable vinyl or rubber gloves, hair covers, particulate respirators, medical masks, gowns, collection containers for used equipment, soaps and alcohol-based hand rubs.
According to MoHFW, in resource-constrained settings, COVID-19 patients can be housed in a ward with good ventilation, with a minimum distance of one metre between two adjacent beds. Further, all such patients need to wear a triple layer of surgical masks at all times. Similarly, suspected cases can be housed in a separate ward with similar conditions. The ministry has cautioned that “under no circumstance, these cases should be mixed up.”
On the other hand, healthcare workers need to adhere to infection prevention control (IPC) practices as prescribed by IPC committees in all health facilities dealing with such patients. These facilities also need to train hospital staff in the washing of hands, respiratory etiquettes, donning and proper disposal of personal protective equipment (PPEs) and bio-medical waste management. Like the patients and suspected cases, healthcare workers also need to wear a triple layer of surgical masks and gloves and for those workers working in isolation and critical wards, the use of PPEs and N95 masks is essential. The support staff, which is in charge of disinfecting and cleaning is also required to wear PPEs.
How are hospital surfaces cleaned in such wards?
As per the ministry, environmental cleaning needs to be practiced twice in such wards, which involves damp dusting and mopping floors with phenolic disinfectants and cleaning of surfaces with sodium hypochlorite solution.
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