Beyond the assistance: additional exposure situations to COVID-19 for healthcare workers

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Abstract

Sir, Although many workers may be exposed to the novel coronavirus, healthcare workers (HCWs) have an increased risk of contracting COVID-19 due to their close contact with patients affected by SARS-CoV-2 [1,2]. For this reason, the World Health Organization (WHO) and other authorities have recommended the adoption of adequate prevention and control measures for HCWs. WHO has recommended that HCWs should use proper personal protective equipment (PPE), such as medical masks, gowns, gloves and eye protection [3]. In some cases, such as in aerosol-generating procedures, WHO has recommended the use of FFP2 respirator masks [3]. Strict compliance with these recommended measures and with good practice procedures for managing infectious diseases may minimize the risk of virus transmission from patients to HCWs. Nevertheless, several HCWs have been infected by SARS-CoV-2. The main reasons for this are a shortage of PPE and the lack of provision of training for infection prevention and control [4]. However, in cases in which HCWs adopted proper PPE and adequate procedures, it is important to consider other situations of potential transmission, such as contacts among colleagues and contacts outside hospital settings. The potential risk of transmission between HCWs when they are not caring for patients should not be underestimated. Clinical case discussions, clinical handovers between HCWs, and lunch breaks are examples of situations in which HCWs may transmit the infection to each other. Moreover, HCWs usually work in confined spaces in which it is not possible to ensure social distancing of at least 1 m, as recommended. For these reasons, it is important to maintain appropriate prevention measures in case of close contact with colleagues, even if there are no patients present in the room. It is fundamental to avoid eating together and to maintain social distancing during meals, as well as during meetings. Finally, we should consider the risk of transmission outside hospital settings. After work, HCWs have contact with other people and they have the same infection risk as the general population. HCWs may potentially be infected because of their exposure to COVID-19 patients during work shifts. For these reasons, we recommend that HCWs should implement adequate prevention and protection measures, not only in hospital contexts but also in other contexts. In this way, they can protect themselves and their relatives and friends against the risk of contracting the disease. We also want to emphasize the continued need to provide HCWs with adequate PPE in order to reduce the high risk of contracting COVID-19 whilst caring for patients. Conflict of interest statement None declared. Funding sources None.

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Reasons for healthcare workers becoming infected with novel coronavirus disease 2019 (COVID-19) in China

J. Wang, M. Zhou, F. Liu (2020)

Sir, The outbreak of novel coronavirus disease 2019 (COVID-19) in mainland China has been declared as a public health emergency (PHE) by the World Health Organization (WHO) [1]. Globally, until February 28th, 2020, there have been reported 83,774 confirmed cases and 2867 deaths [2]. During the periods of outbreak of COVID-19 or other infectious diseases, implementation of infection prevention and control (IPC) is of great importance in healthcare settings, especially regarding personal protection of healthcare workers [3,4]. In order to contain the outbreak of COVID-19 in mainland China, the National Health Commission of the People's Republic of China (NHCPRC) has so far dispatched medical support teams (41,600 healthcare workers from 30 provinces and municipalities) to assist with medical treatment in Wuhan and Hubei provinces [5]. A survey by the Health Commission of Guangdong Province released information on the distribution of 2431 healthcare workers in the Guangdong medical support teams [6]. Nurses (∼60%) were the predominant healthcare workers in the teams, followed by clinicians (∼30%). Half of clinicians with job titles were deputy chief physician, and 25% specialized in respiratory and critical medicine [6]. It is worth mentioning that 5.8% (140/2431) healthcare workers worked on the outbreak of severe acute respiratory syndrome in 2003 [6]. Recently, Wu et al. have reported the problems relating to COVID-19 IPC in healthcare settings, highlighting the personal protection of healthcare workers [7]. However, at a press conference of the WHO–China Joint Mission on COVID-19, NHCPRC reported that up until February 24th 2055 healthcare workers (community/hospital-acquired not to be defined) had been confirmed infected with COVID-19, with 22 (1.1%) deaths [8]. Ninety percent of infected healthcare workers were from Hubei province, and most cases happened in late January. It is worth mentioning that the proportion of healthcare workers infected by COVID-19 (2.7%, 95% CI: 2.6–2.8) was significantly lower compared with healthcare workers infected by SARS (21.1%, 95% CI: 20.2–22.0). Therefore, the director of the National Hospital Infection Management and Quality Control Centre summarized some reasons for such a high number of infected healthcare workers during the beginning of the emergency outbreak [9]. First, inadequate personal protection of healthcare workers at the beginning of the epidemic was a central issue. In fact, they did not understand the pathogen well; and their awareness of personal protection was not strong enough. Therefore, the front-line healthcare workers did not implement the effective personal protection before conducting the treatment. Second, long-time exposure to large numbers of infected patients directly increased the risk of infection for healthcare workers. Also, pressure of treatment, work intensity, and lack of rest indirectly increased the probability of infection for healthcare workers. Third, shortage of personal protective equipment (PPE) was also a serious problem. First-level emergency responses have been initiated in various parts of the country, which has led to a rapid increase in the demand for PPE. This circumstance increased the risk of infection for healthcare workers due to lack of sufficient PPE. Fourth, the front-line healthcare workers (except infectious disease physicians) received inadequate training for IPC, leaving them with a lack of knowledge of IPC for respiratory-borne infectious diseases. After initiation of emergency responses, healthcare workers have not had enough time for systematic training and practice. Professional supervision and guidance, as well as monitoring mechanisms, were lacking. This situation further amplified the risk of infection for healthcare workers. Finally, international communities, especially in other low- and middle-income countries with potential COVID-19 outbreaks, should learn early how to protect their healthcare workers. Furthermore, the COVID-19 confirmed cases have been reported to have surged in South Korea, Japan, Italy, and Iran in the past few days [2]. The increase in awareness of personal protection, sufficient PPE, and proper preparedness and response would play an important role in lowering the risk of infection for healthcare workers. Conflict of interest statement None declared. Funding sources None.

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Occupational risks for COVID-19 infection

David Koh (2020)

Coronaviruses are enveloped RNA viruses found in mammals, birds and humans. At present, six coronavirus species are known agents for illnesses in humans. Four viruses—229E, OC43, NL63 and HKU1—are prevalent and can cause respiratory symptoms. The other two—severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV)—are zoonotic in origin and can cause fatalities [1]. SARS-CoV originated in Guangdong Province, China and was responsible for the severe acute respiratory syndrome outbreaks in 2002 and 2003. It rapidly spread across the globe and resulted in 8098 reported cases and 774 deaths (case-fatality rate, 9.6%) in 37 countries. MERS-CoV originated in the Middle East and caused severe respiratory disease outbreaks in 2012. Since 2012, there have been 2494 reported MERS-CoV cases resulting in 858 deaths (case-fatality rate, 34%) in 27 countries. There were also several rapid outbreaks reported, mainly in hospitals in Saudi Arabia, Jordan and South Korea [2]. On 31 December 2019, the World Health Organization (WHO) China office was informed of cases of pneumonia of unknown aetiology detected in Wuhan city in Hubei Province, central China [3]. By 9 January 2020, WHO released a statement on the cluster of cases, which stated that ‘Chinese authorities have made a preliminary determination of a novel (or new) coronavirus, identified in a hospitalized person with pneumonia in Wuhan’ [4]. The virus was initially referred to as 2019-nCoV, but has since been re-named as SARS-CoV-2 by the WHO on 12 February 2020. Early indications are that the overall case-fatality rate is around 2%. An analysis of the first 425 cases provided an estimated mean incubation period of 5.2 days (95% confidence interval [CI] 4.1–7.0) and a basic reproductive number (R o) of 2.2 (95% CI 1.4–3.9) [1]. It is possible that people with Coronavirus Disease 2019 (COVID-19) may be infectious even before showing significant symptoms [5]. However, based on currently available data, those who have symptoms are causing the majority of virus spread. The WHO declared this disease as a Public Health Emergency of International Concern (PHEIC) on 30 January 2020 [6]. A significant proportion of cases are related to occupational exposure. As this virus is believed to have originated from wildlife and then crossed the species barrier to infect humans, it is not unexpected that the first documented occupational groups at risk were persons working in seafood and wet animal wholesale markets in Wuhan. At the start of the outbreak, workers and visitors to the market comprised 55% of the 47 cases with onset before 1 January 2020, when the wholesale market was closed. In comparison, only 8.5% of the 378 cases with onset of symptoms after 1 January 2020 had a link with exposure at the market [1]. As cases increased and required health care, health care workers (HCWs) were next recognized as another high-risk group to acquire this infection. In a case series of 138 patients treated in a Wuhan hospital, 40 patients (29% of cases) were HCWs. Among the affected HCWs, 31 (77.5%) worked on general wards, 7 (17.5%) in the emergency department, and 2 (5%) in the intensive care unit (ICU). There was apparently a super-spreader patient encountered in the hospital, who presented with abdominal symptoms and was admitted to the surgical department. This patient infected >10 HCWs in the department [7]. China’s Vice-Minister at the National Health Commission said that 1716 health workers had been infected in the country as of Tuesday 11 February 2020, among whom 6 have died [8]. Outside of China, the first confirmed case of COVID-19 infection in Singapore was announced on 23 January 2020 by the Ministry of Health, Singapore (MOH-Sg). The MOH-Sg issues daily press reports to describe case details of confirmed COVID-19 patients. As of 11 February 2020, a total of 47 cases have been confirmed [9]. Among the first 25 locally transmitted cases, 17 cases (68%) were probably related to occupational exposure (Table 1). They included staff in the tourism, retail and hospitality industry, transport and security workers, and construction workers. Table 1. Probable occupationally acquired COVID-19 among 25 locally transmitted cases in Singapore, 4–11 February 2020 Case description (case no.a) No. of cases Staff working in a retail store selling complementary health products primarily serving Chinese tourists (Cases 19, 20, 34, 40) 4 Domestic worker who worked for Case 19 (Case 21) 1 Tour guide who led tour group from China (Case 24) 1 Jewellery store worker who served Chinese tourists (Case 25) 1 Multinational company staff attending an international business meeting in Singapore (Cases 30, 36, 39) 3 Taxi driver (Case 35) 1 Private hire car driver (Case 37) 1 Resorts World Sentosa employee (Case 43) 1 Security officer who served quarantine order to two persons (Case 44) 1 Casino worker (Case 46) 1 Cluster of two workers at the same construction siteb (Cases 42 and 47) 2 aThe case no. denotes the order of cases according to the time of announcement by the Ministry of Health, Singapore. The first 18 cases were imported cases. bTwo other cases (Cases 52 and 56) were reported from the same worksite 2 days later. An international business meeting for 109 staff was organized by a multinational company from 20–22 January 2020 in Singapore. At this event, healthy company workers interacted with other infected participants, which resulted in the transmission of the virus to three employees based in Singapore. Besides those infected from Singapore, one employee from Malaysia, two participants from South Korea and one staff member from the UK were also infected. They presented as cases after leaving Singapore. Crew on board cruise ships with infected passengers are also at risk. At least 10 cases have been reported among the 1035 crew on the liner Diamond Princess, which is currently docked in Yokohama with around 3600 people quarantined since 3 February 2020. A Hong Kong man boarded the ship on 20 January in Yokohama at the beginning of a 14-day round trip cruise. The passenger sailed from Yokohama to Hong Kong, where he disembarked on 25 January. The ship continued its journey, until news was received that the passenger tested positive on 1 February 2020. The Diamond Princess returned to Yokohama a day early, and has been quarantined since then, with guests isolated in their cabins and screened [10]. The quarantine period will end on 19 February 2020. Another cruise ship, the Dutch liner Westerdam, sailed out of Hong Kong on 1 February 2020. It was turned away by the Philippines, Taiwan, Korea, Japan, Thailand and the US territory of Guam, because of fears arising from the COVID-19 outbreak—even though there was apparently no confirmed case on board [11]. The ship was finally allowed to dock in Sihanoukville, Cambodia after 13 days at sea. Besides fears of contagion from people on board cruise ships, which have been likened to ‘floating petri dishes’, fears are also widespread on land. There are increasing reports of HCWs being shunned and harassed by a fearful public because of their occupation. A Member of Parliament in Singapore highlighted what he termed as ‘disgraceful actions’ against HCWs stemming from fear and panic [12]. Some examples of behaviour described were: Taxi drivers reluctant to pick up staff in medical uniform. A healthcare professional’s private-hire vehicle cancelled because she was going to a hospital. A nurse in a lift asked why she was not taking the stairs and that she was spreading the virus to others by taking the lift. A nurse scolded for making the Mass Rapid Transit train “dirty” and spreading the virus. An ambulance driver turned away by food stall workers. However, not all the reactions from the public towards HCWs have been negative. There are probably an equal number of stories of public support and encouragement. Members of the public have showed their appreciation for HCWs and have volunteered to help the more vulnerable in society [13]. For example, a ride-hailing transport operator started a new service offering a dedicated 24-h service for HCWs travelling from work. Volunteers have also stepped forward to distribute hand sanitizers and masks to the elderly and vulnerable in their community, while sharing important public health messages. Such reactions are reminiscent of behaviour during the 2003 SARS outbreak, where not only the general public, but even close family members were afraid of being infected by HCWs exposed to the disease. A survey of over 10 000 HCWs in Singapore during the SARS outbreak of 2003 reported that many respondents experienced social stigmatization. Almost half (49%) thought that ‘people avoid me because of my job’ and 31% felt that ‘people avoid my family members because of my job’. For example, some parents of schoolchildren forbade their children to play or be close to children of HCWs. A large number (69%) of HCWs also felt that ‘people close to me are worried they might get infected through me’ [14]. On the other hand, there was also massive public support for HCWs, who were hailed as heroes in the fight against the disease. Most of the HCWs (77%) felt appreciated by society. COVID-19 is the first new occupational disease to be described in this decade. Our experiences in coping with the previous SARS-CoV and MERS-CoV outbreaks have better prepared us to face this new challenge. While the explosive increase in cases in China has overwhelmed the health care system initially, we know that public health measures such as early detection, quarantine and isolation of cases can be effective in containing the outbreak. All health personnel should be alert to the risk of COVID-19 in a wide variety of occupations, and not only HCWs. These occupational groups can be protected by good infection control practices. These at-risk groups should also be given adequate social and mental health support [15], which are needed but which are sometimes overlooked.

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COVID-19: Health prevention and control in non-healthcare settings

Michael Belingheri, Maria Paladino, Michele Augusto Riva (2020)

Novel coronavirus disease (COVID-19) was first detected in Wuhan City, Hubei Province in China, at the end of 2019 [1]. The virus widely spread to many countries, affecting every continent. On 30 January 2020, the World Health Organization (WHO) declared the outbreak of COVID-19 to be a public health emergency of international concern [2]. At the beginning of March 2020, there were >109 000 confirmed cases and >3800 deaths from COVID-19 [3]. Healthcare workers (HCWs) have an increased risk of contracting COVID-19, but a recent study has reported that other workers may also be exposed to the Coronavirus, including staff in the tourism, retail and hospitality industries, transport and security workers, and construction site workers [4]. Considering the current dynamic situation and the ongoing spread of COVID-19 virus, it is important to provide physicians with information about COVID-19 risk management in non-healthcare settings, which are less familiar with this type of situation. Physicians and other HCWs are generally used to following instructions about containment of infection, while other workers are less accustomed to this. We aim to provide general information about risk management in other workplaces, to minimize the spread of COVID-19 in non-healthcare settings. Physicians, especially those in charge of occupational health services, should provide workers with accurate information and training about COVID-19, to ensure adequate risk perception and to improve compliance with prevention and control measures. COVID-19 is caused by a virus named SARS-CoV-2. Symptoms are generally similar to flu (fever, dry cough, headache, sore throat and runny nose), but ~25% of patients require intensive care and 10% require mechanical ventilation [5,6]. The case-fatality rate is variable and depends on several factors (age, co-morbidity, etc.), but is ~2%. Although several modes of transmission have been identified, the virus is transmitted primarily through large respiratory droplets from close contacts [6,7]. Data on the survival time of the virus in the environment are still poorly understood, but it seems that the SARS-CoV-2 is able to survive for several days [8]. The incubation period varies from 1 to 14 days, with a median of 5–6 days. Therefore, the quarantine period should be around 2 weeks after a close contact with a person with symptoms. The expected number of secondary cases caused by a single person with COVID-19 in a susceptible population (R 0) is 2·2, somewhat higher than seasonal flu (1·0–2·0), but lower than measles (12–18) [4]. A specific vaccine against SARS-CoV-2 is not yet available. In addition to adequate information and training, prevention and protection measures should be implemented in workplaces, to minimize the virus spreading (Table 1). Table 1. Prevention and control measures in non-healthcare settings ➢ Provide information and education about COVID-19 ➢ Stay home in case of symptoms or in case of a suspected transmission of COVID-19 virus (quarantine) ➢ Wash and clean hands with water and soap or with alcoholic solutions ➢ Maintain social distance (1 m) between people ➢ Clean surfaces, objects, clothes, and reduce the sharing of objects ➢ Ensure workplaces ventilation ➢ Do not recommend unnecessary PPE It is vital to emphasize the importance of staying at home and not going to work in the case of flu-like symptoms, to prevent other workers’ exposure. Special attention should be paid to fever (a body temperature above 37·5°C or 99·5°F), cough, sore throat, runny nose and other respiratory symptoms. When exposure to COVID-19 virus may have occurred, the worker should stay home for the quarantine period, monitoring any symptoms. Companies should consider implementing smart working solutions, in which workers can work from home to avoid contact with colleagues, using a computer and an internet connection. Occupational physicians should recommend hand hygiene, an effective measure with minimal costs [8]. Specifically, hands should be washed regularly, using soap and water for 20–40 s. Alternatively, hands can be cleaned with alcohol solution (at least 60% alcohol). Workers should not touch their eyes, nose and mouth to avoid contact with mucous membranes [7]. Cough etiquette is important to reduce the virus spreading, i.e. coughing into a flexed elbow or sneezing into a tissue, that must be immediately disposed of [7]. There is no personal protective equipment (PPE) recommendation for workers in non-healthcare settings. According to the WHO, PPE for COVID-19 virus is recommended only for specific duties in healthcare facilities. Medical mask, gown, gloves or eye protection are not indicated for workers in general settings. However, medical masks should be worn by people with symptoms, to avoid the spreading of droplets [7]. The minimum distance between people (worker–worker, worker–customer) must be at least 1 m (social distance), which prevents droplet transmission [7]. The social distance must be enforced, especially in workplaces with interactions between workers and customers, such as retail stores, hotels, restaurants and any front office activities. In other settings, the social distance is also important, e.g. web meetings instead of face-to-face meetings. Environmental measures must be implemented. It is recommended to frequently clean surfaces (i.e. counters), objects and clothes, and to reduce the sharing of objects. Appropriate ventilation must be ensured in workplaces where there are customers or many workers (i.e. front office activities, open-space offices) [8]. Some workers may be involved in duties that include the handling of cargo or other objects from affected countries, such as shipping or dock workers. Although the COVID-19 virus can survive on surfaces, the use of specific PPE is not recommended but hands should be washed frequently. According to the WHO, contact with goods or products shipped from countries with COVID-19 outbreaks cannot transmit the infection [7]. Italy is the country with the third highest number of COVID-19 cases, after China and South Korea [3]. Many companies have promoted smart working solutions. When smart working solutions could not be implemented workers have been provided with advice about hand hygiene, social distance, daily cleaning and disinfecting of surfaces, and adequate ventilation, to prevent potential contact with droplets. Also, organizational measures have been implemented to avoid overcrowding in workplaces, such as limiting access of customers to front office services.

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M. Belingheri

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Journal ID (nlm-ta): J Hosp Infect

Journal ID (iso-abbrev): J. Hosp. Infect

Title: The Journal of Hospital Infection

Publisher: The Healthcare Infection Society. Published by Elsevier Ltd.

ISSN (Print): 0195-6701

ISSN (Electronic): 1532-2939

Publication date PMC-release: 31 March 2020

Publication date (Electronic): 31 March 2020

Affiliations

[1]School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy

Author notes

[∗ ]Corresponding author. Address: School of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900 Monza, Italy. Tel.: +39 0264488191. michael.belingheri@ 123456unimib.it

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Publisher ID: S0195-6701(20)30132-8

DOI: 10.1016/j.jhin.2020.03.033

PMC ID: 7174833

PubMed ID: 32243947

SO-VID: 61bd6951-e839-4006-9f3d-2197467d99f6

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Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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Date received : 16 March 2020

Date accepted : 26 March 2020

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Beyond the assistance: additional exposure situations to COVID-19 for healthcare workers

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Reasons for healthcare workers becoming infected with novel coronavirus disease 2019 (COVID-19) in China

Occupational risks for COVID-19 infection

COVID-19: Health prevention and control in non-healthcare settings

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