A very sobering piece published in NEJM Catalyst Innovations in Care Delivery (a new digital journal in the NEJM group) describes a catastrophic situation in a hospital in Bergamo, Italy, which has been overrun by COVID-19. We all have much to learn from this experience: about pandemic preparedness, response, and the key role of IPC at all stages of this pandemic.
The use of PPE and the protection of HCWs against highly infectious diseases was (and is) a topic of major importance, around the globe. The recent Cochrane review by Verbeek et al. was probably hoping to offer this “vital” information.
Unfortunately, they found no studies on the effects of goggles, face shields, long-sleeved gloves or taping on the risk of contamination. All they found was very low quality evidence, with high risk of bias and uncertain estimates of effect, that:
- More breathable types of PPE offer more comfort without increasing the risk of contamination
- Double gloving and CDC doffing guidance appear to decrease the risk of contamination, and
- Active more than passive training in PPE use may reduce PPE and doffing errors.
Their conclusions are obvious: we need high-quality studies of the materials, their use and protective effects, safe ways of doffing, and the most adequate training to achieve safe use of PPE for HCWs in the presence of highly infectious diseases or those (even less infectious) that may cause severe harm to HCWs.
But what to do until than? My personal opinion is that we should only use PPE, we are used to and know how to use. First-time users, even if supplied with the best available products, will inevitably fail to remove the PPE without error. Consequently, institutions should have a stable selection of PPE, and in the case of preventing highly infectious diseases, a selected group of HCWs with continuous active training, as it is too late to start when the next epidemic is hitting our healthcare centers.
The contrast in the stringency of the CDC and UK Department of Health / Health and Safety Executive guidelines for infection prevention and control when dealing Ebola virus disease (EVD) patients is striking. This is particularly acute with regard to recommendations for Personal Protective Equipment (PPE) and terminal disinfection. Having recently reviewed both documents for a webinar on Ebola infection prevention and control (you can download the slides here, by the way), I thought I’d share the contrast:
Table: PPE and disinfection recommendations for dealing with patients with Ebola virus disease. Source: US CDC patient and environmental guidelines, and UK Department of Health. (Please note – this summary chart is designed to be illustrative rather than definitive.)
So is there any reason why the level of PPE and type of terminal disinfection required should be any different depending on which side of the Atlantic you happen to be? None whatsoever. So why the discrepancy? It’s difficult to say. This difference in recommendations has prompted the question of “To CDC or not to CDC” in terms of PPE for Ebola, and an opinion piece in Annals of Internal Medicine justifying the CDC approach. It is probably true that the level of PPE recommended by CDC is enough to block transmission, and that the risk of environmental contamination is low enough such that fumigation is not necessary. Probably. But is that good enough when Ebola is on the line? It is certainly true that you can be wearing all the PPE in the world but if you put in on incorrectly, don’t take care of it during use or remove it carelessly you will put yourself at risk.
When I came to decontaminate a room using hydrogen peroxide vapour following a case of Lassa fever in London some years ago, I wore all the PPE that I could lay my hands on (see below)!
Did this level of PPE match the risk of exposure to viable Ebola? Perhaps not, but it certainly made me feel a whole lot more secure about entering the room to do the job!
This time last week, we were on red alert that a MERS-CoV pandemic was gathering pace. The news over the last few days has been more encouraging, with no new cases reported in Saudi Arabia, the epicenter of the MERS-CoV cases. However, there are still plenty of patients with MERS-CoV who need to be cared for around the world. Like SARS-CoV, but unlike the “usual suspects” that cause HCAI such as MRSA and C. difficile, MERS-CoV has the capacity to affect both healthcare workers and patients. Thus, I hope that this ‘survival guide’ will prove useful to those on the front line.
I presented a webinar on ‘MERS-CoV: coming to a hospital near you? Infection prevention and control challenges’. You can download the slides here. I came across a fantastic blog whilst preparing the webinar: ‘Virology Down Under’ by Dr Ian Mackay. I’ve used some of his excellent images in the slides, with his kind permission.
There are two transmission routes to consider for MERS-CoV: droplet / aerosol and contact / fomite. CDC recommends both airborne and contact isolation procedures to reflect these transmission routes. This involves placement of the patient in a negative pressure airborne infection isolation room, and the use of gloves, gowns, eye protection and N95 (FFP3) mask, and, of course, hand hygiene. PHE recommends a similar approach.
First and foremost, as a respiratory virus, inhalation of infected droplets is likely to be the most important transmission route. However, whilst not an ‘airborne’ virus (such as measles), aerosols can be generated by MERS-CoV patients that comprise small droplet nuclei that travel for long distances. A recent study of influenza suggests that the generation of aerosols is surprisingly common, to the extent that ‘living and breathing is an aerosol generating procedure’. Indeed, a recent study showed that a MERS-CoV aerosol diminished by only 7% over 10 minutes (compared with 95% for influenza). The use of an N95 (FFP3) mask will prevent direct inhalation of droplets / aerosols, and gloves, gowns and eye protection will prevent contact with mucous membranes and contamination of clothing or hands for subsequent nasal inoculation. But, if MERS-CoV aerosol is generated in the patient’s room (which seems likely), how long will it last and will the subsequent admission to the next room be at risk?
Let’s assume a patient sheds a MERS-CoV infectious aerosol of 6-log. I’m not aware of any infectious dose data for MERS-CoV yet, but for SARS-CoV it can be as low as <20 plaque forming units. Given the decay rate of 7% over 10 minutes, infectious aerosol above the infectious dose could be present after the discharge of the patient for a little under 26 hours! Even if the virus was shed at a lower titre, infectious aerosol times would still be considerable (Table). Could this be a job for automated room disinfection systems, which address both surface and airborne contamination? One such system, hydrogen peroxide vapour, has recently been shown to inactivate the SARS-CoV surrogate, TGEV.
|Shed titre||Time to reach 20 virus particles|
Table: Relationship between shed titre of MERS-CoV and time to reach 20 virus particles.
Whilst respiratory viruses are not that great at surviving on surfaces compared with C. difficile spores and some vegetative bacteria, they can survive long enough to bring contact / fomite transmission into play. A number of reviews have concluded that contact / fomite transmission is an important route for influenza and other respiratory viruses such as rhinovirus. The SARS-CoV and surrogates exhibit unusual survival properties compared with other respiratory viruses, with survival times often measured in days, weeks or even months. Recent data suggests that MERS-CoV shares this property, surviving for >2 days when dried onto hard surfaces compared with only a few hours for influenza tested in the same study. Fortunately, these enveloped viruses are inactivated rapidly by usual hospital disinfectants, so I can understand the CDC’s recommendation for standard environmental disinfection.
So, how to protect yourself and your patients? The answer is simple for direct patient care: wear your gown, gloves, goggles and N95 (FFP3) mask, and wash your hands! It’s simple in theory, compliance with these measures in practice is not as good as you may expect. Prof Seto published a study in the Lancet in 2003 about compliance with personal protective equipment (PPE) and hand hygiene during the SARS epidemic. Remarkably, even when caring for patients known to be infected with SARS, <30% of healthcare workers self-reported that they wore a mask, glove, gown and washed their hands as they should have done. And this was self-reported, so you’d expect there to be a bias towards compliance! Most importantly, none of the healthcare workers who complied with all four measures became infected.
Figure: Healthcare worker compliance with mask, glove, gown use, and hand washing during the SARS epidemic, stratified by those who became infected with SARS.
To summarise: how to protect you and your patients from MERS-CoV:
- Place patient in negative pressure airborne infection isolation room, where available.
- Wear the correct PPE when in the room (gloves, gown, N95 / FFP3 mask, goggles), and wash your hands.
- Pay attention to the potential for contaminated surfaces and air, particularly following the discharge of the patient.
- Oh, and if you go on holiday to Saudi Arabia, don’t kiss any camels!