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Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 1-3

COVID-19 - A global health pandemic - Safeguarding health-care workers

Editor, JRNM, Professor; Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission20-Jun-2020
Date of Acceptance26-Jun-2020
Date of Web Publication20-Jul-2020

Correspondence Address:
Dr. Anita Saxena
Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrnm.jrnm_15_20

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How to cite this article:
Saxena A. COVID-19 - A global health pandemic - Safeguarding health-care workers. J Renal Nutr Metab 2020;6:1-3

How to cite this URL:
Saxena A. COVID-19 - A global health pandemic - Safeguarding health-care workers. J Renal Nutr Metab [serial online] 2020 [cited 2022 May 26];6:1-3. Available from: http://www.jrnm.in/text.asp?2020/6/1/1/290280

In December 2019, Wuhan City, Hubei Province of China, reported unknown “viral pneumonia” related to a local seafood wholesale market, the first outbreak of severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2). In 2 months' time, the virus spread from Wuhan engulfing almost the entire China, and 33 different countries.

The World Health Organization (WHO) on March 11, 2020, declared SARS-CoV-2 a pandemic which infected over 4 million people and caused nearly 300,000 fatalities over 188 countries.[1]

What is this Corona virus that causes pneumonia and then doesn't respond to antibiotic treatment and kills 10% of the individuals a dreaded threat that has created fear of uncertainties in our lives? “Corōna “ in Latin means a garland worn on the head as a mark of honour or emblem of majesty, halo around a celestial body, top part of an entablature” but here it is like “the Sword of Damocles”, an allusion to the imminent and ever-present intimidating threat necessitating wrapping oneself up in a protective gear and psyching oneself in believing “I am this and I am gona be fine”. The enveloped dreaded virus contains a positive-sense single-stranded RNA genome and a nucleocapsid of helical symmetry of ∼120 nm.[2] The transmission of virus occurs through air via droplets or aerosols. This airborne transmission occurs from coughing/sneezing and even from normal breathing and talking by virus bearing infected person. These mechanisms of viral shedding produce large droplets and small aerosols. The commonly accepted cutoff size between the large droplets and small aerosols is 5 μm, although this varies considerably between studies, ranging up to 12 μm.[3]

Droplets generated during coughing, sneezing, or talking do not remain suspended in air and travel <1 m before settling on the mucosa of close contacts or environmental surfaces. Aerosols have a slow settling velocity, thus they remain suspended in the air longer and can travel further, hence the airborne transmission via aerosols can occur over an extended distance and time. Virus transmission occurs via direct (deposited on persons) or indirect (deposited on objects) contact and airborne (droplets and aerosols) routes.[4]

Inhalation of virus-bearing aerosols results in deep and continuous deposition into the human respiratory tract, and transmission can occur even with low load of virus.[5] Airborne viruses have great mobility and sufficiently long surviving time for dispersion,[6] hence, residents situated in densely populated environments are highly vulnerable. In addition, nascent micrometer-sized aerosols produced from coughing/sneezing of the infected people have the potential of containing many viruses, particularly for asymptomatic carriers.[7] The WHO and the US Centers for Disease Control and Prevention emphasize on prevention of contact transmission, The first issue of JRNM 2020 is an exclusive issue on SARS-CoV-2, which touches upon challenges in medical practice during the COVID-19 pandemic and infection in children and dialysis patients.

Health-care workers (HCW) caring for patients admitted in wards with or without high risk of transmitting infection and working in areas of high-consequence infectious diseases (HCIDs) require protection from pathogen exposure. SARS, or coronavirus (COVID-19), a highly infectious disease with its airborne transmission makes it highly virulent.

HCWs are at much greater risk of infection than the general population, due to their their close proximity with patients. SARS-CoV-2 can be spread by people who are asymptomatic. Specific infection prevention and control (IPC) measures are required in all healthcare settings (specialist and non-specialist). To protect from infections that pose dangers to HCWs,[8] NHS and Public Health England initiated the High Consequence Infectious Disease (HCID) program. Personal protective equipment (PPE) components confer protection not only through their inherent safety, but also with their safe and correct use, which has to be imparted by adequate training and user's familiarity.[9]

PPE reduces the risk by covering exposed body parts. However, different studies indicate different preferences in the choice of PPEs which are best protective and are easier in donning and doffing and how well can the HCWs be trained to use PPE. These studies have evaluated types of full-body PPE and also looked at methods of donning or doffing which will minimize the risk of contamination or infection for HCW and the training methods that would increase compliance with PPE protocols.[10] Studies advocate, though more difficult to don (noncompliance: risk ratio [RR]: 7.5, 95% confidence interval [CI]: 1.81–31.1), the use of a powered, air-purifying respirator with coverall which may confer better protection against the risk of contamination compared to N95 mask and gown (RR: 0.27, 95% CI: 0.17–0.43).[8],[9],[10] Outcome of a randomized controlled trial (59 participants) showed that isolation gowns (very low-certainty evidence) are easy to doff compared to coveralls. Gowns may protect better against contamination than aprons (small patches: mean difference (MD): −10.28, 95% CI: −14.77 to − 5.79). PPE made of more breathable material may lead to a similar number of spots on the trunk. For training purposes, the use of computer simulation may lead to fewer errors in doffing (MD: −1.2, 95% CI: −1.6 to − 0.7). A video lecture on donning PPE may lead to better skills scores (MD: 30.70, 95% CI: 20.14–41.26) than a traditional lecture. Face-to-face instruction may reduce noncompliance with doffing guidance more (odds ratio: 0.45, 95% CI: 0.21–0.98) than providing folders or videos only.[8],[9],[10]

Significant differences exist in the availability of HCW SARS-CoV-2 testing between countries, and the existing programs focus on screening symptomatic rather than asymptomatic staff. Over a period of 3 weeks, a UK teaching hospital screened 1032 asymptomatic HCWs, symptomatic staff, and symptomatic household contacts for SARS-CoV-2 using reverse transcription-polymerase chain reaction to detect viral RNA. In the asymptomatic screened HCW group, 3% tested positive for SARS-CoV-2 and 57% were truly asymptomatic or pauci-symptomatic. Nearly 40% had experienced symptoms similar to coronavirus disease 2019 (COVID-19) >7 days prior to testing who went into isolation. The study emphasizes the need for comprehensive screening of HCWs with minimal or no symptoms, an approach critical for smooth functioning of hospitals by protecting patients and hospital staff.[11],[12]

Survival of patients depends not only on top-quality treatment regimens but also on the unvarying food delivery system.

Health-care facilities have to consider how best to support HCW employed in the food chain to ensure uninterrupted supply of food to the patients, but how often do we think on the safety of HCWs who transport food to the patients. Food is the lifeline of any living being and when it comes to the hospitalized patients, it becomes an important part of the treatment for good clinical outcome. Malnutrition is common in hospitalized patients. Two-thirds of the patients experience disease-related undernutrition and decline in nutritional status while in hospital with negative energy balance and reduction in lean body mass. The prevalence of hospital-acquired malnutrition is as high as 13%–69%.[13]. In view of the above, it is important to ensure the safety of HCW employed in the kitchen from infections, for uninterrupted supply of food to patients whether it is a period of outbreak of ghastly infectious disease or smooth sailing times of clinical practice.

  1. Screening and management in Indian setting (the developing world with fewer resources) – precautions for hospital kitchen staff for handling food: If it is not feasible to test the kitchen staff for COVID regularly due to test burden on the testing laboratories of the hospitals and limited budget, it is advisable to screen all the service boys with thermal scanner prior to entering into the workplace. They should voluntarily declare if they have any symptoms of cold, cough, sneezing, sore throat, or gastrointestinal discomfort. HCWs should be provided educational material stating precautions. Special tutorials showing video on the safety of HCWs should be conducted weekly to ensure compliance. Educational material for HCWs should elucidate information provided below.

The virus causing COVID-19 can survive on surfaces and objects for a certain amount of time. Coronaviruses can remain on hard surfaces such as steel and plastic (steel trolleys, elevator buttons) for up to 3 days, therefore, these surfaces carry the highest risk of transmission of the virus if touched. COVID-19 can remain on cardboard surfaces for up to 24 h.

  1. COVID-19 can be contacted by touching a surface or object that has the virus on it and then touching the mouth, nose, or eyes. Hence, it is imperative to abstain from such practices.
  2. To minimize transmission of the novel coronavirus, wash hands regularly, especially after touching frequently handled objects such as doorknobs or handles
  3. The virus can spread from person to person through respiratory droplets produced when an infected person coughs, sneezes, or talks
  4. These droplets can land into the mouth or nose of people who are nearby or possibly be inhaled into the lungs
  5. This mandates social distancing of at least 1.2 m and covering of nose and mouth with mask
  6. Frequent washing of hands with soap for at least 20 is advisable
  7. Use hand sanitizers frequently
  8. Wipe down all surfaces of the steel food trolleys with wipes. Discard the wipe immediately. Be mindful to avoid touching your face
  9. HCW's adherence to infection prevention and control guidelines includes use of PPE such as masks, face shields, gloves, and gowns
  10. Covering more parts of the body leads to better protection
  11. Worker delivering food should wear a face shield during food distribution and follow stricter cleaning routines in non-covid wards.
  12. Disposable gloves must be used while serving the food
  13. Extra sanitation of gloves before doffing with quaternary ammonium or bleach may decrease contamination
  14. One-step removal of gloves and gown may lead to less bacterial contamination. Double-gloving may lead to less viral or bacterial contamination compared to single gloving (relative risk [RR]: 0.34, 95% CI: 0.17–0.66) but not to less fluorescent contamination (RR: 0.98, 95% CI: 0.75–1.28)[8],[9],[10]
  15. After returning from the ward, HCWs should wash hands with soap before entering into the kitchen
  16. Wear gloves while handling fresh fruits and vegetables
  17. Wash thoroughly under running water. One may even wash the surface with a small amount of soap and water for 20 s before peeling and cooking food
  18. Use of disposable food trays and cups in the holding areas, COVID-positive zones, and in the quarantine HCW zones is mandatory.

Adherence to these precautions with periodic pep-talks with hospital kitchen HCWs will not only make the HCWs that they are being cared for but will also help maintain an uninterrupted food supply to ailing patients

  References Top

World Health Organization. Coronavirus Disease (COVID-2019) Situation Reports. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/2020. [Last accessed on 2020 Jul 13].  Back to cited text no. 1
Fehr AR, Perlman S. Coronaviruses: An overview of their replication and pathogenesis. Methods Mol Biol 2015;1282:1-23.  Back to cited text no. 2
Kutter JS, Spronken MI, Fraaij PL, Fouchier RA, Herfs S. Transmission routes of respiratory viruses among humans. Curr Opin Virol 2018;28:142-51.  Back to cited text no. 3
Tellier R. Aerosol transmission of influenza A virus: A review of new studies. J R Soc Interface 2009;6 Suppl 6:S783-90.  Back to cited text no. 4
Pyankov OV, Bodnev SA, Pyankova OG, Agranovski IE. Survival of aerosolized coronavirus in the ambient air. J Aerosol Sci 2018;115:158-63.  Back to cited text no. 5
van Doremalen N, Bushmaker T, Morris DH, Myndi G. Holbrook Amandine Gamble N Engl J Med 2020;382:1564-7.  Back to cited text no. 6
Houghton C, Meskell P, Delaney H, Smalle M, Glenton C, Booth A, et al. Barriers and facilitators to healthcare workers' adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis. Cochrane Database Syst Rev. 2020;4:CD013582. Published 2020 Apr 21. doi:10.1002/14651858.CD013582.  Back to cited text no. 7
Poller B, Hall S, Bailey C, Gregory S, Clark R, Roberts P, et al. 'VIOLET': A fluorescence-based simulation exercise for training healthcare workers in the use of personal protective equipment. J Hosp Infect 2018;99:229-35.  Back to cited text no. 8
Poller B, Tunbridge A, Hall S. A unified personal protective equipment ensemble for clinical response to possible high consequence infectious diseases: A consensus document on behalf of the HCID programme. J Infect 2018;77:496-502.  Back to cited text no. 9
Verbeek JH, Rajamaki B, Ijaz S, Sauni R, Toomey E, Blackwood B, et al. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. Cochrane Database Syst Rev. 2020;5:CD011621.  Back to cited text no. 10
Rivett L, Sridhar S, Sparkes D, Routledge M, Jones NK, Forrest S, et al. Screening of healthcare workers for SARS-CoV-2 highlights the role of asymptomatic carriage in COVID-19 transmission. Elife 2020;9:e58728.  Back to cited text no. 11
Jones NK, Rivett L, Sparkes D. Effective control of SARS-CoV-2 transmission between healthcare workers during a period of diminished community prevalence of COVID-19. Elife 2020;9:e59391.  Back to cited text no. 12
Ray S, Laur C, Golubic R. Malnutrition in healthcare institutions: A review of the prevalence of under-nutrition in hospitals and care homes since 1994 in England. Clin Nutr 2014;33:829-35.  Back to cited text no. 13

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