COVID-19: The Novel CoronavirusPage 7 of 10

5. Health Professionals, Best Practice

Healthcare personnel (HCP) are on the front lines of caring for patients with confirmed or possible infection with 2019 novel coronavirus. They must be prepared to identify and isolate potentially infected patients in order to protect other patients—and themselves—from exposure. HCPs can minimize their risk of exposure when caring for confirmed or possible COVID-19 patients by following CDC infection prevention and control guidelines, including use of recommended personal protective equipment (PPE) (CDC, 2020k).

Criteria for Evaluation of Patients Suspected of COVID-19

Clinical Features

&

Epidemiologic Risk

Fever or signs/symptoms of lower respiratory illness (e.g. cough or shortness of breath)

AND

Any person, including health care workers, who has had close contact with a laboratory-confirmed 2019-nCoV patient within 14 days of symptom onset

Fever and signs/symptoms of a lower respiratory illness (e.g. cough or shortness of breath)

AND

A history of travel from Hubei Province, China within 14 days of symptom onset

Fever and signs/symptoms of a lower respiratory illness (e.g. cough or shortness of breath) requiring hospitalization

AND

A history of travel from mainland China within 14 days of symptom onset

Protecting Yourself and Others

Healthcare personnel caring for patients with confirmed or possible COVID-19 should adhere to CDC recommendations for infection prevention and control (IPC):

  • Assess and triage patients with acute respiratory symptoms and risk factors for COVID-19 to minimize chances of exposure, including placing a facemask on the patient and isolating them in an Airborne Infection Isolation Room (AIIR), if available.
  • Use Standard, Airborne, and Contact Precautions and eye protection when caring for patients with confirmed or possible COVID-19.
  • Perform hand hygiene with alcohol-based hand rub before and after all patient contact, contact with potentially infectious material, and before putting on and upon removal of PPE, including gloves. Use soap and water if hands are visibly soiled.
  • Practice how to properly don, use and doff PPE in a manner to prevent self-contamination. (CDC, 2020j)

Perform aerosol-generating procedures, including collection of diagnostic respiratory specimens, in an AIIR, while following appropriate IPC practices, including use of appropriate PPE.

There is much to learn about COVID-19, including how readily it spreads. However, based on what is currently known about the virus and what is known about other coronaviruses, spread is thought to occur mostly person-to-person via respiratory droplets among close contacts.

Close contact can occur while caring for a patient, including:

  • Being within approximately 6 feet (2 meters) of a patient with COVID-19 for a prolonged period of time.
  • Having direct contact with infectious secretions from a patient with COVID-19. Infectious secretions may include sputum, serum, blood, and respiratory droplets.

If close contact occurs while not wearing all recommended PPE, healthcare personnel may be at risk of infection (CDC 2020k).

Extended Use and Reuse of N95 Respirators

[The next 3 sections on extended use and reuse of respirators are taken from CDC: Pandemic Planning: Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings (2018).]

CDC has made recommendations for the extended use and limited reuse of N95 filtering facepiece respirators for healthcare workers. Supplies of N95 respirators can become depleted during a pandemic or wide-spread outbreaks of other infectious respiratory illnesses.

Extended use refers to the practice of wearing the same N95 respirator for repeated close contact encounters with several patients, without removing the respirator between patient encounters. Extended use may be implemented when multiple patients are infected with the same respiratory pathogen and patients are placed together in dedicated waiting rooms or hospital wards. Extended use has been recommended as an option for conserving respirators during previous respiratory pathogen outbreaks and pandemics.

Reuse refers to the practice of using the same N95 respirator for multiple encounters with patients but removing it (‘doffing’) after each encounter. The respirator is stored in between encounters to be put on again (‘donned’) prior to the next encounter with a patient. For pathogens in which contact transmission (e.g., fomites) is not a concern, non-emergency reuse has been practiced for decades. For example, for tuberculosis prevention, CDC recommends that a respirator classified as disposable can be reused by the same worker as long as it remains functional and is used in accordance with local infection control procedures.

Even when N95 respirator reuse is practiced or recommended, restrictions should be in place which limit the number of times the same filtering facepiece respirator (FFR) is reused. Thus, N95 respirator reuse is often referred to as “limited reuse”. Limited reuse has been recommended and widely used as an option for conserving respirators during previous respiratory pathogen outbreaks and pandemics.

Respirator Extended Use Recommendations

Extended use is favored over reuse because it involves less touching of the respirator and therefore less risk of contact transmission. But, for safe extended use the respirator must maintain its fit and function. Extended use of N95 respirators in other industries indicates that respirators can function within their design specifications for 8 hours of continuous or intermittent use. Some research studies have recruited healthcare workers as test subjects and many of those subjects have successfully worn N95 respirators at work for several hours before they needed to remove them. Thus, the maximum length of continuous use in non-dusty healthcare workplaces is typically dictated by hygienic concerns (e.g., the respirator was discarded because it became contaminated) or practical considerations (e.g., need to use the restroom, meal breaks, etc.), rather than a pre-determined number of hours.

If extended use of N95 respirators is permitted, adherence to administrative and engineering controls must be ensured to limit potential N95 respirator surface contamination (e.g., use of barriers to prevent droplet spray contamination). Additional training and reminders (e.g., posters) for staff should be used to reinforce the need to minimize unnecessary contact with the respirator surface, strict adherence to hand hygiene practices, and proper Personal Protective Equipment (PPE) donning and doffing technique.

To reduce contact transmission after donning:

  • Discard N95 respirators following use during aerosol generating procedures.
  • Discard N95 respirators contaminated with blood, respiratory or nasal secretions, or other bodily fluids from patients.
  • Discard N95 respirators following close contact with, or exit from, the care area of any patient infected with a disease requiring contact precautions.
  • Consider a cleanable face shield (preferred) to cover an N95 respirator and/or other steps (e.g., masking patients, use of engineering controls) to reduce surface contamination.
  • Perform hand hygiene with soap and water or an alcohol-based hand sanitizer before and after touching or adjusting the respirator (if necessary for comfort or to maintain fit).

Extended use alone is unlikely to degrade respiratory protection. However, healthcare facilities should develop clearly written procedures to advise staff to discard any respirator that is obviously damaged or becomes hard to breathe through.

There is no way to determine the maximum number of safe reuses for an N95 respirator to be applied in all cases. Safe N95 reuse is affected by a number of variables that impact respirator function and contamination over time. However, manufacturers of N95 respirators have specific guidance regarding reuse of their product.

If reuse of N95 respirators is permitted, users should adhere to administrative and engineering controls to limit potential N95 respirator surface contamination (e.g., use of barriers to prevent droplet spray contamination). Additional training and/or reminders (e.g., posters) for staff is important to reinforce the need to minimize unnecessary contact with the respirator surface, strict hand hygiene practices, and proper PPE donning and doffing technique, including physical inspection and performing a user seal check. Healthcare facilities should develop clearly written procedures to advise staff to take the following steps to reduce contact transmission:

  • Discard N95 respirators following use during aerosol generating procedures.
  • Discard N95 respirators contaminated with blood, respiratory or nasal secretions, or other bodily fluids from patients.
  • Discard N95 respirators following close contact with any patient co-infected with an infectious disease requiring contact precautions.
  • Consider use of a cleanable face shield to protect the N95 respirator and/or other steps (e.g., masking patients, use of engineering controls), when feasible to reduce surface contamination of the respirator.

Hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses. To minimize potential cross-contamination, store respirators so that they do not touch each other and the person using the respirator is clearly identified. Storage containers should be disposed of or cleaned regularly. The respirators should only be used by one person.

Clean hands with soap and water or an alcohol-based hand sanitizer before and after touching or adjusting the respirator (if needed for comfort or to maintain fit). Avoid touching the inside of the respirator. If inadvertent contact is made with the inside of the respirator, discard the respirator and perform hand hygiene as described above.

Use a pair of clean (non-sterile) gloves when donning a used N95 respirator and performing a user seal check. Discard gloves after the N95 respirator is donned and any adjustments are made to ensure the respirator is sitting comfortably on your face with a good seal.

To reduce the chances of decreased protection caused by a loss of respirator functionality, the respirator manufacturer should be consulted regarding the maximum number of donnings or uses they recommend for the N95 respirator model(s) used in that facility. If no manufacturer guidance is available, preliminary data suggests limiting the number of reuses to no more than five uses per device to ensure an adequate safety margin.

Risks of Extended Use and Reuse of Respirators

Although extended use and reuse of respirators have the potential benefit of conserving limited supplies of disposable N95 respirators, concerns about these practices have been raised. Some devices have not been FDA-cleared for reuse. Some manufacturers’ product user instructions recommend discard after each use (i.e., “for single use only”), while others allow reuse if permitted by infection control policy of the facility.

The most significant risk is contact transmission from touching the surface of the contaminated respirator. One study found that nurses averaged 25 touches per shift to their face, eyes, or N95 respirator during extended use. Contact transmission occurs through direct contact with others as well as through indirect contact by touching and contaminating surfaces that are then touched by other people.

Respiratory pathogens on the respirator surface can potentially be transferred by touch to the wearer’s hands and thus risk causing infection through subsequent touching of the mucous membranes of the face (i.e., self-inoculation). While studies have shown that some respiratory pathogens remain infectious on respirator surfaces for extended periods of time, in microbial transfer and reaerosolization studies more than ~99.8% have remained trapped on the respirator after handling or following simulated cough or sneeze.

Respirators might also become contaminated with other pathogens acquired from patients who are co-infected with common healthcare pathogens that have prolonged environmental survival (e.g., methicillin-resistant Staphylococcus aureas, vancomycin-resistant enterococci, Clostridium difficile, norovirus, etc.). These organisms could then contaminate the hands of the wearer, and in turn be transmitted via self-inoculation or to others via direct or indirect contact transmission.

The risks of contact transmission when implementing extended use and reuse can be affected by the types of medical procedures being performed and the use of effective engineering and administrative controls, which affect how much a respirator becomes contaminated by droplet sprays or deposition of aerosolized particles. For example, aerosol generating medical procedures such as bronchoscopies, sputum induction, or endotracheal intubation, are likely to cause higher levels of respirator surface contamination, while source control of patients (e.g. asking patients to wear facemasks), use of a face shield over the disposable N95 respirator, or use of engineering controls such as local exhaust ventilation are likely to reduce the levels of respirator surface contamination.

While contact transmission caused by touching a contaminated respirator has been identified as the primary hazard of extended use and reuse of respirators, other concerns have been assessed, such as a reduction in the respirator’s ability to protect the wearer caused by rough handling or excessive reuse. Extended use can cause additional discomfort to wearers from wearing the respirator longer than usual. However, this practice should be tolerable and should not be a health risk to medically cleared respirator users.

Unprotected Exposure

If you have an unprotected exposure (i.e., not wearing recommended PPE) to a confirmed or possible COVID-19 patient, contact your supervisor or occupational health officer immediately.

If you develop symptoms consistent with COVID-19 (fever, cough, or difficulty breathing), do not report to work. Contact your occupational health services (CDC 2020k).

For more information relevant to healthcare personnel, visit https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html.

Environmental Cleaning and Disinfection

Routine cleaning and disinfection procedures are appropriate for COVID-19 in healthcare settings, including those patient-care areas in which aerosol-generating procedures are performed. Products with EPA approved emerging viral pathogens claims are recommended for use against COVID-19. Management of laundry, food service utensils, and medical waste should also be performed in accordance with routine procedures (CDC 2020k).