# 7278
While we don’t know exactly how two healthcare workers (HCWs) in Saudi Arabia came to be infected with the novel coronavirus, the fact that it happened – not once . . but twice – should provide a clear signal on the the importance of maintaining proper infection control procedures in healthcare settings.
As we aren’t in possession of the facts, I don’t intend to speculate on what factors led to these two HCWs becoming infected.
Regardless of what happened, the best defense against this – or any other contagion – in a healthcare environment are solid infection control procedures and strict adherence to wearing the appropriate PPEs (Personal Protective Equipment).
Lest anyone think that lapses in taking protective measures are in anyway unique to hospitals located in `other’ countries, a brief review of the literature shows a different story.
Whether due to inadequate infection control protocols, lack of education - or worse, supplies - or simple non-compliance on the part of the HCWs (PPEs can be hot, uncomfortable, and a considerable bother to put on and take off properly), lapses in infection control happen in hospitals around the world on a regular basis.
Exhibit A:
Infect Control Hosp Epidemiol.
2011 Mar;32(3):293-5. doi: 10.1086/658911.
Factors associated with unprotected exposure to 2009 H1N1 influenza A among healthcare workers during the first wave of the pandemic.
Banach DB, Bielang R, Calfee DP.
Abstract
Protecting healthcare workers (HCWs) from occupational exposure to 2009 H1N1 influenza was a challenge. During the first wave of the pandemic, many HCWs reported that they had been exposed to 2009 H1N1 when they were not using respiratory personal protective equipment. Unprotected exposures tended to be more frequent among HCWs caring for patients with atypical clinical presentations.
In a related article that appeared in Infection Control Today, the findings were discussed. Excerpts below:
Lack of Adherence to Respiratory PPE Seen During First Wave of H1N1 Pandemic
(Excerpt)
The researchers note, "The identification of almost five unprotected healthcare exposures for each patient who presented with ILI was a more unexpected finding. Potential explanations include inconsistent use of the screening and isolation protocol, communication barriers, and suboptimal adherence to recommended PPE use. Each of these warrants further research. Previous studies have demonstrated that healthcare worker compliance with respiratory protection guidance, including that related to influenza, is generally poor. A recent study of healthcare workers’ opinions about respirator use identified the need for new equipment that better meets the needs of healthcare workers."
Banach, et al. add, "Since substantial numbers of unprotected exposures occurred during this period of heightened awareness of influenza and at a time when vaccination was not an option, it is likely that similar or perhaps even more exposures occur during typical influenza seasons. This highlights the importance of healthcare worker immunization, when available, and the need for a better understanding of barriers to effective implementation of screening protocols and adherence to recommended respiratory PPE use among healthcare workers."
Moving on to Exhibit B:
The use of personal protective equipment for control of influenza among critical care clinicians: A survey study.
Daugherty EL, Perl TM, Needham DM, Rubinson L, Bilderback A, Rand CS.
DESIGN, SETTING, AND PARTICIPANTS:
A survey of 292 internal medicine housestaff, pulmonary/critical care fellows and faculty, nurses, and respiratory care professionals working in four ICUs in two hospitals in Baltimore, MD.
MEASUREMENTS AND MAIN RESULTS:
Of those surveyed, 88% (n = 256) completed the survey. Only 63% of respondents were able to correctly identify adequate influenza PPE, and 62% reported high adherence (>80%) with PPE use for prevention of nosocomial influenza. In multivariable modeling, odds of high adherence varied by clinician type. Respondents who believed adherence was inconvenient had lower odds of high adherence (odds ratio 0.42, 95% confidence interval 0.22-0.82), and those reporting likelihood of being reprimanded for nonadherence were more likely to adhere (odds ratio 2.40, 95% confidence interval 1.25-4.62).
CONCLUSIONS:
ICU HCWs report suboptimal levels of influenza PPE adherence. This finding in a high-risk setting is particularly concerning, given that it likely overestimates actual behavior.
Both suboptimal adherence levels and significant PPE knowledge gaps indicate that ICU HCWs may be at a substantial risk of developing and/or transmitting nosocomial respiratory viral infection. Improving respiratory virus infection control will likely require closing knowledge gaps and changing organizational factors that influence behavior.
I could provide more references (such as Addressing the Challenges of PPE Non-Compliance) but the point is, compliance wearing appropriate PPEs in healthcare facilities is far too often – as they phrase it above - `suboptimal’.
Last week the World Health Organization released their Interim Infection Control Guidance On nCoV, and earlier this month PHAC released their Guidance On Handling H7N9 Cases.
Taking an even tougher stance, the CDC released their Interim H7N9 Infection Control Guidelines in the middle of April and are currently recommending their guidance for SARS when dealing with the novel coronavirus (see 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings).
These guidance documents will likely change and evolve as we learn more about this virus, but they provide a solid foundation for interim HCW protection.
Even though the novel coronavirus is not SARS, there are lessons we can learn from how that epidemic was eventually contained. Hospitals turned out to be an ideal breeding ground for the SARS virus, and it required bold, and difficult steps to stop its spread.
With no vaccine or antivirals available containment was accomplished primarily through the use of isolation, quarantine, and stringent infection control measures.
For more on how these measures have been successfully used in the past to contain epidemics, you may wish to revisit EID Journal: A Brief History Of Quarantine.
Today, in response to the news that two HCWs in Saudi Arabia have been infected, WHO issued a statement offering the following advice:
Health care facilities that provide care for patients with suspected nCoV infection should take appropriate measures to decrease the risk of transmission of the virus to other patients and health care workers. Health care facilities are reminded of the importance of systematic implementation of infection prevention and control (IPC).
While the future of this virus is unknowable - if it plays out anything like SARS did in 2003 - the battle against this virus may very well end up being won or lost in the trenches of the health care environment.
The good news is - that with the proper precautions in place - that’s a battle that experience has shown we can win.
