Should COVID-19 positive asymptomatic healthcare workers continue working in COVID-19 positive non critical wards

The new CDC guidelines state that essential workers who may have had possible exposure to the virus may continue to work if they are asymptomatic, wear a mask at all times for 14 days after their last exposure and have their temperature checked before entering the workplace.

They are required to follow CDC guidance on social distancing, stay at least 3-6 feet from co-workers and potential new patients. If they develop any symptoms, they should be sent home immediately and all surfaces at the workplace should be cleaned and disinfected.

Is there any study about COVID-19 virus being present in the shoes

A small study at a Wuhan hospital noted that COVID-19 could be spread by shoes. The study assessed surface samples from an intensive care unit and general COVID-19 ward at the Huoshenshan Hospital in Wuhan, China.

The ICU had 15 patients with severe symptoms and the general ward had 24 patients with milder symptoms. From Feb. 19 to March 2, swab samples were obtained from the floors, computer mice, trash cans, sickbed handrails, patient masks, personal protective equipment, and air outlets.

Floor swab samples had relatively high positivity rate, possibly because of gravity and air flow causing most virus droplets to float to the ground. Additionally, as medical staff walk around the ward, the virus could be tracked all over the floor, as noted by the 100% rate of positivity from the floor in the pharmacy, where there were no patients.

Half of the samples obtained from the soles of shoes of ICU medical workers tested positive, thus urging health officials to conclude that the shoes might serve as carriers.

The 3 weak positive results from the floor of dressing room might also be associated with these carriers. The study recommended that persons disinfect shoe soles before walking out of wards containing COVID-19 patients. The study was published in the Emerging Infectious Diseases Journal.

ICMR advises ‘pool testing’ in low-infection areas to increase number of COVID-19 tests

Yes. Pool testing involves up to five samples at a time, rather than one. If a pool comes up positive, each sample is tested individually. This is the same what we used to do for urine Benedicts test for presence of sugar or SSA for urinary proteins when the strips were not available.

The ICMR advisory has stated that the pool testing algorithm involves the Polymerase Chain Reaction (RT-PCR) screening of a specimen pool, comprising multiple samples. In case a pool tests positive, then each sample will be individually tested.

The RT-PCR test is used to ascertain if an individual has contracted COVID-19. The test is to be used in areas with low prevalence of the infection, i.e., with a positivity rate of <2%. Out of 1,000 samples in an area, if less than 20 test positive for COVID-19, the area is said to have a low positivity rate, and will qualify for pool testing.

As the disease progresses and probability of positive cases increases, the usefulness of the test declines. The tests need to be repeated, and need arises to conduct all tests individually, if the result is positive.

Pool testing is aimed at increasing the capacity of laboratories to screen more samples in the same amount of time without doubling the resources.

A feasibility study conducted at ICMR’s Virus Research & Diagnostic Laboratory (VRDL) at King George’s Medical University (KGMU), Lucknow noted that performing real-time PCR testing for COVID-19 with multiple samples (up to five) is feasible if the prevalence rates of infection are low.

Deconvoluted testing (testing individual samples) is to be done if any of the pool is positive. Pooling of over five samples is not recommended to avoid the effect of dilution resulting in false negatives. Preferable number of samples to be pooled is five, but as few as two samples can also be pooled. Considering the higher probability of missing a positive sample which has a low viral load, ICMR discourages pooling more than five samples together, except during research.

Apart from areas with a low prevalence of COVID-19, to be initially decided based on existing data, the advisory suggests pool testing in areas with positivity of 2-5%. Pooling of samples is not recommended in areas or populations with positivity rates >5%.

It can be used for community survey or surveillance among asymptomatic individuals, but is strictly prohibited in cases of individuals with known contact with confirmed cases and healthcare workers (in direct contact with care of COVID-19 patients). The samples of such high-risk individuals have to be directly tested without pooling. (Excerpts from The Print)

Healthcare coranxiety

The COVID-19 epidemic has created an anxiety among healthcare professionals. Any loss of human life is a tragedy.

Robert M. Kaplan, PhD, a faculty member at Stanford Universitys Clinical Excellence Research Center, stated recently that to look into this issue, they analyzed summaries of physician deaths due to COVID-19 through April 10, 2020, in a report published in Medscape. He focused on physicians rather than all providers because mortality reports appeared more complete. Through April 10, there were 17 physician deaths in the United States. Sixteen of these occurred among physicians aged 60 or older.

The age range was 37-92: the only death under age 65 was an oral surgery resident. About 65% (11 of 17 deaths) occurred in physicians aged 65 or older and 47% where among those older than 70. Obituaries or press releases were available for 16 of the cases. While it is uncertain from the write-ups, it seems that about half of the physicians who died were retired or only practicing part-time. Several of the write-ups noted that the deceased physician had serious health problems, including recurrent cancers.

Kaplan compared the COVID-19 death rate among physicians to that in the general population. There are approximately 1.1 million physicians in the U.S. population of 330 million people. This means, there is approximately one physician for each 300 persons in the population.

By April 10, there were some 20,000 COVID-19 deaths in the US. If physicians are dying at the same rate as people in the general population, about 66 physician deaths would be expected. If the data are accurate, physician deaths are about 75% lower than expected. The risk from exposure to sick patients may be an overestimate as in about half of the cases, the physicians appeared to have retired or reduced clinical practice.

Concerns still remain about the accuracy of the data. It is possible that the Medscape listing is incomplete. However, each physician COVID-19 death is newsworthy and likely to gain attention. Several Google searches have failed to identify additional cases.

An additional concern is that it was difficult to determine the level of current clinical activity from the obituaries. The estimate that half of the cases had retired from clinical practice is hard to validate. (Medpage Today)

Compassionate use of remdesivir for severe COVID-19

In a cohort of patients hospitalized for severe COVID-19 being treated with compassionate-use remdesivir, clinical improvement was observed in 36 of 53 (68%) patients, suggested a study published in The New England Journal of Medicine. Improvement in oxygen-support status was observed in 68% of patients, and overall mortality was 13% over a median follow-up of 18 days. 

Of the patients administered remdesivir, 64% were receiving invasive ventilation at baseline, including 8% who were receiving extracorporeal membrane oxygenation (ECMO). The mortality in this subgroup was 18% compared with 5.3% in patients receiving non-invasive oxygen support. 

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The Journal of Hospital Infection study: researchers attempted to disinfect N95 respirators using a SteraMist Binary Ionization Technology. 

Yes: The main constituent contains 7.8% H₂O₂ solution that is converted to ionized H₂O₂ (iHP) vapor after passing through a cold plasma arc, and moving like a gas throughout the surface of N95 respirator. The by-product of iHP is oxygen and water in the form of humidity.

Journal of Microbiology, Immunology and Infection study showed persistent shedding of COVID-19 virus in stools of infected children

Yu-Han Xing, MD, the Chinese University of Hong Kong, Hong Kong, China, and colleagues analyzed data from 3 children with COVID-19 in Qingdao, Shandong Province, China. Patients were followed-up to March 10, 2020. Clearance of SARS-CoV-2 in respiratory tract occurred within 2 weeks after decrease in fever; however, viral RNA was detectable in stools of pediatric patients for more than 4 weeks. Two children had fecal SARS-CoV-2 undetectable 20 days after throat swabs were negative, while that of another child lagged behind for 8 days.

SARS-CoV-2 may exist in children’s gastrointestinal tract for a longer period of time than respiratory system. None of the children developed severe complications nor required intensive care or mechanical ventilation. All 3 children only presented with fever and mild cough or with no obvious symptom but non-typical radiological abnormalities, and all children had increased lymphocytes. All children showed good response to anti-viral and supportive treatment including inhalation of interferon and oral ribavirin. 

How common are GI symptoms

New research from China shows that a minority of cases appear with gastrointestinal symptoms only. In about a quarter of patients in the study, diarrhea and other digestive symptoms were the only symptoms seen in mild COVID-19 cases, and those patients sought medical care later than those with respiratory symptoms. "Failure to recognize these patients early and often may lead to unwitting spread of the disease among outpatients with mild illness, who remain undiagnosed and unaware of their potential to infect others," said a team from Union Hospital and Tongji Medical College in Wuhan, China.

Coronavirus Can Spread 13 Feet, Cling to Shoes

Yes: The new coronavirus can travel 13 feet through the air and can be carried around on peoples shoes, according to a new report from the CDC.

Do we know the prevalence of COVID-19 in the society

A new study has started recruiting at the National Institutes of Health in Bethesda, Maryland to ascertain as to how many adults in the United States without a confirmed history of infection with SARS-CoV-2 have antibodies to the virus. The presence of antibodies in the blood points to previous infection. In this serosurvey, researchers will collect and analyze blood samples from nearly 10,000 volunteers to provide critical data for epidemiological models. The results will help determine the extent to which the novel coronavirus has spread undetected in the United States and provide insights into which communities and populations are most affected.

CMAAO Coronavirus Facts and Myth Buster 50

What is Medical equipment disinfection and sterilization

The type of cleaning, disinfection, and sterilization required depends on the type of medical equipment.

What is a Noncritical equipments

Medical equipment that comes into contact with intact skin but not mucous membranes (such as stethoscopes, blood pressure cuffs, patient care area surfaces)

What are Semi-critical equipments

Medical equipment that comes into contact with non-intact skin or mucous membranes (eg, thermometers, endoscopes)

What are Critical medical equipments

Medical equipment that comes into contact with sterile tissue or the vascular system (eg, implants, catheters, surgical instruments)

How to clean Noncritical medical equipment

They should be cleaned with the help of a disinfectant that kills most bacteria and some viruses and fungi. It is often sufficient to clean these items with an alcohol wipe between uses.

Mobile communication devices such as pagers and cell phones may also become contaminated with bacteria; these devices should be disinfected in a similar manner.

How to clean semi-critical medical equipments

They should be free from all vegetative microorganisms, but small numbers of bacterial spores are permissible as non-intact skin and mucous membranes are generally resistant to infection by spores.

How to clean critical medical equipment

They must be sterile as any microbial contamination could transmit disease. These items should be purchased as sterile or be sterilized between uses.

Can bleach be harmful

Before using bleach everywhere, its important to understand that bleach is caustic and can emit potentially lethal fumes. It is important to dilute bleach and ensure that its not used at full-strength and should not be mixed with other solutions and chemicals.

The Centers for Disease Control (CDC) recommends using different amounts of bleach and water depending on what is being cleaned. These steps should be appropriately followed to make a safe and effective bleach solution that meets your needs.

Can I mix Ammonia with bleach

Ammonia when mixed with bleach converts the chlorine in bleach to chloramine gas. Breathing in the fumes can cause coughing, shortness of breath, and pneumonia.

Can we mix acidic compounds such as vinegar or window cleaner with bleach

No: Acidic compounds when mixed with bleach create chlorine gas. Excessive exposure can cause chest pain, vomiting, and even death

Can we add alcohol in bleach

No. Alcohol converts to chloroform when mixed with bleach. Breathing it can cause fatigue, dizziness, and fainting.

How long does fresh bleach solution last

Chlorine bleach solution starts losing its disinfectant power quickly on exposure to heat, sunlight, and evaporation. To ensure the strength of the solution, mix a fresh batch every day and discard the left over solution.  Keep it out of the reach of children.

What is the bleach concentration to clean hard surfaces such as plates and counter tops

Mix 1 cup (240 milliliters) of bleach with 5 gallons (18.9 liters) of water. 

What is the bleach concentration to clean and disinfect healthcare facilities

Make a 1:10 solution to disinfect healthcare facilities that may have been contaminated by contagions. This requires 1 part bleach for every 9 parts water. 

What to do if bleach powder gets poured on the skin

If you get any bleach on your skin, wipe it off immediately with a damp cloth.

Do I still need to use soap and water

Wash the surface with soap and hot water before using bleach. After applying the beach, let the surface being cleaned air dry.

How do I prepare 1% chlorine solution

 Guidelines for Preparation of 1% sodium hypochlorite solution

Product                                    Available chlorine                  1percent Sodium hypochlorite

Liquid bleach                           3.5%                                        1 part bleach to 2.5 parts water

Sodium hypochlorite liquid    5%                                           1 part bleach to 4 parts water

 NaDCC (sodium dichloroisocyanurate)

 powder                                   60%                                         17 grams to 1 litre water

NaDCC (1.5 g/ tablet) – tablets 60%                                     11 tablets to 1 litre water

Chloramine – powder             25%                                        80 g to 1 litre water

Bleaching powder                 70%                                        7g  to 1 litre water

Approach to disinfection and sterilization of medical devices

EPA: Environmental Protection Agency.* 2% glutaraldehyde-based products, 6% stabilized hydrogen peroxide, chlorine, peracetic acid.¶ 2% glutaraldehyde-based products, 6% stabilized hydrogen peroxide, peracetic acid.

Modified from: Rutala WA. APIC guideline for selection and use of disinfectants. Am J Infect Control 1996; 24:313.

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Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA