Should we be using N95 masks for all patients undergoing aerosol-generating procedures?
As more cases of SARS-CoV-2/COVID-19 occur and more data is released, we learn more about this pandemic. While the number of cases being reported in the United States is alarming, the hope is that analysis of them will yield critical pieces of insight into the transmission trends and opportunities for improvement.
Healthcare personnel (HCP) are a critical part to pandemic response and with overwhelmed healthcare systems, like those in New York City, and personal protective equipment (PPE) supply strains, there is an increasing concern about the rate of HCP infections. Recent publications have shown that of those COVID-19 cases with occupational data available (only about 16%), 19% were healthcare personnel. A majority of these cases were in women and most did not require hospitalization. Unfortunately, this data did not include information on exposures and potential risk for transmission. In terms of contact with confirmed cases, 55% of those healthcare personnel noted contact only in a healthcare setting, whereas 27% reported contact only in a household setting.
Understanding these nuances and where potential exposures occur is crucial, especially for HCPs and infection control efforts that work to reduce risk through processes and PPE. Review of COVID-19 infections in HCPs following an exposure to a hospitalized patient in Solano County, California, has provided additional information regarding these risk factors. In this case, a patient was hospitalized without suspicion of COVID-19 and did not have isolation precautions for the four days of their hospitalization. This patient also underwent several aerosol-generating procedures and was then transferred to another healthcare facility, where PCR test was done and yielded positive SARS-CoV2 results.
The researchers note that “Among 121 hospital A health care personnel (HCP) who were exposed to the patient, 43 (35.5%) developed symptoms during the 14 days after exposure and were tested for SARS-CoV-2; three had positive test results and were among the first known cases of probable occupational transmission of SARS-CoV-2 to HCP in the United States.”. Since this is a novel disease and experience, little is known about nosocomial transmission of SARS-CoV-2, especially among HCP. Interviews were conducted with 37 staff, including the three with positive results. For those three, a trend included performing physical examinations and being present for nebulizer treatments.
Based off these findings, this is one of the most high-risk scenarios and it’s not surprising that secondary cases occurred. Not only was there a lack of PPE and isolation precautions utilized but use of nebulizer treatments fall under aerosol-generating procedures, which required enhanced respiratory protection like N95 respirators. These findings, while not surprising, are helpful in reinforcing the need for rapid isolation of the patient and use of enhanced respiratory protection during aerosol-generating procedures. This begs the question if all patients undergoing such procedures should require enhanced respiratory protection, regardless of COVID-19-like symptoms. As there is changing data on the percentage of COVID-19 cases who are asymptomatic or pre-symptomatic, these findings suggest that we should account for periods of time without symptoms. Moreover, how is this challenge faced with limited PPE? Will we move to a COVID-19 screening model for all patients?
Overall, this study provides insight into nosocomial transmission and the desperate need to understand healthcare personnel infections better. We must invest in more widespread diagnostics and ensure HCP have access to PPE. As the COVID-19 pandemic continues, there is a need to consider more sustainable efforts to protect staff and other patients during medical care.
What can we learn from nosocomial COVID-19 transmission?
Gaps in isolation and PPE usage — insight into a COVID-19 healthcare transmission
Should we be using N95 masks for all patients undergoing aerosol-generating procedures? Data on HCW COVID-19 cases sheds light on these challenging questions.
Insight from a cluster of healthcare personnel COVID-19 cases — exposures and lessons learned