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| REVIEW ARTICLE |
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| Year : 2021 | Volume
: 9
| Issue : 1 | Page : 1-7 |
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Emerging issues and preventive measures for health care workers in the diagnostic field in coronavirus disease 2019 pandemic
Arshdeep Kaur1, Madhu Sinha1, Abhijit Das1, Natasha Gulati1, Manmohan Mehndiratta2, Chandra Shekhar3
1 Department of Pathology, Janakpuri Superspeciality Hospital, New Delhi, India
2 Department of Neurology, Janakpuri Superspeciality Hospital, New Delhi, India
3 Department of Neurosurgery, M D Hospital, New Delhi, India
| Date of Submission | 11-May-2020 |
| Date of Decision | 08-Aug-2020 |
| Date of Acceptance | 20-Jul-2021 |
| Date of Web Publication | 24-Sep-2021 |
Correspondence Address:
Dr. Madhu Sinha
Department of Pathology, Janakpuri Superspeciality Hospital, C2B Janakpuri, New Delhi - 110 058
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jpsic.jpsic_8_20
Coronavirus disease 2019 caused by severe acute respiratory syndrome-CoV-2 is an emerging infectious disease first identified in Wuhan City, Hubei Province, China, which subsequently spread as a global pandemic posing a global threat. As per World Health Organisation worldwide around 38 lac people have been infected and 2.6 lac people have died from the disease and in India 59,662 people are infected with 1981 deaths by May 9, 2020. It is feasible that potentially infectious specimens may be submitted in our laboratory those are the impending source of infection to the laboratory personnel. Using imaging equipment on coronavirus confirmed/suspected patient/carriers is a serious hazard for healthcare providers because there is a risk that the virus could remain on the surface of the computed tomography scan machines or ultrasound (US) probes/patient bed/couch. Here, we have enlisted the rigorous biosafety measures which if executed appropriately can significantly drop the chances of spread of infection to health care workers in these diagnostic sections.
Keywords: Biosafety, coronavirus disease 2019, health care workers, pandemic
How to cite this article:
Kaur A, Sinha M, Das A, Gulati N, Mehndiratta M, Shekhar C. Emerging issues and preventive measures for health care workers in the diagnostic field in coronavirus disease 2019 pandemic. J Patient Saf Infect Control 2021;9:1-7 |
How to cite this URL:
Kaur A, Sinha M, Das A, Gulati N, Mehndiratta M, Shekhar C. Emerging issues and preventive measures for health care workers in the diagnostic field in coronavirus disease 2019 pandemic. J Patient Saf Infect Control [serial online] 2021 [cited 2023 Jan 28];9:1-7. Available from: https://www.jpsiconline.com/text.asp?2021/9/1/1/326623 |
| Introduction | |  |
The coronavirus outbreak came to light in December 2019 in China when China informed the cluster of cases of pneumonia of unknown cause to World Health Organisation (WHO) in its Wuhan city of Hubei Province.[1] Subsequently, the disease spread to more provinces in China and then to almost 200 countries in the rest of the world. The WHO declared it as pandemic on March 11, 2020.[2] The virus has been named severe acute respiratory syndrome (SARS)-CoV-2 and the disease is called coronavirus disease 2019 (COVID-19). As per the WHO by 9th May, 2020, around 38 lac people have been infected and 2.6 lac people have died from the disease globally and in India, there are 59,662 infected cases with 1981 deaths.[3]
Coronaviridae are large (120 nm), enveloped positive-sense single-stranded RNA viruses. Their specific tissue tropism and infectivity are conferred by the spike protein, which interacts with a specific cell receptor. The receptor for the virus is the angiotensin-converting enzyme 2 receptor on ciliated bronchial epithelial cells.[4] Laboratory results indicated that SARS-CoV-2 is similar to some of the beta (β) coronaviruses genera identified in bats, which is situated in a group of SARS/SARS-like CoV.[5],[6],[7] The initial presentation is with mild to severe respiratory symptoms such as cough and dyspnoea whereas in severe cases disease may progress to respiratory, circulatory and renal failure.[8],[9] The latest guidelines from Chinese health authorities described three main transmission routes for the COVID-19: Droplets transmission through coughing and sneezing, contact transmission and aerosol transmission in closed spaces.[10],[11] Fomites transmission is also a big concern.[12] Suspected cases are tested for the virus with real-time reverse transcriptase-polymerase chain reaction (real-time RT-PCR) to confirm the clinical diagnosis of SARS-CoV-2. RT-PCR is advised to detect the positive nucleic acid of SARS-CoV-2 in sputum, throat swabs and lower respiratory tract samples.[11],[13],[14] There is no specific antiviral treatment or vaccine recommended for COVID-19 infection, so we are concerned with the infectivity and mode of transmission of SARS-COV-2 to combat the alarming spread of infection.[15]
The Indian Council of Medical Research (ICMR) said that 80% of the total coronavirus patients had no or mild symptoms and were asymptomatic carriers who can spread the infection to the community. Quarantine, personal protective equipment (PPE) and social distancing of one m, cleaning of surfaces with disinfectant are essential measures to prevent community spread.[16] Adhere rigorously to the measures like avoiding close contact with patients suffering from acute respiratory infections and following strict personal hygiene and frequent handwashing (>20 s) to minimise the possibility of exposure to the pathogen.[17]
Rapid collection of the samples of the suspected patients for testing is required for the diagnosis of the infection and control of the spread. However, testing of the huge population is not possible considering cost, workforce and testing facility; therefore, ICMR has purported the following current testing strategy:[18]
- All asymptomatic people who have undertaken international travel:
- They should stay in home quarantine for l4 days
- They should be tested only if they become symptomatic (fever, cough, difficulty in breathing, etc.,)
- If test result is positive, then they should be isolated and treated as per the standard protocol.
- All contacts of laboratory-confirmed positive cases:
- They should stay in home quarantine for l4 days
- They should be tested only if they become symptomatic (fever, cough, difficulty in breathing etc.,)
- If test result is positive, then they should be isolated and treated as per the standard protocol.
- Health-care workers (HCWs) managing respiratory distress/severe acute respiratory illness should be tested when they are symptomatic.
HCWs are being constantly infected, posing an occupational health risk to them. According to the WHO around 22,000 healthcare workers were infected by coronavirus by the end of April 2020. Looking into the seriousness of this matter prevention of infection in the medical staff is imperative since we cannot sustain a significant loss in our medical manpower. The laboratory technical staff is always at the risk of acquiring the infection while collecting and handling the samples of the suspected COVID-19 patients or from asymptomatic carriers who are visiting the hospital for other health issues and services.[19] The samples include the nasopharyngeal or oropharyngeal swabs/washes, sputum, bronchoalveolar lavage, tracheal aspirates, stools, urine or serum, these should be considered infectious as per WHO guidelines.[20] Positivity rate in various types of samples [Table 1][21] helps to assess the risk in microbiology, serology, biochemistry and cytology laboratories to prevent the transmission of the infection in the laboratory personnel.[21]
Facility-specific risk assessment should be conducted by each laboratory to identify the hazard, prioritize the risk, make a plan, set a proper protocol to alleviate the risk and providing an adequately trained staff to perform the assigned procedures in the laboratory.[22] Risk assessment guides the selection of appropriate biosafety levels and required microbiological practices and safety equipment (primary barriers) and facility-level safeguards (secondary barriers) to prevent the spread of infection.[23] The WHO has given risk assessment evaluation template to assess the risk and prioritise the implementation of risk control measures.[24] Review the mitigation strategies after implementation to ensure measures are effective or not and training should be given to the laboratory personnel about all the latest guidelines regarding biosafety during the COVID-19 pandemic.
The recent emergence of zoonotic coronavirus has gained the heightened need to revise the in-house biosafety practices in the laboratory to limit the transmission and fast spread of the virus in the laboratory personnel. There are following safety precautions which should be followed-
- Universal precautions including hand hygiene and PPE should be followed while collecting and dealing with the specimens considering them potentially infectious as we do not know which specimen can have viable or transmissible virus.[25] There may be samples of undiagnosed and asymptomatic patients who may be shedding virus
- Essential samples to be collected in COVID-19 suspected patients are
Oropharyngeal swab and nasopharyngeal swab.
The optimal timing for collection of these swabs is within 3 days of symptoms onset or later than 7 days and preferably before initiation of antimicrobial chemoprophylaxis or therapy.
Oral and nasal swabs to be collected in viral transport media.
Other specimens which can be collected are bronchoalveolar lavage, tracheal aspirate or sputum. These all have to be collected in the wide mouth sterile plastic container.
Appropriate PPE must be donned while collecting samples which includes a disposable gown, gloves, cap, shoe cover, protective eyewear/face shield and N 95 respirator.[26],[27]
| Transport Precautions | | |
Proper PPE comprised of disposable gown, gloves, eye protection and medical mask should be worn by trained personnel while transporting the specimens.
Triple packaging system [Table 2][28] to be used for transport of specimens.[28]
Adequate cushioning of materials inside the box to absorb shocks during transport.
Adequate absorbing material to absorb any spillage if it occurs.
Request forms were kept separate from the specimen containers as the outer surface of the specimen container may be contaminated.
Specimen request forms should be put into a separate plastic bag.
The outer container, secondary container and specimens rack for transport should be thoroughly cleansed and disinfected periodically (at least daily) and when contaminated.
| Storage of Specimen | | |
Specimen was kept refrigerated (2°C–8°C) as it had to be processed (or was sent to a reference laboratory) within 48 h.
Specimen was kept frozen (−10°C–−20°C) if it had to be processed after the first 48 h or within 7 days.
Specimen was kept frozen (−70°C) if had to be processed after a week. The sample can be preserved for extended periods.
| Transport of Routine Blood Samples (Biochemistry and Haematology Tests) | | |
Well labelled samples for blood investigations should be sent in double transparent zip-lock pouches.
Sample requisition form should be placed inside the pouch in a way so that patient details are clearly visible from outside without opening the pouch.
Specimens should be delivered by hand and not through pneumatic tube because of the chances of samples being lost and the risk of spillage.[26]
Standard precautions as per HIV specimens (National AIDS Control Organisation [NACO guidelines]) to be followed.[29]
Cytotechnicians and haematology technicians processing fresh cytology/haematology samples must don appropriate PPE which includes disposable gown, gloves, cap, goggles and N 95 mask.[27],[28] Preparatory steps that may generate aerosols or droplets include expelling aspirates from the needle or syringe after performing fine-needle aspiration cytology and the making of smear, should be done gently and face should be kept as far as possible. Trained personnel should handle all the potentially infectious materials, comprising all those that may cause droplets, splashes or aerosols of infectious materials (e.g., loading and unloading of sealed centrifuge cups, vigorous shaking or mixing). The lid of the centrifuge should be opened slowly, and the caps of the centrifuge tubes should be removed gently.[30] Additional barriers between the specimen and the personnel should be provided like a splash shield, centrifuge safety cups and sealed centrifuge rotors to reduce the risk of exposure to laboratory personnel. Smears should not be dried by shaking them or blowing air as this can lead to aerosol production. Air drying of smears should be ideally performed in Class II biosafety cabinets (BSCs).[30] If there is lack of equipment like BSCs and the sealed centrifuge rotors, extra precautions must be taken. The room should be adequately ventilated with windows open and it is recommended to keep the central air conditioning system non-operational. Rapid on-site evaluation should be done based on the risk assessment guideline template of the WHO.[28] The used needles should be discarded in the puncture-proof sharp container and the syringes should be discarded after treating with 0.1%–1% sodium hypochlorite. The needles should not be burnt to prevent the generation of aerosols.
Release of reports should also be done via E-mail or WhatsApp to avoid minimum contact with the patients and preventing exposure to the virus.
| Personal Protective Equipment Instruction | | |
Technical staff should be instructed to use PPE [Table 3] [31] more consistently and properly must be removed on leaving the laboratory and hygiene practices including handwashing must be meticulously practiced donning and doffing guidelines should be followed. The donning and doffing space should not be in the workspace.[31] Perform hand hygiene frequently with an alcohol-based hand rub (an alcohol-based hand sanitiser containing at least 62% alcohol can be used) if your hands are not visibly dirty or with soap and water if hands are dirty. Eyes, nose and mouth should not be touched wearing a face mask if you have respiratory symptoms and performing hand hygiene after disposing of the mask, maintain social distance (a minimum of 1 m) from persons with respiratory symptoms.
| Disinfection And Contact Time | | |
Work surfaces and equipment must be decontaminated after specimens have been processed, irrespective of the containment area. All the surfaces that may have come into contact with specimens or specimen containers should be carefully disinfected. Because the virus can remain viable on surfaces (especially plastic and stainless steel surfaces) for up to 72 h, it is recommended to decontaminate all work surfaces multiple times per day, using environmental protection agency-approved disinfectant solutions, wipes or sprays.[28] SARS coronavirus has a relatively strong ability to survive in human specimens and in the environment.[32] The WHO recommends disinfectants with proven activity against enveloped viruses, such as sodium hypochlorite 0.1%, a minimum of 62%–71% ethanol, 0.5% hydrogen peroxide ammonium or phenolic compounds.[33],[34] For spillage 1% hypochlorite solution is used. It is important to realise the importance of the above protocols as it has been shown that air, surface environment and PPE are commonly contaminated by SARS-CoV-2.[35] The contact time with the surface to be disinfected is 15 min.[4],[36]
| Biomedical Waste Management | | |
All the infectious waste must be disposed in separate double yellow/red bags labeled as COVID-19 with biohazard label. Adequate biohazard containers should be in the immediate working area for the correct disposal of contaminated materials. All the laboratory-generated biomedical waste from COVID-19 positive/suspected samples must be packed and sent to a separate place as mandated by the Pollution Control Policy and guidelines made by the Central Pollution Control Board of India.[37]
To maintain optimal and healthy workforce to keep all the crucial services functional the manpower of the hospitals can be divided into three thirds. One-third be on deployment, one third on standby and one third on post-deployment home quarantine.[28]
[Table 4][22] and [Figure 1] illustrate the risk in the laboratory workflow and biosafety practices while handling specimens in the COVID-19 outbreak.[22] | Figure 1: Biosafety practices in laboratory dealing with suspected coronavirus disease 2019 patients
Click here to view |
| Radiology Preparedness During Covid-19 Pandemic | | |
Radiology alertness in COVID-19 outbreak is required as it is highly transmissible. The use of imaging equipment on coronavirus confirmed/suspected patients is a serious hazard for health-care providers and other patients. Computed tomography (CT) scanners are large and complex pieces of machinery. They must be properly cleaned between each suspected COVID-19 patient, still there is a risk that the virus could remain on the surface in a CT scanner room. Also moving potential COVID-19 patients to and from a CT scanner room further increases the risk of spreading the virus inside of healthcare facilities. To restrict the spread of infection it is mandatory to set the policies and procedures directly applicable to the imaging department.[38]
All the radio diagnostic centres who are performing any imaging procedure during this COVID-19 outbreak should follow at least following as minimum requirement:
- Minimum of 1 m social distance at reception, preferably only one patient in the reception area. The greatest risk of transmission is through droplets within 3 feet but may travel up to 6 feet[39]
- In the waiting area every patient/attendant group to be seated separately from other groups and minimum 6 feet distance between them, this means most centres will be able to allow only one or two patients at single point of time in their centres[40] Patients can be scheduled by appointment and else can be asked to sit in their cars or on their two-wheelers. Keeping social distance is mandatory and clinics hospitals are no exception
- Persons at reception should sanitise their hands before and after handling patient file and cash
- Every person should sanitise their hands on entering the procedure room any time
- Disposable bed covers for every patient, alternatively reusable bedsheets to be changed after every patient which has to be washed in soap and water or spray sanitization of the patient couch after every use with 1% sodium hypochlorite solution and wiping by tissue paper or by new cloth every time
- Face mask to be put on by every patient and attendant
- Sanitise radiologist's hands before and after seeing patient documents
- Handwashing with soap and water of radiologist after every patient
- Radiologist to use disposable gloves preferably
- Ultrasound probe should be sanitized after use on every patient. Making sure that the surfaces of transducers are cleaned and disinfected according to manufacturer specifications considering the recommended 'wet time' for wiping transducers and other surfaces with disinfection agents[41]
- Deep cleaning of the equipment is necessary in the case of high infectivity[41]
- Use of PPE (fluid-resistant gown, pair of disposable gloves, goggles, face mask) is strongly endorsed to radiologist
- Development of standard operating procedures for safe imaging of patients with suspected or known COVID-19 is advised
- Education of the technical staff regarding PPE and disinfection techniques.[42]
According to the Spaulding classification of the Centres for Disease Control and Prevention and Food and Drug Administration, low levels or intermediate levels disinfectant, such as iodophor germicidal detergent solution, ethyl alcohol or isopropyl alcohol should be used to decontaminate the surfaces like CT and magnetic resonance imaging machine gantries, USG probes, image viewing stations and keyboards.[43],[44]
| Conclusion | | |
Zoonotic coronavirus is highly infectious and communicable and have infested thousands of HCWs posing an occupational hazard to them. The rapid progression of COVID-19 is an organizational challenge for all hospitals. Adherence to best practices of protection can successfully inhibit the transmission of coronavirus to HCWs. PPE, hand hygiene, surface disinfection and proper waste management are essential to prevent the spread of disease in medical staff. Suitable training regarding the above and implementation is the solution. As there are no specific therapies to control SARS-CoV-2, early control and stoppage of further spread are crucial to stop the ongoing spread and break this novel infectious chain. Transmission in the health-care settings can be successfully prevented when appropriate measures are consistently performed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4]
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