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Table of Contents
REVIEW ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 244-253

COVID-19: A review of protective measures


1 Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Sharma Diagnostic Centre, Wardha, Maharashtra, India
3 Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Submission06-May-2020
Date of Decision11-May-2020
Date of Acceptance20-May-2020
Date of Web Publication19-Jun-2020

Correspondence Address:
Abhishek Mahajan
Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_172_20

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  Abstract 


The coronavirus disease 2019 (COVID-19) started as a pneumonia of unknown etiology in 44 patients in the Wuhan city of China and has progressed into a pandemic affecting more than 4.7 million people to date. The morbidity, mortality, and socioeconomic consequences of the disease are grave. Personal protective measures taken by the general public and health-care providers along with the implementation of strategies, policies, and legislation at the state, national, and international levels are important to limit the community spread of COVID-19. Well-articulated protocols decrease confusion and increase the efficiency of the working staff, thus playing an important role in the protection of both the patients and health-care providers. In this review, we discuss the guidelines and protocols for the preventive measures to be implemented when dealing with patients in health-care establishments, especially with regard to performing imaging studies, surgeries, admission to the intensive care unit (ICU), disposal of medical waste, and the last rites of the body of the deceased.

Keywords: Coronavirus, coronavirus disease, imaging, novel coronavirus, personal protective equipment, severe acute respiratory syndrome-coronavirus 2


How to cite this article:
Kulkarni T, Sharma P, Pande P, Agrawal R, Rane S, Mahajan A. COVID-19: A review of protective measures. Cancer Res Stat Treat 2020;3:244-53

How to cite this URL:
Kulkarni T, Sharma P, Pande P, Agrawal R, Rane S, Mahajan A. COVID-19: A review of protective measures. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Sep 19];3:244-53. Available from: http://www.crstonline.com/text.asp?2020/3/2/244/287220




  Introduction Top


The coronavirus disease 2019 (COVID-19) is a communicable viral disease. First reported in the Wuhan city of China, the outbreak soon progressed to a full-blown pandemic affecting millions of people globally.[1] It spreads primarily through respiratory secretions but can also spread by contact with asymptomatic carriers and fomites.

The International Committee on Taxonomy of Viruses has named the new virus, “severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2).”[2],[3],[4] The virus causes a mild-to-moderate respiratory infection in immunocompetent people. However, because of the absence of herd immunity, the infection can be severe in the vulnerable groups of people, such as the older population, pregnant women, and immunocompromised individuals.[5]

Several personal protective measures have been suggested and strategies and policies implemented to effectively contain the spread of the virus. In this review, we discuss guidelines pertaining to the specific protective measures to be implemented by health-care providers in the face of this pandemic.


  Key Points in Epidemiology Top


Incubation period

It is the period between exposure to the infectious agent and development of symptoms. The incubation period for SARS-CoV-2 is estimated to be between 1 and 14 days, most commonly 5 days.[6]

Carrier

COVID-19 primarily spreads through droplet transmission from the respiratory tract of the infected individuals. However, the virus has also been detected in asymptomatic individuals, and its transmission from asymptomatic carriers has been reported.[7] An example of this is the COVID-19 outbreak on the “Diamond Princess” cruise ship on which 82 out of the 112 cases (73%) were asymptomatic.[8]

[Figure 1] demonstrates the testing algorithm which is generally followed in case of symptomatic and asymptomatic persons with contact.
Figure 1: Algorithm for an individual in outpatient department

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  Preventive Strategies Top


Personal

The personal protective measures for the general public [Figure 2] include frequently cleaning hands with soap and water or an alcohol-based hand-rub, practicing social distancing, avoiding touching the face, and covering the mouth and nose with a tissue paper which should be discarded immediately followed by practicing hand hygiene or coughing and sneezing into the crease of the elbow. Additionally, one should stay at home and follow the directions given by the local health authorities.[9],[10],[11] Face masks provide both inward and outward protection [Figure 3], and decrease the risk of spread of infection by respiratory routes; however, personal respirators provide the most protection against aerosol transmission.[12] The World Health Organization (WHO) recommends the use of medical masks for patients with respiratory symptoms, health-care workers, and those in close contact with a COVID-19-positive individual. Healthy people are required to wear a mask only if they are taking care of a person with COVID-19. Additionally, people must wear a mask if they are coughing or sneezing.[13] Contrary to this, the Centers for Disease Control and Prevention (CDC) recommends the universal use of cloth face coverings in the public settings, especially when social distancing measures are difficult to follow, like in areas with significant community transmission.[14]
Figure 2: Protective measures for the general public

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Figure 3: Rationale of using face mask

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Pets and animals

Although the initial cases of infection with SARS-CoV-2 were linked to a live animal market in Wuhan, currently, the virus is spreading through respiratory droplets of the infected individuals. In certain circumstances, transmission from humans to animal may occur. The first animal to have tested positive for COVID-19 was a symptomatic tiger from the New York City Zoo.[15] Similarly, human-to-feline and feline-to-feline transmission in pet cats has been demonstrated. The 2016 influenza outbreak in New York highlighted the effects of feline-to-human transmission in the animal shelter workers. Moreover, cats can act as silent intermediate hosts, posing a risk of infection for their owners.[16] General hygiene should be practiced around pets and other animals by washing hands after handling them, cleaning of the pets regularly and properly, and visiting the veterinarian regularly. Individuals suspected or confirmed to be COVID-19 positive should restrict their contact with pets to ensure their safety, just as they would do with other members of the house.[17]

Health-care personnel

COVID-19-related measures for personnel protection can be considered in three levels, depending on the nature and extent of contact with the patients.

Level I protection

Health-care personnel working in the general outpatient departments and preexamination triage should wear disposable surgical caps and masks, uniforms, and latex gloves.

Level II protection

Health-care personnel in the fever clinic and isolation wards and those performing non-respiratory specimen examination and imaging should use disposable surgical caps, medical protective masks, such as an N95 respirator, uniforms, disposable protective medical uniforms, latex gloves, and goggles.

Level III protection

Health-care personnel who carry out procedures that are likely to expose them to the respiratory secretions of the patient, such as tracheal intubation, fiberoptic bronchoscopy, endoscopy, or those performing surgeries or autopsies of patients suspected or confirmed to be COVID-19 positive, should in addition to the level II protective measures use a full-face respiratory protector or a powered air-purifying respirator.[18]

Health-care providers, during times of crisis, face challenges such as increased work pressure, high risk of infection, inadequate protection, isolation, and exhaustion. These are bound to adversely affect their overall well-being and hence the quality of care provided. To combat this, measures such as providing support and assistance, duty rotations, and psychological interventions should be considered.[19],[20],[21]

National and international efforts

Border control with universal health screening of the international passengers must be implemented. Timely and precise communication of the various policies and health-care measures, including those regarding restrictions on international travel to countries with a vast spread of the disease, is essential. Mass gatherings should be avoided or at least postponed till they are deemed safe. The scope of legislative measures in times of crisis includes adjourning parliamentary sessions and adopting electronic means to allow the governing bodies to meet or vote electronically. Legal support for insurance coverage, telehealth services, paid leaves, unemployment benefits, extension of legal deadlines, protective guidelines for schools, and quarantine or isolation should be provided.[22] Legislative measures such as the Epidemics Diseases Act, 1897, and The Indian Penal Code, 1860 have been implemented in India.[23] A nationwide lockdown has been imposed and all non-essential government and private commercial activities have been suspended, with an exemption for hospitals and other health-related establishments.[24] Social media is playing a significant role in creating awareness among the masses about the pandemic with hashtags such as “#CORONA-2019,” “#Safehands,” and “#TogetheratHome.” The WHO has dedicated an artificial-intelligence-assisted chat-bot on WhatsApp to provide access to authentic information while sitting at home.[25],[26]

Special population groups

People with cancer are at a higher risk of infection with SARS-CoV-2 because of their immunocompromised status due to the malignancy and the associated treatment. In a study on patients with cancer and COVID-19 treated in the Montefiore Health system, New York, it was observed that mortality due to COVID-19 was 25% in patients with solid tumors (especially lung, gastrointestinal, and gynecological malignancies) and 37% in those with hematological malignancies. Increased mortality was associated with increased age, comorbidities, need for ventilator support, and raised biomarker levels (D-dimer, lactate, lactate dehydrogenase etc.). Special social settings such as prisons have an increased risk of transmission among the inmates due to overcrowding, inability to practice social distancing, and lack of hygiene. The basic principles of the United Nations state that prisoners have a right to health, and thus, they must be given the right to prevention and treatment of diseases like the rest of us.[27],[28] Similarly, refugee settlements should be provided help in the form of adequate supply of sanitation products and trained health-care workers.[29]


  Special Circumstances Top


Protecting the protectors

While caring for patients suspected or confirmed to be COVID-19 positive, a minimal personal protective equipment (PPE) set comprising a filtering facepiece respirator (valved or nonvalved), protective goggles (or face shield), a long-sleeved water-resistant gown, and gloves must be used.[30],[31],[32] A comprehensive list of links is given in [Table 1] to important guidelines regarding patient care.
Table 1: Links to guidelines and protocols from around the globe (as accessed on March 22, 2020

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[Figure 4] illustrates the steps to be followed while wearing and removing the PPE. The use of a mask is more effective along with hand hygiene practices. The mask should be disposed of as soon as it gets damp and should not be reused.[33],[34] The CDC recommend judicious use of the N-95 respirators by the health-care personnel; their use is not recommended for the general public.[35],[36]
Figure 4: Steps of donning and doffing

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“Extended use” is defined as wearing the same N95 respirator without removing it in between close contact encounters with several patients.[37],[38]

The mask should not be removed intermittently to ensure a reduced risk of contact transmission.

“Reuse” is defined as the use of the same N95 respirator for multiple encounters with patients, but doffing it after and donning it prior to the next encounter with a patient.[39] This should be avoided as it involves touching the respirator frequently, thus increasing the risk of contact transmission.

New methods allowing the reuse of N95 respirators are being considered in view of their ever-growing need and shortage. These include rotation or decontamination. Rotation involves a pre-decided number of N95 respirators (e.g., 5) being acquired by each health-care personnel and using them in rotation each day. Used masks should be allowed to dry for long enough (72 h) so that virus is no longer viable.[40] Dried masks should be stored in paper bags. Decontamination by ultraviolet germicidal irradiation, hydrogen peroxide vapors, and moist heat before reuse of the masks is being tested.[41] To circumvent the insufficiency of hygiene products, the WHO has made available an online guide to enable the local production of hand rub formulations.[42]

Protocols for radiology department

A real-time reverse transcription-polymerase chain reaction is the standard method of diagnosis for COVID-19, as it is less resource consuming than imaging.[43],[44] Nevertheless, the priorities of the radiology department are early detection of infection and limiting the exposure of staff and other patients. Therefore, effective screening stations should be set up at the main entrance of the hospital as well as the department entrance.

Whenever possible, ambulatory services should be used; when this is not possible, centers with fewer people around should be preferred. Non-essential staff and patients should not be allowed to wander around. The use of containment zippers should also be considered. Precautions against droplet transmission should be taken while providing services to patients suspected or confirmed to be COVID-19 positive. After performing the procedure, decontamination of the room and passive air exchange should be carried out for a period of 30 min to 1 h (room down time). The patients should wear a mask during the procedure. Airborne precautions should be taken when managing critically ill patients or patients undergoing aerosol generating procedures such as intubation, bronchoscopy, nebulization, open suction. Airborne precautions need not be considered in ventilated patients as the system is closed.[45]

Increased work flexibility, with a work from home facility, for the staff should be considered, especially for those who need not be present at the site of potential exposure. Isolated reading rooms should be provided for reporting. Non-essential staff meetings should be avoided, and essential meetings should be held by virtual conferencing. Providing the staff with personal workstations can decrease the need for coming to the workplace; this helps in the diagnostic department as well as in the procedural section to sustain work, as backup can be provided later.

In academic institutions, online courses or meetings can be scheduled for educational purposes to avoid missing out on teaching sessions.[46] Vertical communication should be detailed and should include well thought out policies. Online seminars and courses on infection control should be organized for the staff. The interdepartmental communication should be increased, and staff rotation should be halted. Scheduling of future elective procedures should be put on hold. Adequate PPE should be made available and proper donning and doffing techniques should be taught to the staff.[47]


  Protective Measures for Radiologic Technologists Top


Technologists posted in the ambulatory X-ray units and computed tomography (CT) scan department are front-line workers, and hence, should be provided with PPE. Notifying the clinical status of the patients in advance, is of utmost importance for preparing the staff and the surrounding environment.[48]

After discussion with the radiologists and referring physicians, non-urgent examinations and procedures should be rescheduled. For procedures that cannot be deferred, protective measures like maintaining a 6-feet distance between individuals in the waiting area, following disinfection policies, practicing hand hygiene, and increasing the time between two appointments to allow for adequate cleaning should be implemented. Screening stations should be set up at the entrance of the imaging facility and screened patients should be marked for easy identification. Careful screening of the health-care personnel is important from time to time. Upon exposure to a COVID-19-positive patient or development of COVID-19 symptoms, the personnel should be tested and quarantined for at least 14 days.

Radiography

A dedicated portable radiography machine should be used whenever feasible. Surfaces of these machines should be frequently cleaned with a disinfectant. The radiographer should practice proper hand hygiene and use PPE. A chest radiograph is less sensitive for COVID-19-related changes than a CT scan. Therefore, it may appear normal early in the course of the disease or in case of a mild infection.

Ultrasonography

If possible, a dedicated system should be used for COVID-19 suspects and patients. Low-level disinfection is effective for external use and interventional procedures.[49] Covers for ultrasound transducers and keyboard/console should be used as physical barriers.[50]

Interventional radiology

All elective procedures should be deferred until the situation is brought under control. For all emergency procedures, the concerned clinical team should be instructed to assess the patients for respiratory symptoms. Information regarding suspects or confirmed cases should be conveyed in advance to allow for adequate preparations.


  General Standard Preventive Measures for Radiology Department Staff Top


All staff must wear face masks at all times in the department. In addition, the staff must ensure that the patients wear a mask or cover their nose and mouth with a cloth, before they are sent for any imaging or procedure. Hand sanitizers should be provided in the department, and the staff should be encouraged to use them frequently. Approval from the faculty should be taken before performing a scan on a COVID-19-suspect or -positive patient; moreover, all necessary information regarding such cases should be communicated with the concerned personnel and authorities. If a CT scan taken for some other indication shows features typical of COVID-19, the CT machine should be immediately shut down and disinfected.

Two technologists are desirable for imaging of COVID-19 suspects or positive patients. One technologist should wear the PPE and set up the patient on the CT imaging table with the help of an attending medical doctor. The other technologist should operate the CT console.[51]


  Sanitization of the Computed Tomography Room or Hospital Room Top


Proper sanitization of the CT room should be performed after imaging a COVID-19-suspect or -positive patient or patients with CT findings suggestive of COVID-19. During the ongoing pandemic, sanitization should be performed every day at a specific time, preferably after imaging a cluster of suspected COVID-19 patients. For effective cleaning, a three-step process should be used for the CT machine and the floor of the CT room. First, the surface of the CT machine should be cleaned with cotton wipes dipped in detergent water. This should be followed by wiping with clean water and finally 1% sodium hypochlorite. Similarly, the floor of the CT room should be cleaned thoroughly. Additionally, care must be taken to wring out excess water from the wipes to avoid damage to the CT machine from excess moisture. Post this, the CT room should be fumigated for 30 min and remain closed for 45 min thereafter. The CT room should be used once all the surfaces have dried completely. In the reading room, one keyboard and mouse should be allotted per person; there should be no sharing. The system should be wiped clean with alcohol and allowed to dry before and after every use.[52]

A similar three-step process should be followed in the wards while cleaning the floor. Apart from the floor, the ceiling, walls, doors, doorknobs, isolation rooms, laboratories, and areas where biological fluid spill is expected should be cleaned as per the standard procedure. Stethoscopes, thermometer, and blood pressure cuffs should be cleaned with detergent and water and wiped with an alcohol-based rub or spirit swab before contact with each patient.[53]

There should be dedicated ambulances for carrying COVID-19-suspect or -positive patients; a strict adherence to cleaning and decontamination protocols for these ambulances should be ensured.[54]

Operating room preparations and guidelines

The decision to defer surgery should be made after taking multiple aspects into considerations.[55] The American College of Surgeons suggests referring to the Elective Surgery Acuity Scale for triaging surgeries.[56],[57] A negative-pressure operating room with a separate access and situated at one end of the operating complex should be used for performing surgeries on a suspected or confirmed COVID-19 patient. The same operating room, anesthesia machine, and transport ventilator should be used for all such surgeries throughout the pandemic. The anesthesia filters and the soda lime granules in the machine should be changed after each case, considering that respiratory secretions are the main mode of transmission of COVID-19. Ideally, disposable airway equipment should be used. Repeated attempts at instrumentation of the airway should be avoided. Transfer of the patient from the ward to the operating room should be done by the ward nurses with PPE. Thorough decontamination of all surfaces in the operating room with vaporized hydrogen peroxide should be done.[58]

Disposal of used masks

Properly removing the face mask is as important as wearing it. Care should be taken to not touch the exposed surface of the face mask. For string masks, the strings below should be untied first followed by the strings above.[59] Special containers should be used for the disposal of used masks. They should be transported in specialized vehicles and disinfected prior to incineration or deep burial.[60]

Guidelines for those in quarantine

Quarantine and isolation are the main pillars of containment. Quarantine refers to the separation of asymptomatic individuals with a history of contact with a COVID-19 patient. Isolation refers to the separation of symptomatic individuals who are suspected or confirmed to be COVID-19-positive. The suspects are kept in isolation till they test negative for COVID-19. If they test positive, they are kept hospitalized until they test negative twice, consecutively. The National Centre for Disease Control has provided guidelines for setting up isolation facilities/wards.[61],[62]

A home quarantined person should stay in a well-ventilated single room, preferably with an attached/separate toilet. Only one assigned family member should be tasked with taking care of the quarantined person and no visitors should be allowed. The quarantined person should stay away from older people and pregnant women, not participate in any social or religious gatherings, avoid sharing household items with other people at home, and wear a disposable surgical mask at all times which should be changed every 6–8 h and disposed properly. If the quarantined person develops symptoms such as cough, fever, or difficulty in breathing, the health authorities should be immediately informed, and all close contacts should be home quarantined for 14 days, till they test negative. Surfaces that are frequently touched by the quarantined person should be cleaned with 1% sodium hypochlorite solution. Disposable gloves should be used while handling soiled linen.

Management of dead bodies

The risk of transmission of COVID-19 from a dead body to health-care workers or family members is low. However, standard precautions should be taken while handling the body. Only the lungs of patients, if handled improperly during an autopsy, can be infectious. It is not a compulsion to cremate the body; the last rites can be performed as per one's religious beliefs. Health-care workers or mortuary staff preparing the body should wear appropriate PPE. Strict instructions should be given to the family members to avoid any physical contact with the body. The autopsy of suspected COVID-19 patients should be performed in a well-ventilated room with minimal staff and adequate PPE. The instruments and surface used for autopsy should be cleaned and disinfected with 1% sodium hypochlorite or 70% ethanol.[63],[64]


  Conclusion Top


PPE are effective when used in addition to general protective measures like practicing hand hygiene and social distancing, limiting contact time, etc. It should be used by health-care personnel who work in a sterile field and operative or procedural settings, thus requiring airborne and droplet protection. Extended use and reuse strategies, like rotation and decontamination, are important for the judicious use of the N95 respirators. Places, such as wards, imaging rooms, procedure rooms, and ambulances that have a high risk of exposure to infected individuals should be decontaminated according to the standard protocols.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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