Personal Protective Equipment Recommendations Research Articles

A Systematic Review of PPE Recommendations for First Responders, and Medical Professionals to Nuclear Radiological Events at Nuclear Power Plants

Introduction:Due to climate change, many countries are exploring nuclear power as a clean, sustainable, and alternative energy source. However, radiophobia stemming from a history of major accidents at nuclear power plants (most recently Fukushima Daiichi) inhibits the expansion of this industry. In an unlikely event of a large-scale accident, the risks posed to humans are minimal when mitigation measures are followed. This includes appropriate Personal Protective Equipment (PPE) for first responders, and medical professionals responding to these emergencies. An examination of the PPE recommendations for these scenarios will highlight best practices for minimizing exposures, and the effects of radiation.Method:A systematic literature review will provide a historical baseline of the PPE worn during previous nuclear power plant events. Additionally, current recommendations for PPE levels in response to these emergencies will be explored. Five databases will be utilized for this study, including PubMed, Web of Science, and SCOPUS.Results:Many studies examine different types of nuclear radiological exposures, but few focus on nuclear power plant scenarios. More than 5,000 articles emerged from a preliminary survey of the five databases. However, less than 1% of them satisfied the extraction criteria, and reviewed PPE for nuclear power plant accidents. Medical responders caring for “exposed” individuals who present at Emergency Departments have minimal exposure once they’re decontaminated, and everyday PPE is maintained. However, data on PPE recommendations for on-site response remains unexplored. Airtight suits and full-face respirators emerged as industry gold standard for protection, but a closer examination of these types of suits, and responders' self-efficacy utilizing the gear would clarify their actual protective qualities.Conclusion:While nuclear power plant accidents do not occur often, many remain fearful of their impact. Maintaining proper PPE (including respiratory habiliment) for event responders is one way to minimize the adverse health effects of these nuclear radiological exposures.

Impact of the Coronavirus Disease 2019 Pandemic on Pediatric Gastrointestinal Endoscopy: A Questionnaire-based Internet Survey of 162 Institutional Experiences in Asia Pacific.

The impact of coronavirus 2019 (COVID-19) on gastrointestinal (GI) endoscopy procedures in adults has been reported, with a drastic reduction in the number of procedures. However, there are no sufficient data regarding the impact on pediatric GI endoscopy. Here, we aimed to report that impact in the Asia-Pacific region. A questionnaire-based internet survey was conducted from June to November 2021 among pediatric endoscopy institutions in the Asia-Pacific region, with each institution providing a single response. Overall, 25 questions focused on the impact of the number of procedures conducted, the usage of personal protective equipment (PPE), and endoscopy training programs during the pandemic. A total of 162 institutions across 13 countries in the Asia-Pacific region participated in the study, and 133 (82.1%) institutions underwent procedure changes since the emergence of COVID-19. The number of esophagogastroduodenoscopy and ileocolonoscopy procedures decreased in 118/133 (88.7%) and 112/133 (84.2%) institutions, respectively. Endoscopy for patient with positive COVID-19 in an emergency or urgent cases still carried out in 102/162 (62.9%) institutions. Screening of COVID-19 for all patients before endoscopy was done across 110/162 (67.9%) institutions. PPE recommendations varied among institutions. Pediatric gastrointestinal endoscopy training programs were discontinued in 127/162 (78.4%) institutions. This study reports the impact of the COVID-19 pandemic on pediatric gastrointestinal endoscopy in the Asia-Pacific region. There has been a significant reduction in the number of endoscopic procedures and relevant training programs.

Health Care Personnel Exposures to Subsequently Laboratory-Confirmed Monkeypox Patients - Colorado, 2022.

The risk for monkeypox transmission to health care personnel (HCP) caring for symptomatic patients is thought to be low but has not been thoroughly assessed in the context of the current global outbreak (1). Monkeypox typically spreads through close physical (often skin-to-skin) contact with lesions or scabs, body fluids, or respiratory secretions of a person with an active monkeypox infection. CDC currently recommends that HCP wear a gown, gloves, eye protection, and an N95 (or higher-level) respirator while caring for patients with suspected or confirmed monkeypox to protect themselves from infection† (1,2). The Colorado Department of Public Health and Environment (CDPHE) evaluated HCP exposures and personal protective equipment (PPE) use in health care settings during care of patients who subsequently received a diagnosis of Orthopoxvirus infection (presumptive monkeypox determined by a polymerase chain reaction [PCR] DNA assay) or monkeypox (real-time PCR assay and genetic sequencing performed by CDC). During May 1-July 31, 2022, a total of 313 HCP interacted with patients with subsequently diagnosed monkeypox infections while wearing various combinations of PPE; 23% wore all recommended PPE during their exposures. Twenty-eight percent of exposed HCP were considered to have had high- or intermediate-risk exposures and were therefore eligible to receive postexposure prophylaxis (PEP) with the JYNNEOS vaccine§; among those, 48% (12% of all exposed HCP) received the vaccine. PPE use varied by facility type: HCP in sexually transmitted infection (STI) clinics and community health centers reported the highest adherence to recommended PPE use, and primary and urgent care settings reported the lowest adherence. No HCP developed a monkeypox infection during the 21 days after exposure. These results suggest that the risk for transmission of monkeypox in health care settings is low. Infection prevention training is important in all health care settings, and these findings can guide future updates to PPE recommendations and risk classification in health care settings.

SARS-CoV-2 infection in public hospital medical doctors in an Eastern Cape metro.

BackgroundEvidence-based Infection Prevention and Control (IPC) measures are critical in protecting medical doctors from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Concerns surrounding access to personal protective equipment (PPE), compliance with IPC measures and the quality of available PPE have been raised as possible causes for high rates of SARS-CoV-2 infection in medical doctors in high transmission settings. This study aimed to determine the prevalence of SARS-CoV-2 infection and the risk factors for occupational infection in doctors in the hospitals in Nelson Mandela Bay (NMB).MethodsWe conducted a cross-sectional study wherein we electronically surveyed medical doctors in public-sector NMB hospitals from 01 March 2020 to 31 December 2020. We collected demographic, health, occupational and SARS-CoV-2 infection and exposure data. Categorical data were described as proportions and a multiple variable logistic regression model was used to identify risk factors for SARS-CoV-2 infection.ResultsThe survey was distributed amongst 498 doctors, 141 (28%) of whom replied. Forty-three (31%) participants reported that they had tested positive for SARS-CoV-2 during the study period. Eighty-nine participants (64%) reported inadequate access to PPE whilst only 68 (49%) participants adhered to PPE recommendations when interacting with patients with confirmed or suspected SARS-CoV-2 infection. We were unable to identify any significant predictors of SARS-CoV-2 infection.ConclusionThis study demonstrates a high prevalence of SARS-CoV-2 infection in public hospital doctors in NMB. Most participants reported inadequate access to PPE and poor compliance with IPC protocols. These findings suggest an urgent need for the improved implementation of IPC measures to protect doctors from SARS-CoV-2 infection.

2022 Interim Guidance to Health Care Providers for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration With the American Academy of Pediatrics, American Association for Respiratory Care, the Society

2022 Interim Guidance to Health Care Providers for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration With the American Academy of Pediatrics, American Association for Respiratory Care, the Society

Infectious Diseases Society of America Guidelines on Infection Prevention for Healthcare Personnel Caring for Patients with Suspected or Known COVID-19.

BackgroundSince its emergence in late 2019, SARS-CoV-2 continues to pose a risk to healthcare personnel (HCP) and patients in healthcare settings. Although all clinical interactions likely carry some risk of transmission, human actions like coughing and care activities like aerosol-generating procedures likely have a higher risk of transmission. The rapid emergence and global spread of SARS-CoV-2 continues to create significant challenges in healthcare facilities, particularly with shortages of personal protective equipment (PPE) used by HCP. Evidence-based recommendations for what PPE to use in conventional, contingency, and crisis standards of care continue to be needed. Where evidence is lacking, the development of specific research questions can help direct funders and investigators.ObjectiveDevelop evidence-based rapid guidelines intended to support HCP in their decisions about infection prevention when caring for patients with suspected or known COVID-19.MethodsIDSA formed a multidisciplinary guideline panel including frontline clinicians, infectious disease specialists, experts in infection control, and guideline methodologists with representation from the disciplines of public health, medical microbiology, pediatrics, critical care medicine and gastroenterology. The process followed a rapid recommendation checklist. The panel prioritized questions and outcomes. Then a systematic review of the peer-reviewed and grey literature was conducted. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence and make recommendations.ResultsThe IDSA guideline panel agreed on eight recommendations, including two updated recommendations and one new recommendation added since the first version of the guideline. Narrative summaries of other interventions undergoing evaluations are also included.ConclusionsUsing a combination of direct and indirect evidence, the panel was able to provide recommendations for eight specific questions on the use of PPE for HCP providing care for patients with suspected or known COVID-19. Where evidence was lacking, attempts were made to provide potential avenues for investigation. There remain significant gaps in the understanding of the transmission dynamics of SARS-CoV-2 and PPE recommendations may need to be modified in response to new evidence. These recommendations should serve as a minimum for PPE use in healthcare facilities and do not preclude decisions based on local risk assessments or requirements of local health jurisdictions or other regulatory bodies.

Perception of Gastrointestinal Endoscopy Personnel on Society Recommendations on Personal Protective Equipment, Case Selection, and Scope Cleaning During Covid-19 Pandemic: An International Survey Study.

Background/AimsThe Thai Association for Gastrointestinal Endoscopy published recommendations on safe endoscopy during the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to assess the practicality and applicability of the recommendations and the perceptions of endoscopy personnel on them. MethodsA validated questionnaire was sent to 1290 endoscopy personnel globally. Of these, the data of all 330 responders (25.6%) from 15 countries, related to the current recommendations on proper personal protective equipment (PPE), case selection, scope cleaning, and safety perception, were analyzed. Ordinal logistic regression was used to determine the relationships between the variables. ResultsDespite an overwhelming agreement with the recommendations on PPE (94.5%) and case selection (95.5%), their practicality and applicability on PPE recommendations and case selection were significantly lower (p=0.001, p=0.047, p<0.001, and p=0.032, respectively). Factors that were associated with lower sense of safety in endoscopy units were younger age (p=0.004), less working experience (p=0.008), in-training status (p=0.04), and higher national prevalence of COVID-19 (p=0.003). High prevalent countries also had more difficulty implementing the guidelines (p<0.001) and they considered the PPE recommendations less practical and showed lower agreement with them (p<0.001 and p=0.008, respectively). A higher number of in-hospital COVID-19 patients was associated with less agreement with PPE recommendations (p=0.039).ConclusionsUsing appropriate PPE and case selection in endoscopic practice during a pandemic remains a challenge. Resource availability and local prevalence are critical factors influencing the adoption of the current guidelines.

Short-term outcomes of infants born to mothers with SARS-CoV-2 infection

Objective The rate of transmission of SARS-CoV-2 from mothers to infants in the peri- and post-natal period remains an area of ongoing investigation. This study aims to determine rates of development of clinically significant COVID-19 disease within 1 month among infants born to symptomatic and asymptomatic SARS-CoV-2 positive mothers. Materials and methods This was a single-center, retrospective cohort study of all infants born to SARS-CoV-2 positive mothers who were admitted to the Well Baby Nursery (WBN) at New York University Langone Hospital-Brooklyn from 23 March–23 September 2020. Infants born to asymptomatic mothers were allowed to room-in, while infants born to mothers with symptoms of SARS-CoV-2 were isolated and discharged home to an alternate primary caregiver. A phone follow-up program contacted mothers at 2 weeks and 1 month post discharge to inquire about newborn symptoms, maternal symptoms, personal protective equipment (PPE) usage, and any presentations to care. Medical records were also reviewed for clinic and hospital visits to determine if exposed infants developed any symptoms following discharge. Results Of 1903 deliveries during the study period, 131 mothers (21 symptomatic, 110 asymptomatic) tested positive for SARS-CoV-2 and had infants admitted to the WBN. 57 infants (21 born to symptomatic mothers, 36 born to asymptomatic mothers) were tested prior to discharge, and none were positive. 121 of 133 infants had at least 1 follow up call in the study period. Of these, 31 had symptoms potentially concerning for SARS-CoV-2 infection or Multisystem Inflammatory Syndrome in Children, and 19 presented to medical care for these symptoms. 4 infants had SARS- CoV-2 testing after discharge, and none were positive. 2 infants were admitted to the hospital for fever but neither had a positive SARS-CoV-2 result. 65% of mothers reported always adhering to PPE recommendations. Conclusion Our results suggest that infants born both to symptomatic and asymptomatic mothers are unlikely to develop clinically significant COVID-19 disease in the peri- and post-natal periods.

A mixed-methods analysis of personal protective equipment used in Lassa fever treatment centres in Nigeria

SummaryBackgroundLassa fever (LF) is a viral haemorrhagic fever endemic in West Africa. Lassa virus is maintained in and spread to humans from rodents, with occasional secondary human-to-human transmission. Present recommendations for personal protective equipment (PPE) for care of patients with LF generally follow those for filovirus diseases. However, the need for such high-level PPE for LF, which is thought to be considerably less transmissible between humans than filoviruses, is unclear.AimIn Nigerian Lassa Treatment Centres (LTCs) we aimed to describe current PPE practices, identify barriers and facilitators to implementation of existing guidance, and assess healthcare workers' understanding. This would inform the development of future PPE guidelines for LF.MethodsWe performed a mixed-methods study, including short cross-sectional surveys of PPE used in LTCs, observations of practice, and in-depth interviews with key informants. We described the quantitative data and we conducted a thematic analysis of qualitative data.FindingsOur survey of 74 HCWs found that approximately half reported problems with recommended PPE. In three LTCs PPE was used highly variably. Full PPE, as recommended in Nigeria CDC guidelines, was used in less than a quarter (21%) of interactions. In-depth interviews suggested this was based on availability and HCWs' own risk assessments.ConclusionWithout specific guidance on Lassa, the current approach is both resource and labour-intensive, where these are both limited. This has led to low adherence by health care workers, whose own experience indicates lower risk. The evidence-base to inform PPE required for LF must be improved to inform a more tailored approach.

We've Got You Covered: Return Demonstration from 4000+ Employees

Background Despite being one of the most important preventive measures for infection prevention and control, the use of personal protective equipment (PPE) is often neglected by healthcare workers (HCW) and can lead to a decrease in compliance and adherence levels. HCW are at a much greater risk of exposure than the general population, due to their potential contact with communicable diseases and pathogens. A visit from the Centers for Disease Control (CDC) revealed staff failures in complying with PPE recommendations as well as a lack of formalized staff education and compliance monitoring in the proper use of PPE. How does a group of three Infection Preventionists go about training, evaluating, and documenting completed return demonstration of 4000+ employees in an efficient and effective manner? Does combing multiple purpose mandatory education events compared to a single purpose mandatory education event produce better turnout results for compliance of completion? Methods The Infection Preventionists implemented a return demonstration process that consisted of first viewing a video of proper donning and doffing, following CDC evidence based best practice standards. Multiple event times were scheduled, and return demonstration was mandated. Both single purpose events for return demonstration along with combing the return demonstration with other mandatory education events were scheduled and took place. Results Mandatory nurse skills fair yielded the greatest amount of completed return demonstrations, 43%. Combining with annual flu shot vaccination clinics brought several return demonstrations to be completed, 44%. Single events of only return demonstrations resulted in a mere 9% of completion. Conclusions Return demonstration yields a greater response when offered as part of a mandatory educational event. Proper use of PPE aides in protecting patients, and HCWs. A facility-wide program, backed by administration, involving both the organization and the individuals can overcome limiting factors such as knowledge deficit and improve compliance for proper PPE usage. Despite being one of the most important preventive measures for infection prevention and control, the use of personal protective equipment (PPE) is often neglected by healthcare workers (HCW) and can lead to a decrease in compliance and adherence levels. HCW are at a much greater risk of exposure than the general population, due to their potential contact with communicable diseases and pathogens. A visit from the Centers for Disease Control (CDC) revealed staff failures in complying with PPE recommendations as well as a lack of formalized staff education and compliance monitoring in the proper use of PPE. How does a group of three Infection Preventionists go about training, evaluating, and documenting completed return demonstration of 4000+ employees in an efficient and effective manner? Does combing multiple purpose mandatory education events compared to a single purpose mandatory education event produce better turnout results for compliance of completion? The Infection Preventionists implemented a return demonstration process that consisted of first viewing a video of proper donning and doffing, following CDC evidence based best practice standards. Multiple event times were scheduled, and return demonstration was mandated. Both single purpose events for return demonstration along with combing the return demonstration with other mandatory education events were scheduled and took place. Mandatory nurse skills fair yielded the greatest amount of completed return demonstrations, 43%. Combining with annual flu shot vaccination clinics brought several return demonstrations to be completed, 44%. Single events of only return demonstrations resulted in a mere 9% of completion. Return demonstration yields a greater response when offered as part of a mandatory educational event. Proper use of PPE aides in protecting patients, and HCWs. A facility-wide program, backed by administration, involving both the organization and the individuals can overcome limiting factors such as knowledge deficit and improve compliance for proper PPE usage.

Personal Protective Equipment Adherence of Pediatric Resuscitation Team Members During the COVID-19 Pandemic

Study objectiveDuring the COVID-19 pandemic, health care workers have had the highest risk of infection among essential workers. Although personal protective equipment (PPE) use is associated with lower infection rates, appropriate use of PPE has been variable among health care workers, even in settings with COVID-19 patients. We aimed to evaluate the patterns of PPE adherence during emergency department resuscitations that included aerosol-generating procedures.MethodsWe conducted a retrospective, video-based review of pediatric resuscitations involving one or more aerosol-generating procedures during the first 3 months of the COVID-19 pandemic in the United States (March to June 2020). Recommended adherence (complete, inadequate, absent) with 5 PPE items (headwear, eyewear, masks, gowns, gloves) and the duration of potential exposure were evaluated for individuals in the room after aerosol-generating procedure initiation.ResultsAmong the 345 health care workers observed during 19 resuscitations, 306 (88.7%) were nonadherent (inadequate or absent adherence) with the recommended use of at least 1 PPE type at some time during the resuscitation, 23 (6.7%) of whom had no PPE. One hundred and forty health care workers (40.6%) altered or removed at least 1 type of PPE during the event. The aggregate time in the resuscitation room for health care workers across all events was 118.7 hours. During this time, providers had either absent or inadequate eyewear for 46.4 hours (39.1%) and absent or inadequate masks for 35.2 hours (29.7%).ConclusionFull adherence with recommended PPE use was limited in a setting at increased risk for SARS-CoV-2 virus aerosolization. In addition to ensuring appropriate donning, approaches are needed for ensuring ongoing adherence with PPE recommendations during exposure.

Surgical tracheostomy in acohort of COVID-19patients.

BackgroundOne of the main symptoms of severe infection with the new coronavirus‑2 (SARS-CoV-2) is hypoxemic respiratory failure because of viral pneumonia with the need for mechanical ventilation. Prolonged mechanical ventilation may require a tracheostomy, but the increased risk for contamination is a matter of considerable debate.ObjectiveEvaluation of safety and effects of surgical tracheostomy on ventilation parameters and outcome in patients with COVID-19.Study designRetrospective observational study between March 27 and May 18, 2020, in a single-center coronavirus disease-designated ICU at a tertiary care German hospital.PatientsPatients with COVID-19 were treated with open surgical tracheostomy due to severe hypoxemic respiratory failure requiring mechanical ventilation.MeasurementsClinical and ventilation data were obtained from medical records in a retrospective manner.ResultsA total of 18 patients with confirmed SARS-CoV‑2 infection and surgical tracheostomy were analyzed. The age range was 42–87 years. All patients received open tracheostomy between 2–16 days after admission. Ventilation after tracheostomy was less invasive (reduction in PEAK and positive end-expiratory pressure [PEEP]) and lung compliance increased over time after tracheostomy. Also, sedative drugs could be reduced, and patients had a reduced need of norepinephrine to maintain hemodynamic stability. Six of 18 patients died. All surgical staff were equipped with N99-masks and facial shields or with powered air-purifying respirators (PAPR).ConclusionOur data suggest that open surgical tracheostomy can be performed without severe complications in patients with COVID-19. Tracheostomy may reduce invasiveness of mechanical ventilation and the need for sedative drugs and norepinehprine. Recommendations for personal protective equipment (PPE) for surgical staff should be followed when PPE is available to avoid contamination of the personnel.

Autopsies in pandemics - a perspective on barriers and benefits. Is it time for a revival?

Influenza virus and coronavirus pandemics regularly sweep the globe, at great cost of health and economy. Our aim was to conduct a PubMed search for autopsy studies on influenza and coronavirus to investigate the contribution of autopsies during pandemics, focussing on autopsy methods and procedures and the role of autopsy findings in pandemics. The retrieved autopsy studies generally relied on microscopy, polymerase chain reaction (PCR), immunostaining and electron microscopy. Most were small and reported on lung effects, including diffuse alveolar damage (DAD), pneumonia and tracheobronchitis. Antibiotic therapy has diminished a role for bacterial pneumonia, whereas obesity is an emerging risk factor. Autopsy studies have provided new insights into coronavirus disease 2019 (COVID‐19) treatments like anti‐coagulative therapy. Unfortunately, autopsies during pandemics are hampered by lack of guidelines, facilities and expertise for handling potentially infectious corpses and by widely varying recommendations for personal protective equipment and procedures. The Department of Forensic Pathology, at the Forensic Institute, at the University of Copenhagen in Denmark has, in collaboration with the Department of Pathology, Rigshospitalet, Copenhagen, initiated a prospective observational study on COVID‐19‐related deaths encompassing postmortem imaging, standardized autopsy procedures/reporting and extensive tissue sampling for histological, chemical, microbiological and genetic analysis. The study involves a diverse array of research groups at the University of Copenhagen, and the clinical field.

Strategies for Optimizing the Use of PPE During Surgery in COVID-19 Pandemic: Rapid Scoping Review of Guidelines.

Personal protective equipment (PPE) plays a fundamental role in the prevention of spread to Health Care Professionals (HCP) ; especially in a surgical setting. This scoping review of surgery guidelines was performed to appraise the quality of appropriate PPE recommendations and propose a strategy to optimize the PPE usage. This rapid scoping review of guidelines on surgery during COVID-19 was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews protocol. Important databases were searched from January 1, 2020 to July 31, 2020, for relevant studies produced by a national/international academic association/organization, in English literature, using relevant keywords. Quality of evidence was graded according to GRADE guidelines. The searches yielded a total of 1725 studies, out of these 41 guidelines on surgery during COVID-19 matching with pre-defined criteria were evaluated. The level of evidence was uniformly rated “low,” as assessed by GRADE guidelines and recommendations provided by them were mostly non-specific covering a narrow range of items. The crucial issue of optimization of PPE was not addressed at all. Economic implications demand optimization of PPE and conservation of resources. A simple decision-making algorithm addressing all the limitations of guidelines can be constructed, which allows HCPs to safeguard themselves and at the same time optimize/ conserving resources.

COVID-19: Additional Precautions against Aerosols for the Slit Lamp User.

To the Editor: We read with great interest the article by Lam et al,1 which describes the special precautions in ophthalmic practice required due to COVID-19. However, precautions related to aerosol transmission may need to be emphasized due to evolving understanding of transmission of the disease. Early in the COVID-19 pandemic, droplet and contact transmission were postulated to be the main modes of transmission. Droplets were defined as being “large” and measuring 20 to 100 μm. Upon expulsion, these droplets rapidly drop to land within 1 m of the infected individual. Transmission may also occur by direct contact with an infected individual or a surface that the person has touched. Recently, the World Health Organization (WHO) has relooked into the modes of transmission for COVID-19.2 Aerosols are generally defined as respiratory particles <10 μm. Generation of aerosols has been normally associated with coughing or sneezing but notably, may be produced even by normal breathing and speech. In fact, SARS-CoV-2 RNAs have been detected in air samples near infected patients despite them not coughing during sample taking.3 Pertinently, aerosols can remain suspended in the air and viral particles have been found in greater concentrations closer to the infected person.4 These aerosols may be carried by air currents to distances above 10 m, which may greatly increase its transmissibility. Furthermore, aerosols are thought to be able to penetrate the lower respiratory tract including the alveoli. Since SARS-CoV-2 in aerosols can be viable for up to 3 hours,5 these may pose an increased risk to those in proximity to infected individuals through breathing and normal speech. THREAT TO THE SLIT LAMP USER Ophthalmologists have been identified as an at-risk specialty for contracting respiratory disease due to the proximity at the slit lamp and higher likelihood of potential exposure to patients’ conjunctival and respiratory secretions.1 In view of the evolving knowledge of aerosol transmission in the chain of spread of COVID-19, we wish to bring attention to current personal protective equipment (PPE) recommendations which may not adequately protect the ophthalmologist. EXISTING PPE RECOMMENDATIONS AND PITFALLS Various ophthalmological societies have provided guidelines on the use of PPE. The Royal College of Ophthalmologists and the American Academy of Ophthalmology (AAO) recommend ophthalmologists to wear surgical masks and eye protection when examining patients. In addition, the AAO has also recommended the use of commercially available slit lamp breath shields to protect against droplets from coughs and sneezes. In view of the mounting evidence of aerosol transmission particularly in indoor environments, there is an increased risk of COVID-19 infection to the ophthalmologists due to inadequate PPE. This is considerably so as presymptomatic transmission may be as high as 50% to 60%.6 IMPLICATIONS TO THE SLIT LAMP USER Administrative procedures such as the setting up of triage stations at hospital entrances which include symptom-based questionnaires and temperature screening have been recommended as part of infection control measures.7 This should be complemented with universal masking for those who wish to seek ophthalmic care as COVID-19 patients may not exhibit any symptoms. Surgical masks have been shown to reduce coronavirus RNA in aerosols and droplets from exhaled air samples8 and could be used to reduce transmission risk. This has already been adopted in the current AAO guidelines. Universal patient mask-wearing at the slit lamp seems particularly prudent. To mitigate against aerosol transmission at the slit lamp, ophthalmologists must adhere to the wearing of a protective mask and eye protection. Despite some evidence of surgical masks and respirators providing similar levels of protection,9 respirators have been shown to have stronger association with reduced infection rates compared to surgical masks.10 Where local resources permit and prevailing rates of community transmission are high, the use of respirators should be preferred to surgical masks. CONCLUSIONS In the presence of evolving evidence of aerosol and presymptomatic transmission in COVID-19, it is timely to reevaluate existing PPE recommendations to ophthalmologists. Slit lamp shields may reduce contamination and exposure to large droplets but aerosols will circumvent these to reach the ophthalmologist. Universal masking within eye clinics should be considered to reduce presymptomatic transmission. PPE recommendations for ophthalmologists could also be reviewed to include the use of a respirator during routine slit lamp examination. In the context of frequent close contact with many patients over the course of a day and in communities with high prevalence of COVID-19 cases, this makes good sense. However, the ideal protective measures will depend on the availability of resources locally. An alternative is the use of surgical masks for both ophthalmologists and patients.

Self-Reported Use of Personal Protective Equipment during the SARS-CoV-2 Pandemic in Emergency Medical Service Employees in Germany—A Survey

Background: Multicentric prospective cohort investigation survey conducted between 1st of March and 1st of April 2021on SARS-CoV-2 occupational risk for German Emergency Medical Services (EMS) personnel. Study Objectives: Primary: The objective is to take stock of the use and availability of Personal Protective Equipment (PPE) in German EMS, both at managerial and employee level, during the SARS-CoV-2 pandemic. Secondary: Generate additional data on individual perceptions of risk of infection and occurrence of infections at respective places of service. Methods: Multicentric prospective cohort investigation survey conducted online at two levels of German EMS personnel—EMS managers and EMS employees, both medical and paramedical—with questions adapted slightly to fit the respective study population. Results: A total of 34 responses were received in the managerial group; a total of 2389 responses were received in the group of employees. Self-reported PPE adherence of EMS employees for confirmed SARS-CoV-2 positive patients: use of gloves (99.8%), FFP2 or FFP3 masks (99.8%), gowns or coveralls (99.1%), goggles (89.7%), face shields (24.0%), surgical masks (0.0%). Self-reported PPE adherence of EMS employees for suspected SARS-CoV-2 positive patients: gloves (98.8%), FFP2 or FFP3 masks (total: 99.4%), gowns or coveralls (total: 95.9%), goggles (85.6%), face shields (19.2%), surgical masks (0.2%). Conclusions: Findings included an overall improved self-reported adherence to PPE compared to studies that were conducted before the pandemic. Self-reported general adherence to PPE recommendations when attending to confirmed SARS-CoV-2 positive patients was good, with the exception of goggles. Self-reported adherence to PPE recommendations dropped when attending to suspected SARS-CoV-2 positive patients.

The Importance of Personal Protective Equipment Design and Donning and Doffing Technique in Mitigating Infectious Disease Spread: A Technical Report

During the current coronavirus pandemic, significant emphasis has been placed on the importance of mitigating nosocomial spread of coronavirus disease 2019 (COVID-19). One important consideration involves the appropriate use of effective personal protective equipment (PPE), which may reduce a healthcare provider's likelihood of becoming infected while simultaneously minimizing exposure to other patients that they care for. This may reduce demands placed on the healthcare system and help to preserve the workforce. First, the importance of PPE design cannot be underestimated, as the manufacturing process must strive to maximize protection of the user while ensuring adequate comfort. Second, it has been demonstrated that inadequate education and training can significantly impact compliance with PPE recommendations. Technique regarding donning and doffing of PPE is crucial to the protection of those who don it. The purpose of this technical report is two-fold: first, to describe some important considerations in the manufacturing and design process of face shields to maximize protection for healthcare providers, and second, to describe a simulation scenario that may be used to train healthcare workers in the appropriate donning and doffing of PPE.

Rewriting the playbook: infection prevention practices to mitigate nosocomial severe acute respiratory syndrome coronavirus 2 transmission.

Given the limited evidence and experience with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), this novel pathogen has challenged the field of infection prevention. Despite uncertainty, infection prevention principles and experience with similar diseases have helped guide how to best protect providers and patients against disease acquisition. Guidance to date has relied on data from SARS-CoV-1 and MERS-CoV to guide practices on patient isolation and personal protective equipment (PPE) use. Although a face mask and eye protection are likely adequate for most clinical scenarios, published guidelines for PPE can be confusing and conflicting. Consensus for what constitutes a high-risk aerosol-generating procedure (AGP) is lacking, but most agree providers performing procedures such as bronchoscopy, intubation, and cardiopulmonary resuscitation would likely benefit from the use of an N95 respirator and eye protection. Needed research to elucidate the predominant SARS-CoV-2 mode of transmission is not likely to be completed in the immediate future. Recommendations for PPE to mitigate procedure-associated risk remain controversial. Nonetheless, implementation of existing measures based on basic infection prevention principles is likely to prevent transmission significantly.

AGA Institute Quality Measure Development for the Diagnosis and Management of COVID-19

AGA Institute Quality Measure Development for the Diagnosis and Management of COVID-19

Pediatric anesthesia during the coronavirus disease epidemic - One pediatric surgical hospital's rapid transition back to care.

Shriners Hospitals for Children - Northern California provides highly specialized pediatric surgical care. The rapid spread of coronavirus disease 2019 (COVID-19) required timely suspension of our elective surgeries. Mitigating disease spread and protecting patients and staff became paramount. Because pediatric patients in particular carry and may spread SARS-CoV-2 while asymptomatic, and due to the large amount of respiratory aerosols produced during airway manipulation, an unprecedented risk of provider infection came to exist. Surgical cases were tiered based on urgency and only emergent or urgent cases proceeded using airborne precaution personal protective equipment (PPE)1 . Furthermore, asymptomatic patients infected with SARS-CoV-2 undergoing surgery have higher postoperative morbidity and mortality2 . However, surgery in children is rarely completely elective and could not be postponed indefinitely. The ability to resume pediatric surgical care during this pandemic would only be possible if a completely new path was forged.