Michael Klompas, MD, MPH
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-0751.
Corresponding Author: Michael Klompas, MD, MPH, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215; e-mail, firstname.lastname@example.org.
Author Contributions: Conception and design: M. Klompas.
Drafting of the article: M. Klompas.
Critical revision of the article for important intellectual content: M. Klompas.
Final approval of the article: M. Klompas.
VA Sierra Nevada Healthcare System
March 14, 2020
Transfers of COVID-19 patients within the hospital
Dear Editor:I am writing this letter in response to a recently published article by Dr Klompas. Recently in our intensive care unit we received a patient -a “PUI” (person under investigation for corona virus disease - COVID 19), on non invasive ventilation (NIV) from the emergency department. A question was raised of how to transfer the patient safely while on mechanical ventilation (MV) or NIV. I have taken this opportunity to address the issues related to patient admission and airborne precautions during their stay .Patient should not be transported out of the negative pressure isolation room unless it is absolutely necessary.If patient is on room air and needs to be transported he needs to wear a surgical mask. Healthcare professionals (HCP) need to maintain at least 3 feet distance from the patient during transfer unless medically necessary. HCPs should also wear standard personal protective equipment (PPE) and a surgical mask with a face shield during transfers . If patient is on oxygen delivered via nasal cannula the transfer/transport guidance is the same as #2. During transfer it should be ensured that hallways and elevators are cleared and in the enclosed spaces there is only necessary staff along with the patient .If the patient is intubated we need to ensure that there are high efficiency particulate air (HEPA) filters for both the inspiratory and expiratory circuits on the transport ventilator. HCPs should also wear standard PPE and a surgical mask with a face shield during transfers . If the patient is on NIV then the recommendation would be to consider discontinuing NIV if possible, or intubating the patient if clinically justified. This has to be judged against risks and benefits related to the transfer. If patient is transported with NIV then he would be considered “very-high” risk for airborne transmission of the virus. In that case the recommendation would be to consider N-95 masks for all the healthcare workers who are involved in the transportation in addition to standard PPEs. Consider additional precautions as mentioned in #4. References:1. https://www.cdc.gov/coronavirus/2019-ncov/index.html2. Lindsley WG, Noti JD, Blachere FM, Szalajda JV, Beezhold DH. Efficacy of face shields against cough aerosol droplets from a cough simulator. J Occup Environ Hyg. 2014;11(8):509-183. Gammon J, Hunt J. A review of isolation practices and procedures in healthcare settings. Br J Nurs. 2018 Feb 08;27(3):137-1404. Seto WH. Airborne transmission and precautions: facts and myths. J. Hosp. Infect. 2015 Apr;89(4):225-8
Sugihiro Hamaguchi, Kie Yaguchi, Yohei Nakamoto, Tetsuro Aita, Yoko Shimotani
Department of General Internal Medicine, Fukushima Medical University
March 17, 2020
The more PCR, the more burden
Dear EditorAs long as the virus spread relatively all over the country, aggressive detection of covid-19 infection by PCR in the early stage of illness can cast a heavy burden of patients with no or mild symptoms on health care providers especially medical personnel at hospitals. We suggest that the aggressive case detection by PCR not be a mainstay strategy anymore to conquer the battle against this rampant viral pandemic in the country.Japan has been criticized both nationally and internationally about the limited number of PCR implementation and there is a public concern about potentially more undetected cases with no or mild symptoms who are spending their daily lives.(1)However, the number of deaths is still 28 in Japan as of March 17th, 2020 after excluding the number of cases infected in the Diamond Princess cruise ship.(2) This figure is extremely smaller and its increase rate is much slower than that of other countries, considering the fact that the first case in Japan was reported on January 14th when other countries did not have many patients yet.One of the most notorious characteristics compared to other viral infections is its large potential of developing pneumonia, leading to the high mortality rate in elderly patients or those with chronic underlying illnesses.(3) Mortality of this infection has nothing to do with the number of PCR implemented since there is no specific treatment for this virus at the moment and early detection of cases does not alter the therapeutic strategy. On the other hand, all cases who died of unexplained pneumonia in this period would receive PCR test for covid-19 and there is almost no possibility of underreporting in the number of patients who died of covid-19 pneumonia in Japan. Therefore, the small number of deaths indicates that the overall infection control has been successful.What we need to do is, regardless of more PCR implementation, reducing the mortality while being more aggressive about respiratory/hand hygiene, and public health measures such as restrictions on people’s movement to prevent potential cluster spreads. Case detection by PCR and positive case tracing are effective for the prevention of disease spread when the number of cases is still small. As the number of cases increases, however, we need to change the strategy from relying on PCR to basic public health methods and care for patients according to the disease severity.1. Takahashi R. Coronavirus testing now covered by Japan's national insurance. The Japan times News; 2020.2. Ministry of Health LaW 2020;Pageshttps://www.mhlw.go.jp/stf/seisakunitsuite/bunya/newpage_00032.html on 16 March 2020.3. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020.
University of South Alabama Medical Center, Mobile, AL, USA
March 19, 2020
Conflict of Interest:
In symptomatic patients viral respiratory panel check is mandatory to contain the pandemic
I peruse with interest and agree with the idea of Michael Klompas about mandatory check of symptomatic patients with viral respiratory panel. Now as the picture is unfolding and experience is accumulating fast. The negative result of respiratory panel in a symptomatic patient could be an indication of COVID-19. In infection with COVID-19, usually no virus and bacteria grow. However, as the silent careers are not very uncommon in the society usual precautions must be applied at everyplace and all the times.
Carmen McDermott MD, FACP
Providence Sacred Heart Medical Center and University of Washington School of Medicine
March 25, 2020
Emerging Knowledge of Gastrointestinal Manifestations in COVID-19 Elevates Concern For Bio-aerosol Transmission.
Thank you Dr. Klompas for your thoughtful article. Additionally, given the novelty of SARS-CoV2, we lack evidence to determine whether or not bio-aerosol transmission occurs as discussed in an analysis by bio-aerosol expert Dr. Lisa Brosseau (1). New evidence describes gastrointestinal manifestations in up to 33% of patients with SARS-CoV-2, fecal shedding in potentially 50% of patients, and reports of probable in-hospital transmission from patients with gastrointestinal symptoms to health care providers and other patients (2-5). Given these findings, experts have raised concern for transmission not only through fecal surface contamination, but also the potential for infectious aerosols which are known to be produced by toilet flushing (7-9). Clearly more research is urgently needed to clarify this issue, yet until then, a precautionary approach to infection control in the hospital and community is prudent. Interim considerations for mitigating this mode of transmission in the hospital setting could include: using lids on toilets, use of non-flushing bedside toilets, modifying ventilation, and using air filtration systems. Increased public messaging about the potential for bio-aerosol transmission and gastrointestinal manifestations is important as well. In this time of urgent need to reducing transmission, we can engage experts and expedited research into the potential for bio-aerosol transmission.REFERENCES:1. Brosseau, Lisa. http://www.cidrap.umn.edu/news-perspective/2020/03/commentary-covid-19-transmission-messages-should-hinge-science2. Johnson, David commentary: https://www.medscape.com/viewarticle/926856?src=mkm_ret_200322_mscpmrk_gastroenterology_covid&uac=315924MJ&impID=2318549&faf=13. Gu J, Han B, Wang J. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology. 2020 Mar 3. pii: S0016-5085(20)30281-X. [Epub ahead of print] https://doi.org/10.1053/j.gastro.2020.02.0544. Xiao F, Tang M, et al. Evidence for gastrointestinal infection of SARS-CoV-Gastroenterology. 2020 Mar 3. pii: S0016-5085(20)30282-1. [Epub ahead of print] https://doi.org/10.1053/j.gastro.2020.02.0555. Luo S, Zhang X, Xu H, Don't overlook digestive symptoms in patients with 2019 novel coronavirus disease (COVID-19), Clinical Gastroenterology and Hepatology (2020), doi: https://doi.org/10.1016/j.cgh.2020.03.043.6. Liang W, Feng Z, Rao S, et al Diarrhoea may be underestimated: a missing link in 2019 novel coronavirus. Gut Published Online First: 26 February 2020. http://dx.doi.org/10.1136/gutjnl-2020-3208327. Knowlton, Samantha D et al. “Bioaerosol concentrations generated from toilet flushing in a hospital-based patient care setting.” Antimicrobial resistance and infection control vol. 7 16. 26 Jan. 2018, https://doi.org/10.1186/s13756-018-0301-98. Johnson, David et al. “Aerosol Generation by Modern Flush Toilets.” Aerosol science and technology: the journal of the American Association for Aerosol Research vol. 47,9 (2013): 1047-1057. https://doi.org/10.1080/02786826.2013.8149119. Johnson, David L et al. “Lifting the lid on toilet plume aerosol: a literature review with suggestions for future research.” American journal of infection control vol. 41,3 (2013): 254-8. https://doi.org/10.1016/j.ajic.2012.04.330
Klompas M. Coronavirus Disease 2019 (COVID-19): Protecting Hospitals From the Invisible. Ann Intern Med. 2020;:. [Epub ahead of print 11 March 2020]. doi: https://doi.org/10.7326/M20-0751
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Published: Ann Intern Med. 2020.
Hospital Medicine, Infectious Disease.
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