September 23, 2020

General

Many more health workers than we ever thought are catching COVID-19 on the job

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The Victorian government released much-anticipated figures showing the proportion of the state’s health-care workers who caught COVID-19 at work.

Victoria’s chief medical officer Andrew Wilson said that 70-80% of health workers testing positive to COVID-19 were infected at work. That’s compared with 22% in the first wave.

That figure, which equates to at least 1,600 people infected in the workplace, is shocking and tragic. This is because occupational exposure of health-care workers to SARS-CoV-2, the virus that causes COVID-19, represents a failing of hazard control in many workplaces — across multiple locations, in hospital and in aged care.

We also need to acknowledge this problem is fundamentally an occupational health and safety issue rather than simply an infectious disease problem. This means experts in occupational health and safety need to be intrinsically involved in recommendations and guidance to government and employers.

What else did the report find?

The report found infection of health-care workers was greatest in areas where there were many patients with COVID-19 being cared for together (known as “cohorting”), and where health-care workers congregated, such as tea rooms.

Other contributing factors were the increased risk associated with putting on and taking off (donning and doffing) personal protective equipment (PPE), staff moving between health-care facilities, and poor ventilation systems with inadequate air flow.

The report tells us health-care workers in aged care accounted for around two in five infections, and hospital workers around one-third.

However, further details were not provided. These include the actual number of health-care workers infected at work, and a detailed breakdown of the category of health-care worker infected, as well as their age ranges and gender.

We also don’t know the severity of health-care worker infections (number of people who are or have been hospitalised, in ICU, or died).

How big a problem is this?

The number of health-care workers infected with COVID-19 in Victoria has reached 2,799. That makes a seven-day average of 43 new cases each day.

This means that while the state’s total number of new cases continues to decline, health-care worker infections make up around 30% of new cases each day.

Controlling the number of new health-care worker infections is essential, not only for health-care workers but for the sustainability of our health-care system, and to reduce the overall number of cases.

As the total number of health-care worker infections has risen, key groups representing doctors and nurses have called on the government to produce data on the number of health-care workers infected at work and a breakdown of the data by health-care worker type, age, location and severity.

Yesterday the government released its keenly awaited analysis.

What should we do about it?

In light of the report, the Victorian government has established a new health-care worker infection prevention and well-being taskforce.

This is an important step forward and hopefully includes representation from all expert groups, especially occupation health and safety exerts.

Data from earlier in the year, and indeed prior experiences with SARS (severe acute respiratory syndrome), have already given us a blueprint for how to protect health-care workers today.

The blueprint includes implementing a system of hazard control measures (called a hierarchy of control model) in all health-care settings using experts in the field of occupational health and safety, including occupation hygienists.

The government report also outlines plans to develop ventilated and heated marquee-type tents for workers to have their tea breaks in, which is also good news. This recognises the contribution poor air flow makes to the transmission of SARS-CoV-2.

The planned introduction of PPE “spotters” in workplaces is also positive but further details are needed to understand exactly what they will do.

This will hopefully reduce staffing pressure in the workplace and ensure correct donning and doffing of PPE.

What about ‘fit testing’ respirators?

The report also included the surprising announcement that the government was going to undertake a fit-testing trial of respirators.

Testing that respirators, such as N95 face masks, fit and that staff are trained to use them are essential parts of workplace safety, in any industry. It is required as part of Australian standard AS 1715.

So, there is no need to trial fit testing. This is clear from experience in other industries where workers are exposed to hazards such as asbestos or dangerous laboratory fumes.

What is needed is immediate implementation of fit testing and training so health-care workers can be assured their masks fit correctly and do not allow the virus in. This is especially important for females, with many reporting the standard respirator size does not fit properly.

The government needs to do more

The government’s report acknowledged the likelihood of aerosol spread as a mechanism for the transmission of SARS-COV-2. So it has engaged the Victorian Health and Human Services Building Authority to conduct a study aimed at investigating aerosols and their spread on surfaces.

We do not have to wait for the results of this research. The government can act now and take the next step and immediately change its guidelines for PPE for health-care workers.

The Victorian PPE guideline for health-care workers still does not recommend universal PPE designed to protect health workers from aerosols when caring for COVID-19 suspected or positive patients.

The guidelines instead recommend PPE to protect against droplet transmission (such as surgical masks), even in the situation where a person with COVID-19 is severely coughing.

Disappointingly, national guidance still remain unchanged regarding its advice for health-care workers caring for COVID-19 suspected or positive patients. It too does not recommend universal aerosol precaution PPE (including respirators) when health-care workers care for patients with COVID-19.

These guidelines need to be urgently updated to protect health-care workers.

There is also an urgent need for a comprehensive, publicly accessible state and national registry of health-care worker infections that provides regularly updated disaggregated data about health-care worker infections.

This is essential so the magnitude of the problem can continue to be addressed and immediate preventative strategies put in place.

Finally, now the problem of occupational exposure of health-care workers to SARS-CoV-2 has been acknowledged, we must make all these changes immediately.

Alicia Dennis, Associate Professor MBBS, PhD, MPH, PGDipEcho, FANZCA, University of Melbourne

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Elective surgery backlog needs extra hands

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The NSW Nurses and Midwives’ Association (NSWNMA) is urging the NSW Government to bring forward the delivery of extra nurses to help cope with the elective surgery waiting list backlog due to COVID-19.

The latest Bureau of Health Information (BHI) data shows the number of elective surgery procedures dropped by almost 60 per cent per week in NSW during the height of COVID-19 in March and April.

With more than 100,000 patients stuck on waiting lists at the end of June, NSWNMA General Secretary, Brett Holmes, said it was imperative the government increased the nursing workforce now to assist with tackling the backlog over coming months.

“There’s no denying the COVID-19 pandemic had a ripple effect through our public and private hospitals, and we know elective surgery declined sharply from 26 March, when the Federal Government was forced to put the brakes on,” said Mr Holmes.

“In late April, some additional elective surgery procedures were permitted and by mid-May a three-stage pathway for further elective surgeries was rolled out.

“That said, the BHI data shows there were 101,026 elective surgery patients stuck on waiting lists, up 20.1 per cent compared to the same period last year.

“Our members are telling us activity has ramped up in their operating theatres, with the Ministry of Health confirming they are working at more than 100 per cent capacity. We are also aware of the pressure to rapidly catch-up the waiting list backlog during the December-January holiday period.

“We’re urging the government to bring forward the roll-out of extra nursing staff now if they intend go down this path, rather than relying on nurses to pick up the pace and the overtime needed, under current staffing.

“This government has been exploiting the goodwill of nurses and midwives for too long. They’ve been on the frontline, keeping us all safe during this one in a hundred year pandemic, and now they’re expected to simply keep going.

“Nurses and midwives already feel unsupported and undervalued, thanks to the government’s cruel wage freeze.

“It’s time this government started paying attention to the health and wellbeing of its own public sector workforce, instead of making their lives harder thanks to poor economic policy decisions on the run.”

“Gowns out of garbage bags”: study highlights lack of PPE for primary health

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An Australian study has found “insufficient personal protective equipment (PPE)” was being made available in primary health care settings, putting nurses at incredible risk through COVID-19. 

The study of 637 primary health nurses from across the country indicated a severe shortage of PPE in many primary health workplaces, with only 26% of respondents indicating they had sufficient access to gown and 23% indicating they had access to P2/N95 masks at all time. 

Worryingly, less than half (47%) of respondents said that their workplaces had COVID-19-specific PPE guidelines at their facilities. 

Survey respondents revealed that they were forced to resort to shockingly inadequate PPE measures, including purchasing stock privately or making gowns out of garbage bags. 

“We couldn’t source long sleeved gowns when COVID hit so had some home‐made”, one respondent said. 

The lack of PPE was resulting in primary health nurses considering resignation, with 52% of those who were considering leaving the profession blaming “personal safety” as their reason. 

The authors noted that “more needs to be done to ensure sufficient stockpiles [of PPE] are maintained”. 

“The shortage of PPE during the COVID‐19 pandemic has been extensively reported”, the study stated. 

The NSW Nurses and Midwives’ Association is continuing its advocacy to ensure all nurses and midwives have access to adequate personal protective equipment. Members can report unsafe PPE practices here. If you’re not yet a member, you can join today. 

PPE unmasked: why health-care workers in Australia are inadequately protected against coronavirus

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In Victoria, more than 1,100 health-care workers have now been infected with SARS-CoV-2, the coronavirus that causes COVID-19. Some 11% of active cases are workers in the health-care sector.

Health-care workers are reported to be among those fighting for life in Victorian intensive care units.

While we don’t know what proportion of the Victorian health-care workers currently infected with COVID-19 acquired it at work rather than in the community, it’s almost certain a portion of these infections were contracted in the workplace.

Early experience from China found the proportion of health-care workers who contract COVID-19 can be up to 29% in settings with inadequate personal protective equipment, or PPE.

Lessons from China also show workplace transmission of SARS-CoV-2 can be reduced to negligible numbers with sufficient supply, and correct use of, airborne precaution PPE.

Right now, Australia is sitting somewhere in the middle. National guidance needs to be urgently updated to reflect safest practice and acknowledge what we’re learning about the airborne spread of the virus.

What is PPE?

PPE is a crucial part of controlling exposure to hazards in all workplaces.

It includes items such as masks, respirators, face shields, gowns and gloves.

PPE is categorised into three tiers, corresponding to the type of hazard.

Level 1: standard and contact precaution PPE

This PPE limits exposure to standard contact hazards. Examples include face coverings and administrative controls such as hand hygiene, cough etiquette and physical distancing.

Level 2: droplet precaution PPE

This PPE prevents exposure to contact and droplet hazards. Examples include surgical masks, eye shields or goggles, long-sleeved gowns, and gloves.

Level 3: airborne precaution PPE

This PPE aims to prevent exposure to contact, droplet and airborne hazards. It includes N95/P2 respirators or powered air-purifying respirators with a P2 filter, eye shields or goggles, fluid-resistant gowns, double gloves, disposable head and neck wear, and protective footwear.

Current Australian guidelines

The national guidance on the use of PPE in hospitals during the COVID-19 outbreak has been written by the Infection Control Expert Group and endorsed by the Australian Health Protection Principal Committee.

The guidance doesn’t recommend universal airborne precaution PPE for health-care workers dealing with patients suspected or confirmed to have COVID-19. It only recommends level 3 protection for highly specialised procedures such as intubating a patient.

A preprint in the Medical Journal of Australia has criticised the current guidance, noting it’s not aligned with increasing scientific evidence regarding airborne transmission of SARS-CoV-2 and is therefore inadequate to protect health-care workers.

Inadequate national guidance has led to an inconsistent and non-standardised approach to airborne precaution PPE across all health-care settings.

In the absence of strong national safety guidance, some hospitals and jurisdictions are making independent improved safety recommendations to their staff.

y direct contact with droplets and contaminated surfaces — but emerging data suggests it can also be spread by the airborne route.

Why we need level 3

Transmission of SARS-CoV-2 occurs bAn analysis of health-care worker deaths in the United Kingdom found none among wearers of level 3 PPE, suggesting airborne precaution PPE was protective.

Importantly, surgical masks are primarily designed to protect the environment from the wearer. They’re not designed to protect the wearer from respiratory pathogens.

A recent review found N95 respirators offered significantly better protection against viruses including COVID-19 than surgical face masks, while one study found N95 respirators provided 8-12 times more protection than surgical masks against small viral particles.

In Australia, N95 is synonymous with P2 respiratory protection and refers to the filtration efficiency (so N95 means 95% of particles are filtered). But it’s the total inward leakage — what goes through and around the facemask — that’s the critical factor in determining the level of protection the wearer achieves.

To ensure total inward leakage is minimised, respiratory masks used under level 3 PPE must meet certain standards, including fit testing and the training of wearers in their use.

We need immediate action

SARS-CoV-2 is a highly contagious virus with the potential to cause significant ill health and death. In health-care settings, it should be classified as a lethal biohazard and managed accordingly.

The safest approach is to consider all people with confirmed or suspected COVID-19 in hospital, being transported to hospital or being tested for COVID-19 as being able to spread the virus via the airborne route. As such, the use of airborne precaution PPE with a correctly fitted N95/P2 respirator is essential.

There’s also an urgent need for a national registry of health-care worker infections, containing data about the category of health-care worker, where the infection was acquired, severity of disease, hospitalisation, intensive care and death numbers.

This will give us a better understanding of the scope and specifics of the problem, and inform policy and prevention strategies.

Finally, adequate supply of airborne precaution PPE must be available throughout Australia to protect health-care workers from COVID-19.The Conversation

Alicia Dennis, Associate Professor MBBS, PhD, MPH, PGDipEcho, FANZCA, University of Melbourne and Jane L Whitelaw, Certified Occupational Hygienist, University of Wollongong

This article is republished from The Conversation under a Creative Commons license. Read the original article.

“More positive view”: most Australians see health workers more favourably after COVID-19

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COVID-19 has changed Australians’ perspectives on fellow members of their community, and none more so than in their opinions of health care workers and care staff.

A recent Essential poll has shown that 56% of Australians have developed a “more positive view” of health care workers as a result of the pandemic. In contrast, only 4% have developed a “more negative view” of the same cohort.

This means that over half of all Australians have developed a better perspective on health care workers – like nurses and midwives – through COVID-19.

This is on top of the already high trust levels that Australians have towards nurses and midwives, who have consistently topped lists of most trusted professions. 

The pandemic has also resulted in many Australians feeling greater sympathy for the more disadvantaged, with the research showing Australians are developing a more positive view of individuals who are unemployed or homeless, as well as those living with mental illness.

On the whole, around one in five people now see these disadvantaged groups more positively. This may be due to increases in unemployment and mental illness as a result of the pandemic and related economic effects. 

What does it mean to be immunocompromised? And why does this increase your risk of coronavirus?

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Immunocompromised is a broad term reflecting the fact someone’s immune system isn’t as strong and balanced as it should be.

Because immunocompromised people’s immune systems are defective or ineffective, they’re unable to stop invasion and colonisation by foreign intruders, including the SARS-CoV-2 virus, which causes COVID-19.

An under-performing immune response leaves people susceptible to infection, but the severe symptoms in some people are actually caused by a huge immune response sweeping over the whole body.

The reasons for this are varied, and can be complex and intertwined.

What causes compromised immune systems?

Primary immunodeficiencies arise when someone is born with a condition that directly affects their immune system. These illnesses are rare and usually diagnosed early in life. They include common variable immunodeficiency, severe combined immunodeficiency and X-linked agammaglobulinaemia.

Secondary immunodeficiencies are more common and arise as a consequence of outside factors. Exposure to environmental toxins including some pesticides, heavy metals, petrochemicals and air pollutants such as cigarette smoke can reduce the effectiveness of the immune system, particularly at the surface of the lung.

Poor nutrition and drug and alcohol abuse can also impair immunity, as can medications, age and even pregnancy.

Illness and injury

Some illnesses and injuries can cause someone to be immunodeficient. These are also classified as secondary immunodeficiencies. This includes acquired immunodeficiency syndrome (AIDS) as a consequence of human immunodeficiency virus (HIV) infection, severe burns, and not having a functional spleen. This organ is crucial for blood filtration and coordinating the immune response.

Cancers of the bone marrow and white blood cells, such as leukemia and lymphoma, can also cause immunodeficiency.

Bone marrow and white blood cells usually fight infections. The treatment for these cancers is commonly to wipe out all white blood cells using chemotherapy. This incapacitates the immune system even more.

Early information about COVID-19 in a small number of cancer patients in China suggests they have a higher risk of contracting coronavirus and developing severe disease.

Medications

Like chemotherapy, other medications can bring about an immunocompromised state. These drugs are called immunosuppressants.

People who receive organ transplants are one group who need to take immunosuppressants. This dampens their immune system so it cannot react against and reject the donor’s transplant.

People with autoimmune diseases, which cause the immune system to attack the body’s own cells and tissues, also use these medications. Between 2% and 7% of the population have an autoimmune disease, such as multiple sclerosis, type I diabetes, lupus, rheumatoid arthritis and Sjögren’s syndrome, to name a few.

It’s too soon to know the impact of immunosuppressants on COVID-19, but anecdotal evidence is coming through from affected regions.

In Northern Italy, for example, two kidney transplant recipients were treated for COVID-19. Hospital doctors quickly switched their usual broad immunosuppressive medications to drugs that more specifically suppress the parts of the immune system that appear to go haywire in this infection. One patient recovered, the other did not.

Steroids are the most commonly used immunosuppressants – 1-2% of the population in developed countries take them, and the rate is far higher in developing countries where access to more sophisticated medicines is limited.

Clinical trials are currently underway to assess whether steroids might actually protect people against the severe immune response linked to severe illness in COVID-19.

But until the results are clear, steroid use is not recommended to treat COVID-19.

Age

Age is a key element to consider when thinking about our immune system and its ability to work optimally.

A newborn will have no mature immune system to protect his or her body against invaders. In this context, breastmilk will be a precious source of antibodies to help fight viruses.

On the other side, older people are also considered immunocompromised, as they have an ageing, weakened immune system, not fit enough to start and win a fight. As a consequence, elderly people are more susceptible to contracting symptomatic coronavirus infection.

COVID-19 can become severe when older people have underlying health issues that weaken the organs which are strained by the coronavirus infection, such as the heart and lungs.

Pregnancy

Pregnancy weakens women’s immune systems.

Through our evolution, we have developed a necessary state of immunosuppression during pregnancy. This is because within the pregnant mother’s body is an organism with parts that look foreign to the mother, encoded by the DNA from the other biological parent.

Natural suppression of the immune system during pregnancy stops the mother’s immune system from mounting a response against the baby.

The early information we have on the severity of COVID-19 in pregnancy is encouraging, although it’s still too early to know the full story.

So what does the research say so far?

There are a few early reports emerging from heavily hit areas on how COVID-19 differs in prevalence and severity among immunocompromised people.

The world has been primed to worry about these people contracting COVID-19 because they’re more susceptible to severe illness when infected with the range of viruses that usually cause respiratory illness, including common colds.

However, because the severe illness in COVID-19 is actually a result of excessive immune responses, immunocompromised people don’t seem to be presenting with more severe disease than the general population.

It’s worth exploring each case, though, and reviewing our understanding as the evidence emerges.

So far in a key hospital in Bergamo, in the red zone of the Italian COVID-19 outbreak, none of the immunocompromised patients who tested positive for coronavirus developed a severe disease.

Meanwhile, a 47-year-old woman from Wuhan who was taking steroids to suppress her autoimmune disease lupus, contracted the coronavirus and didn’t fall ill. But her compromised immune system couldn’t efficiently clear the virus and she spread it to her father and sister before testing positive.

While this gives hope that immunocompromised people may not be in such dire straits as we had predicted, they may fly under the radar, picking up the virus and spreading it while remaining asymptomatic.

Immunocompromised individuals may also be at risk of losing out to coronavirus through indirect competition for treatment and the medications that allow them to lead relatively normal lives.The Conversation

Sarah Jones, Research Fellow, Centre for Inflammatory Disease Monash Health, Monash University and Fabien B. Vincent, Research Fellow; Rheumatology Research Group, Centre for Inflammatory Diseases, Monash University

This article is republished from The Conversation under a Creative Commons license. Read the original article.