Recommendations for clinical and endoscopic examination
The risk of contamination is very high in upper respiratory
examinations. In Chinese patients, SARS-Cov-2 was detected in 63% of
nasopharyngeal swabs, in 46% of the fiberoptic bronchoscopic brush
biopsies and in 93% of bronchoalveolar lavage fluid
specimens.28 Higher
viral loads were detected after symptoms onset of COVID-19, with higher
viral load in the nose than in the
throat.29 In
spite of that, recommendations for clinical and endoscopic examination
can be very controversial because adequate PPE to all staff involved in
patient care cannot be available everywhere. For sure, at least “WHO
infection prevention and control (IPC) standards” should be in place at
international level. Disruption of supply chains and depletion of stock
of PPE can drive anxiety in health
professionals.30
The Working Group of 2019 Novel Coronavirus, Peking Union Medical
College
Hospital,21 criteria
for the selection of front-line medical personnel included passing
physical examinations and professional training for COVID-19.
Candidates were excluded if they were pregnant, aged over 55 years, had
history of chronic diseases such as chronic hepatitis, renal diseases,
diabetes mellitus, autoimmune diseases, and tumors. All individuals with
acute fever were also excluded. For those who are working with COVID-19
suspicious or infected patients, isolation or observation was compulsory
in the following conditions: a) those with close unprotected contact
with COVID-19 pneumonia patients (health workers should be relatively
isolated, “avoiding walking around and extensive contact with
others”); b) onset of fever, cough, shortness of breath and other
symptoms (medical personnel should be isolated immediately and receive
appropriate care); c) when work in the COVID-19 infection ward is
finished, nasopharyngeal or oropharyngeal swabs for COVID-19 and a full
blood count should be carried out. Those who have abnormal test results
should undergo strict isolation and observation; while others will be
generally isolated for observation and resume work after one week.
However, there are no consensus on these recommendations as to how long
COVID-19-positive healthcare professionals should refrain from patient
care. Viral secretion was found in hospitalized Chinese patients who
recovered to last from 8 to 37 days with a median of 20
days.5
During the COVID-19 pandemic status, effective biosafety precautions
must be implemented in all clinics and hospitals because most infected
patients are not symptomatic and may have been examined only with
inadequate protection. Medical and dental examinations and procedures
can produce aerosols. Even subsequent patients in the same room or suite
are at elevated
risk.1 31, 32.
Consequently, healthcare professionals are at high risk of
contamination.
Aiming to preserve and ensure staff and patient safety, the USA Center
for Diseases Control (CDC) recommends that healthcare facilities cease
elective care and restrict their activities to providing urgent and
emergency visits and procedures for several weeks. All elective and
non-time sensitive, non-urgent surgical procedures and admissions must
be rescheduled as
necessary.33 In
other parts of the world, like Hong Kong, and, and most recently, Italy,
France and Belgium, there has also been a reduction in elective clinics
and operations, with the aim of prioritizing the use of personnel and
available facilities to the diagnostic and therapeutic pathways of
COVID-19 management. However, most oncologic interventions are still
proceeding in the belief that cancer surgery is time-sensitive. It would
be prudent to confirm that the patient is SARS-CoV-2 free through swab
testing. This recommendation must change when the situation becomes
critical and the whole healthcare facility is under strain from COVID-19
patients.8 This
may ensue even in more-developed countries.
Working in the epicenter of the current
pandemic,1 169
staff workers involved in a dental emergency unit at the School and
Hospital of Stomatology, Wuhan, China, have treated >700
patients with emergent dental care since January 24 under using adequate
protection measures. Since February 3, they have also provided
consultations to >1,600 patients on an online platform. No
COVID-19 infection has been reported among the staff, confirming the
effectiveness of the established infection control measures in COVID-19
prevention within dental settings. They established triage stations to
measure and record the temperature of all staff and patients. Patients
and accompanying persons were provided with medical masks and
temperature measurement once they entered the hospital. All the dentists
undertook strict personal protection measures and avoided techniques
that could produce aerosols. Rubber dams and high-volume saliva ejectors
were used to minimize aerosol or spatter during the surgical procedures.
Face shields and goggles were considered essential with use of drilling
with water spray. A 4-handed technique and saliva ejectors were
considered beneficial.