This article was written and shared with us by Dr. Lucy E. Wilson. Dr Wilson is Professor of Emergency Health Services at UMBC and Director of the UMBC Graduate Program in Emergency Health Services and an infectious disease physician.
US healthcare workers must feel safe in order for our country to respond effectively to a novel coronavirus outbreak.
Millions are mourning the death of Dr. Li Wenliang, a physician who attempted to warn colleagues of the novel coronavirus outbreak in Wuhan City. He is far from the only healthcare worker who has been affected by COVID-19 disease. Today, China alarmingly reports that 1,700 healthcare workers have become infected since the start of the epidemic, and six have died.
While supply and proper use of protective equipment may account for a number of the reported infections in China, these stunning numbers are a wakeup call for the United States. The dedicated members of the healthcare community, vital to our public health response effort at every level, are tasked with striking a balance between their deep sense of commitment to patient care and their realistic fear of risk of personal harm to themselves and their families. Doing right by healthcare workers is essential to an effective national response.
Historically, assuring effective levels of personal protection to medical workers during novel virus outbreaks, including which types of masks, gowns and gloves to recommend, have been difficult challenges in the public health response. Challenges address essential issues and include understanding whether the virus can be aerosolized versus spread by droplets, providing widespread effective training to remove protective garments without self-contamination, assuring proper garment fit, and maintaining an intact supply and distribution chain of equipment. Inclusion of a broader scope of the workforce in these efforts, such as first responders, environmental cleaning staff, and frontline workers is essential for effective infection control. Finally, the characteristics of the patients themselves guides response: is disease spreading from a respiratory or gastrointestinal route, does the patient have a high level of virus such that they are “super spreaders”, or is the patient in a special needs category where they can’t communicate or act to take steps to minimize spread of infection? Consideration of all these factors must be incorporated in the national response plan.
Recent history suggests that it is difficult to protect medical workers. During the 2003 SARS outbreak, hospital worker infection accounted for approximately 20% of all infections in both mainland China and Hong Kong hospital workers. During the same outbreak, in one Toronto, Canada hospital, 36.7% of the 128 infected with SARS were hospital workers. In total, 436/850 of Toronto’s paramedic workforce during the peak of the outbreak were placed under 10-day quarantine for SARS exposure, effectively decommissioning over half of the available workforce. After the first case of Ebola virus disease was manifest in the US and two nurses in Texas became infected, a heightened level of personal protective equipment was recommended by The Centers for Disease Control and Prevention. Currently, CDC recommends healthcare workers caring for those with suspected COVID-19 don respirators with gowns, gloves and goggles, on the theory that there may be a risk of inhaling microscopic air particles carrying the virus. This recommendation, however, is different from that of WHO, who recommends less respiratory protection (a surgical mask) for most clinical scenarios for prevention of COVID-19. Concern remains for spread by gastrointestinal as well as respiratory mechanisms and more research is needed. What’s right for the new coronavirus – the disease now called COVID-19 -- hinges on additional detail about its mechanism of spread. There are numerous COVID-19 cases in the population at large in affected areas of Asia without a known exposure source. The world is watching with trepidation, as the passengers and crew of the Diamond Princess, a Japanese cruise ship, have become subjects of a natural experiment in epidemiology. Resolving the mechanism of transmission must be a top scientific priority. Already during this outbreak, too many healthcare workers on the front lines of emergency response both in the US and worldwide have informally communicated their uncertainty as to whether they are appropriately protected from potential infection and whether they have the tools to do their work effectively.
To protect healthcare workers adequately, four steps are critical.
First, as we await more detail regarding this novel coronavirus, the US should continue to push forward on behalf of its healthcare workers. This means that the communication of a secure plan for infection protection should be in place, a stable supply of N95 respirator masks and other vital protective equipment secured, proper training on equipment use and environmental cleaning exercised, and occupational health monitoring and treatment for all staff involved in medical response.
Second, while basic scientific understanding of the virus is actively under investigation, we should also study different ways of protecting healthcare workers and the environment, reducing human error in high-risk settings, and innovations in responding to capacity challenges as case numbers surge.
Third, the US should assure health care workers that they will be first in line for vaccine when it is developed. This will honor their willingness to put themselves in harm’s way.
Fourth, public health leaders should be transparent about efforts to understand the risks and take actions to protect healthcare workers. Without credible communications, confidence in the response may waver, endangering us all.