The CDC relaxed previous recommendations regarding ways healthcare workers can protect themselves from COVID-19 in revised interim guidance issued Wednesday.
“The time to prepare your healthcare facility for community transmission is now, ” Amber Vasquez, MD, MPH, CDC epidemic intelligence service officer and member of the COVID-19 Response Infection Control Team, explained during a Clinician Outreach and Communication Activity (COCA) call on Thursday.
“However, with community transmission of COVID-19 in the U.S. being reported in multiple areas, contact tracing and risk-assessment of all potentially exposed healthcare personnel has become impractical for implementation by healthcare facilities in those situations,” Vasquez said.
In areas of community transmission, all healthcare personnel are at “some risk” for exposure to COVID-19, whether at work or in the community. Dedicating resources to contact tracing and “retrospective risk assessment” takes resources away from other critical infection prevention and control measures, she explained.
Instead, the CDC recommends facilities to shift focus to more “routine practices,” Vasquez said, including “self-reporting” to their occupational health program any “recognized exposures” such as potential travel or community-related exposures as specified by a separate interim guidance.
Healthcare personnel should also regularly monitor themselves for fever and any signs of respiratory infection and not come to work if they’re ill.
“Facilities should develop a plan for how they will screen symptoms and evaluate ill health personnel,” Vasquez said, such as having staff confirm an absence of fever and symptoms before work each day.
But the revised guidance also states that for healthcare workers with low-risk exposure who are “self-monitoring” their health status “with delegated supervision,” the agency has eliminated the requirement that healthcare facilities “actively verify absence of fever and respiratory symptoms” for clinicians reporting to work.
“That’s now optional,” she said.
The CDC’s revised guidance also streamlines “risk exposure categories” which are based on several factors including the presence or absence of source control measures, the use of personal protective equipment (PPE) by the healthcare provider, and the level of contact with the patient.
In addition to this updated guidance, the CDC also released its “Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United States” the previous weekend, which Vasquez recommended healthcare facilities use to guide their own planning.
In addition to educating staff, this second set of guidance recommends: identifying alternatives to “face-to-face triage and visits,” optimizing healthcare facility’s supply of PPE, and “reviewing triage and management of patients with respiratory illness to ensure that all appropriate precautions are in place” and ensuring that staff understand the plan. The guidance also includes advice for healthcare facilities that are already experiencing community spread based on the setting: inpatient, outpatient, and long-term care.
CDC staff also emphasized the importance of PPE and highlighted additional guidance on “Strategies for Optimizing the Supply of N-95 Respirators.”
Capt. Lisa Delaney of the CDC’s COVID-19 Response Worker Heath and Safety Team warned healthcare organizations to plan for “increased demand and decreased supply of PPE.”
Members of CDC staff also answered questions from clinician viewers of the CDC’s webcast and listeners on the phone including:
Q: How can clinicians obtain remdesivir for patients who test positive for COVID-19?
Remdesivir, originally developed to treat Ebola, is the one drug with in vitro data showing that it inhibits replication of the virus in non-human cells, Angela Campbell, MD, MPH, a member of the CDC’s COVID-19 Response Clinical Team, said, but she stressed that there aren’t any human data on the drug yet.
It’s also not FDA-approved. There are no FDA-approved therapeutics for COVID-19 at this time.
A small number of patients have accessed remdesivir through “compassionate use” through emergency requests submitted to the manufacturer, Gilead Sciences, through its website or the number 1-866-MEDI-GSI. A second option is to participate in an NIH adaptive randomized double-blind, placebo-controlled trial, which will be used to look at remdesivir and other future products as they enter the pipeline, Campbell said. Two other open-label trials of Remdesivir announced Wednesday are being launched by Gilead for hospitalized patients.
Campbell also recommended against the use of cortical steroids, unless indicated for other problems such as COPD exacerbation, because of the “potential for prolonging viral replication.”
Q: Should patients who have traveled to Washington state’s King County be tested for COVID-19?
Answering broadly, Sue Gerber, MD, a member of CDC’s COVID-19 Response Epidemiology Task Force, said that clinicians could consider the “clinical picture” and whether it’s consistent with COVID-19. She recommended considering what other potential risk factors the patient might have experienced. For example “did that patient visit a healthcare facility … or other [places] where there might be COVID-19 patients?”
She also recommended that clinicians consult with their local and state public health department to determine what testing is appropriate.
Q: Is it safe to assume that a person who tests positive for the flu cannot also have COVID-19?
Campbell encouraged ruling out other diagnoses, but she said she had heard anecdotally, not in the published research, of “a couple of instances of co-infection,” not just with flu and COVID-19 but also with other respiratory illnesses.
She recommended that providers rely on their overall “index of suspicion for COVID-19 based on some of the epidemiological factors as well.”
Q : Can respirators that haven’t been FDA-approved be worn in a healthcare setting?
The FDA regulates the types of respirators used in surgical settings, such as N-95s, Delaney said. However, the CDC’s National Institute for Occupational Safety and Health (NIOSH) approves a “whole suite” of disposable respirators, used in construction and other settings, that are “at least as protective as N-95s.” These industrial respirators, which include non-surgical N-95s, R-99s, P-100s, and a few other masks, don’t receive FDA-approval.
Earlier in the week, the FDA approved a request from the CDC for an emergency use authorization allowing healthcare personnel to use certain industrial respirators during the COVID-19 outbreak in healthcare settings.
Q: What is the risk of transmission for surfaces?
There isn’t “definitive” data to answer this question, Vasquez said.
However, she emphasized the “paramount importance” of hand-washing, since “the main risk of transmission from surfaces is through contamination of one’s hands and subsequent self-inoculation from touching your mouth, nose, or eyes.”
Vasquez also emphasized the need for using EPA-registered, hospital-grade, disinfectant to clean all surfaces or “products with label claims against human coronavirus” and focus on ensuring those “high touch surfaces” are cleaned.
Q: Do children display different symptoms from COVID-19 compared with adults?
Based on limited data, the symptoms and clinical course of COVID-19 are similar to those in adults, appear more mild in children than in adults. Respiratory symptoms include sore throat, headache, cough, and nasal congestion. Some patients experience diarrhea and nausea, prior to fever and lower respiratory symptoms. And there are reports suggesting “clinical deterioration” in the second week of illness, Campbell said.
Of the 44,000 confirmed cases of COVID-19 in China, roughly 2% were younger than 20, and no deaths were reported in patients under age 10. Severe disease, requiring ICU admission or ventilator support seems to be “uncommon” in children with COVID-19, Campbell said.
She said she knew of one 13-month child who developed acute respiratory distress syndrome and septic shock and required ICU admission, and that child lived, Campbell said.
While risk factors haven’t yet been characterized for children, those with underlying medical conditions may be at higher risk of severe illness.
A recording of the full webcast is available on Facebook.