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Pregnant Healthcare Workers (HCWs), Vulnerable HCWs and HCW with Other
Pre-Existing Disease Version 3, 30/03/2020
In order to ensure the health and safety of our HCWs, this guidance provides advice for vulnerable HCWs, HCWs with pre-existing disease and HCWs who are pregnant, and their managers.
Advice for Pregnant Healthcare Workers
1. There is no evidence and no reason to expect that HCW’s who are pregnant, are substantially more likely to become infected with COVID-19 than non-pregnant HCW’s, or to suffer more adverse consequences as a result of Covid-19 infection than non-pregnant HCW.
2. The Institute of Obstetricians and Gynaecologists (IOG) in the Royal College of Physicians of Ireland have reviewed the recent UK Royal College of Obstetricians and Gynaecologist recommendations and have concluded that the recommendation that pregnant HCWS after 28 weeks gestation should not be put on front line duties, is not evidence-based.
3. IOG recommends that facilities may want to consider limiting risk of exposure of pregnant HCWs to patients with confirmed or suspected COVID-19, especially during higher risk procedures (e.g., aerosol-generating procedures) if feasible based on staffing availability.
Advice for ‘Vulnerable’ Health Care Workers
As per the government guidelines the following workers should not be at work as per guidance from the Department of Health. The HCW can provide their manager with a letter from their treating specialist confirming their ‘Vulnerable HCW’ status. There is no requirement for Occupational Health input.
1. HCWs who are solid organ transplant recipients
2. HCWs with specific cancers
a. HCWs with cancer who are undergoing active chemotherapy or radical radiotherapy for lung cancer.
b. HCWs with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment.
c. HCWs having immunotherapy or other continuing antibody treatments for cancer.
d. HCWs having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors
3. HCWs who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs
4. HCWs with severe respiratory conditions including cystic fibrosis, severe asthma and severe COPD as confirmed by their specialist.
5. HCWs with rare diseases and inborn errors of metabolism that significantly increase the risk of infections (such as SCID, homozygous sickle cell)
6. HCWs on immunosuppression therapies sufficient to significantly increase risk of infection have a weak immune system. While the following is a list of immunosuppression therapies, this list is not exhaustive; the HCW may seek an opinion from his/her treating specialist regarding the level of immunosuppression.
a. Daily receipt of high dose corticosteroids is immunosuppressive. The following doses of prednisolone (or equivalent dose of other glucocorticoid) are likely to be immunosuppressive:
1. ≥40 mg/day for more than 1 week, or
2. ≥20 mg/day for 2 weeks or longer
3. Advice should be sought from the treating physician if necessary regarding the level of immunosuppression.
b. There is no contra indication to attending work if the steroid treatment is:
i. Short term (<7days) irrespective of dose
ii. Long term (≥2 weeks) < 20mg/day of prednisolone or equivalent
iii. Long-term, alternate-day treatment with short-acting preparations
iv. Maintenance physiologic doses (replacement therapy)
v. Topical (skin or eyes) or by inhalation
vi. Intra-articular, bursal, or tendon injection
vii. Fludrocortisone <300 micrograms/day
c. Immunomodulatory treatment causes immunosuppression and includes biological disease modifying anti-inflammatory drugs (bDMARDs) such as:
vii. Mycophenolic acid preparations
viii. Sirolimus and Tacrolimus, in addition to biologics, such as
ix. NFα blocking agents
x. Severely reduced immunogenicity can occur from treatment with
2. Methotrexate (>0.4 mg/kg/week)
3. Methotrexate and TNF inhibitor combination therapy
5. Use of topical Calcineurin inhibitors (TCIs, e.g., Tacrolimus and Pimecrolimus) for atopic dermatitis in otherwise healthy adults does not result in significant systemic absorption or immunosuppression.
7. HCW who are pregnant with significant heart disease, congenital or acquired
8. HCW over 70 years of age
HCW with Other Pre-Existing Disease
1. HCWs with other medically managed pre-existing disease, are unlikely to be at greater risk of acquiring COVID-19 virus infection compared with other HCW’s
2. These HCWs can continue to work UNLESS there is a specific recommendation from their treating specialist.
Vulnerable health care workers as described in this document should not be at work. Pregnant HCWs and HCW with other pre-existing disease, who adhere to recommended Infection Prevention and Control precautions are unlikely to be at greater risk of acquiring COVID-19 virus infection compared with other HCW’s and do not need to be excluded from providing care to such patients.
Where possible and consistent with expressed preference of the healthcare worker it is pragmatic to allocate these healthcare workers to the care of other patients if feasible, based on staffing availability.
Health Services Executive. (2017). Immunisation Guidelines for Ireland - Chapter 3. Available: https://www.hse.ie/eng/health/immunisation/hcpinfo/guidelines/chapter3.pdf. Last accessed 30th Mar 2020. Department of Health. (2020).
Guidance on cocooning to protect people over 70 years and those extremely medically vulnerable from COVID-19. Available: https://www.gov.ie/en/publication/923825-guidance-on-cocooning-to-protect-people-over-70-years-and-those-extr/#what-we-mean-by-extremely-medically-vulnerable. Last accessed 30th Mar 2020.
Note on Recommendations to use surgical masks for all patient encounters and meetings between staff where social distancing (2 metres) cannot be maintained.
Many of you will be aware that one hospital has issued guidance to all staff that they should wear surgical masks for all patient encounters and meetings between staff where social distancing (2 metres) cannot be maintained.
The basis of the recommendation made is stated as being to prevent spread of infection from a mildly symptomatic or asymptomatic healthcare worker to patients and other staff members. The recommendation is to use 3 masks per day if working a 12 hour shift and 2 masks per day for working less than 12 hours.
Other hospitals have since adopted this position. The purpose of this note is to clarify national guidance on this issue and the basis for that guidance.
The recommendation that all staff should wear a surgical mask for all patient encounters and meetings between staff where social distancing (2 metres) cannot be maintained is not supported by evidence and is not consistent with national guidance.
The basis for the recommendation is problematic in that it may suggest that the risk from mildly symptomatic healthcare workers attending work can be managed by mask use.
The recommendation is problematic because it can be expected to promote poor practice in relation to use of masks and thereby increase risk for patients and colleagues. If a hospital recommends adoption of a measure that is not supported by evidence or consensus of expert opinion it has a responsibility to ensure that the measure does not expose staff to increased risk. Safe mask use means that masks are tied appropriately and removed and discarded any time the healthcare worker needs to take a toilet break, answer the telephone or uncover their mouth to eat or drink or for any other reason. This cannot be accomplished with the number of masks proposed in the recommendation above.
Background and Rationale
The stated purpose of the recommendation is to prevent spread of infection from a mildly symptomatic or asymptomatic healthcare worker to patients and other staff members. It is apparent also that many healthcare workers are fearful for their own health and believe that routine mask use will protect them from acquiring infection from a mildly symptomatic or asymptomatic colleague or patient. It is in everyone interest to support healthcare workers to protect their own health. Wearing of masks provides a sense of security for many people. However the recommendation to use 3 masks per day if working a 12 hour shift and 2 masks per day for working less than 12 hours is likely to be counterproductive.
The use of surgical masks
Surgical masks are an important item of personal protective equipment (PPE) for healthcare workers (HCW) who need to apply droplet precautions in patient care scenarios conducted within the radius of droplet spread (typically 1 to 2 meters)
Surgical masks are also used as part of standard precautions, where there is a risk of splashes of blood or bodily fluids to the nose or mouth (e.g., during operative procedures)
A surgical mask may also be worn by a person with clinical evidence of a droplet transmitted respiratory infection others (e.g., SARS-CoV-2 (COVID-19), influenza), with the aim of reducing droplet dissemination from the person, especially when they are waiting in a communal area or during transfer between clinical areas
Some relevant guidance related to surgical masks and COVID-19
WHO Guidelines on rational use of PPE for COVID-19 (27th Feb 2020) state “for asymptomatic individuals, wearing a mask of any type is not recommended. Wearing masks when they are not indicated may cause unnecessary cost and a procurement burden and create a false sense of security that can lead to neglect of other essential preventive measures”
Public Health England Guidance on COVID-19 Infection Prevention & Control (March 2020) state that surgical masks should cover nose and mouth, not be allowed to dangle around the neck after or between each use, not be touched once put on, be changed when they become moist or damaged, be worn once and then discarded as clinical waste – hand hygiene must be performed after disposal.
Irish recommendations for use of PPE in management of suspected or confirmed COVID-19 (17th March 2020) state this guidance DOES NOT RECOMMEND the use of surgical facemasks in situations other than for contact with patients with droplet-transmitted infections including COVID-19.
Other relevant background
HIQA recently reviewed the evidence of asymptomatic transmission for the Expert Advisory Group to the National Public Health Emergency Team and concluded as follows:
“There were 11 case reports reporting pre-symptomatic or asymptomatic transmission. However, the level of evidence (case reports) is low and is subject to a number of potential sources of bias and therefore the evidence should be interpreted with caution.
The modelling studies may provide another source of evidence for asymptomatic transmission but they need to be carefully assessed for quality and applicability to Ireland.”
The Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) notes:
“The proportion of truly asymptomatic infections is unclear but appears to be relatively rare and does not appear to be a major driver of transmission.”
A very recent publication from Klutymans-van den Bergh based in the Netherlands described testing of healthcare workers in two large teaching hospitals who suffered from fever or mild respiratory symptoms. 86 of 1353 (6.4%) of this cohort of HCWs were identified as having COVID-19 on a single sample. Only 53.5% had fever but 91.9% were captured by a cases definition of fever and/ or coughing and/or shortness of breath. Extending this to include severe myalgia and/or general malaise would capture 100% of healthcare workers. The majority (62.8%) reported that they had worked while symptomatic. As the study was limited to those reporting some symptoms truly asymptomatic healthcare workers would not have been detected. As the diagnosis was based on as single oropharyngeal sample it is possible that some patients withere COVID-19 were not detected.
Reservations regarding the Recommendation on routine use of surgical masks.
- The study of Klutymans-van den Bergh emphasises the common experience that healthcare workers tend to present for work when they have symptoms. It is a concern that the recommendation above may suggest that the risk posed by mildly symptomatic healthcare workers attending for work may be managed by wearing a surgical mask. The message needs to be very clear and consistent with current national HSE guidance that symptomatic healthcare workers should not attend for work but should be assessed and tested if appropriate.
- There is some uncertainty regarding the extent to which infected but asymptomatic people may disperse infectious droplets but in so far as it occurs, it is likely to be very much less than those who are symptomatic. The WHO report indicates that asymptomatic infection does not appear to be a major driver of transmission.
- Even if the hypothesis that transmission from truly asymptomatic healthcare workers in the healthcare setting is significant it accepted, there is no evidence that the universal use of surgical masks is effective in reducing this beyond what is achieved by Standard Precautions (hand hygiene, respiratory hygiene and cough etiquette and environmental cleaning) and minimising interpersonal interaction.
- If universal use of surgical mask is adopted with a view to preventing transmission of infection it is essential that the masks are used appropriately as per standard guidance on surgical mask use in this context.
- Appropriate surgical mask use for the purpose of preventing infection requires that the masks is applied appropriately so that the it can be removed safely without touching the front of the mask and discarded.
- It is highly unlikely that healthcare workers can adhere to safe mask use in the context of the recommendation to use a single mask for a period of 4 to 6 hours. Safe use for 4 to 6 hours would mean that he mask cannot be removed to drink, eat, take toilet breaks or answer the telephone. If the telephone is answered while wearing the mask the telephone may be contaminated by the mask. In these circumstances most healthcare workers will resort to unsafe mask use – for example tying the masks behind the neck so that it can be pulled up and down and touching the front of the mask. The mask may create the illusion of protection but in fact the practice recommended is probably more likely to increase the risk of transmission of infection to both patients and colleagues and to increase the risk of acquiring infection.
M Cormican MCRN 011105 28 March 2020
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