Exposures to Viruses Among Healthcare WorkersOn February 12, 2020 by Raul Dinwiddie
COEH CE: Thank you all so much for joining us for today’s webinar exposures to viruses among healthcare workers will be getting started and another couple of minutes. COEH CE: Thank you all so much for joining us today. Our webinar will be getting started in just another couple of minutes. COEH CE: As we wait for people to log in here. I’d love to tell you guys about some upcoming events and webinars that we have COEH CE: Our next NIOSH Industrial Hygiene webinar is going to be on March 10th and that’ll be on respiratory exposures and outcomes among chemists workers by Dr. Christopher Simpson. COEH CE: We also have an ergonomics webinar sponsored by our an Irish ERC group and that’ll be next week on February 19 and that is using anthropology biomechanics and usability to inform product design with Dr. Pete Johnson can learn about these events and more at CH berkeley.edu COEH CE: Thank you all so much for joining us today on behalf of the NIOSH supported education and research centers throughout the country. COEH CE: are pleased to present the 2020 Industrial Hygiene Webinar Series offering free monthly webinars. COEH CE: This collaborative effort on behalf of each year sees continuing education program aspires to provide access to current research supported through nyasha ERC programs. COEH CE: Today’s webinar exposures to viruses among healthcare workers is brought to you by the Rocky Mountains you H and Dr. Rachel Jones. COEH CE: A few housekeeping items. First, you’ll be muted during this presentation. If you would like to ask a question, please enter it into the online chat or Q AMP. A we will save time at the end of the presentation to address all questions. COEH CE: This webinar is also being recorded and will be archived for viewing on CH Northern California YouTube channel. COEH CE: At this time, we’re pleased to welcome our presenter Rachel Jones PhD and CH. COEH CE: Dr. Jones is an associate professor in the Department of Family and preventative medicine and the Industrial Hygiene program director at the Rocky Mountain center for Occupational and Environmental Health at the University of Utah. COEH CE: See after graduate degree training at the University of California, Berkeley, one of Dr Jones’s primary research areas is occupational exposures to infectious diseases. And the implication of these exposures for occupation ality acquired infections. Thank you so much for joining us today. Rachael Jones: Thank you. Rachael Jones: So you’ll have to excuse me if I cough, a little bit. I’m just getting over the flu. Rachael Jones: But hopefully I can make it through the presentation today. So today we’re going to talk about Rachael Jones: There we go. Rachael Jones: Okay, just working here, excuse me, that’s me up in the right hand corner. And of course, immediately after I got my head shot I got new glasses, but Rachael Jones: Today’s primary objectives are shown here and match what’s in the advertisements for them for the webinar we’re going to talk about that how healthcare workers are exposed Rachael Jones: How to measure those exposures discuss the implications of these exposures for healthcare workers health and for personal protective equipment and at the end of the talk, I’ll cover the latest information about the novel coronavirus which, as of today was named coven 2019 Rachael Jones: And why is this talk about viruses and not about bacteria or any of the other hazards prion diseases, for example, healthcare workers experience. Rachael Jones: Well, one is that we know from emerging infectious viral diseases that is clear that healthcare workers can become infected. And we know this because of the current outbreak with coronavirus where healthcare workers in Rachael Jones: China have become infected with with the virus. We also know this from Ebola where healthcare workers were infected and many of our emerging infectious diseases are viruses and so that means we need to continue to think about Rachael Jones: issues around viral exposures. We do know that there is also a burden among healthcare workers from endemic virus diseases. Rachael Jones: And some work that I did with you and shot a number of years ago we were asked to estimate how many healthcare workers in the United States got routine infectious diseases like norovirus seasonal influenza, as well as Rachael Jones: Tuberculosis and some other organisms. We’ve published it influenza work where we show that 10s of thousands of healthcare workers annually and hospitals and emergency departments acquire seasonal influenza infections, even though they’re vaccinated Rachael Jones: Not all of these infections result in over a disease, but it is a significant burden. Rachael Jones: Viruses are something that healthcare workers remain susceptible to over time. There are limited vaccines available for viruses. Rachael Jones: And viruses can affect otherwise healthy adults, whereas for multi drug resistant bacterial organisms infection it predominantly occurs among people with other health conditions viruses can affect healthcare workers who are otherwise healthy Rachael Jones: And it’s important to remember that healthcare workers need to be protected. Not only is it the right thing to do but healthcare workers who are ill can infect other people Rachael Jones: And it’s essential to maintain trust with the healthcare workforce in the, in the event of epidemics and other kinds of outbreaks this trust is helpful to manage fear so that healthcare workers will continue to work and obtain their participation and compliance with various Rachael Jones: Procedures administrative controls and personal protective equipment that’s being used in the workforce. And this was a huge issue in the context of Ebola virus, where Rachael Jones: Healthcare workers had developed initial distrust with the CDC recommendations for personal protective equipment. Rachael Jones: There was great fear because of the high mortality of the disease seen in Africa, which did not necessarily manifested in in developed countries. Rachael Jones: But still, created a lot of fear and hysteria and when we were interviewing hospitals representatives from hospitals in the Chicago area. Rachael Jones: Fear manifested in a number of ways, including that healthcare workers wanted excessive personal protective equipment that made it impossible for them to actually perform the work Rachael Jones: They didn’t want to participate in or be trained to be part of people response teams. Rachael Jones: And ultimately these fears were managed through educational campaigns and integration of healthcare workers in education and practice with personal protective equipment. Rachael Jones: But this is an ongoing challenge that needs to be addressed before crises occur so that healthcare workers are prepared to provide care to build patients. Rachael Jones: So viruses have a number of roots of exposures and. This table shows how exposure roots are defined for several common viral diseases that are caught in healthcare facilities, I guess, Cyrus Colby isn’t common, but it is a well known virus in in healthcare. Rachael Jones: And how the diseases is considered transmitted by CDC and the healthcare infection control practices advisory committee or hick pack. Rachael Jones: And contact transmission droplet transmission and airborne other primary routes that are considered for the transmission of any infectious diseases and healthcare settings. Rachael Jones: Contact me direct or indirect and involves the deposition of viruses on two body parts. Rachael Jones: So indirect would be the virus ends up on a surface that has been touched or ends up on the hand of a healthcare worker that is then transferred to a place where infection can occur. Rachael Jones: I’ll talk a little bit more about the distinction between drop that an airborne but droplet is essentially when when someone coughs on your face. Rachael Jones: And airborne refers to inhalation and you’ll see that for all of these viruses contact is considered a route of exposure that’s relevant. Rachael Jones: For most of these droplet of the respiratory viruses are considered transmitted through droplet routes and airborne sometimes. So this means that there are some epidemiologic evidence that Rachael Jones: The virus transmission that was observed could not be explained by contact or droplet. And so in the CDC pick pack documents for isolation precautions. They’ve talked about kind of these a typical aerosol routes. Rachael Jones: For norovirus influenza and also for rhinovirus now some things to consider. Rachael Jones: Here is that when you get assigned a transmission route by the CDC and hit pack. This triggers specific types of personal protective equipment. So for example, if you have a contact transmissible disease, then the health care workers are supposed to wear gloves and gowns. Rachael Jones: To protect the keep their bodies clean so that when they leave the patient room, they can take off the gloves and gowns and wash their hands and there’s no more virus on their body to expose themselves or others. Rachael Jones: And drab let they would add a mask with may or may not have an ice shield attached to it. So again, this would be a surgical mask that’s designed to protect Rachael Jones: The, the spray of large droplets on to the face, whereas for airborne we would done out a respirator, and the standard respirator that’s used as in 95 filtering face piece respirator, although other respirators. Rachael Jones: Can be worn and are born and healthcare settings but a couple things. When we think about the these classifications. Rachael Jones: Is that if you read this document carefully. This really driven by epidemiology and not really by an understanding of the mechanistic process of Rachael Jones: Exposure pathway and infection. So, for example, there’s a discussion of Rachael Jones: Where in the body are receptors that the viruses can initiate infection and it just talks about, well we got these people were infected and they were close together. So it was probably contact and droplet and not airborne. But there was an outbreak that said Rachael Jones: For example, that somebody vomited in the theater and people that were 10s of meters away got infected. So maybe norovirus is an airborne disease, sometimes. And so it’s it’s driven by the epidemiology. Rachael Jones: Um, the other thing is that there’s a concept that’s emerged in the last 15 years that is Rachael Jones: Important in healthcare setting because there’s an idea that a pathogens transmission route is somewhat flexible. So a pathogen could be an obligate Rachael Jones: To transmit through a certain route that is they have to be transmitted in this way. Rachael Jones: Preferential meaning it’s predominantly in one way, but it could be something else. If a circumstance arose and again opportunistic where you get this rare circumstance where that is an opportunity Rachael Jones: And in health care. This is important because for viral diseases, especially respiratory viral diseases. Rachael Jones: They can require patients to undergo medical treatments and therapies that create aerosols or other kinds of things that are not seen in natural transmission settings. And so there’s an opportunity Rachael Jones: For the virus to be transmitted in a healthcare setting that it might not experience where it at home. Right. And this was something that I wrote about in the context of the bullet with my colleague, Liza or so and others as well in Rachael Jones: In the sense that when you have a patient with Ebola in a developed country, they may get, for example, respiratory support. Rachael Jones: And we know that many respiratory procedures, including mechanical ventilation can create aerosols, which is a potential for the virus to distribute Rachael Jones: In a different way in the environment and creating a different kind of risk for healthcare workers, then might be experienced in a home where the patient is ill and lying in bed and not receiving such treatment. Rachael Jones: So the droplet versus airborne has been a debate in the literature for a number of years. Rachael Jones: And there’s, I think, more consensus, now that we should not be focused too closely on these distinctions between droplet an airborne Rachael Jones: So the table shows the definitions of droplet an airborne that’s used by the CDC and pick pack so droplet, as I said, Rachael Jones: It occurs is basically when someone calls on your face that you’re standing close to them. These large droplets and packs on to your face and your facial mucous membranes. Rachael Jones: And you actually, you know, can feel the dampness from that whereas airborne occurs at a long distance Rachael Jones: These this term called droplet nuclei to describe particles that are in the rest verbal size range and that exposure route really isn’t deletion. Rachael Jones: And but the problem is is that these definitions arose, you know, prior to the 1940s, 1950s and early 1960s, and since then advances in technology have allowed us to have a much better understanding of how pathogens viral pathogens are emitted. Rachael Jones: Through the reference the respiratory tract. Rachael Jones: And to understand costs. And so it’s very clear that costs are poly dispersed aerosols, they undergo very rapid evaporation, but the size range of evaporated particles in a car are still things that can be inspired. Rachael Jones: Or inhaled. And so there isn’t really this clear distinction with regard to particle size or distance and Rachael Jones: The distance that particles will transport from a cost through the environment is multifactorial and has to do with the angle which the cost is emitted in the forest, but also with ventilation in the room. And so that is actually a very hard to predict. Rachael Jones: So these are so and I propose aerosol transmission is a concept to describe this this concept had been described before, in some Rachael Jones: CDC working groups around influenza and others have called it short range airborne transmission with this idea that when you’re close to somebody who’s coughing Rachael Jones: You can both have particles deposit onto your facial mucous membranes and be inhaled. This has a specific meaning for healthcare workers because it says that Rachael Jones: Just because somebody’s coughing at you, the facemask will only protect you from the things that are projected onto the face. Rachael Jones: Enzo and anything that’s small enough to be inhaled and deposit in the lower parts of the respiratory tract, just go around the edge of those loose. Rachael Jones: loose fitting surgical masks and this is what motivates recommendations for healthcare workers to wear respiratory protection for viral respiratory diseases. Rachael Jones: These are just some images from our paper from Rachael Jones: That talk about aerosol disease transmission and try to illustrate this. So here we have the event that person a is coughing and person B is able to inhale particles than the dots of different colors are different sizes, representing vaguely the Polly Rachael Jones: Polly dispersed aerosol from a cough and so these particles clearly kind of project and deposit onto the facial mucous membranes of person be one person be can also inhale. These and inspire these Rachael Jones: aerosol particles. Now, over time, we get dispersion in the room that depends upon particle size. Rachael Jones: ventilation, and air flow, various other parameters. But you see that there are some size selective separation and yet still see person see as far enough away that they’re not getting any exposure, whereas ultimately over time person see has the opportunity Rachael Jones: To inhale the smaller cough particles that remain suspended in air while the larger particles have deposited Rachael Jones: Now, how to measure how healthcare workers are exposed to viruses. Rachael Jones: There’s many different technologies that have been used in the literature to measure viral exposures. Rachael Jones: Over here on the right, starting from the top left is that NIOSH Tuesday’s by air sampling device which collects particles into two tubes and to a filter. So there’s three different Rachael Jones: Sized selection processes. Next to that one to the right is a is an image of an Anderson impactor below that is a button sampler. Rachael Jones: The bottom there is what’s called a Burkhardt cyclones to the very high volume air sampler. Most people will probably familiar with the SK see bio sampler. And of course, your standard filter cassette for viruses people typically use PT FP filters for these because they’re pretty Rachael Jones: Smooth, so it’s easier to extract when choosing a sampling device, though, there’s a lot of different factors to consider, which is why people have used a lot of different instruments. Rachael Jones: So one of the first factors to consider is, are you planning to identify your virus or quantify your virus using culture based methods or culture independent methods like PCR or other genomic sequencing techniques. Rachael Jones: And if one is planning to use culture based methods, it’s important to try to minimize the damage to the virus during sample collection. Rachael Jones: And so that prompts people to use things like impinges where you’re sampling the virus into a fluid. And so it’s less likely to be desiccated and destroyed. Rachael Jones: Such as might happen if you are sampling it onto a filter and the continued airflow is like dehydrating that people will also use the Anderson impactors for that because you can can sample things into media. Rachael Jones: For PCR methods. There’s a wider variety of tools available because you’re not worried about virus destruction in the same way. Rachael Jones: And then your trick is just making sure that you have an efficient extraction of the genetic material from the sampling medium. Rachael Jones: One of the nice things about the knife samplers is that, for example, the tubes can then be readily analyzed in the laboratory and don’t require additional processing to extract genetic material from those Rachael Jones: sample collection devices. And the next question is kind of what is the necessary sensitivity of your sampling method. And so this is really where you’re trying to manage the trade off between Rachael Jones: Having a sampling flow rate and the sample duration for the task to collect enough material for the tasks that you want to sample. Rachael Jones: And whether or not you need to have size selection. So for example, in the NIOSH sample or your volume of errors now divided into three different pockets, which would decrease this potential sensitivity of your sampling method. Rachael Jones: You know, high flow rate sampling devices have are nice, but they tend to be bulky instruments and so you can’t necessarily use those for personal sampling devices. Rachael Jones: And for healthcare tasks when we’ve done sampling those tasks tend to be Rachael Jones: A five to 15 minute duration. So like, you know, if a healthcare worker goes into a patient room to perform a care activity. Rachael Jones: That’s a relatively short sampling duration. And so if you’re operating you’re sampling device at two to three liters per minute. You know, you’re running into sensitivity issue, and I’ll show results to that effect later. Rachael Jones: You also have to decide if you want to use personal or stationary samplers not all of the samplers are very wearable Rachael Jones: And some stationary samplers in particular can be operating at very high volume, which can can help. Rachael Jones: Boost your sensitivity to detect the organisms. But for example, you know, the logistics of wearing an s Casey bio sample or pin to the lapel are incredibly challenging and Anderson. There are personal Anderson impactors that you could use. But those aren’t are not common. Rachael Jones: And we also have to decide, do we have a value for a sigh selective samplings so size selective sampling for influenza, for example, has been a priority in the past because Rachael Jones: We’re uncertain about what is actually the transmission route and characterizing the virus in the rest verbal range is important. Rachael Jones: To understand whether or not inhalation is an important transmission route for influenza. If your goal is simply to know that things are there. And that President then size selective sampling may not necessarily be a value to you. Rachael Jones: Now there’s not a whole lot of information about how all of these samplers perform for viruses and I’ve shown a couple of results here. Rachael Jones: That are trying to demonstrate kind of equivalency between instruments. But there haven’t been a very many studies. Rachael Jones: That talk about specifically the efficiency of the instruments so it’s it’s difficult to make comparisons between instruments, because we don’t know how well each of them performs. And certainly, you know, Rachael Jones: The extraction procedures that are used for all of the samples to do the PCR analysis can vary a little bit between laboratories. And so there’s a lot of challenges with comparing information across studies. Rachael Jones: And again, sometimes the higher sampling flow rate devices are cumbersome to use, but they can be. They can be used. It has been used for exposures to viruses. Rachael Jones: Now, when we go to start thinking about Rachael Jones: How to measure exposures to surfaces. Again, we have to decide if we want to use culture or PCR methods. Rachael Jones: And here. One of the issues is the destruction of the sampling device. So for example, when we were preparing to do our hospital studies. Rachael Jones: We had proposed to our PCR laboratory technicians that we we use the cellulose sponge with just shown here on the bottom left, because that’s what we were using and some laboratory Rachael Jones: Studies with fluorescent tracer but they the cellulose spawned breaks up when you Rachael Jones: Beat it to extract the genetic material and creates fragments that were concerned that might interfere with the PCR analyses. Rachael Jones: So on the top left is that is called a microphone swab this specifically as an environment. Max swab. It’s about the size of a small tampon is the the size of the phone piece here and on the right is a co pan swab, which is basically like a large Q tip. Rachael Jones: So these are three of the common swabs that are utilized that environments foam swab. On the left is what is used by the CDC for their narrow norovirus sampling, such as the work on cruise ships. Rachael Jones: But the koeppen swabs are popular in healthcare studies because they tend to just be around healthcare settings, because they’re used for other medical purposes. Rachael Jones: And they work fine. Except that they’re very small so you can’t necessarily sample a large surface area with these devices. Rachael Jones: And so there are also a variety of wipes that are used for have been used for virus sampling and again whites have the advantage that you can cover a larger surface areas and it’s clear that the efficiency of some of these swabs depend upon the surface area that they sample. Rachael Jones: Again, there’s more data about the performance of swabs for sampling and terek viruses on surfaces on the left is an example from a study by new park with the CDC and Rachael Jones: And their environment. Max foam swab. That’s the microphones swab and here they’re comparing for different swabs a cotton around a polyester swab. Rachael Jones: And sampling for different surface areas and the y axis here is the viral RNA recovery and you’ll see that even the highest bars. Rachael Jones: For the microphone swab, which is the, the one on the farthest right of each grouping is still less than 30% recovery of viral RNA. Rachael Jones: But it is by far better than three other sampling devices, but also that the viral recovery decreases with the larger surface area samples and these this study was a laboratory based study using stainless steel surfaces and the the G to four norovirus Rachael Jones: There was a recently there’s been some reviews of the literature about this and it is, in general, I would just say that the sampling efficiency results are kind of all over the place. Rachael Jones: Some studies show that efficiency depends on the virus concentration. Some studies show efficiency or most studies show that efficiency differs by surface type. So the more Rachael Jones: textured your surfaces. The lower efficiency, you’re going to have. There’s also generally that Rachael Jones: The law, the more dry the material is the lower the sampling efficiency that you have. So studies that put down a moist a wet virus suspension onto a surface and sample immediately. Rachael Jones: Will tend to collect more material than if that virus suspension is allowed to dry for 30 to 60 minutes and then they are sampled. There are some Rachael Jones: Influence of the sampling type, as we can see in the figure on the left, and there’s limited evidence that there’s difference between the viruses that has not been fully explored to know if it’s really specific at the strain level. Rachael Jones: Or it’s more like it’s an envelope versus an envelope or somehow depends upon the shapes. Rachael Jones: Overall that detection limit seem to be on the order of 10 to the three or 10 to the 14 calm calm copies and the sampling efficiencies vary widely, but are most frequently below 50% so turn edge and Gibson have a review of papers that were study published as of 2017 Rachael Jones: And again, most of these studies are performed with interrogate viruses. Rachael Jones: Not respiratory viruses and with respect to desiccation time I will note that many of the samples sampling devices. The swabs, and the wipes can be purchased dried or pre moistened Rachael Jones: And most people purchase the pre moistened ones in our experience in the lab, we were testing some dried sampling devices and the issue dried macro foam sampling devices and the issue was is if you have a little pool of water. The Rachael Jones: The kind of surface tension on the on the DR foam. Rachael Jones: Means that it you know it does kind of is next to the water and then suddenly, it’ll, it’ll finally break that tension and all be sucked up Rachael Jones: And I think to cup compensate for this issue of desiccation people tend to use the pre moistened, especially if you’re using culture, you can get the swabs that are pre moistened with like a protein buffer to help enhance viral growth or culture later. Rachael Jones: On healthcare workers there have been some studies to directly major viruses and I’ll show you our results in in a minute. There’s a couple what methods that are used. Rachael Jones: One is an illusion methods and the glove juice method is commonly used to study healthcare workers can contamination, especially for multi drug resistant bacterial organisms. Rachael Jones: And in the glove geez method. You basically take the healthcare workers hand and you put it in a bag or glove that’s filled with some kind of buffer, then you massage the hand. Rachael Jones: To a loop the virus or bacteria off the hand into the liquid. And then you can analyze the liquid for your organism of interest. Rachael Jones: And health care workers generally will agree to do this, they don’t find this particularly invasive. Rachael Jones: And the, the citations here are from some studies by Lisa Casanova at Georgia State University who uses illusion methods. Rachael Jones: In her studies about self contamination during pp doffing she’s also demonstrated that you can take, you know, whole pieces of personal protective equipment and recover. Rachael Jones: Virus from that. But again, she’s doing this in the context of simulation studies, mostly using a bacteriophage. Rachael Jones: You can also do swabs or wipes on healthcare workers and I’ll show some results later of our swabs with healthcare workers, we find that Rachael Jones: Healthcare workers are fairly willing to have their hands swapped are wiped, but they don’t are not as receptive to having their faces swapped or white. Rachael Jones: So as I’ve talked about that measurement methods. I think there’s some gaps that are very clear that we have limited data about the efficiency of many of our sampling methods which Rachael Jones: Makes it difficult to compare across studies at a highly quantitative level I think qualitatively we get a sense and studies are show that there’s a lot of variability in general. And so it’s hard to, it’s hard to compare directly Rachael Jones: But certainly, comparing within studies to look at relative magnitudes. This is robust in this context. Rachael Jones: It’s not always clear how to interpret environmental measurements for the actual dose to the health care workers because what’s on the surface or what’s on their hands. It doesn’t necessarily relate directly to how much Rachael Jones: virus gets to the actual place in the body where infection is initiated and we to date really relied on exposure modeling that considers human behavior to describe the transport from the environment into the body sites where infection occurs. Rachael Jones: So I’m going to talk now a little bit about some work that that we did my research team did when I was at the University of Illinois at Chicago was funded by the Rachael Jones: The Centers for Disease Control prevention epi center programs. Rachael Jones: And we’re going to talk a little bit about the aspect of our study, it was specifically about measuring virus exposures to healthcare workers in the hospital. Rachael Jones: And overall, I say that we demonstrated that yes healthcare workers are really exposed to viruses and that while not every sample is going to be positive. Rachael Jones: They’re going to be positive frequently enough that given the limitations in the methodology of the sample collection is pretty safe to assume that viruses are present in the air and on surfaces around infectious patients. Rachael Jones: And so the part of this study that I’m going to talk about involved observing about three hours of patient care in the morning when all of the activity is going on in the hospital for 58 patients. Rachael Jones: We sample for the virus with which the patient had been diagnosed within the last three days. Rachael Jones: So we weren’t just looking for any viruses, we were looking for the specific virus associated with the patient. Rachael Jones: In addition to sampling for virus reserved a bunch of information about time activity patterns and GPUs. Rachael Jones: And I want to point out a lot of my research team here from my former students at Chicago going from right to left as human Sue, he has graduated as now. Rachael Jones: Working in the semiconductor industry and Taiwan as a health and safety professional Rachael Jones: You Adam one day was an undergraduate, working with us. She’s now working on completing her master’s of public health and epidemiology. Rachael Jones: Lynn fan finished her PhD and is now a research safety specialist at Stanford University and Rachel Weber completed her master’s degree. And now as an infection prevention is that northwestern Memorial Hospital. Rachael Jones: So I’m really proud and want to acknowledge their important contributions to this work in particular, a lot of what I’m showing as part of Lynn’s PhD research. Rachael Jones: So in our study, like I said, we ended up observing 58 patients. It took us a year and a half to do that. Rachael Jones: Not continuously because we were working mostly during infectious seasons of our patients. The majority of them had influenza air influences be followed by rhinovirus. Then we had one or two patients with respiratory syncytial virus or parrot influenza. Rachael Jones: And this is just some qualitative information about how frequently we found different viruses on different surfaces and I will say all of these patients were hospitalized at the University of Illinois Hospital in Chicago. Rachael Jones: They were in a variety of different patient settings. And when we reviewed their medical records. They were not highly ill. So there was nothing particularly severe about their infections or or or co-morbidities or anything like that. Rachael Jones: Some of the patients were quite mobile when we were in the room, others were entirely bedroom, but none of them were really severely ill. Rachael Jones: And so these are some of the surfaces that we sampled we sampled before at some surfaces at the beginning of the observation period and again at the end of the observation period and somewhere sample just at the end of the observation. So this is one sample. Rachael Jones: It for each each patient at a maximum. So, you see that they’re not every surface is always contaminated, but things are frequently contaminated. So the keyboard. Rachael Jones: Is on the Computer, Workstation that is assigned to the room is permanently in the patient room, not the mobile Rachael Jones: Computer station. Some wards had mobile computer stations, the call button is for the patients to call the medical staff and the bed rail. And so you see that that there is some variety. But things are are fairly frequently contaminated. Rachael Jones: Quantitatively these results show quite high variability. So, note this is a log scale on the Y axis of gene copies per square centimeter Rachael Jones: And there’s not statistically significant or obviously pattern differences between the amount of contamination on the different surfaces, but the the concentration of virus gene copies on these surfaces varies by several orders of magnitude. Rachael Jones: We did air sampling in two ways. We play stationary air samplers in the patient rooms within about a meter meter and a half of the head of the patient’s bed. They sample for about two and a half hours. Rachael Jones: And then we had a total of 47 stationary samples we then also tried to recruit at least one healthcare worker per day to wear a personal air sampling device while they were providing patient care. Rachael Jones: It was difficult. Not everybody wanted to wear that. And so you’ll see we don’t have quite as many samples for that those samples, as I said are relatively short duration about 10 minutes Rachael Jones: Overall, the stationary samplers were positive 43% of the time we were using the NIOSH bio sampler, which, as I said, has three different size fractions. And so the pattern amongst the different size fractions was not consistent on all of the different sampling Rachael Jones: Times or every time we sampled it wasn’t that one stage was positive. It was a mix of stages in the sampling device that were positive Rachael Jones: The other thing to note is that the mean concentrations here shown here about 10 to the three gene copies per cubic meter, but it went up as high as 10 to the fifth gene copies per cubic meter. Rachael Jones: For the personal air samples only 22% were positive and any stage and none of them were positive for that the third stage which is the larger viral particles, but given the low numbers of samples, it’s difficult to interpret. Rachael Jones: Here and I don’t know why that’s six. I think it should be five of Rachael Jones: Positive. Um, one thing to note though is that the virus concentrations in the personal air samples were relatively high compared to the stationary air samples which makes sense because the health care workers generally weren’t close to the patient. Rachael Jones: But they were on the order of 10 to the six of 10 to the seven when they were positive. So this is a mean of the positive samples. Not mean of all of the samples, but this is important because it suggests that healthcare workers will have moments where they have a high potential exposures. Rachael Jones: And this is not really surprising. It’s also consistent with some work that we did to look at aerosols emitted during bronchoscopy where we get very periodic very high concentrations Rachael Jones: Which show short duration extremely high risk potential, given the low infectivity of many of these are the high infectivity of many of these viruses. It’s important that we anticipate and control these short duration high exposures. Rachael Jones: We did do some work to try to identify potential determinants of virus in the environment and this show some correlation between contact patterns of healthcare workers and virus concentrations Rachael Jones: But nothing really stood out. And part of this, I think, was just a limitation in terms of sample size and the fact that Rachael Jones: There was not there was variability in the virus concentrations, but not so much variability and some of the other things, notably Rachael Jones: Positive stationary samples were associated with the event that healthcare more than five healthcare worker encounters occurred with the patient during that three hour window which may reflect that there’s Rachael Jones: More activity in the patient room increasing aerosol concentrations or it could be that these patients were just more sick. Rachael Jones: We also tried to get health care workers with a sample on their bodies and personal protective equipment and this, we’re done using those little co pens swabs. Rachael Jones: And so we found virus on gloves gowns masks personal stethoscopes. We also found them on bare hands. This was before hand hygiene on the face in on the scrubs that were worn under the gowns. Rachael Jones: That concentrations, you’ll notice here, I’m much lower than what we saw on environmental surfaces, except that there were kind of extreme Rachael Jones: Values here and this should be copies per centimeter squared. Rachael Jones: Not per cubic meter. But this does confirm and we believe is the first study to confirm that viruses are on healthcare workers after they provide Rachael Jones: care to patients. Now, we did not major healthcare workers as they were going into the room. So some of this contamination could be residual from previous patient care activities. Rachael Jones: But it does confirm that the virus of the patient. So again, we were just measuring the virus that the patient was sick with is on healthcare workers. Rachael Jones: We also were looking at surface contacts, which showed some interesting patterns, bye bye job. Rachael Jones: So on the left is the total number of times people touch the surface and green here. And again, you’ll see providers, which would be nurse practitioners and physicians Rachael Jones: contacting the environment, much less often than other jobs and again here self contacts were much lower amongst nurses and nurse technicians. Rachael Jones: Then they were among other job titles. That means that those healthcare workers touch their own body less frequently than others. Rachael Jones: So we were looking at how people touch their bodies during care and this was kind of the frequency with which healthcare workers touch their own body during a patient care activity and you’ll see they are frequently touching their, their personal protective equipment. Rachael Jones: Which is a potential for self contamination. Rachael Jones: So so surface is I think our work and the work of others show that this is ubiquitous and that there’s concern for short term high risk exposures for healthcare workers for inhalation. Rachael Jones: Now I’m unfortunately in healthcare, there’s a strong reliance on personal protective equipment, rather than looking at a lot of engineering controls. Rachael Jones: And so we had a paper that came out last month in the American Journal of infection control that is trying to argue that we should use a systematic risk based approach. Rachael Jones: Which is not a novel approach at all to selecting P P for in the industrial hygiene realm but has not been adopted in the Rachael Jones: healthcare setting. And this would be what we described as starting out with a job hazard analysis where you’re looking at what are the infectious body fluids President, how are they contacted infectious disease hazards going through Rachael Jones: A selection, where you’re trying to document and make your decision making transparent to build trust with healthcare workers. Rachael Jones: And align the hazard analysis with the infectious disease hazards. Rachael Jones: As well as an undergoing a robust evaluation of P P or you’re not only looking at donning and doffing but usability. In general, and whether or not it’s fit for purpose. Rachael Jones: And this came out of our experience interviewing people in their Ebola preparations and how every hospital we talked to was doing their own trial and error approach and trying to figure out how best to protect our own health care workers but Rachael Jones: We wanted to describe this more formally, we’d like to move this forward and see if we can develop a guidance document and test with users. So if anyone is interested in participating in such an activity, please get in contact with me. Rachael Jones: So now to coronavirus today, it was announced that it’s now called code into 2019 instead of novel coronavirus Rachael Jones: You probably all are where we have more than 40,000 cases today in China and more than 1000 deaths. Rachael Jones: While the initial cases were linked to a specific seafood market. Rachael Jones: The actual host at the seafood market. That was the source is as unknown it the genetic sequence indicates that the virus is originally has a natural reservoir and bats, but they don’t know yet what the Rachael Jones: The mediating animal is at this point, there is a PCR based Rachael Jones: Diagnostic tests available and the important. One of the important things for healthcare workers is that the receptor binding domain for the new virus is similar to that and SARS Colby Rachael Jones: And that it looks like it uses the H2 receptor, which is located in the lower respiratory tract, indicating that inhalation and deposition of the virus in the lower respiratory tract poses a risk of infection to health care workers. Rachael Jones: And descriptions of K series from China indicate that the initial symptoms are fever and coughing with shortness of breath among hospitalized patients at least pneumonia is extremely common. More than 70% of Rachael Jones: cases reported case serious presenting with pneumonia fatality seems to follow bilateral pneumonia with multiple organ failure. Rachael Jones: There has been some reports of a typical presentation with abdominal pain, and it has been confirmed that at least among patients with abdominal pain that the virus is it diarrhea that the virus can be found in stool. Rachael Jones: The initial case reports from China show increase severity among elderly men with co-morbidities but that may just be a feature of of the specific cases that are reporting. Rachael Jones: At this point, the CDC is indicating that they believe that incubation period is anywhere from 12 to 14 days, which I think means that they don’t really know Rachael Jones: And the presumed transmission route is similar to stars and MERS which is described as respiratory droplets Rachael Jones: Epidemic modeling from the case reporting and China sick chest that the basic reproductive number is about 2.5 Rachael Jones: With which means that there should is, you know, can it’s continuing to grow. There’s not an indication yet that the Rachael Jones: That the epidemic is controlled that we’re going to start seeing a reduction in the number of new cases, the model by whoo at all in particular predicts emerging outbreaks in many of the major cities in China and one is now being seen in Beijing. Rachael Jones: In the US. SO AS OF THE JANUARY 17 the CDC has increased screening at airports, but they have only identified a few cases for testing at the airports. Rachael Jones: On the US does manage 18 quarantine facilities that ports of entry and some of these and quarantine facilities that military bases are being used for the the flights of people that were brought by the US government out of Lu Han Rachael Jones: They activated their emergency operations center and have released that PCR diagnostic tests. Rachael Jones: On the 31st. There was a presidential proclamation that limited entry to the US of persons who have traveled to mainland China to citizens and permanent residence. And this is something that has not been done. Rachael Jones: In my for a long time. It’s very striking. So the CDC in their recent reports as a Friday and morbidity Morbidity and Mortality Weekly reports. Rachael Jones: Indicate that this was done in part to help the public health system and hospitals in the US, prepare for an interest in you know in case that there Rachael Jones: Is a surge of cases in the United States. Rachael Jones: As of the fourth of February, the CDC reported that there are 293 persons under investigation for coronavirus in the United States and 11 diagnose cases nine of whom had traveled to move on to cases among close contacts. Rachael Jones: The CDC apparently has received inquiries regarding 650 persons of those they recommended testing for just under 300 and about 210 have been tested. Rachael Jones: And most of these patients were identified through healthcare settings that includes emergency departments at hospitals outpatient clinics as well as interestingly enough student health clinics. Rachael Jones: Which is a new area that I hadn’t seen received a lot of attention in terms of preparations for public health control. Rachael Jones: So these are the CDC recommendations and the CDC, I think stepped up a little bit. This time compared to some of the recommendations for other outbreaks. Rachael Jones: So on the left are some recommendations for in in health care facilities in particular patients are supposed to be isolated and to wear a mask unless they are put in an airborne infection isolation room, at which point they can remove their masks. Rachael Jones: Aerosol joining procedures are supposed to be. You’re supposed to limit the number of people present and do culture only and BSL three facilities. Rachael Jones: This time, the CDC has recommended respirator use so they have contact droplet an airborne precautions. So they recommend hand hygiene gloves gowns respirators and I protection on a specifically not that these things should be used consistent with OSHA regulations. Rachael Jones: This is a change from recommendations and previous outbreaks that they have stepped up immediately to say respirators and I protection should be used. Rachael Jones: For all patient contacts, not just for aerosol generating procedures. They also specify healthcare workers must be educated train and practice with the p p Rachael Jones: And while most healthcare facilities with would do this based on their own personal experience. It’s a great recommendation from the CDC this time and Rachael Jones: To work with Monica to work with public health authorities to monitor healthcare workers and to use non punitive sickly policy so that healthcare workers who were exposed are developed symptoms are not penalized. As a result, in terms of lost income or lost jobs. Rachael Jones: last note here is that there’s a review that came out a rapid review that came out in 2020 not 2010 came out last Friday. Rachael Jones: Looking at SARS and Murs and other human coronavirus and terms of surface persistence and cleaning effectiveness. Rachael Jones: This review concluded that it’s likely that like other human. In fact, just Corona viruses that person’s on the persistence on the surface would be up to nine days depends a little bit on temperature and humidity. Rachael Jones: Corona viruses and animals have been shown that in fact animals routinely have been shown to persist longer and but the other ones that infect humans have lower persistence. Rachael Jones: The efficacy studies for cleaning show that ethanol greater than 70% or two propanol greater than 70% or hydrogen peroxide greater than point 5% or sodium hypo chloride, a greater than the only value tested was point two 1% given a one minute contact time will yield up Rachael Jones: Three law 10 reduction. So it’s not a full elimination, but it’s a substantial reduction. Rachael Jones: They, they do have some other Rachael Jones: cleaning materials that are also effective at this level but require longer contact times Rachael Jones: So, thank you. And we’ll be making some materials available. So I’m happy to take some some questions at this time. COEH CE: Wonderful, thank you so much for that excellent presentation. COEH CE: At this time we are opening it up to questions and answers. And so please feel free to use that Q AMP a bar in your zoom window to ask any questions to Dr. Jones. COEH CE: And we do have another question. This come in already and someone else I wondering how you protected the researchers during your study. Rachael Jones: Yeah, so during our study, we asked our research team to wear the same personal protective equipment that was required for the healthcare workers at a minimum, and Rachael Jones: Though none of our patients that we were studying were under airborne precautions. We made available to our research team and 95 respirators as well as power. They are purifying respirators. Rachael Jones: For them to use as they choose chose, but normally they would wear a gown gloves, a mask with a face shield and or a respirator. COEH CE: Wonderful, thank you again, you can enter your questions into the online webinar chat and also the Q AMP a bar. Someone did have a question regarding which one the CDC uses that person could please be more specific as to which part of the webinar, you’re referring to. That would be wonderful. COEH CE: And we do have another question, given two to 14 day incubation periods is a transmission period earlier than two days. Rachael Jones: Um, Rachael Jones: I think that question is asking how when when when do people become infectious and it’s not clear, there is some discussion in the published studies and the CDC documentation that people may be infectious. Rachael Jones: Before they’re symptomatic. But I think at this point because most of the cases are in China. And it sounds like it’s a very chaotic situation there. We don’t have robust data about when people become infectious over that pathway. Rachael Jones: Over that incubation period. COEH CE: Thank you. Another question. Are they doing air sampling for coronavirus determine if it’s truly airborne versus droplet transmission Rachael Jones: I personally do not know if they are doing any sampling for that. Thank you. COEH CE: Another question about hand sanitizers how effective are hand sanitizers with 70% ethanol considering contact time have one minute is needed to significantly reduce many viruses. Rachael Jones: So I personally don’t don’t know the database answer for that. But I would say that people generally don’t use the hand sanitizer for one minute the evaporation time for that hand sanitizer is much quicker than that. Rachael Jones: So I would say that it would probably remove some virus from the hands, but not enough. Rachael Jones: I’m not sure if you’re aware, but that the FDA recently has asked some of the manufacturers in particular, go Joe of the hand sanitizer products to change their advertising about these Rachael Jones: Products preventing things like flu and Ebola, because it is clear that they do kill some of those viruses, but it’s not Rachael Jones: Clear as I was mentioning before about how much virus on a hand translates to infection risk. So I think that they do kill some viruses and they would kill some Corona viruses, but I’m not sure that they would obtain the same efficacy for coronavirus as as using soap and water. COEH CE: Okay, thank you. And we have another question. COEH CE: They said that they have a supply of P P from SARS response that they’re looking at deploying for C Corp ID. COEH CE: Do you know if expired pp E, including surgical masks are still any good. Rachael Jones: So, there Rachael Jones: Wasn’t this one. I mean, there’s nothing fundamentally about a surgical mask that degrades over time, but I can’t, I can’t, in good faith recommend that you use a product that’s expired. Hey, thank you. COEH CE: Um, let’s see, we were having a lot of questions about the coronavirus COEH CE: very tightly presentation. So I’m just working through these COEH CE: Here. So thank you everyone for your questions. COEH CE: Someone I was wondering if how effective that virus can be transmitted through building ventilation systems. Rachael Jones: So I, I don’t know know there is a news report that came out last night of potential transmission within a building and Hong Kong. Rachael Jones: Although the transmission pathway is more hypothesized around plumbing pipes than ventilation systems. And I think at this point we don’t know how long the virus would survive in air, but Rachael Jones: To to know if we’re looking at concerns about transmitting over long distances through ventilation. But that was a concern with SARS. And I think that that’s something that Rachael Jones: Is a potential at this point, we just don’t have all that much information about this specific coronavirus but if we recall back to the SARS outbreak mean there was clearly Rachael Jones: Transmission between apartment buildings through the air as well as through sewer pipes or venting of sewer pipes. Rachael Jones: Within an apartment complex and that virus was also found in in stool, like the current coronavirus is so I think it’s something that we need to be aware of, but I don’t know that we’ve gotten to the point of having to to panic about that in at least in the United States. Yeah. COEH CE: Great, thank you. And we also had an attendee who I wanted to add a comment about pee pee in the end and 95 masks and they noted that elastic can also get brittle and break. Eat more easily. Rachael Jones: Yeah, with respect to the expiration date. Rachael Jones: Yeah, same thing with with gloves and some of the other Rachael Jones: Gown materials that over time. The materials can degrade so that they offer less protection or are more fragile to us, then, initially, which is why why the expiration dates are there in particular. Great. COEH CE: And it looks like someone also added that Nashville soon be putting out some guidance about expired and 95 as well so Rachael Jones: Keep your COEH CE: Eyes open for that. And I asked guidance. Rachael Jones: Yeah, and the, the National personal protective Technology Laboratory had a webinar this morning about healthcare. Healthcare and 95 storage stockpiling and kind of efficiency of use. Rachael Jones: Unfortunately, I was, I missed that. But I assume that they’re working very diligently on that issue and and would be a great resource going forward. COEH CE: Thank you. But we also have another question about air sampling are anti air sampling devices installed to collect samples and hospitals where the COEH CE: coronavirus has been reported in the USA, are you aware about that. Rachael Jones: I am not aware. Okay. COEH CE: We have plenty more questions. So thank COEH CE: You everyone online. I’m doing COEH CE: My best to get to all of these COEH CE: Are you familiar with any studies examining exposures to viruses related related to surgical smoke plumes. Rachael Jones: Not specifically viruses. I know that there have been case reports of, you know, for example, papilloma or Herpes infections among people who are doing like laser hair removal and some of those procedures. Rachael Jones: And I feel like I’ve seen a study Rachael Jones: That attempted to measure that viruses. So if the person wants to follow up with me afterwards, I can point them to that, but I don’t think there’s a big body of literature on that. Rachael Jones: I know that there’s ongoing work looking at exposures to general particulate associated with surgical lasers and laser hair removal Rachael Jones: Including some by my colleagues and one of our students here at the University of Utah. But I have I, I’m just feeling like I’ve seen an article from maybe seven to 10 years ago that had some data about that. COEH CE: Great, thank you. We have another question regarding if hospitals have varying requirements regarding disinfection procedures for rooms. Rachael Jones: Yes, in general, they do have very different. They can have different procedures for disinfection requirements. Rachael Jones: And different products that are used in different tools that are used and that varies between hospital. So there are some general guidance. Rachael Jones: But there’s no specific policies that come out from CDC and pick pack about when you need to clean a room, how often you need to clean a room and and what tools are products. So the EPA Rachael Jones: Tests and Sir or doesn’t test but certifies certain disinfectants not all of those disinfectants however are tested against all of the organisms that are of interest in healthcare settings. Rachael Jones: And in particular, a lot of them are not tested very, very competently very much against viruses. So my some of my colleagues at Clemson University have been working on a study testing. Rachael Jones: And disinfecting products against norovirus and getting some slightly different results than then we expect, but those are very preliminary Rachael Jones: So it’s up to the individual hospitals to set the policies and procedures for their, their cleaning Rachael Jones: That’s in general, but also for something like a an epidemic. COEH CE: Great, thank you. I’m going to continue on with that question. Someone also had it was wondering how ventilation systems, specifically might be disinfected Rachael Jones: Oh my goodness. I have no idea. COEH CE: Great question. Rachael Jones: ventilation systems are super complicated and this is an issue that they’ve struggled with with Legionnaires disease for many years, as well as how do you get a complicated Rachael Jones: System that’s hidden behind walls and ceilings clean and I would say that probably the only Rachael Jones: Things that that would be feasible, because you can manually clean them would be some kind of gaseous disinfectant or potentially a UV source that could distribute through the ventilation systems, but that’s beyond my Rachael Jones: I can’t, I can’t say that I’ve seen evidence that those things have been used or that they work. COEH CE: Great, thank you. And we are coming towards the end of our time here but if you do have another question. Dr. Jones has provided her email address right up there on the screen. So you’re welcome to follow up with her for the slides and other COEH CE: Reference articles, I would like to again thank you to everyone who joined us for today’s webinar. And a special thank you to Dr. Rachael Jones: Jones. COEH CE: The NIOSH Education and Research Center Industrial Hygiene Webinar Series taking place. The second Tuesday of every month. COEH CE: And this new series is in addition to our Nash ERC ergonomics webinar series, which takes place. The third Wednesday of every month. COEH CE: And be sure to check back to our website for more information and to register for upcoming events and you can do [email protected] and there is a specific page dedicated to all of the nyasha ERC webinars. COEH CE: Thank you all so much for your wonderful questions and participation and I hope you have a wonderful day. Thank you, Dr. Jones. Thank you.