Optimizing and Unifying Infection Control Precautions for Respiratory Viral Infections

M. Klompas, C. Rhee
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Notwithstanding this framework, the United States Centers for Disease Control and Prevention’s (CDC) infection control guidelines include a hodgepodge of different personal protective equipment recommendations for different respiratory viruses [1]. These span the gamut from respirators, eye protection, gowns, and gloves to care for patients with emerging pathogens such as Middle East Respiratory Syndrome (MERS), avian influenza, and now, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); surgical masks alone to care for patients with influenza; gloves and gowns alone without masks or eye protection to care for patients with respiratory syncytial virus (RSV); and nothing at all to care for immunocompetent adults with parainfluenza. This curious mix of recommendations appears to be the product of a handful of studies conducted predominantly in the 1980s and 1990s that evaluated the additive benefit of one or more of these precautions against one of these viruses, mostly RSV. None of the cited studies compared infection rates between viruses or provided evidence why one virus should be treated differently from another. Many of the source studies only reported on nosocomial infection rates in patients but did not consider infections in healthcare workers. And almost all the studies focused on pediatric populations. The suitability of these studies to support current infection control recommendations is dubious. For example, 2 key studies are cited to support the use of gloves and gown alone without a mask or eye protection to care for patients with RSV. The first was a quality improvement initiative in a children’s hospital designed to increase providers’ compliance with gloves and gowns over the course of 3 RSV seasons from 1982 to 1985. The investigators reported that an increase in glove and gown use from 39% to 81% of audits was associated with a 3-fold decrease in nosocomial RSV infections [2]. The investigators did not assess whether adding masks and eye protection could further decrease infections and the study only evaluated infections in patients; infections among staff members were not assessed. The second study was a prospective comparison of nosocomial RSV rates among children assigned to wards with different precaution sets over 3 RSV seasons [3]. Nosocomial RSV rates ranged from 26% of patients when using no precautions, 28% with gloves and gowns alone, 19% with cohort nursing alone, and 3% with gloves and gowns combined with cohort nursing. The fact that the only successful strategies included cohort nursing belies the importance of staff as vectors of infection, yet the study did not report on staff infection rates. This study also did not evaluate the marginal benefit of masks and eye protection. Instead, the investigators cited a study that reported that nose and eye protection was associated with striking decreases in both staff and patient infections [4] but explained that they decided not to include nose and eye protectors in their strategies because “they are not popular with clinical staff and are frightening to children” [3]. It is very difficult to reconcile the CDC’s patchwork of legacy recommendations for different respiratory viruses with the wealth of data now demonstrating the primacy of the respiratory route in respiratory viral transmission [5, 6]. It has become evident that the majority Received 05 May 2022; editorial decision 05 May 2022; accepted 06 May 2022; published online 10 May 2022 Correspondence: Michael Klompas, MD, MPH, Department of Population Medicine, 401 Park Drive, Suite 401 E, Boston, MA 02215, USA (mklompas@bwh.harvard.edu). The Journal of Infectious Diseases © The Author(s) 2022. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions @oup.com https://doi.org/10.1093/infdis/jiac197","PeriodicalId":22572,"journal":{"name":"The Indonesian Journal of Infectious Diseases","volume":"76 1","pages":""},"PeriodicalIF":0.0000,"publicationDate":"2022-05-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"1","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"The Indonesian Journal of Infectious Diseases","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.1093/infdis/jiac197","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"","JCRName":"","Score":null,"Total":0}
引用次数: 1

Abstract

The coronavirus disease 2019 (COVID19) pandemic has focused an intense spotlight on respiratory precautions for healthcare workers managing patients with respiratory viral infections. Prevailing wisdom before the pandemic was that most respiratory viruses are transmitted by large respiratory droplets and fomites. These droplets were believed to have a carrying radius of 3–6 feet before rapidly falling to the ground by virtue of gravity. Surgical masks were presumed to provide adequate protection in most situations by providing a barrier between patients’ emissions and the mucous membranes of providers’ mouths and noses. Notwithstanding this framework, the United States Centers for Disease Control and Prevention’s (CDC) infection control guidelines include a hodgepodge of different personal protective equipment recommendations for different respiratory viruses [1]. These span the gamut from respirators, eye protection, gowns, and gloves to care for patients with emerging pathogens such as Middle East Respiratory Syndrome (MERS), avian influenza, and now, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); surgical masks alone to care for patients with influenza; gloves and gowns alone without masks or eye protection to care for patients with respiratory syncytial virus (RSV); and nothing at all to care for immunocompetent adults with parainfluenza. This curious mix of recommendations appears to be the product of a handful of studies conducted predominantly in the 1980s and 1990s that evaluated the additive benefit of one or more of these precautions against one of these viruses, mostly RSV. None of the cited studies compared infection rates between viruses or provided evidence why one virus should be treated differently from another. Many of the source studies only reported on nosocomial infection rates in patients but did not consider infections in healthcare workers. And almost all the studies focused on pediatric populations. The suitability of these studies to support current infection control recommendations is dubious. For example, 2 key studies are cited to support the use of gloves and gown alone without a mask or eye protection to care for patients with RSV. The first was a quality improvement initiative in a children’s hospital designed to increase providers’ compliance with gloves and gowns over the course of 3 RSV seasons from 1982 to 1985. The investigators reported that an increase in glove and gown use from 39% to 81% of audits was associated with a 3-fold decrease in nosocomial RSV infections [2]. The investigators did not assess whether adding masks and eye protection could further decrease infections and the study only evaluated infections in patients; infections among staff members were not assessed. The second study was a prospective comparison of nosocomial RSV rates among children assigned to wards with different precaution sets over 3 RSV seasons [3]. Nosocomial RSV rates ranged from 26% of patients when using no precautions, 28% with gloves and gowns alone, 19% with cohort nursing alone, and 3% with gloves and gowns combined with cohort nursing. The fact that the only successful strategies included cohort nursing belies the importance of staff as vectors of infection, yet the study did not report on staff infection rates. This study also did not evaluate the marginal benefit of masks and eye protection. Instead, the investigators cited a study that reported that nose and eye protection was associated with striking decreases in both staff and patient infections [4] but explained that they decided not to include nose and eye protectors in their strategies because “they are not popular with clinical staff and are frightening to children” [3]. It is very difficult to reconcile the CDC’s patchwork of legacy recommendations for different respiratory viruses with the wealth of data now demonstrating the primacy of the respiratory route in respiratory viral transmission [5, 6]. It has become evident that the majority Received 05 May 2022; editorial decision 05 May 2022; accepted 06 May 2022; published online 10 May 2022 Correspondence: Michael Klompas, MD, MPH, Department of Population Medicine, 401 Park Drive, Suite 401 E, Boston, MA 02215, USA (mklompas@bwh.harvard.edu). The Journal of Infectious Diseases © The Author(s) 2022. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions @oup.com https://doi.org/10.1093/infdis/jiac197
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优化和统一呼吸道病毒感染感染控制措施
2019年冠状病毒病(covid - 19)大流行使管理呼吸道病毒感染患者的医护人员的呼吸道预防措施成为人们关注的焦点。大流行之前的普遍看法是,大多数呼吸道病毒是通过大的呼吸道飞沫和污染物传播的。据信,这些液滴在重力作用下迅速落到地面之前,携带半径为3-6英尺。外科口罩被认为在大多数情况下可以提供足够的保护,因为它在病人的排放物和提供者的口鼻粘膜之间提供了屏障。尽管有这样的框架,美国疾病控制和预防中心(CDC)的感染控制指南包括针对不同呼吸道病毒的不同个人防护装备建议[1]。这些产品包括呼吸器、护目镜、防护服和手套,以及对中东呼吸综合征(MERS)、禽流感和现在的严重急性呼吸综合征冠状病毒(SARS-CoV-2)等新发病原体患者的护理;只使用外科口罩照顾流感病人;护理呼吸道合胞病毒(RSV)患者时仅使用手套和防护服,不戴口罩或护眼;对于有免疫功能的副流感成年人,根本没有任何护理措施。这种奇怪的建议组合似乎是主要在20世纪80年代和90年代进行的少数研究的产物,这些研究评估了一种或多种预防措施对其中一种病毒(主要是RSV)的附加效益。被引用的研究都没有比较病毒之间的感染率,也没有提供证据说明为什么一种病毒应该区别对待另一种病毒。许多来源研究只报告了患者的医院感染率,而没有考虑医护人员的感染。几乎所有的研究都集中在儿科人群上。这些研究是否适合支持当前的感染控制建议值得怀疑。例如,引用了两项关键研究来支持仅使用手套和罩衣而不戴口罩或护眼来护理呼吸道合胞病毒患者。第一个是儿童医院的质量改进倡议,旨在提高医务人员在1982年至1985年三个RSV季节期间对手套和长袍的依从性。研究人员报告说,手套和罩衣的使用从39%增加到81%,与院内RSV感染减少3倍有关[2]。研究人员没有评估增加口罩和护眼是否能进一步减少感染,研究只评估了患者的感染情况;没有对工作人员的感染情况进行评估。第二项研究是对分配到不同预防措施病房的儿童在3个RSV季节的院内RSV发病率进行前瞻性比较[3]。院内RSV发生率从不使用预防措施的26%,单独使用手套和防护服的28%,单独使用队列护理的19%,手套和防护服结合队列护理的3%不等。唯一成功的战略包括队列护理,这一事实掩盖了工作人员作为感染媒介的重要性,但该研究没有报告工作人员的感染率。这项研究也没有评估口罩和护眼的边际效益。相反,研究人员引用了一项研究,该研究报告称,鼻子和眼睛的保护与工作人员和患者感染的显著减少有关[4],但他们解释说,他们决定不将鼻子和眼睛的保护纳入他们的策略,因为“它们不受临床工作人员的欢迎,对儿童来说很可怕”[3]。CDC对不同呼吸道病毒的传统建议的拼凑与现在显示呼吸道病毒传播途径主要的丰富数据是非常困难的[5,6]。很明显,大多数人收到2022年5月5日;编辑决定2022年5月5日;2022年5月6日接受;通信:Michael Klompas,医学博士,公共卫生硕士,人口医学系,401 Park Drive, Suite 401 E, Boston, MA 02215, USA (mklompas@bwh.harvard.edu)。传染病杂志©作者(s) 2022。牛津大学出版社代表美国传染病学会出版。版权所有。有关许可,请发送电子邮件至:期刊。权限@oup.com https://doi.org/10.1093/infdis/jiac197
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