key: cord-0736376-fvjf89ni authors: Abramowicz, J. S.; Basseal, J. M.; Brezinka, C.; Dall'Asta, A.; Deng, J.; Harrison, G.; Lee, J. C. S.; Lim, A.; Maršal, K.; Miloro, P.; Poon, L. C.; Salvesen, K. Å.; Sande, R.; ter Haar, G.; Westerway, S. C.; Xie, M. X.; Lees, C. title: ISUOG Safety Committee Position Statement on use of personal protective equipment and hazard mitigation in relation to SARS‐CoV‐2 for practitioners undertaking obstetric and gynecological ultrasound date: 2020-04-07 journal: Ultrasound Obstet Gynecol DOI: 10.1002/uog.22035 sha: bfcfb4363aa1b68e91b8fe9658592c88d9537970 doc_id: 736376 cord_uid: fvjf89ni nan  The ultrasound room or enclosed area is typically small;  The ultrasound rooms often have restricted ventilation, as the air-conditioning systems are in some cases closed loop and/or there are no windows;  The examination time may last between 10 and 60 min;  Invasive or transvaginal procedures may need to be carried out;  The woman may be asked to inhale or exhale deeply, and hold her breath;  Therapeutic and interventional procedures may increase the risk of exposure to bodily fluids;  There is a risk of the patient coughing, sneezing or exhaling heavily;  The surfaces of the ultrasound machine, especially the keyboard, touch screen and trackball, are touched frequently. These attributes have not been formally studied in relation to the risk of transmission of viral infection during ultrasound examination. A recent study on the ability of an exhaled turbulent gas cloud to carry respiratory pathogens a long distance, suggests that appropriate PPE should be considered for all healthcare workers, even if they remain further than 2 meters away from a symptomatic patient 5 . Given that the undertaking of an ultrasound examination inevitably prevents distancing and requires that a doctor or sonographer remains in close contact with a patient for a long period of time, mitigation measures should be considered to reduce the risk of SARS-CoV-2 transmission. During the COVID-19 pandemic, depending on local disease prevalence and staff shortage, high-risk patients should be prioritized for ultrasound assessment, while prioritization by type of scan should be considered, with the second-trimester anatomy scan taking precedence over the first-trimester scan and growth scans performed based on coexisting and emerging comorbidities. Further details are provided in the ISUOG Consensus Statement on organization of routine and specialist obstetric ultrasound services in the context of COVID-19 6 . Very few studies have assessed environmental contamination as a route of transmission of SARS-CoV-2 in the healthcare setting 7 . Infection control advice is based on the reasonable assumption that the transmission characteristics of COVID-19 are similar to those of the 2003 SARS-CoV outbreak. Adequate ventilation is the main way to reduce air environmental contamination and exposure to COVID-19 infection. The WHO divides environmental ventilation methods into three types: mechanical, natural and mixed-mode 8 . Good ventilation of rooms to clear aerosols is recommended by several organizations [9] [10] [11] . Although most guidelines refer to conditions in which aerosol-generating procedures (AGP) are performed, AGPs are rare in routine ultrasound practice. The rate of clearance of aerosols in an enclosed space depends on the number of air changes per hour. A single air change is estimated to remove 63% of airborne contaminants and after five air changes less than 1% of airborne contamination is thought to remain 9 . After an AGP, a minimum of 20 min of ventilation is considered pragmatic, which can be reduced to 5 min if ultraclean ventilation is used (e.g. in some operating theaters). This situation is very unlikely to pertain to obstetric and gynecological ultrasound. This article is protected by copyright. All rights reserved. Air-conditioning systems equipped with high-efficiency particulate air (HEPA) filters provide adequate protection especially if combined with the use of PPE and face masks. Most hospital systems are not equipped with HEPA filters, hence, turning off air conditioning and, where there are windows, opening them for good ventilation if an independent air supply is not feasible, has been recommended by WHO for rooms hosting patients with suspected SARS infection 12 . As every ultrasound environment is different and there are no consistent regulations or advice regarding ventilation, we recommend that consideration is given to ventilation in ultrasound rooms in individual workplaces. First point of contact: should temperature be taken and history of travel, occupation, contact and cluster (TOCC) be asked before or on arrival at the ultrasound department? According to the Royal College of Obstetricians and Gynaecologists, maternity departments with direct entry for patients and the public should put in place a system for identification of potential cases of COVID-19 as soon as possible, to prevent potential transmission to other patients and staff 13 . This system should be set up at the first point of contact (either near the entrance or at reception) to ensure early recognition and infection control. This should be employed before a patient sits in the maternity waiting area 13 . From an epidemiological point of view, the SARS-CoV-2 virus first emerged in the Hubei province in China. Therefore, in the early phase of the epidemic, history of travel to the Hubei province, as well as contact with people known to have been infected by SARS-CoV-2, obtained via TOCC assessment was advocated as the first measure to identify potential carriers of the SARS-CoV-2 virus 14, 15 . Nonetheless, the rapid spread of the disease across countries and continents, as well as the evidence of existence of asymptomatic carriers 16 , has led to circumstances in which all patients are to be considered at risk of infection and hence potential carriers of the SARS-CoV-2 virus. On this basis, and following the available recommendations 2, 9, 15 , in the most affected areas, such as northern Italy, several maternity units have implemented strict protocols for the triage of women accessing the unit. Such measures include the arrangement of 'check point' triage areas in which dedicated medical personnel equipped with PPE take the temperature and assess the medical history, in terms of symptoms and contact, of women attending the maternity units and the ultrasound departments. Women should be advised that triage of their symptoms and contact represents the first-line assessment in order to allow the identification of contacts should they develop symptoms at a later stage. According to ISUOG's Interim Guidance, patients identified to be at risk for SARS-CoV-2 infection should delay their antenatal visit and routine ultrasound assessment by 14 days 15 . We recommend that this advice is considered on a local basis after taking into account the potential implications of a delayed ultrasound examination in the context of local/national regulations. This advice applies only to routine ultrasound examinations; clearly, pregnancies requiring time-critical examinations should be considered on a case-by-case basis. 4 The rationale for the use of surgical masks is two-fold: to protect the wearer from sources of infection, such as splashing or spraying of blood, hand-to-face contact and large droplets and sprays, and to protect others from the wearer in case they are a source of infection 17 . If no mask is used, the mucosal surfaces of the nose and mouth are exposed, providing an easy route of entry to the body for pathogenic microorganisms. There is no standard definition of a surgical mask, and there is a wide variation in the design and quality of the masks currently in use. In terms of the design, it is recommended that masks should fully cover the nose and mouth of the wearer. Two randomized controlled trials support the use of surgical masks in a community setting 18, 19 and the use of masks is recommended in cases of suspected or confirmed SARS-CoV-2 carriers in order to prevent spread of the infection 1-3,20 . N95 and FFP2 respirators filter out particles, including bacteria and viruses 2 . Statements from leading health organizations (ECDC, WHO and CDC) 1-3 provide different recommendations for the use of respirators in a healthcare setting. However, respirators are recommended for use only by healthcare professionals requiring protection from both airborne and fluid hazards (e.g. splashes, sprays), while no indication exists outside of the healthcare setting 2 . There is little or no evidence supporting the use of N95 or FFP2 masks by patients. The rapid increase of the epidemic curve of the SARS-CoV-2 virus, together with evidence that carriers of the disease can be asymptomatic 16 , has led to a situation in which all individuals, including the medical staff and patients, represent potential carriers of the infection. On this basis, and despite the lack of evidence as to whether asymptomatic carriers contribute to the spread of the SARS-CoV-2 virus, in certain countries both the healthcare staff and patients, as well as other hospital attendants, have been advised to don surgical masks in a healthcare setting in order to minimize the dispersal of respiratory secretions and reduce environmental contamination. We consider that, currently, there is too little evidence to recommend the routine use of patient masks by asymptomatic low-risk patients. We do, however, recommend that local protocols should advise that patients with symptoms of COVID-19, or those judged to have suspected or probable infection, should wear a surgical mask when undergoing imaging or other ultrasound investigation. The SARS-CoV-2 virus is spread mainly by close contact and respiratory droplets, with airborne transmission being likely in specific circumstances 21 . In general, respirators, as opposed to surgical masks, are recommended for healthcare personnel who come in contact with patients with strongly suspected or confirmed COVID-19 infection, however, surgical masks are an acceptable substitute when supply of respirators is limited 22 . A detailed description of available surgical masks and respirators is provided in Appendix 3. Staff age and comorbidities  Ultrasound providers of advanced age or with health conditions that predispose them to infection and severe disease should avoid scanning patients with suspected or confirmed COVID-19 disease, and should consider wearing appropriate PPE when working in a region affected by the COVID-19 pandemic, even if they are examining an asymptomatic and TOCC-negative patient. This article is protected by copyright. All rights reserved.  Individuals at highest risk for severe COVID-19 disease and death include those aged over 60 years and those with underlying conditions, such as hypertension, diabetes, cardiovascular disease, chronic respiratory disease and cancer.  Individuals who have a comorbidity should ensure that their occupational health departments are aware of their underlying condition, age and area of deployment.  Attention should be paid to train ultrasound providers on safe donning, doffing and disposal of PPE 23, 24 .  Proper functioning of respirators requires that an effective seal is created between the mask and the face of the wearer. Variation in face size and shape, and availability of different respirator designs, mean that a proper fit is only possible for a minority of healthcare workers for any particular mask. All healthcare workers should therefore undergo a fitting test for respirators and should continue to wear the type of respirator for which they have been fit-tested.  Hand hygiene should be performed before and after patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove pathogens that might have been transferred to bare hands during the removal process. Hand hygiene should include use of 60-95% alcohol or washing hands with soap and water for at least 20 sec. 22  To avoid infection through respiratory droplets, practitioners should don appropriate PPE, including a surgical mask, upon entering the ultrasound room.  To avoid infection through contact, all patients with suspected or confirmed COVID-19 disease should preferably be scanned in a single dedicated room. The practitioner should don appropriate PPE, including gloves and gown, upon entering the ultrasound room, and use of disposable equipment should be preferred, where possible.  To avoid airborne transmission, the patient should be asked to wear a surgical mask if they are symptomatic or have confirmed COVID-19 infection. The healthcare worker should wear appropriate PPE, including a fit-test approved respirator or surgical mask, depending on the level of infection risk, gloves, gown, face and eye protection, upon entering the room. High-risk healthcare workers should be restricted from entering the ultrasound room and disposable equipment should be used where possible. Guidance is provided in Table 1 according to patient symptoms and infection status, considering three groups of patients: 1. Asymptomatic and TOCC-negative patients in a region in which there is no widespread community transmission. 2. Asymptomatic and TOCC-positive patients in a region in which there is no widespread community transmission. 3. Patients with suspected/probable/confirmed COVID-19 disease or in a region in which there is widespread community transmission. 6 There is little difference between gynecological, early-pregnancy and obstetric scans from the standpoint of infection, so precautionary measures are applicable to all three fields. Transvaginal ultrasound probes should undergo high-level disinfection as condoms and commercial covers may break 25 . Tracing and record keeping for high-level disinfection is essential. Detailed guidance regarding ultrasound equipment and transducer cleaning in the context of COVID-19 has been provided in a separate document 26 . 25 Staffing/environment --Ideally scan at bedside rather than in a clinic; minimize number of staff in room and ensure that most senior person is undertaking scan Disinfection/cleaning 26 Low-level disinfection for external probes; high-level disinfection for internal probes Low-level disinfection for external probes; high-level disinfection for internal probes; additional low-level disinfection for ultrasound machine and cables Low-level disinfection for external probes; high-level disinfection for internal probes; additional low-level disinfection for ultrasound machine and cables *Symptomatic patient with or without travel, occupation, contact and cluster (TOCC) risk factors, in area in which there is widespread community transmission. †Extended use of surgical facemasks is practice of wearing same surgical facemask for repeat close-contact encounters with several different patients, without removing facemask between patients. In most cases, one face mask can be safely used for a typical clinic of 3-4 h. Surgical facemask should be removed and discarded if it is soiled, damaged or hard to breathe through. Healthcare workers should take care not to touch their surgical facemask; if they touch or adjust their surgical facemask, they should immediately perform hand hygiene. Healthcare workers should leave patient care area if they need to remove their surgical facemask. Re-use should be implemented according to CDC guidance 27 . ‡All healthcare workers should undergo training on appropriate use of and fit testing for respirators. Alternatives to respirators: filtering facepiece respirator, elastomeric half-mask and full facepiece air purifying respirator, if available; all these alternatives provide equivalent or higher protection than N95 respirators when worn properly. Extended use refers to practice of wearing same N95 respirator for repeat close-contact encounters with several different patients, without removing This article is protected by copyright. All rights reserved. respirator between patient encounters. Extended use of respirators is well-suited to situations in which multiple patients with COVID-19, whose care requires use of respirator, are cohorted (e.g. housed in same hospital unit). Limited re-use of N95 respirators when caring for patients with COVID-19 might become necessary. However, it is unknown what is the potential contribution of contact transmission for SARS-CoV-2, therefore, caution should be exercised. Re-use should be implemented according to CDC guidance 28 . Recommendation: When putting on new mask/respirator, even if it is type, size and shape that fitted last time, recheck sealability, not only in neutral head position, but also in positions taken when actually scanning a patient, for example, by turning head to side or tilting chin up to face monitor, or during use of two hands to hold transducer or other device. This article is protected by copyright. All rights reserved. If patient has symptoms, postpone nonessential examinations. Screen patients using standardized checklists for symptoms and risk factors. If patient has symptoms, postpone nonessential examinations. Screen patients using standardized checklists for symptoms and risk factors. If patient has symptoms, postpone nonessential examinations. Screen patients using standardized checklists for symptoms and risk factors. If patient has symptoms, postpone nonessential examinations. Prioritize examinations (emergency vs routine or essential vs non-essential). Interview patients by phone before arrival. Accompanying persons limited to one, or none allowed. No accompanying person allowed. In Singapore, one accompanying person allowed, who is subjected to same screening criteria as patients. In other territories, no accompanying person allowed. (extended use). Use of gloves and gowns (single use). (extended use).Use of gloves and gowns (single use). This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved. Infection Prevention and Control For the Care of Patients With 2019-nCoV in Healthcare Settings COVID-19). Frequently Asked Questions about Personal Protective Equipment 2020. 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Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations Centres for Disease Control and Prevention. Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings Centres for Disease Control and Prevention. Sequence for putting on Personal Protective Equipment Sourcing Personal Protective Equipment During the COVID-19 Pandemic Analysis of the integrity of ultrasound probe covers used for transvaginal examinations ISUOG Safety Committee Position Statement: safe performance of obstetric and gynecological scans and equipment cleaning in the context of COVID-19 Centres for Disease Control and Prevention. Strategies for Optimizing the Supply of N95 Respirators: Contingency Capacity Strategies Ultrasound staff infections in Wuhan during the COVID-19 epidemic (in Chinese) This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved. In China, there is a medical specialty known as 'ultrasound doctor'. These doctors see many patients per day and perform only ultrasound. The comparison to practice outside China is transferable to the extent that the findings might apply to any doctor or imaging practitioner, for example, sonographers or midwives, whose work is largely ultrasound-based.Based on a study by Xie and his team conducted at the epicenter in Wuhan, the SARS-CoV-2 infection rate of ultrasound staff is approximately 3.4%, which is considerably higher than the estimated overall infection rate of 2.2% among Wuhan healthcare workers, regardless of their specialty ( Table 1) .The overall number of staff infection in Wuhan is subject to further verification, as no official update on staff infection figures is currently available and because the total number of healthcare workers on Wuhan Health Commission official website was last updated in 2017. There are also certain specialties (e.g. rehabilitation) who might be considerably less active than other teams (e.g. respiratory, cardiovascular and radiology, including ultrasound departments) during the lockdown.The reported zero infection rate among the rescue medics from the rest of China who were on the frontline in Wuhan, in the whole of China emphasizes the importance of sufficient personal protective equipment (PPE) provision and donning/doffing training. However, the case of a nurse who suffered cardiac arrest and its critical consequence highlights PPE's possible, though rare, adverse impact on wellbeing, and the need to consider carefully a time limit for how long PPE should be used while doing intensive work. : Lower-grade PPE should only be used at local hospital/clinic' discretion or own discretion when no alternative supply is available (often experienced during a pandemic/epidemic). Ultrasound providers at higher risk for developing severe COVID-19 should be excluded from procedure. AGP, aerosol-generating procedure. This article is protected by copyright. All rights reserved.