key: cord-1025540-7zhae02j authors: Walker, Inna; Powers, Cassandra; Fortescue-Webb, Duncan; Montague, Chloe; Skidmore, Angela; Walker-Bone, Karen; Fraser, Simon title: An alliance with public health in pursuit of COVID-19 evidence date: 2020-10-10 journal: Occup Med (Lond) DOI: 10.1093/occmed/kqaa164 sha: e06b80a8ac112d54613ff20a1673e347d69b98f7 doc_id: 1025540 cord_uid: 7zhae02j nan The COVID-19 pandemic presented occupational health (OH) teams with unprecedented challenges and demands [1] . Early in the pandemic, guidance from specialty societies and Royal Colleges began to emerge. It was often based on extrapolations from pathogens before SARS-CoV-2, not specific enough to inform the frequently complex scenarios facing OH specialists, and at times contradictory. Hefty responsibility fell on the shoulders of OH professionals, who hold the delicate balance of advising on how best to protect staff while not compromising care for patients. Public health (PH) is, like OH, a relatively small specialty. Its focus is on populations and communities, rather than individuals, and its mission is to work collaboratively with all relevant stakeholders to improve health and reduce health inequalities [2] . As is the case in OH, the discipline has been profoundly affected by the pandemic. Most of the workforce was redeployed or diverted to the COVID-19 response. Wessex in the South of England was no exception, with consultants and specialty trainees seeking ways to apply their skills to protect the health of the public. One of the core skills and objectives of PH professionals is to use evidence and intelligence to inform practice, assess risk and influence policymakers. In a new collaboration, PH colleagues offered to provide rapid, regular evidence support in order to inform the decision-making of OH colleagues in a tertiary NHS Foundation Trust responsible for over 11 000 staff. A virtual project team of four PH registrars (all in different training locations) and a PH consultant formed within days and, working closely with an information specialist from the University Library, created bespoke search strategies to yield evidence on the questions prioritized by OH. Key questions were set on the following topics: epidemiology of COVID-19, including risk factors increasing susceptibility for contracting the virus or developing complications; the risk of occupational transmission amongst healthcare workers; risk associated with aerosol-generating procedures and other specific work scenarios and settings, such as operating theatres; risk to pregnant workers and their babies; sensitivity and specificity of different types of antigen and antibody testing; impact of the pandemic on the mental health of healthcare workers; and evidence about the effect of different types of personal protective equipment on risk of transmission in healthcare settings. Another important topic was assessment of the vulnerability of workers with underlying long-term conditions, such as diabetes, hypertension, cardiovascular disease, obesity, asthma and chronic obstructive pulmonary disease (COPD). In addition, we looked for evidence on the role of smoking in COVID-19, as well as that of specific medications, such as angiotensinconverting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs). Each PH team member led on one or two topics, registering to receive daily alerts from MEDLINE, as per tailored search strategies. Once a search strategy was set up, an initial search was run, generating a large number of records for baseline screening of papers published to date. Thereafter, daily updates listed all papers which had been published on the specific topics since the last alert, including those ahead of print. The numbers of papers yielded by the searches rapidly increased in many of the key topics as the pandemic progressed and further countries became affected. All papers in the baseline search and subsequent daily alerts were screened by the allocated PH team member, taking account of study quality. Study findings were assessed to identify those of greatest relevance to the key questions defined by OH, in order to collate the most informative new evidence on each topic. Initially, while high-quality evidence was scarce, summaries of the most relevant individual papers were created in a PI(E)COS (Population, Intervention/Exposure, Comparison, Outcomes, Study Design) format, before switching to a format of extracting key details, including abstracts, for each selected paper, when the volume of records in the alerts started to increase, reaching thousands of articles per week at its peak. Summaries of the relevant individual papers were organized into weekly updates, which were shared electronically with the OH team, together with pdf copies of the papers. Additionally, key publications, perceived as potentially having a more important or immediate impact on OH practice, were highlighted by email to the OH leads. These included guidelines and reviews of which the PH team became aware through avenues other than the MEDLINE daily alerts. As a result, members of the OH team were able to quickly scan the most recent and relevant articles, presented in an accessible manner by themes, access the full text if needed and assess applicability of the findings to their practice. In addition to these shared summaries, the leads for the OH and PH teams met virtually on a regular basis to ensure the ongoing relevance of the searches and selected articles. The OH team was able to make important changes to policy and practice rapidly and safely, in line with the best evidence. For example, at the start of the pandemic, all staff members reporting a diagnosis of asthma treated with inhaled corticosteroids, were initially assessed as 'level 2: at increased risk of complications from COVID-19'. In practice at the time this meant that, because of the number of cases of COVID-19 and the relative lack of testing capacity, these staff members were all moved away from patient-facing work. Within a few weeks, guided by the emergence of higher-quality evidence, more than 400 staff members could be re-assessed and brought back to clinical work when it became clear that well-controlled asthma was not a major risk factor for COVID-19 complications. Similarly, as results of larger studies became available, we were able to re-assess staff members with diagnoses of hypertension and diabetes, asking more focused questions that allowed us to assess their individual vulnerability more accurately, and consequently return many of them to their usual role. Another area where timely access to evidence provided reassurance was the theoretical increase in risk initially suspected to be associated with the use of ACEIs and ARBs for hypertension. Early on it was not clear whether people treated with these agents might be at increased risk of COVID-19 or its complications, because of potentially increased binding of SARS-CoV-2 to cells. Based on the evidence, the OH team was able to advise and reassure staff treated with these drugs. Likewise, having initially removed all pregnant workers from patientfacing activity, members of the OH team were subsequently able to have one-to-one discussions with those workers who were less than 28 weeks of gestation, which led, in many cases, to their return to patientfacing roles. Moreover, summaries of the evidence on testing and occupational transmission have contributed to the Trust-wide approaches to staff testing and resumption of elective clinical care. Over time, the topics for searching have been introduced, when new concerns emerged (e.g. we became interested in evidence on the vulnerability of black and minority ethnic individuals and the role of obesity in relation to COVID-19 outcomes); adjusted to be more, or less, focused; or dropped, when they were no longer actively required, such as when a reasonable degree of consensus was transpiring from the literature. These decisions about prioritization were essential, as search result volumes grew, and were taken collaboratively as a result of regular virtual discussions between representatives of the two teams. At the time of writing, this approach has resulted in an electronic library of OH-related articles on relevant topics in COVID-19, handpicked and summarized over several months. The pandemic has shone a light not only on blind spots and inefficiencies in the way healthcare systems operate, but also on opportunities that exist for collaboration and support between specialties and teams. Our alliance has enabled the OH team to remain up to date during unprecedented demand, facilitated by preparation of evidence summaries in real time by the PH team. This project cannot and will not continue indefinitely. As the evidence base on COVID-19 strengthens, the need for constant review of the literature lessens. However, this project has fostered new, effective ways of interdisciplinary working, and we are actively considering ways in which the learning from this work can be furthered in an ongoing collaboration. Our experience is also a reminder that not all NHS trusts employ or have direct access to PH specialists. This collaboration is just one practical example of the many ways PH professionals can make a valuable contribution in the hospital setting, working synergistically with other specialties, not only at times of crisis, but routinely, helping trusts to both treat and prevent. Occupational health: the thin line protecting the front line Faculty of Public Health. Specialise in the Bigger Picture and Help Make the World a Better Place The authors would like to acknowledge the invaluable contribution of Paula Sands, University of Southampton Library; Julia Smedley and Caroline Marshall, University Hospital Southampton NHS Foundation Trust; and Robin Poole, Southampton City Council. None declared.