key: cord-1054745-vm13e4e2 authors: Moseley, Tanya W; Conners, Amy L; He, Hongying; Barth, Jean E; Lightfoote, Johnson B; Parikh, Jay R; Whitman, Gary J title: Mitigating the Transmission of COVID-19 with the Appropriate Usage of Personal Protective Protocols and Equipment in Breast Imaging and Intervention date: 2021-01-22 journal: J Breast Imaging DOI: 10.1093/jbi/wbab007 sha: bb1329594f57fbd8400135cc81e618b4ef12325f doc_id: 1054745 cord_uid: vm13e4e2 The integration of personal protective equipment (PPE) and procedures into breast imaging and intervention practices will mitigate the risk of transmission of COVID-19 during the pandemic. Although supply chain shortages have improved, understanding the proper use of PPE and protocols to mitigate overconsumption are important to ensure efficacious utilization of PPE. Protocols and best practices are reviewed, and guidelines and resource materials are referenced in order to support breast imaging healthcare professionals. Coronaviruses are positive-sense RNA viruses with clubshaped proteins on their surfaces that resemble the prongs of a crown (1) . Before the severe acute respiratory syndrome (SARS) epidemic of 2003, epidemiologists expected that coronaviruses only caused mild self-limited respiratory infections. Although deadly, SARS was contained locally because individuals were isolated and their contacts were quarantined through effective tracing (2) . The novel coronavirus causing the current pandemic is severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease it causes is coronavirus disease 19, . COVID-19 is highly infectious and readily spreads among people, including healthcare workers who treat COVID-19 patients. Frontline healthcare workers have at least a 3-fold increased risk of reporting a positive test or an infection, compared to the general population (4) . Although not historically considered frontline healthcare workers, breast imaging professionals are in close contact with patients (less than six feet, or two meters, apart) when performing mammography, scanning patients in ultrasound, or performing biopsies. The appropriate usage of personal protective equipment (PPE) and procedures creates barriers between the healthcare worker and the potentially infectious patient; PPE and associated procedures therefore play central roles in the prevention of COVID-19 transmission. The purpose of this paper is to empower breast imaging healthcare professionals with current information regarding COVID-19 and to describe strategies regarding implementation of PPE. In this paper, we describe COVID-19 transmission and review appropriate PPE usage by breast imaging technologists, sonographers, and radiologists. We discuss approaches to PPE reuse and reprocessing. Costs, responsible use, and supply chain issues related to PPE are discussed, along with other ways to prevent COVID-19 transmission. Transmission of COVID-19 occurs primarily by droplets spread by an infected individual speaking, coughing, or sneezing, whether symptomatic or not, or through direct contact with an infected person (5, 6) . Persons at risk of contracting COVID-19 are the general population in close contact with an infected person and healthcare workers who care for the infected people. The difficulty in identifying all infected patients increases the importance of using appropriate PPE in the healthcare setting. Many infected individuals are asymptomatic. Presymptomatic patients have detectable SARS-CoV-2 before the onset of symptoms (7) . Presymptomatic and asymptomatic patients may transmit the virus to others as they have no symptoms to cause them to self-isolate or seek healthcare (7, 8) . Symptoms related to COVID-19 usually manifest between two and 14 days after exposure and most commonly include difficulty breathing, shortness of breath, dry cough, and fever (9, 10) . Other symptoms include myalgias, chills, sore throat, and new onset of loss of taste or smell (10) . Data from the World Health Organization (WHO) suggest that about 80% of infected people are asymptomatic; 15% of infections are severe, requiring oxygen supplementation; and 5% are critical, requiring mechanical ventilation (11) . Although, most people will recover from COVID-19 (11) , careful consideration of testing of patients before breast imaging studies and procedures would decrease the exposure of breast imaging personnel to this highly contagious disease. Appropriate personal protective procedures and PPE for providers caring for COVID-19 positive patients depend primarily on whether the procedure is aerosol-generating (Table 1 ). If no aerosol-generating procedure (AGP) will be performed, then providers can follow modified droplet precautions, which include using the following: • Surgical face mask (12) (13) (14) • Eye protection, which may be a plastic face shield, a polycarbonate face shield, a helmet, disposable or reusable protective eyewear, or a mask with an attached face shield (15) • A fluid-resistant gown, which may be disposable or reusable • Gloves (16) Examples of AGPs include intubation and extubation, cardiopulmonary resuscitation (CPR), airway and esophageal procedures, and procedures that may trigger a cough or a release of pulmonary secretions into the air. For known or suspected COVID-19 positive patients undergoing an AGP, healthcare workers should wear a fit-tested N95 mask or a powered air purifying respirator (PAPR), in addition to the aforementioned modified droplet protection items (13, 17) . Healthcare workers need specific training on appropriate donning and doffing (removal) techniques for PPE. One study showed that 90% of observed doffing was done incorrectly; staff may not have previously received training in appropriate use (18) (19) (20) (21) . During the pandemic, practices should assume that a small percentage of patients and staff are asymptomatic or pre-symptomatic COVID-19 positive individuals capable of transmitting the virus to others. Therefore, practices need to take steps to mitigate the risk of transmission of COVID-19 between patients and staff, amongst staff members, and from patient to patient (22, 23) . A screening program at the facility entrance to check the temperatures of patients and visitors and ask about symptoms and recent exposures can prevent asymptomatic COVID-19 carriers or people with recent high-risk exposures from entering the facility. Practices can avoid crowding by having a no visitor policy or limiting the number of visitors accompanying each patient. Furthermore, patients should be encouraged not to arrive until shortly before their scheduled appointment times. There should be social distancing • Determining appropriate personal protective equipment (PPE) depends on the level of suspicion or proof of COVID-19 and whether the procedure is aerosol-generating. • Breast imaging healthcare professionals should employ appropriate practices to mitigate transmission of COVID-19 between patients, between members of the breast imaging team, and between patients and healthcare providers. • Reprocessing and reuse of masks by the same provider while caring for patients not suspected of having COVID-19 may be undertaken if the masks are not soiled or damaged. • The U.S. PPE supply chain needs to be more robust and, therefore, responsible usage of PPE is encouraged. in the waiting areas, with at least six feet between each occupied seat. The scheduling template should allow for appropriate intervals between appointments to allow for room and equipment cleaning. In addition, many types of communications can be done electronically, and workflows should be examined for opportunities to decrease face-to-face interactions, including minimizing the number of people in the room during procedures and imaging studies. During the normal course of providing screening and diagnostic breast imaging studies, substantial protection is provided by having both the provider and the patient wear masks. If the patient does not have an appropriate mask, then the technologist should provide one to the patient. The addition of eye protection (a full-face shield or protective glasses) can help to mitigate the risk of ineffective patient masking and can prevent the need for staff members to quarantine if it is learned retrospectively that a patient was COVID-19 positive during his or her visit (15, 23) . Eye protection should be chosen to account for the patient's position relative to the provider, (eg, a sonographer would avoid a face shield angled such that a patient on an ultrasound table could exhale into the area underneath the shield). Face shields that do not protect the upper face should be avoided during stereotactic and MRI-guided procedures. Any PPE used during MRI studies and procedures should be MRI compatible (24) . During breast interventional procedures, providers should add to their mask and eye protection any additional PPE appropriate for that procedure, such as sterile gloves or splash protection. Few procedures in breast imaging are aerosolgenerating, so do not necessitate the use of an N95 mask or PAPR. However, there are notable exceptions (Table 1) : • Some providers choose to wear an N95 mask or a PAPR and a gown when sampling supraclavicular or cervical lymph nodes, especially when the procedure requires the clinician to sit or stand in close proximity to the patient's mouth for an extended time. • Because CPR is an AGP, modified droplet precautions, using either an N95 mask or a PAPR, should be followed regardless of the patient's COVID-19 status. Breast imaging practices should ensure that required PPE will be available and that responders know how to protect themselves. Being prepared for CPR is particularly important for practices that use iodinated contrast material for contrast-enhanced mammography. There are some challenges regarding appropriate PPE utilization by breast imaging staff. One significant vulnerability is employee unmasking during breaks and meals. It is important to assess breakroom space within your facility, making sure that there are sufficient appropriately distanced spaces where staff members can eat and drink. Given that breaks and meals are typically social, it is important to have clear policies indicating that staff members should be appropriately distanced during these times. If food would normally have been provided for a meeting, attendees should take their food at the end of the meeting to eat elsewhere. As the COVID-19 pandemic wears on (25) , additional vulnerabilities are "mask fatigue" and lack of adherence to social distancing and PPE policies. A multifaceted approach to these problems is suggested: • Facilities should create clear policies and communicate them in multiple venues (eg, posted signs, emails, and team huddles). Some staff members may respond best to data, others to stories, and others to rules. A variety of message types may help to clarify the communications. • Consistent modeling of the expected behaviors by leaders is key. • Create a system for routine "mask rounds," during which adherence can be directly assessed by the leaders. This allows for immediate one-to-one feedback and opportunities to identify barriers that the leaders can address (eg, inadequate breakroom space). For individuals not following the established policies, a gentle reminder would be appropriate initially, noting that persistent refusal to follow the policies may require disciplinary action. • Leaders should empower staff members to speak up when they notice colleagues who are inadequately masked or socially distanced. It may be helpful to provide example scripting as a guide. Given shortages in PPE (26), many practices are interested in reusing, reprocessing, and reclaiming items. Masks worn while caring for patients not suspected of having COVID-19 can generally be reused by the same provider as long as they are not soiled or damaged (27) . N95 masks may also be reused, though they may lose their shape and not fit well after prolonged use or multiple occasions of donning and doffing (28) . Face shields can be reused if they are disinfected after each shift. Several approaches have been taken to decontaminating PPE for reuse, particularly for N95 masks (29) . Hydrogen peroxide vapor inactivates influenza viruses and allows for maintained filtration efficiency and fit (30) (31) (32) . Ultraviolet (UV) light is effective against viruses such as H1N1, though mask materials may break down at higher UV exposures (30, (33) (34) (35) . Steam and moist heat decontaminated masks when tested against H1N1 (33, 35) . Of note, masks cannot be decontaminated if soiled with makeup, lotion, or sunscreen, so healthcare workers should avoid these items if wearing masks intended for reprocessing. Although PPE is essential, procedures and policies are just as important in avoiding COVID-19 transmission. The WHO recommends administrative, environmental, and engineering controls. The global economic impact of the pandemic has been astronomical, and the U.S. healthcare system lost about $202.6 billion in revenue during the four months ending June 30, 2020 (37) . The U.S. PPE supply chain developed over time to meet a steady-state demand efficiently; it was maladapted to meet the unexpected and massive increase in need for PPE resulting from the rapidly developing pandemic (38) . At the outset, healthcare systems reported shortages of PPE (26) . Most of the PPE used in U.S. healthcare systems is not manufactured in North America, and distribution channels have been disrupted both domestically and internationally. Within the United States, PPE continues to be in limited supply. The Department of Health and Human Services' Strategic National Stockpile (SNS) and state-based stockpiles are intended to ensure PPE availability in times of emergency. However, the SNS stock is smaller than required for a severe influenza pandemic (39) . Also, information regarding the contents of the SNS and the process of PPE allocation is not transparent or accessible (38) . The U.S. PPE supply chain needs to be more robust. It is estimated that at least 3.5 billion N95 masks and 500 million surgical masks should be housed in the SNS, and additional supplies should be kept in local and state warehouses (39, 40) . A transparent, real-time inventory system would provide information regarding the type and the amount of available supplies, and how to acquire them. During crises, PPE should move quickly, efficiently, and seamlessly into healthcare systems (38) . Cost and supply chain issues have led to possibly risky conservation of supplies, with healthcare workers reusing PPE and working with inadequate PPE. The Institute for Health Metrics and Evaluation projects that 394 693 people in the United States will die due to SARS-CoV-2 by the end of January 2021 (41) . With such a high incidence and resulting demand, PPE use must be optimized to meet the needs of healthcare workers and patients. Strategies put forward by the WHO to optimize PPE include minimizing the need for PPE, using it rationally and appropriately, and coordinating supply chain management (16) . The need for PPE is eliminated in telemedicine clinical encounters, however, telemedicine is imperfectly suited to breast imaging and intervention. Physical, transparent barriers can protect patients and clerical personnel at the breast imaging registration desk and thus reduce the need for full PPE. Additionally, PPE can be conserved by selectively deferring care for patients with suspected or proven COVID-19 (16) . Overuse of PPE results in unnecessary consumption, and PPE usage should be determined by each healthcare worker's risk of exposure and the type of care being provided (direct contact, droplet, or aerosol-generating) (16) . National and international supply chain management systems should coordinate the availability and the distribution of PPE (16) . COVID-19 is a global public health concern because it is highly infectious, potentially lethal, and spreads easily among humans, including healthcare workers caring for patients with or without symptoms. Frontline healthcare workers and breast imaging professionals working in spaces less than six feet in greatest dimension are at risk of transmission of SARS-CoV-2. The use of PPE and procedures such as masking, hand hygiene, respiratory hygiene, and social distancing help to control, mitigate, and prevent the spread of COVID-19. Although there are significant costs associated with blunting the pandemic, the supply chain for PPE in the United States should be improved. In addition, breast radiologists and technologists should use PPE responsibly. Coronavirus genome structure and replication Can we contain the COVID-19 outbreak with the same measures as for SARS? A new coronavirus associated with human respiratory disease in China Coronavirus Pandemic Epidemiology Consortium. 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Total deaths We thank Sharon Lai-Fang and Lakecia Quinney for their help in manuscript preparation. T.W.M. is a medical consultant for Hologic, Inc. and Merit Medical, Inc. G.J.W. is an editor of UpToDate. The remaining authors have no conflicts of interest to declare. This project was supported by the National Institutes of Health/ National Cancer Institute under award number P30 CA016672.