Doctors across the country — many of them colleagues I know well — are raising concerns about this. While the health system is testing and sequestering people suspected of having covid-19, the bigger risk to health-care workers (and our patients) may be those who are unknowingly infected yet still able to shed the virus and infect those around them.
Without adequate, accurate and fast testing, we cannot know who is or is not infectious. Yet we are not treating everyone, health-care workers and patients, as potentially infectious — or susceptible to infection by those who are infected without showing any sign of the disease.
This concern is what motivates the recommendations to self-quarantine for 14 days if you travel from a high-risk area, such as New York City: You may be carrying the virus; you may be on the cusp of developing symptoms — or you may never develop symptoms — but you should protect others until the two-week self-quarantine has passed.
What that means for all of us — in hospitals and out — is that any other person we come in contact with may have the virus.
We need to adopt a universal precautions mentality.
Universal precautions is an approach to infection control that assumes all body fluids could be infected and must be treated as such. Early in the AIDS epidemic, HIV, the virus that causes AIDS, infected health workers through needle sticks and other exposures to blood products. Experts introduced universal precautions as HIV spread and health-care workers were recognized as being at risk from handling fluids from patients.
Those of us who treated HIV-positive patients in the early days developed such practices for handling of all fluids capable of transmitting infection because it was apparent some patients might be carrying the virus without us knowing it.
Today we have the novel coronavirus that causes covid-19. We cannot know for certain who has covid-19 and can infect others.
The only reasonable approach to keeping health-care workers safe is to assume that anyone can spread the virus. Moreover, that is the only way to ensure the safety of patients who are not infected from health-care workers who might be asymptomatic.
Although there remain a lot of unknowns with this new coronavirus, we know with reasonable confidence that personal protective equipment, commonly known as PPE, can decrease risk. Properly used, PPE, along with good hand-washing and wiping of surfaces can keep health-care workers safe. The PPE needs to be high quality and worn appropriately. The hand-washing needs to be intensive and the housekeeping fastidious. But it can be done.
Many people think of PPE as the mask, face shield, gloves and gowns — and it is just impracticable to wear them all on every interaction. But wearing at least a surgical mask or higher-filtering N95 mask, along with hand hygiene, would be universal protection in high-risk environments where people are gathering. If there is contact with a possibly infected patient in the course of clinical care, then the entire PPE is needed.
The infection of health-care workers (and patients by health-care workers) should be understood as a safety issue — that is, preventable with proper, high-quality practices. We should commit to making it a “never event.” As a result, harm to a health-care worker, and by extension, to their families and friends as a result of their service on the front lines, should be a never event. It seems within our grasp to make it so.
In many places in China, hospitals adopted these practices. In a webinar I hosted not long ago with Chinese experts, they reported that they were able to eliminate health-care worker infection in many settings where they used PPE and other best practices. Even when not in direct contact with patients. They wore masks throughout the hospital, not just in the covid-19 wards. When stocks were low, they wore their masks all day, doing their best to conserve them when they could.
So what should we do? We should adopt a universal precautions policy for health-care workers. We need to release national stockpiles of PPE. The federal government should mandate production, if necessary, and resolve the shortage immediately.
Making more PPE is a lot easier than producing more ventilators and will decrease the need if prevention is successful.
We also must destigmatize the use of masks and other gear. In many parts of Asia, people with colds typically use masks to protect others. I believe we must embrace that approach — and, in this moment, extend it.
Does everyone need the top-tier N95 mask? It is hard to know, and even a makeshift mask is probably better than no mask at all. For now, we should use the N95 masks in high-risk environments where people are in proximity to patients or others, mostly because of the still limited availability of N95s and their cost (which we should be urgently addressing) — and employ the best we have otherwise, including surgical masks or — if absolutely necessary — even homemade ones. Some are suggesting that we lack evidence that masks are necessary, but they provide a barrier, a signal to others that we are social distancing (wear a mask and people give you a wider berth), and they keep you from touching your face after contact with other surfaces.
Let’s start changing the mind-set and using what we have. Research will ultimately tell us what masks are effective in what settings, but we need to act now on the best information we have.
And we should be thinking of this more broadly as extending to everyone providing vital services on the front lines, including police officers, firefighters, cashiers at pharmacies and grocery stores, and others in such positions. All of these individuals are placing themselves in the path of the virus to help others. Yet, they can infect and be infected. We need not only the PPE but also the mind-set.
HarlanKrumholz is a professor of medicine at Yale and director of the Yale New Haven Hospital Center for Outcomes Research and Evaluation, one of the nation’s first research units dedicated to improving patient outcomes and promoting better population health.