Introduction
The 2019–20 corona virus pandemic is an ongoing pandemic of Corona Virus Disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Corona Virus-2 (SARS-CoV-2).1 The outbreak started in Wuhan, Hubei province, China, in December 2019. The World Health Organization (WHO) declared the outbreak to be a Public Health Emergency of International Concern on 30 January 2020 and recognized it as a pandemic on 11 March 2020.2, 3 As of 4th April 2020, more than 1,140,000 cases of COVID-19 have been reported in more than 200 countries and territories,4 resulting in more than 60,900 deaths.5
The virus mainly spreads during close contact, and by small droplets produced during coughing, sneezing, or talking.6, 7 These small droplets may also be produced during breathing, but rapidly fall to the ground or surfaces and are not generally spread through the air over large distances.7, 8 Effective human-to-human transmission even by asymptomatic and/or pre-symptomatic carriers has been major a reason underlying the rapid worldwide spread of the disease.9 People may also catch COVID-19 by touching a contaminated surface and then their face. 7 The virus can survive on surfaces up to 72 hours.10 The presence of the virus in faecal swab, blood and tears or conjunctival secretions indicates that other modes of transmission are also plausible.11, 12 It is most contagious during the first 3 days after symptom onset, although spread may be possible before symptoms appear and in later stages of the disease.8 Though the incubation period was reported to between 1 to 14 days, it has been found to be contagious even during the latency period.13
COVID-19 manifest as flu like illness, with common symptoms like fever, cough, shortness of breath, occasional diarrhea, vomiting. Complications may include pneumonia, acute respiratory distress syndrome resulting in multi organ failure & mortality. High morbidity has been observed among the elderly, those with additional co morbidities and those under immunosuppression.14 At this time, there are no known vaccines or any specific antiviral treatments for COVID-19. Primary treatment is symptomatic with supportive therapy. Preventive measures like hand washing, covering one’s mouth while coughing & sneezing, social distancing, monitoring and self isolation of the suspected people are the key factors to minimize the transmission.
Methods
After analyzing the literature, guidelines issued by various professional societies and practice patterns being followed by our colleagues and fellow hospitals, Safe Practice Patterns (SPP) have been formulated for fellow ophthalmologists and Health Care Workers (HCW) (Table 1).
Every HCW is at high risk of getting viral infection from one or other. There are many safety guidelines recommended by concerned societies for every country and every specialty but in our study, we are highlighting the SPP compiled after review of literature. These SPP can be administrative, engineering controls, use of Personal Protective Equipments (PPE), policy making and patient management.
Basic SPP is 4M`s: Minimal patients, Minimal stay at hospital, Minimal exposure, Minimal revisits.
Before entry; Hospital should inform its patients in advance through mass communication means (website, mass messages, incoming phone calls, placards/posters at entry gate etc) that it will not entertain normal Out Patient Department (OPD) and elective procedures. Such patients can avail free telephonic consultation by doctors on the given hospital numbers during fixed hours. Old and chronic patients can collect medicines from the pharmacy through any messenger. If there is urgency to consult, patient should come alone or with minimum attendants. In case of rush at reception, patient should be motivated to wait in his own vehicle. Hospital administration should prepare a list of conditions in which, it will provide urgent care during COVID-19 epidemic considering patients’ need and hospital resources and make it available to the staff and patients. Hospital should maintain visitors’ register at the entry in which name and mobile number of each visitor (staff, patient, attendant, vendor) should be entered by hospital staff. Strictly no handshake by any staff. Every patient and attendant must cover their mouth and nose with a mask and wash/rub their hands at the entry. At the reception, if possible, air flow should be from staff to patient and windows to be kept open. Safe distance must be maintained patient to patient and patient to staff (1 meter). Patient should fill the Covid-19 questionnaire cum consent Form 1 (Table 2). Thermal screening with non touch thermometers is a better choice. In case, a patient is in high risk group (any one or more positive response), he should be referred to a designated centre. Plastic money should be preferred. Limited staff should be posted for longer duty hours and in less frequency so that lesser number of staff is exposed to risk at a given time.
After registration, there should be minimal waiting time. Dilation of pupil should be avoided as far as possible. Needless to say that safe distance and face mask has to be followed at all levels. In doctor’s room, air flow should be from doctor to patient. It can be easily maintained by air purifier or small exhaust/ table fan. Doctor must use proper face mask (N95 mask or 3 layered surgical mask, Cap & Gloves). Use hand sanitizer before and after every patient. Proper breath shield during slit lamp exam is a safer approach. You can cut a transparent file cover and put it in the eye pieces to make your own breath shield. Non Contact Tonometer (NCT) producing air currents should be avoided. Ask the patient not to talk during eye examination; all discussion should be after ophthalmic examination when doctor and patient are at safe distance. Patient should be given treatment and sent home quickly, emergency care/first aid may be with torch examination only if justifiable. Procedures like syringing and staining should be avoided. No elective procedures are to be scheduled. If there is an emergency such as fresh Retinal Detachment, Retinopathy of Prematurity, Perforating injury, Lens induced Glaucoma/ acute glaucoma/ sudden diminution of vision, basic SPP such as safe distance, minimum stay, hand sanitization and PPE must be followed. Ask for symptoms of COVID-19 as per questionnaire. Get X-ray chest done. Plan the emergency procedure as per COVID-19 Figure 1. No positive pressure in operation theatre during surgery of COVID-19 confirmed/ suspected patient during surgery & 20 minutes after. Same precautions (safe distance and face mask) should be followed at the pharmacy. In case, any exposure is suspected, refer to Figure 2 for Post Exposure Prophylaxis (PEP) for COVID-19 exposure.
Housekeeping should be done frequently. In addition, mopping of floors, door handles, walls and furniture surfaces with freshly prepared 1% Sodium Hypochlorite solution should be done frequently. All the PPE should be disposed off as per normal Bio Medical Waste (BMW) guidelines. Special BMW guidelines are applicable to hospitals who are dealing with isolation of COVID-19 patients and quarantine of COVID-19 suspects.
Sodium Hypochlorite is available as 5% solution or powder, commonly called as Bleaching solution/ bleaching powder. Stability of 5% solution is as per expiry date on the bottle. But stability of diluted 1% solution is only 24 hours so it should be diluted only when it is to be used. Sometimes in the market, it is available as Chlorine 10% which is equivalent to 1% Sodium Hypochlorite.
Following points should be taken care of while Donning & Doffing PPE:
Button your shirt/ gown
Use half sleeve shirts, bare below elbow
Don’t use Mobiles, wrist watch, bangles & jewellery while on duty
Use N95/ 3 layered surgical mask & hand sanitizer
Eye shield and cap in lab
HIV kit in case of Operation Theatre, provided the patient is Non Covid-19
Full body protection suit if patient is Covid-19 positive/ suspect
Hand sanitizers: Alcohol based are better than others.
Results
Most people infected with the Corona Virus Disease 2019 (COVID-19) virus experience mild to moderate respiratory illness and recover without requiring special treatment.15
Healthcare workers face an elevated risk of exposure to infectious diseases including COVID-19. It is imperative to ensure safety of health care workers not only to safe guard continuous patient care but also to ensure that they do not transmit the virus. More than 100 HCW throughout the world have died from COVID 19 including the first doctor to raise the alarm about the Corona virus, Dr. Li Wenliang, MD, 33 yr old Ophthalmologist worked in Wuhan, China. Ophthalmologists are one of the more at risk medical specialties for this new pathogen due to close physical contact (that too near the face) nature of their work. Anecdotal reports suggest COVID-19 can cause conjunctivitis and possibly be transmitted through aerosols contact with conjunctiva, but this remains to be confirmed.13 Additionally, a medical expert, who visited Wuhan to investigate the COVID-19 outbreak, after returning to Beijing, initially exhibited conjunctivitis of the lower left eyelid before the appearance of catarrhal symptoms and fever.16 The individual tested positive for COVID-19, suggesting its tropism to non-respiratory mucosal surfaces, thus limiting the effectiveness of face masks.17
It is important to understand that corona virus can spread through eyes (tears) just as it can through mouth or nose. When any COVID-19 patient coughs, sneezes or talks, micro droplets containing virus particles spray from their mouth or nose, on to others face or surfaces. These tiny droplets can enter through nose mouth and also through eyes. One can become infected when he touching eyes after touching some surface that has virus on it.
There are studies which quote corona virus can cause conjunctivitis. But it is extremely rare.13 For everyone’s health and safety, ophthalmologists have been told not to see patients during the corona virus pandemic except for emergency care. It limits the contact between the doctor and patient thereby reducing the spread of virus. The evidences clearly states that sub clinical patients also transmit the virus along with known patients who can also shed high amount of virus and infect others even after recovery from acute illness. These conditions need aggressive measures (such as N95/ triple layered surgical masks, Eye Shields, Impervious gowns) to ensure the safety of health care workers during this COVID-19 outbreak as well as future outbreaks especially in the primary stages where no or partial information about the transmission and effective potency of the virus is available.17
Table 1
Safe practice Pattern (SPP)
Table 2
Corona Virus Disease 2019 (COVID-19) Declaration cum consent form
Discussion
In conclusion, we illustrate the variety of SPP guidelines for our colleagues in the face of this incredible threat to human life. Most of the safety guidelines available are neither perfect nor applicable in toto to all the healthcare organizations especially the eye care organizations (ECO). We have compiled those which can be applied on most of the small & medium ECO. In the mean time, Ophthalmologists working in ECO must also prepare for the potential financial implications of COVID-19 as procedures in these ECO reduced drastically over the quarantine/ lockdown period in the region.
Also National Accreditation Board for Hospitals and Healthcare Providers (NABH) says in its logo: Safety & Quality; in every chapter, safety of staff & safety of patients is prime concern along with quality, same is required while dealing with patients during this pandemic. During NABH assessments, it was observed that it is very difficult to teach the staff use of PPE and hand wash and get it implemented, but now, this is the prime requirement and disease has taught all the 130 crore in India. Our purpose is to ensure that it is followed.
This pandemic has lead to severe global socio economic disruption, postponement/ cancellation of cultural, sporting events, elective medical procedures and other routine healthcare facilities leading to widespread fears & panic. Looking at the present scenario, every individual visiting the hospital should be considered as infective or asymptomatic carrier.
Although these safe practice guidelines are relevant to control the current health crisis but more high quality research and reliable ways are needed to manage this kind of health threatening emergency in both short and long term.
The world is closed for renovation. Grand opening expected soon.
