Risk of Transmission of infection to Healthcare Workers delivering Supportive Care for Coronavirus Pneumonia;A Rapid GRADE Review

  1. TK Luqman Arafath
  2. Sandeep S Jubbal
  3. Elakkat D Gireesh
  4. Jyothi Margapuri
  5. Hanumantha Rao Jogu
  6. Hitesh Patni
  7. Tyler Thompson
  8. Arsh Patel
  9. Amirahwaty Abdulla
  10. Suma Menon
  11. Sudheer Penupolu

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Abstract

Abstract Background: Avenues of treatment currently implemented for Covid-19 pandemic are largely supportive in nature. Non -availability of an effective antiviral treatment makes supportive care for acute hypoxic respiratory failure is the most crucial intervention. Highly contagious nature of Covid-19 had created stress and confusion among front line Health Care Workers (HCWs) regarding infectious risk of supportive interventions and best preventive strategies. Purpose: To analyze and summarize key evidence from published literature exploring the risk of transmission of Covid-19 related to common supportive care interventions in hospitalized patients and effectiveness of currently used preventive measures in hospital setting. Data Sources: Curated Covid-19 literature from NCBI Computational Biology Branch ,Embase and Ovid till May 20,2020.Longitudinal and reference search till June 28,2020 Study Selection: Studies pertaining to risk of infection to HCWs providing standard supportive care of hospitalized Covid-19 mainly focusing on respiratory support interventions.Indirect studies from SARS,MERS or other ARDS pathology caused by infectious agents based on reference tracking and snow ball search . Clinical, Healthy volunteer and mechanistic studies were included. Two authors independently screened studies for traditional respiratory supportive-care (Hypoxia management, ventilatory support and pulmonary toileting) related transmission of viral or bacterial pneumonia to HCWs. Data Extraction: Two authors (TK and SP) independently screened articles and verified for consensus. Quality of studies and level of evidence was assessed using Oxford Center for Evidence Based Medicine (OCEBM) , Newcastle - Ottawa quality assessment Scale for observational studies and Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for grading evidence. Data Synthesis: 21 studies were eligible for inclusion. In 11 mechanistic studies, 7 were manikin based,1 was in the setting of GNB pneumonia ,2 were healthy volunteer study and 1 was heterogenous setting.Out of 10 clinical studies ,5 were case controlled and 6 were cohort studies. Risk of corona virus transmission was significantly high in HCWs performing or assisting endotracheal intubation or contact with respiratory secretion.(Moderate certainty evidence, GRADE B) Safety of nebulization treatment in corona virus pneumonia patients are questionable(Low certainty evidence, GRADE C).Very low certainty evidence exist for risk of transmission with conventional HFNC (GRADE D) and NIV (GRADE D),CPR (GRADE D),Bag and mask ventilation(GRADE D).Moderate certainty evidence exist for protective effect of wearing a multilayered mask, gown , eye protection and formal training for PPE use (GRADE B).Low certainty evidence exist for transmission risk with bag and mask ventilation, suctioning before and after intubation and prolonged exposure (GRADE C).Certainty of evidence for wearing gloves,post exposure hand washing and wearing N 95 mask is low(GRADE C). Limitations: This study was limited to articles with English abstract. Highly dynamic nature of body of literature related to Covid-19, frequent updates were necessary even during preparation of manuscript and longitudinal search was continued even after finalizing initial search. Due to the heterogeneity and broad nature of the search protocol, quantitative comparisons regarding the effectiveness of included management strategies could not be performed. Direct evidence was limited due to poor quality and non-comparative nature of available Covid-19 reporting. Conclusions: Major risk factors for transmission of corona virus infection were, performing or assisting endotracheal intubation and contact with respiratory secretion. Risk of transmission with HFNC or NIV can be significantly decreased by helmet interface, modified exhalation circuit or placing a properly fitting face mask over patient interface of HFNC. Evidence for risk of transmission with CPR, suctioning before or after intubation or bag and mask ventilation of very low certainty. Significant protective factors are Formal training for PPE use, consistently wearing mask, gown and eye protection. Primary Funding Source: None Disclosure: None of the authors have any conflict of interest to disclose.

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  1. ScreenIT

    SciScore for 10.1101/2020.07.06.20146712: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.
    Cell Line AuthenticationAuthentication: Articles were further organized into groups of interventions and assessed for inclusion by authors TK and SP. Articles not pertaining to respiratory supportive care(high flow nasal canula (HFNC), non-invasive positive pressure ventilation (NIV), proning, Chest physio therapy or other pulmonary toileting) were excluded.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Initial attempt was to gather evidence from direct studies related to Covid-19 infection,but initial screening of data bases(Medline,Embase and LitCovid) showed only 1 study involving Covid-19.
    Embase
    suggested: (EMBASE, RRID:SCR_001650)
    Citations were managed with the help of EndNote X9 version software and duplicates were removed.
    EndNote
    suggested: (EndNote, RRID:SCR_014001)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    ) Our review has limitations. Due to lack of qualifying comparative studies on Covid-19 supportive care and risk of transmission, this study is not strictly a systematic review. We attempted to extrapolate indirect evidence form previous corona virus epidemics and in some case from non-viral pneumonia.(37) The included original studies had poor reporting quality and were mostly observational. Included mechanistic studies could not draw meaningful conclusion on effect size. Different designs and lack of uniformity in approaching clinical questions deterred a possibility of quantitative pooling of the data without serious risk of bias. Across the spectrum of studies serious confounding due to potential variations in PPE use were not always adjusted. In conclusion we attempted to answer fundamental concerns of frontline HCWs fighting the Covid-19 pandemic regarding nosocomial infection risk by critically appraising limited available evidence mostly extrapolating from past corona virus epidemics with few additions from current pandemic. We adhered to CEBM level of evidence tool and NOS scoring system to appraise individual studies and incorporated information from mechanistic and volunteer studies while making GRADE assessment of intervention of interest. We found non invasive oxygenation strategies like HFNC, NIV with modified circuit or helmet interface is as safe as nasal cannula oxygen. Endotracheal intubation remains high risk for nosocomial transmission in corona virus and ...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  2. Version published to 10.1101/2020.07.06.20146712v1 on medRxiv