Confusion over updated coronavirus mask advice

Matt Woodley

7/02/2020 3:36:01 PM

Some authorities say surgical masks are safe to use for swabs in ‘mild cases’, but that appears to contradict other recommendations.

Doctor taking specimen
Collecting respiratory specimens, such as nasopharyngeal or oropharyngeal swabs, is a ‘low-risk procedure’ and can be performed using contact and droplet precautions, including surgical masks.

newsGP understands the guidelines, which first appeared on the NSW Health and Victorian Department of Health and Human Services (DHHS) websites, will soon be adopted nationwide following recommendations from the Infection Control Advisory Group (ICAG).
The Communicable Diseases Network Australia (CDNA) coronavirus guidelines have been updated to reflect the new position, but at the time of publication the Australian Department of Health (DoH) was still recommending more stringent personal protection measures.
The DoH advice states airborne protections, including a P2 or N95 respirator, ‘must … be used while collecting specimens’.
The RACGP has been clear in its recommendation that GPs adhere to DoH advice and use a P2 or N95 respirator when collecting coronavirus samples.
ICAG Chair Professor Lyn Gilbert told newsGP the new surgical mask recommendations are based on existing definitions of aerosol-generating procedures, which had been temporarily superseded by a more conservative approach given uncertainty surrounding the virus.
‘[The new guidelines] are different from what has been recommended previously in some jurisdictions, which were based on a highly precautionary response,’ she said. ‘However, the evidence supports contact and droplet precautions [such as] surgical masks, except for aerosol-generating procedures.
‘In the past, the collection of upper-respiratory specimens such as nasopharyngeal or throat swabs has never been regarded as an aerosol-generating procedure.’
However, the Victorian DHHS and NSW Health are also still recommending the collection of a lower-respiratory specimen – sputum – which under the existing DoH guidelines and CDNA recommendations would require an aerosol-generating procedure and thus the use of a P2 or N95 respirator.
A NSW Health spokesperson told newsGP the collection of respiratory specimens, such as nasopharyngeal or oropharyngeal swabs, is a ‘low-risk procedure’ and can be performed using contact and droplet precautions, including surgical masks, for most patients with mild illness.
‘If the patient has severe symptoms suggestive of pneumonia – for example, fever and breathing difficulty, or frequent, severe or productive coughing episodes – then contact and airborne precautions should be observed,’ the spokesperson said.
‘We understand that the Australian Department of Health is updating its fact sheets in line with this advice.’
Associate Professor Mark Morgan, Chair of the RACGP Expert Committee – Quality Care (REC–QC), told newsGP questions remain over the source of the information, how it has been disseminated, and whether it is based on evidence that has been gathered overseas.
‘It would give GPs much more confidence if, in addition to the fact sheets, there was reference information for those who want to dig into it and understand where the advice comes from,’ he said.
‘Is there a science behind this based on the measurement of viral shedding or information that’s been gathered from the experience in China and other countries, or is this just some expert opinion that could be changed again in light of health workers being infected by taking the lesser level of precaution?
‘If we start infecting the healthcare population, then our ability to manage the next phase of the pandemic will be deeply impaired.’

Associate Professor Morgan said that while the overall response to date appears to have been successful insofar as there has been no human-to-human transmission in Australia, the management and dissemination of information could be improved.
‘It’s almost as if the information about Australia’s planning remains a secret to be trickled out on a daily basis after the meeting of the communicable disease committee,’ he said. 
‘People would have more confidence if the information all changed at the same time, was disseminated from the same source, and if we knew on what basis the information was changing.
‘It would be nice to understand the shape of future responses, not just today’s response.’
The updated surgical mask guidelines were released around the same time the World Health Organization confirmed the coronavirus-related death of Dr Li Wenliang, a 34-year-old ophthalmologist in China who was the first to raise the alarm over the outbreak and later arrested by Chinese police.
At least 14 healthcare workers in China have been infected with coronavirus, according to figures most recently updated on 20 January.
Professor Gilbert said she is ‘hopeful’ finalised infection control guidelines and fact sheets, which have also been approved by the Australia Health Protection Principal Committee (AHPPC), will be on health department websites soon. She also stressed the ICAG is still taking a precautionary approach to more serious cases.
‘Airborne precautions for the collection of specimens from the minority of patients who have evidence of lower-respiratory infection or pneumonia … [and] in the GP’s clinical judgement are likely to require admission to hospital irrespective of nCoV-2019 PCR [novel coronavirus 2019 polymerase chain reaction] result [remain the same],’ she said.
‘In these sick patients, we recommend use of P2 or N95 respirators for the collection of specimens on the assumption that it may generate aerosols.
‘This also means that P2 and N95 respirators must be used correctly, must be fit-tested, otherwise they will not be effective. It also means that the specimen should be collected in a negative-pressure room or a room that can be left vacant for at least 30 minutes afterwards.
‘It is recognised that most GPs are unlikely to be able to meet these criteria for airborne precautions and therefore the recommendation is that these patients be referred to hospital.’
The new advice is the latest in a string of updates that have been issued by various health departments across Australia, which GPs have said are inconsistent and seem to lack coordination.
GPs have also had difficulties accessing masks following confusion over what masks were being issued. In recent information obtained from the DoH, it has been confirmed only surgical masks are being distributed by the Federal Government via Primary Health Networks after lobbying from RACGP President Dr Harry Nespolon.
Some state governments are distributing surgical and P2/N95 masks.
At the time of publication, Australia had 15 confirmed coronavirus cases across Queensland, NSW, Victoria and South Australia. There have been more than 31,000 confirmed cases worldwide and at least 638 fatalities.
The RACGP has more information on coronavirus available on its website.
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Dr KaluarachchiLiyanage Kalhari Kumari Liyanage   9/02/2020 4:30:16 AM

This article is very useful to me because I work as a senior medical officer in a heavy medical ward in Sri Lanka.

Dr Mark Robert Miller   12/02/2020 1:00:47 AM

Please also take note also of this study
Original publication

Günter Kampf, Daniel Todt, Stephanie Pfaender, Eike Steinmann: Persistence of coronaviruses on inanimate surfaces and its inactivation with biocidal agents, in: Journal of Hospital Infection, 2020, DOI: 10.1016/j.jhin.2020.01.022
The novel coronavirus 2019-nCoV is making headlines worldwide. Since there is no specific therapy against it, the prevention of infection is of particular importance in order to stem the epidemic. Like all droplet infections, the virus can spread via hands and surfaces that are frequently touched. "In hospitals, these can be door handles, for example, but also call buttons, bedside tables, bed frames and other objects in the direct vicinity of patients, which are often made of metal or plastic," explains Professor Günter Kampf from the Institute of Hygiene and Environmental Medicine at the Greifswald University Hospital.

Together with Professor Eike Steinmann, head of the Department for Molecular and Medical Virology at Ruhr-Universität Bochum (RUB), he has compiled comprehensive findings from 22 studies on coronaviruses and their inactivation for a future textbook. "Under the circumstances, the best approach was to publish these verified scientific facts in advance, in order to make all information available at a glance," says Eike Steinmann.

Infectious on surfaces for up to nine days

The evaluated studies, which focus on the pathogens Sars coronavirus and Mers coronavirus, showed, for example, that the viruses can persist on surfaces and remain infectious at room temperature for up to nine days. On average, they survive between four and five days. "Low temperature and high air humidity further increase their lifespan," points out Kampf.

Tests with various disinfection solutions showed that agents based on ethanol, hydrogen peroxide or sodium hypochlorite are effective against coronaviruses. If these agents are applied in appropriate concentrations, they reduce the number of infectious coronaviruses by four so-called log steps within one minute: this means, for example, from one million to only 100 pathogenic particles. If preparations based on other active ingredients are used, the product should be proven to be at least effective against enveloped viruses ("limited virucidal activity"). "As a rule, this is sufficient to significantly reduce the risk of infection," explains Günter Kampf.

Findings should be transferable to 2019-CoV

The experts assume that the results from the analyses of other coronaviruses are transferable to the novel virus. "Different coronaviruses were analysed, and the results were all similar," concludes Eike Steinmann.

A.Prof Christopher David Hogan   15/02/2020 9:35:57 AM

This confusion & contradiction is a normal human response to an emerging novel infection, It has been seen so often in the past with previous novel infections & will doubtless recur in the future .
We must never underestimate the power of the primal fear we all experience in the face of Contagion.
To be able to recognise in ourselves the difference between fear & caution is a real test of our professionalism.
There is always an element of physical risk when we practice as doctors- we can never avoid it but we can minimise it .