Resources for COVID19
The Office Bearers of PBSA appreciate the efforts and resilience of all healthcare workers, doctors, nurses, paramedic staff, lab technologists and medical technologists who are striving in finding a cure for COVID19. Reference material that will be useful for all and will also help in ensuring better preparation has been uploaded. Among these, we have included the Bioprism manual – the training manual used by the organization during biosafety and biosecurity trainings. This manual has been made available to all, so that they may better protect themselves during these troubled times.
On behalf of National Institute of Health (NIH) we are also uploading the National Guidelines Infection Prevention and Control 2020. These are so that all members are working in coordination with the national standard, and all can create response systems using these same established formats.
We will continually update this section with new information as and when it arrives. Keep returning to this section to see more updates.
Frequently Asked Questions about SARS-CoV-2 and COVID-19
Questions about PPE and prevention methods:
Q: Do protective goggles need be coupled with Face shields?
A: Occupational Safety and Health Administration recommends goggles as primary protectors because they form a protective seal around the eyes and prevent objects or droplets from entering under or around them. Face shields are recommended as secondary protectors to use in combination with goggles to provide additional protection to the whole face.
Q: Many of our lab people and HCWs have beard, so masks fail the fitness test, how to deal with this issue? should they be given responsibility other than being front line people directly dealing with COVID-19 patients or their samples?
A: In an ideal situation, it is advised to provide face shields to HCW with beards, as these offer the most protection. Recently, the NHS has been discussing the impact of beards on the health and working capacity of NHS staff. They highlighted that it would be considered as implicit religious discrimination against minority communities for whom it is a religious obligation (such as Muslims and Sikhs)
It is best to discuss the matter with HCW and resolve the matter at the source. This should be in accordance with High Reliability Organization Principles https://www.ncbi.nlm.nih.gov/books/NBK542883/
We also refer to the following NIH documents for reference
Q: Does a N95 mask wetted by sweating still offer good protection?
A: Recommendations on the use of N95 masks usually say that they must be changed when soiled or wet. However, there is no mention of any rationale for this.
Some studies have focused on the breathing comfort of N95 and similar masks. They generally conclude that wet masks offer higher resistance to breathing, and are therefore less comfortable to wear. But no studies seem to have considered a possible loss of efficacy. Based on the materials N95 masks are made of, we might expect some differences, though. Masks that contain cellulose might for instance be more prone to suffer some alteration when wet than masks exclusively made of polypropylene fibers. Anyway, in absence of available data, some caution is required regarding excessive wetting of masks.
It may also be worth mentioning here that some models of N95 masks have an exhaling valve that aims to facilitate breathing and reduce moisture within the mask. However, these masks only protect the wearer, and not others, in case the wearer was infected and shedding microbes. Their use is thus usually not recommended in the current Covid-19 pandemic context.
Q: What is the efficacy of surgical masks when compared to N95 respiratory masks?
A: While N95 masks are designed and tested to ensure protection of the wearer, surgical masks aim at protecting patients from bodily fluids possibly emitted by the wearer. Surgical masks are therefore not considered personal protective equipment. While N95 respiratory masks should be worn by exposed healthcare and laboratory professionals, surgical masks should rather be worn by Covid-19 patients and suspected cases.
Still, some studies (see links) indicate that surgical masks, despite their absence of seal and tight face fit, tend to offer some level of personal protection. In a situation of shortage of N95 masks, they could thus be an acceptable option for healthcare and laboratory workers.
Q: Should healthy people wear masks?
A: The source indicates the face mask use recommendations by different health authorities.
Q: Can homemade or cloth masks offer protection from SARS-CoV2 and could cloth masks be a substitute for surgical masks?
A: CDC recommends wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain. The general public can use cloth masks to protect those around them. The cloth face coverings recommended are not surgical masks or N-95 respirators. Those are critical supplies that must continue to be reserved for healthcare workers and other medical first responders
Q: For how long can a normal surgical mask or N95 mask be worn?
A: The normal suggested time for wearing an N95 mask is 8 hours, however in a relatively clean atmosphere this can usually be extended. You can also consider wearing an “over mask” to extend the longevity of N95 masks. Please see pages 6-7 of Dr. Philippe Stroot’s document. http://www.xibios.eu/20200408_COVID-19_Masks_Options.pdf
Q: Can N95 masks be sterilized and reused?
A: For N95, details pertaining to reuse are still being researched. CDC has some information to consider.
If N95 and surgical masks are to be reused take the following into consideration: 70C /158F heating in an oven (not your home oven) for 30min, or hot water vapor from boiling water for 10 min, are additional effective decontamination methods. Dr. Philippe Stroot has put together a comprehensive guidance document about the reuse of N95 masks given shortages of PPE which can be found here:
A recent study conducted at the US National Institutes of Health also provides some guidance.
The study investigators are with NIH’s Rocky Mountain Laboratories (RML) in Hamilton, Montana, part of the National Institute of Allergy and Infectious Diseases (NIAID). With collaborators from the University of California, Los Angeles, they tested the decontamination of small sections of N95 filter fabric that had been exposed to SARS-CoV-2, the virus that causes COVID-19. Decontamination methods tested included vaporized hydrogen peroxide (VHP), 70-degree Celsius dry heat, ultraviolet light, and 70% ethanol spray. All four methods eliminated detectable viable virus from the N95 fabric test samples. The investigators then treated fully intact, clean respirators with the same decontamination methods to test their reuse durability. Volunteer RML employees wore the masks for two hours to determine if they maintained a proper fit and seal over the face; decontamination was repeated three times with each mask using the same procedure. The scientists found that ethanol spray damaged the integrity of the respirator’s fit and seal after two decontamination sessions and therefore do not recommend it for decontaminating N95 respirators. UV and heat-treated respirators began showing fit and seal problems after three decontaminations-suggesting these respirators potentially could be re-used twice. The VHP-treated masks experienced no failures, suggesting they potentially could be re-used three times. The authors concluded that VHP was the most effective decontamination method, because no virus could be detected after only a 10-minute treatment. UV and dry heat were acceptable decontamination procedures as long as the methods are applied for at least 60 minutes. The authors urge anyone decontaminating an N95 respirator to check the fit and seal over the face before each re-use.
Q: Do regular surgical masks offer protection from COVID-19?
A: In laboratory experiments, the masks significantly reduced the amounts of various airborne viruses coming from infected patients University of Maryland. “Wearing surgical masks in public could help slow COVID-19 pandemic’s advance: Masks may limit the spread of diseases including influenza, rhinoviruses and coronaviruses.” ScienceDaily, 3 April 2020. <www.sciencedaily.com/releases/2020/04/200403132345.htm>.
Q: What are the alternatives to N95 masks?
A: For healthcare professionals, the alternatives are provided here.
Q: Can an N95 mask be used without a Fit Test?
A: No. It will become a risk and portal of entry for the wearer. Always do fit test with N95 to ensure complete protection. This Link explains N95 fit test
Q: Is it important to cover facial hair if one is close to a COVID-19 positive case?
A: Having a moustache or beard can affect the seal of the face filtering respirators
Q: What are minimum material requirements for PPE, especially coveralls for red zones for HCWs?
A: Nonsterile, disposable patient isolation gowns, which are used for routine patient care in healthcare settings, are appropriate for use by patients with suspected or confirmed COVID-19. While the transmissibility of COVID-19 is not fully understood, gowns are available that protect against microorganisms. The choice of gown should be made based on the level of risk of contamination. Certain areas of surgical and isolation gowns are defined as “critical zones” where direct contact with blood, body fluids, and/or other potentially infectious materials is most likely to occur. If there is a medium to high risk of contamination and need for a large critical zone, isolation gowns that claim moderate to high barrier protection can be used. For healthcare activities with low, medium, or high risk of contamination, surgical gowns (ANSI/AAMI PB70 Levels 1-4pdf icon) can be used. These gowns are intended to be worn by healthcare personnel during surgical procedures. If the risk of bodily fluid exposure is low or minimal, gowns that claim minimal or low levels of barrier protection can be used. These gowns should not be worn during surgical or invasive procedures, or for medium to high risk contamination patient care activities.
Healthcare workers performing aerosol-generating procedures such as swabbing should wear the suggested PPE set for droplet, contact and airborne transmission (gloves, goggles, gown and N95 or European equivalent FFP2/FFP3 respirator) If there is a shortage of FFP2/FFP3 respirators, healthcare workers performing procedures in direct contact with a suspected or confirmed case (but not at risk for generating aerosol) can consider wearing a mask with the highest available filter level, such as a surgical mask, in addition to gloves, goggles and gown. If there is an insufficient stock of respirators, then staff engaged in environmental cleaning and waste management should wear a surgical mask, in addition to gloves, goggles and gown.
Q: Is it necessary for the material used for PPE made locally to be certified and tested?
A: CDC’s guidance for Considerations for Selecting Protective Clothing used in Healthcare for Protection against Microorganisms in Blood and Body Fluids outlines the scientific evidence and information on national and international standards, test methods, and specifications for fluid-resistant and impermeable gowns and coveralls used in healthcare. Many organizations have published guidelines for the use of personal protective equipment (PPE) in medical settings. The American National Standards Institute (ANSI) and the Association of the Advancement of Medical Instrumentation (AAMI) describes the liquid barrier performance and a classification of surgical and isolation gowns for use in health care facilities. As with any type of PPE, the key to proper selection and use of protective clothing is to understand the hazards and the risk of exposure. Some of the factors important to assessing the risk of exposure in health facilities include source, modes of transmission, pressures and types of contact, and duration and type of tasks to be performed by the user of the PPE. (Technical Information Report (TIR) [AAMI 2005]).
For gowns, it is important to have sufficient overlap of the fabric so that it wraps around the body to cover the back (ensuring that if the wearer squats or sits down, the gown still protects the back area of the body).
PPE made locally or internationally must meet certain criteria to provide enough protection against the biological agent we are working with. Testing and certification bodies check for those criteria against the product. So, it is definitely necessary for the organizations to meet those criteria and get their products certified.
Q: How does one properly dispose of COVID-19 used PPE?
A: Handle laboratory waste from testing suspected or confirmed COVID-19 patient specimens as all other biohazardous waste in the laboratory. Currently, there is no evidence to suggest that this laboratory waste needs additional packaging or disinfection procedures.
Medical waste (trash) coming from healthcare facilities treating COVID-2019 patients is no different than waste coming from facilities without COVID-19 patients. CDC’s guidance states that management of laundry, food service utensils, and medical waste should be performed in accordance with routine procedures. There is no evidence to suggest that facility waste needs any additional disinfection.
PPE materials such as gowns, gloves and masks that are considered soiled by hospital policy would be thrown into a biohazard trash bag and disposed of as infectious medical waste
Q: Which is preferable: hand washing with soap or hand rubbing with a sanitizer?
A: This matter has long been a debated issue, with pros and cons for each option – see specific FAQ on this. However, hand washing with soap is generally considered the gold standard in many situations, especially in limited resource settings. So, many agencies – with the notable exception of the US CDC – recommend hand washing as the general option, and advise hand sanitizing when water or soap is not available (as in some public areas such as markets), or when hand decontamination must be performed frequently on clean hands (as in between each patient or hospital room visit, when gloves are not worn).
Q: What are the pros and cons of hand washing vs using a hand sanitizer?
A: Advantages and drawbacks of hands washing vs hand sanitization with an alcohol-based product relate to their relative efficacy, safety profiles and practical aspects such as availability.
With respect to decontamination efficacy, washing hands with soap adds a physical elimination of all types of hand contaminants, virus included, and is therefore considered effective in most situations (and in any case with respect to SARS-CoV-2). Then, since alcohol evaporates quickly, it provides a rather short contact time, and it is not or less effective in killing some types of micro-organisms (however, it is efficacious against SARS-CoV-2). In addition to this, the alcohol concentration of hand sanitizers available on the markets is rarely mentioned, and may be suboptimal – see specific FAQ about this –. Then, in contrast to water and soap, hand sanitizers are not effective in eliminating microorganisms from soiled or dirty hands.
With respect to health and safety, intensive or frequent use of soap is much less likely to generate skin damage such as fine cracks or peeling than frequent rubbing with hydro-alcoholic products. Moreover, alcohol-based solutions or gels present some toxic risks (as in case of accidental ingestion, for instance by children).
Last but not necessarily least, water and soap are generally more readily available and much less prone to shortage, and also cheaper, than hand sanitizers. On the other hand, hand sanitizers and dispensers for hand sanitization can easily be installed anywhere, without technical constraints.
Q: What is the recommended alcohol content of a hydro-alcoholic hand sanitizer?
A: The recommended alcohol concentrations of a hydro-alcoholic solution or gel for hand sanitization are above 60% if the alcohol is ethanol, and 70% if it is isopropanol. WHO recommends two formulations for the local production of alcohol-based multi-purpose sanitizers: one with 80% ethanol, the other with 75% isopropanol, both with traces of hydrogen peroxide (0.125%).
Please note that the alcohol contents of many hydro-alcoholic hand sanitizers available on the markets are not specified, and may be suboptimal (as they have a significant impact on the product manufacturing costs)
Q: Is Dettol an effective disinfectant against any viruses?
A: Dettol actually does not refer to one product, but to a whole range of products designed for different purposes (surface disinfection, hand disinfection…). These Dettol products vary in their composition and in the concentrations of the different components. Most Dettol products are alcohol-based (but not all), but different alcohols can be used in the different products. Moreover, the alcohol concentration, which is generally recommended for optimal disinfection (including by the WHO), is generally not reached (but potentially compensated by the use of other chemical substances). Last, Dettol generally claims a 99.9% disinfection (without specifying against which types of “germs”), which is less than what is considered necessary to claim a virucidal or bactericidal activity (at least according to US or European standards). Dettol should therefore be avoided in a high-risk healthcare or laboratory settings, and if a Dettol product is considered in such a workplace, its exact composition, the SDS (safety data sheet) and testing records should be required from the supplier.
On the other hand, appropriate Dettol products can be useful in low risk situation, such as household use.
Q: Is it necessary for the general public to wear gloves? Is it necessary to wear hand gloves when we go to malls or is hand sanitizer enough?
A: The CDC only recommends wearing gloves if you are caring for someone who is sick or cleaning your home. In general, wearing gloves in public will not protect you from SARS-CoV-2 because gloves can easily become contaminated and create a false sense of security. Gloves are not a substitute for hand hygiene and sanitizers; , handwashing with soap is the best practice.
Q: Which is more effective, hand sanitizer or soap?
- CDC recommends washing hands with soap and water whenever possible because hand washing reduces the amounts of all types of germs and chemicals on hands. But if soap and water are not available, using a hand sanitizer with at least 60% alcohol can help you avoid getting sick and spreading germs to others. The guidance for effective hand washing and use of hand sanitizer in community settings was developed based on data from a number of studies. Hand sanitizers may not be as effective when hands are visibly dirty or greasy.
Q: In case of reuse of Goggles & face shields, what is the best disinfectant? How to disinfect them and what is the time recommended for disinfection/decontamination?
A: With reference to the use of face shields, the disinfection/decontamination data is still being collected, and no concrete results have yet been published. However, we refer to the following for current findings of research on the topic.
Q: Is it safe for air to pass through the COVID-19 testing areas maintained in tents or should air not be allowed to pass through?
A: We recommend the following links that describe testing centers in Pakistan:
Q: How to disinfect currency notes and coins?
A: Research is still ongoing on the topic. We do have one article which discusses the topic:
Q: Guidance regarding SOPs of routine lab tests like CBC, ferritin, of COVID-19 positive patients and precautions?
A: NIH Pakistan has shared relevant strategies for COVID19 patient administration as well as details regarding routine lab tests.
We also recommend the following WHO guidelines:
Q: How many days should a suspected person, having travel history, showing symptoms be isolated? In case of suspicion, shall test be carried out immediately or test should be carried out after completion of incubation period?
A: WHO has posted a series of recommendations pertaining to this aspect in this link. To answer this question: “Travellers returning from affected areas should self-monitor for symptoms for 14 days and follow national protocols of receiving countries. Some countries may require returning travellers to enter quarantine. If symptoms occur, such as fever, or cough or difficulty breathing, travellers are advised to contact local health care providers, preferably by phone, and inform them of their symptoms and their travel history. For travellers identified at points of entry, it is recommended to follow WHO advice for the management of travellers at points of entry. Guidance on treatment of sick passengers on board of airplanes is available on ICAO and IATA websites. Key considerations for planning of large mass gathering events are also available on WHO’s website. Operational considerations for managing COVID-19 cases on board of ships has also been published.
For countries which decide to repatriate nationals from affected areas, they should consider the following to avoid further spread of COVID-19: exit screening shortly before flight; risk communication to travellers and crew; infection control supplies for voyage; crew preparedness for possibility of sick passenger in flight; entry screening on arrival and close follow-up for 14 days after arrival. (WHO recommendations to reduce risk of transmission of emerging pathogens from animals to humans in live animal markets)”
With reference to the details pertaining to Pakistan’s approach, NIH has shared recommendations as follows:
Q: What are disposal methods for Nasopharyngeal swabs?
A: The waste produced during sample collection process should be sealed in a double-layered yellow bag with a “special infection” label and delivered to the medical waste temporary storage room.
Q: How to carry out disinfection of ambulances used for COVID-19 patients? How to properly disinfect ventilators used for COVID-19 patients?
A: We refer to the following information provided by NIH, that accurately will assist in proper disinfection of surfaces
Q: Is Dettol an effective disinfectant against any viruses?
A: Specific Dettol products have demonstrated effectiveness (>99.9% inactivation) against coronaviruses, given the structural similarities of the COVID-19 virus to the coronavirus strains tested previously (SARS-CoV, MERS-CoV, Human Coronavirus), and based on the evidence, it is expected that Dettol would be effective against SARS-CoV-2.
Q: What are ways to disinfect cell phones and other electronics?
A: Consider the use of alcohol-based wipes or sprays containing at least 70% alcohol to disinfect touch screens. Dry surfaces thoroughly to avoid pooling of liquids.
Q: Which sanitizer is used in walk through gates?
A: Chlorine based disinfectants
Q: Will the sanitizing walk through gates help control the spread of coronavirus infection?
A: No. Spraying alcohol or chlorine all over your body will not kill viruses that have already entered your body. Spraying such substances can be harmful to clothes and mucous membranes (i.e., eyes, mouth). The use of these tunnels may give a false sense of security and may have adverse health effects as sodium hypochlorite have many harmful effects on the human body
Q: Can we use a chlorine-based spraying gate at entrance of some essential factories, grocery store and Hospital?
A: Spraying alcohol or chlorine all over your body will not kill viruses that have already entered your body. Spraying such substances can be harmful to clothes and mucous membranes (i.e. eyes, mouth). Be aware that both alcohol and chlorine can be useful to disinfect surfaces, but they need to be used under appropriate recommendations.
Q: Is it recommended to clean the parcels with any disinfectant?
A: There is still a lot that is unknown about COVID-19 and how it spreads. This coronavirus is thought to be spread most often by respiratory droplets. Although the virus can survive for a short period on some surfaces, it is unlikely to be spread from products or packaging that are shipped over a period of days or weeks at ambient temperatures. Currently there is no evidence to support transmission of COVID-19 associated with imported goods and there have not been any cases of COVID-19 in the United States associated with imported goods. Information will be provided on the Coronavirus Disease 2019 (COVID-19) website as it becomes available.
There is no evidence of human or animal food or food packaging being associated with transmission of the coronavirus that causes COVID-19.
Q: What can we use at home for disinfectant if hand sanitizer is not available?
A: Use Soap.
https://www.who.int/publications-detail/water-sanitation-hygiene-and-waste-management-for-covid-19 and https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html
Q: What is the proper purge timing of hand sanitizers? How many seconds are needed to destroy the microorganism on skin?
- A. Twenty seconds at least. Make sure that your fingernails are cleaned as that is a portal for entry. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html
Q: How long does the virus survive on fruit and vegetables?
A: Coronaviruses are generally thought to be spread from person to person through respiratory droplets. Currently, there is no evidence to support transmission of COVID-19 associated with food. Before preparing or eating food it is important to always wash your hands with soap and water for at least 20 seconds for general food safety. Throughout the day use a tissue to cover your coughing or sneezing, and wash your hands after blowing your nose, coughing or sneezing, or going to the bathroom.
It may be possible that a person can get COVID-19 by touching a surface or object, like a packaging container, that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this is not thought to be the main way the virus spreads.
In general, because of poor survivability of these coronaviruses on surfaces, there is likely very low risk of spread from food products or packaging.
Based on information about this novel coronavirus thus far, it seems unlikely that COVID-19 can be transmitted through food – additional investigation is needed.
Corona virus does not seem to spread through exposure to food. Still, it’s a good idea to wash fruits and vegetables under running water before you eat them. Perform hand hygiene after visiting supermarket and before entering your home.
Q: What is the best disinfectant for the decontamination of goggles and face shields before reuse?
A: Alcohol (70% ethanol) is the most suitable disinfectant to use to decontaminate such items before reuse: it is effective as a surface disinfectant against SARS-CoV-2, it is readily available in laboratory and hospital settings, and it does not leave residues. Contact time should be 1 minute. Decontaminating such pieces of personal protective equipment after using them and before storing them is preferable to right before reuse.
Q: How to decontaminate mattresses used by Covid-19 patients?
A: In intensive care units and many other hospital rooms, mattresses are protected from contamination by an impervious layer, which can easily be decontaminated using surface disinfectants such as ethanol or bleach, and possibly be washed, or discarded as contaminated waste if disposable.
In other situations, that is when the mattresses themselves have been contaminated, including at home, the technique that has been recommended by some Western authorities for mattresses is steam cleaning. However, this necessitates a specific steam cleaning device, which may not be available everywhere. A first alternative to steam cleaning could be washing with hot water and a strong detergent, in which case some time should be allowed afterwards for in-depth drying. Another option can be counting on natural viral decay, and waiting at least 72 hours before possible, as for Coronavirus-contaminated waste in non-healthcare settings. In this case, the room should be ventilated and not be used during the waiting period.
Questions about transmission dynamics:
Q: During waste segregation in medical centers we have many types of bio waste. How we can we keep our general labor or sweepers safe from infection during waste handling? What are SOPs for sanitary workers?
A: Some aspects pertaining to waste management principles have been taught recently by PBSA in a series of webinars which considered waste management in the context of COVID19, which also consider guidelines given to general sanitary staff
Q: As the virus is an obligate intracellular parasite and remains on different surfaces for certain time (hours to day) and then deactivates and decay on its own.
1) Is it ok to keep the premises and quarantine center used by COVID-19 patient empty for one to two weeks and it will automatically become free of all the viruses?
A: According to the latest interim guidance of the WHO, and Clinical Management of COVID19, this is not true. The premise and quarantine center must be decontaminated to protect all who are working here:
2) How to decontaminate the mattresses used by COVID patients?
A: The latest interim WHO guidelines mention that mattresses should be decontaminated using EPA registered and approved products (a list of which is present in Pakistan and published by the government). Furthermore, clinical management of COVID19 (as published by WHO) highlights the aspects to consider
Q: As SARS-CoV-2 falls on ground due to gravity, now is there any data available about transferring of virus from one spot to other through mops?
A: Currently, there is no direct data available on monitoring the virus transfer using mops. There are only precautions advised by WHO and CDC on the subject.
Q: Can autoclave be used to decontaminate N95 masks?
A: Yes. There are specific instructions to follow with reference to N95 reuse and decontamination. According to research, Most N95 masks retain fit and filtration after 5 cycles between 80 and 85 degrees C, for thirty minutes. This same research has shown that the mask can be reused up to three to five times, depending on extant of usage.
Q: We use collection tubes for elution steps in PCR method. it is considered as solid waste but what about liquid waste obtained in this process? how can we segregate it? and which procedure should we follow for its disposal?
A: The best that we can recommend is to follow the interim guidance of the WHO regarding liquid waste.
With relevance to PCR method, NIH Pakistan also provided guidelines that consider the PCR use and scenario
Q: Can a person become re-infected? or can the disease be relapsed in a patient?
A: As of April 2020, two research articles have specifically discussed the aspects pertaining to COVID19 reinfection. The first one is a case report which considers re-infection with COVID-19
there is a chance of prolonged nucleic acid conversion rather than recurrence. In both cases, they emphasize that due to false negative tests leading to a false sense of security (current guidelines state that two consecutive negative tests are sufficient to discharge patients) it is advised to take vigilant steps, as these could lead to concerns of “relapsing COVID19”.
Q: Someone’s test result was inconclusive, then positive and then negative from same or different labs, what does it mean? (depends on persons immune system, time since entry of virus in body, skill of patient taking sample, sample storage and transport conditions, skills of the pathologist/molecular biologist interpreting the test results specially with borderline cases or of the patients with low viral load, handling practices by the test performing personnel, quantity of sample, sensitivity of the testing kit used)
A: In the context of Pakistan, it is advisable to approach NIH approved laboratories which are testing for COVID19
However, if the tests are not giving conclusive results, it is advisable to consider WHO guidelines first regarding testing equipment, material, and overall laboratory conditions
We also refer to NIH Pakistan who have provided all possible interpretations of test results: https://www.nih.org.pk/wp-content/uploads/2020/04/Laboratory-Testing-Recommendations-for-COVID-19.pdf
Q: Could Covid-19 be a sexually transmitted disease (STD)?
A: There is currently no evidence of sexual transmission of SARS-CoV-2. However, a recent article (link) reports some semen testing that was positive for the virus in 6 out of 38 confirmed Covid-19 cases. Despite the limited number of cases and possible questions (live virus or only RNA detected?), sexual transmission should therefore not be totally excluded.
The main mode of transmission of SARS-CoV-2 is through liquid droplets from the upper respiratory tract, including throat and nose. Regardless of these results, one should remember that close contact and more especially kissing are major risk factors.
Q: What is the chance of humans passing this on to animals or birds? Can SARS-CoV2 be transmitted from pets or wild animals to patients?
A: Coronaviruses are a large family of viruses that are common in animals. Occasionally, people get infected with these viruses which may then spread to other people. For example, SARS-CoV was associated with civet cats and MERS-CoV is transmitted by dromedary camels. Possible animal sources of COVID-19 have not yet been confirmed. To protect yourself, such as when visiting live animal markets, avoid direct contact with animals and surfaces in contact with animals. Ensure good food safety practices at all times. Handle raw meat, milk or animal organs with care to avoid contamination of uncooked foods and avoid consuming raw or undercooked animal products. WHO is aware of instances of animals and pets of COVID-19 patients being infected with the diseaseAs the intergovernmental body responsible for improving animal health worldwide, the World Organization for Animal Health (OIE) has been developing technical guidance on specialized topics related to animal health, dedicated to veterinary services and technical experts (including on testing and quarantine);There is a possibility for some animals to become infected through close contact with infected humans. Further evidence is needed to understand if animals and pets can spread the disease; Based on current evidence, human to human transmission remains the main driver; It is still too early to say whether cats could be the intermediate host in the transmission of the COVID-19.
Q: If a person is infected (both symptomatically or asymptomatically) and they smoke a cigarette, is it possible to pass it to people nearby through secondhand smoke?
A: Coronavirus is thought to mainly spread through person-to-person contact when an infected person coughs, sneezes or speaks, producing respiratory droplets which land in the mouths or noses of those nearby. While we were unable to find information directly on the topic of smoking, it is likely that these respiratory droplets are also produced when an infected person exhales smoke. Therefore, coronavirus could be passed by smokers not through secondhand smoke but through respiratory droplets.
Q: What are the chances of vertical transmission (mother to child)?
A: We still do not know if a pregnant woman with COVID-19 can pass the virus to her foetus or baby during pregnancy or delivery. To date, the virus has not been found in samples of amniotic fluid or breast milk. Mother-to-child transmission of coronavirus during pregnancy is unlikely, but after birth a newborn is susceptible to person-to-person spread.
Q: Is it right to keep a large number of beds in one big hall designated as a Quarantine center?
A: Page 4 of the document found at this link gives recommended guidelines for quarantine centers. Rooms should be well ventilated and each bed should be separated by 1-2 meters on all sides. https://ncdc.gov.in/WriteReadData/l892s/90542653311584546120.pdf
Q: Do severe/critical case patients pose more risks than patients with milder symptoms in Isolation ward with > 1 patient? Is it safe for a suspected person, coming for testing, to wait in open air with proper distancing?
A: Critically ill patients in ICU if on Ventilatory support or on suction are also generating aerosols. HCW needs to handle them more often thus critical patients can transmit the disease more easily than healthy patients in isolation wards. Secondly, Yes, it is safe to keep testing patients in open rather than in room. Reason is simply dilution of viruses in air and less chance of transmission. Indus Hospital is doing the same. Solution for Pollution is dilution.
Q: Is it possible to aerosolize the virus by flushing a toilet and transmitting it that way?
A: The virus that causes COVID-19 has been detected in the feces of some patients diagnosed with COVID-19. The amount of virus released from the body (shed) in stool, how long the virus is shed, and whether the virus in stool is infectious is not known. The risk of transmission of the virus that causes COVID-19 from the feces of an infected person is also unknown. However, the risk is expected to be low based on data from previous outbreaks of related coronaviruses, such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). There has been no confirmed fecal-oral transmission of COVID-19 to date. CDC is reviewing all data on COVID-19 transmission as information becomes available. At this time, the risk of transmission of the virus that causes COVID-19 through sewerage systems is thought to be low. Although transmission of the virus that causes COVID-19 through sewage may be possible, there is no evidence to date that this has occurred. The World Health Organization has indicated that “there is no evidence to date that COVID-19 virus has been transmitted via sewerage systems, with or without wastewater treatment.”
There have been no reports of fecal−oral transmission of the COVID-19 virus.
Q: Do food animals (*presumably animals used for food) have receptors for this virus like feline and canine families do?
A: We don’t know for sure which animals can be infected with the virus that causes COVID-19. CDC is aware of a very small number of pets, including dogs and cats, outside the United States reported to be infected with the virus that causes COVID-19 after close contact with people with COVID-19. A tiger at a zoo in New York has also tested positive for the virus.
Recent research shows that ferrets, cats, and golden Syrian hamsters can be experimentally infected with the virus and can spread the infection to other animals of the same species in laboratory settings. Pigs, chickens, and ducks did not become infected or spread the infection based on results from these studies. Data from one study suggested dogs are not as likely to become infected with the virus as cats and ferrets. These findings were based on data from a small number of animals, and do not indicate whether animals can spread infection to people.
There is no evidence for any such transfer from companion animals and animal products.
Q: Is SARS-COV 2 an airborne disease?
A: COVID-19 is mainly transmitted through droplets generated when an infected person coughs, sneezes, or speaks. These droplets are too heavy to hang in the air. They quickly fall on floors or surfaces. Airborne precautions must be taken in settings where aerosol generating procedures and support treatment are being performed
Q: What are aerosol producing procedures in labs and in hospitals?
A: The procedures or support treatments that generate aerosols include; i.e., endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, turning the patient to the prone position, disconnecting the patient from the ventilator, non-invasive positive-pressure ventilation, tracheostomy, and cardiopulmonary resuscitation.
Q: Is there any evidence of transmission of COVID-19 through blood transfusion?
A: According to Canadian Blood Services, “viruses rely on ‘binding sites’ on their host cells, proteins which allow them to attach and invade the host immune system. The binding sites for COVID-19 are located in the lungs and the intestines. “There is no evidence this new coronavirus targets blood cells, or even uses plasma to move around and invade other organs,”
There’s no evidence the respiratory virus can be transmitted by blood. COVID-19 is primarily a respiratory virus, with potential to infect the digestive system as well. People can get infected when they inhale or ingest the virus, but not via a blood transfusion.(Canadian Blood Services) According to the US Food and Drug Administration, “respiratory viruses are not known to be transmitted by blood transfusion, and there have been no reported cases of transfusion-transmitted coronavirus.”
Q: Can flies and other insects transfer COVID from secretions / excretions of patients to healthy persons?
A: At this time, CDC has no data to suggest that this new coronavirus or other similar coronaviruses are spread by mosquitoes or ticks. The main way that COVID-19 spreads is from person to person. See How Coronavirus Spreads for more information.
To date there has been no information nor evidence to suggest that the new coronavirus could be transmitted by mosquitoes.
Questions about the virus:
Q: Can the body fluids or samples from COVID-19 patients be used as bioweapons?
A: The following article discusses this exact question: https://www.researchgate.net/profile/Jorma_Jormakka2/publication/340916582_Is_Covid-19_a_bioweapon/links/5ea3d73245851553faace328/Is-Covid-19-a-bioweapon.pdf
However, to determine how much impact COVID19 has had on societies, and thus why it is important to consider scientific evidence first and foremost, we are linking articles which analyze the psychosocial impact of COVID19 on societies:
Q: How to prevent spread of virus from corpses and dead bodies?
A: The Government of Pakistan provides a guideline for Infection Prevention and Control (IPC) for the safe management of a Dead body during COVID-19 Outbreak.
Q: What is the main reason of recovery after Cov-2 Positive, since there is no medicine developed so far?
A: The immune response generated against the viral agent results in protection and harnesses the recovery of the patient. However, no study has evaluated whether the presence of antibodies to SARS-CoV-2 confers immunity to subsequent infection by this virus in humans.
Discharged patients who recovered from COVID-19 produce virus-specific antibodies and T cells, However, the responses of different patients are not all the same.
Q: When to use the antimalarial drug for positive patients?
A: On May 1, 2020, FDA issued an Emergency Use Authorization to allow remdesivir to be distributed and used by licensed health care providers to treat adults and children hospitalized with severe COVID-19.
Chloroquine phosphate and hydroxychloroquine may possibly help very sick patients, FDA is allowing these drugs to be provided to certain hospitalized patients under an EUA issued March 28, 2020.
Health professionals who are being exposed to COVID-19 positive patients and those who test positive but are asymptomatic should be taking drugs such as Chloroquine and Hydroxychloroquine. These populations remain most in need, and because of limited supply, these individuals need to be prioritized.
Q: How long this Pandemic situation lasts?
A: It is likely that SARS-CoV-2 will continue to circulate in the human population and will synchronize to a seasonal pattern with diminished severity over time, as with other less pathogenic coronaviruses
Q: Does it have any relevancy with changing weather pattern?
A: It is not yet known whether weather and temperature affect the spread of COVID-19
Q: What are the SOPs for Travelers from abroad before Corona Test?
A: The following document elaborates the SOPs for international passengers during COVID-19 pandemic. http://covid.gov.pk/travel_guidelines/SOPs%20for%20International%20Passenger%20Flights__.pdf
Q: Why the rate of mortality is lower in Asian countries as compared to Europe or USA?
A: The high-risk group of people aged 60 and above being affected are less in Asian countries (particularly Pakistan and India) as compared to in Europe and the US, and presence of less severity of the virus in the region.
Q: What should you do if a person has symptoms, but their test comes back as negative?
A: If a person test negative for COVID-19 by a viral test, he probably was not infected at the time when sample was collected. However, that does not mean that a person will not get sick. The test result only means that he did not have COVID-19 at the time of testing. If someone test positive or negative for COVID-19, no matter the type of test, still he should take preventive measures to protect himself and others.
There is a chance of either a false negative result and or presence of some other viral infection.
Q: Does age factor pose more threat in case of infection or any link with patients having respiratory complication?
A: The mortality of elderly patients with COVID-19 is higher than that of young and middle-aged patients. Elderly patients with COVID-19 are more likely to progress to severe disease.
Q: Why mortality rate due to SARS-CoV-2 seems to be higher in KP?
A: Until scientific evidence presents the actual courses, or until government presents solutions which KP government is able to implement, PBSA cannot comment on the reasons. Currently, reports are being presented by media outlets. It is noteworthy that, according to the Pakistan government official covid19 stats (as of May 6 2020), KP had 939 recovered cases out of 3712
Q: What are the chances of getting infection from dead bodies of COVID patients, what is infectious potential of the corpses at different time since death?
A: We refer to the following March 2020 guidance by WHO (https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf).
Guidelines for handling dead bodies and funerals
Q: How can we dispose of dead bodies safely?
A: Except for hemorrhagic fevers and cholera, dead bodies are generally not infectious. With respect to Covid-19, only the lungs or upper respiratory tract might be a source of infection if not handled properly, for instance during autopsy. However, to date there is no evidence of any case of someone becoming infected from exposure to the bodies of persons who died from Covid-19.
As a result, no precautions other than standard measures to handle bodies, including hand hygiene before and after interaction with the body, as well as wearing of PPE adapted to nature and level of intervention on the body are needed. People who have died from Covid-19 can be either buried or cremated, and it is generally recommended not to modify funeral practices (except for the protection of the attendees from each other).
Q: Is it possible the virus was designed artificially through synthetic biology? Why did it come so suddenly? Wouldn’t we expect a longer duration of reported cases rather than so many clusters of cases in a short period of time? Can this be the case with a slowly evolving virus?
- No. Evidence suggest that the virus is a naturally evolved disease-causing agent. It was not developed through synthetic biology. It was first identified in Wuhan, China as a result of an animal-to-human transfer.
https://www.nature.com/articles/s41564-020-0695-z. As far as pandemic aspects of COVID19 are concerned, we refer to the following article.
Q: Does temperature affect COVID19?
A: Generally, coronaviruses survive for shorter periods at higher temperatures and humidity than in cooler or drier environments. However, we don’t have direct data for this virus, nor do we have direct data for a temperature-based cutoff for inactivation at this point. The necessary temperature would also be based on the materials of the surface, the environment, etc. Regardless of temperature please follow CDC’s guidance for cleaning and disinfection.
Outside body: If virus is outside the body and is on any surface, researchers have demonstrated that it deactivates earlier at higher temperatures. Inside Body: Our body follow a homeostasis mechanism and slight rise in temperature (as in fever) will not have effect of killing the virus.
The COVID-19 virus can be transmitted in ALL AREAS, including areas with hot and humid weather and in areas with cold weather. The normal human body temperature remains around 36.5°C to 37°C, regardless of the external temperature or weather.
Questions about treatment:
Q: Do you suggest the use of hyperimmune serum to treat COVID-19 patients?
A: It is too early to suggest these treatments. Many types of treatments and vaccines are under trial and we have to wait until we get scientific evidence.
Several studies are in process of using hyperimmune serum of recovered patients for treatment of confirmed patients.
Q: Could drinking hot water would be helpful to denature SARS-CoV2 proteins which is present in a patient’s body?
A: There is no scientific evidence to this theory till now. Once the virus is inside the body of a human, drinking hot water will not kill the virus.
Q: Are antimalarial, anti-influenza, and drugs against HIV drugs effective in treating patients with COVID-19?
A: Some drugs have shown an in vitro effect to treat the COVID-19, but any drug has to pass human trials before it gets approved. Likewise, some drugs were found effective against COVID-19 but required a dose which was toxic to human cells. Therefore, It is too early to say if these are effective to treat COVID-19 inside a human body. We have to wait until clinical trials show evidence of their effectiveness.
Studies are being carried out but no confirmed treatment is finalized by WHO yet. WHO has launched the mega trial of four drugs as well.
Q: Can you use one ventilator to support multiple patients at the same time to meet the disaster surge? Is it safe?
A: No, it should not be used, but several studies are under process. The US Public Health Department suggests occasional use of a single ventilator (If all other alternatives are exhausted, care providers could consider ventilation of two patients on a single ventilator for short-term use, although there are significant limitations to this strategy. Alternatively, manual bag-valve-mask ventilation done by ancillary providers can be considered as a bridging option to mechanical ventilation)
Questions from researchers
Q: What precautions are important if serum separation of Positive COVID blood sample is done in BSL 2 level labs?
A: Unless a country decides otherwise, taking into account the newly acquired knowledge and effective preventive measures described above, viral isolation on clinical specimens from patients who are suspected or confirmed to be infected with novel corona virus should be performed only in laboratories capable of meeting the following additional essential (minimal) containment requirements: • A controlled ventilation system which maintains directional airflow into the laboratory room.
- Exhaust air from the laboratory room is not recirculated to other areas within the building. Air should be HEPA filtered, if reconditioned and recirculated within the laboratory. When exhaust air from the laboratory is discharged to the outdoors, it must be dispersed away from occupied buildings and air intakes. This air may be discharged through HEPA filters.
- All manipulations of infectious or potentially infectious materials must be performed in appropriately maintained and validated Biological Safety Cabinet (BSC)
- Access to the laboratory is restricted when work is in progress.
- Practices recommended for containment laboratories — Biosafety Level 3 in the WHO Laboratory biosafety manual, 3rd edition, are rigorously followed.
- Laboratory workers should wear protective equipment, including disposable gloves, solid front or wrap-around gowns, scrub suits, or coveralls with sleeves that fully cover the forearms, head coverings, shoe covers or dedicated shoes, eye protection (goggles or face shield), and respiratory protection (fit-tested particulate respirator, e.g. EU FFP2, US 6 NIOSH-certified N95 or equivalent, or higher protection), because of the risk of aerosol or droplet exposure.
- A dedicated hand-wash sink should be available in the laboratory.
- Centrifugation of specimens should be performed using sealed centrifuge rotors or sample cups. These rotors or cups should be loaded and unloaded in a BSC.
- All materials transported within and between laboratories should be placed in a secondary container to minimize the potential for breakage or a spill. An example includes transfer of materials from the biological safety cabinet to an incubator and vice versa. Specimens leaving the BSC should be surface decontaminated.
Q: Is it possible to transmit the virus through aerosols while processing biological fluids (blood, serum or urine) in lab?
A: There are still many things unknown about transmission of the virus. For procedures with a high likelihood to generate aerosols or droplets, use either a certified Class II Biological Safety Cabinet (BSC) or additional precautions to provide a barrier between the specimen and personnel. Examples of these additional precautions include personal protective equipment (PPE), such as a surgical mask or face shield, or other physical barriers, like a splash shield; centrifuge safety cups; and sealed centrifuge rotors to reduce the risk of exposure to laboratory personnel.
Site- and activity-specific biosafety risk assessments should be performed to determine if additional biosafety precautions are warranted based on situational needs, such as high testing volumes, and the likelihood to generate infectious droplets and aerosols.
Q: What would you recommend as the minimum requirements of lab design, infrastructure and equipment to start molecular testing of Covid19 testing in a Lab?
A: Routine laboratory procedures, including diagnostic work and PCR analysis on clinical specimens from patients who are suspected or confirmed to be infected with novel coronavirus should be conducted adopting practices and procedures described for basic laboratory — Biosafety Level 2 (BSL-2), as detailed in the WHO Laboratory biosafety manual, 3rd edition.
Q: Which BSL level is required for working with SARS COV 2?
A: Routine diagnostic testing of patient specimens, such as the following activities, can be handled in a BSL-2 laboratory using Standard Precautions:
- Using automated instruments and analyzers
- Staining and microscopic analysis of fixed smears
- Examination of bacterial cultures
- Pathologic examination and processing of formalin-fixed or otherwise inactivated tissues
- Molecular analysis of extracted nucleic acid preparations
- Final packaging of specimens for transport to diagnostic laboratories for additional testing. Specimens should already be in a sealed, decontaminated primary container
- Using inactivated specimens, such as specimens in nucleic acid extraction buffer
- Electron microscopic studies with glutaraldehyde-fixed grids
Q: Reasons for high rate of false positive or false negative results during corona PCR testing?
A: In the case of real-time RT-PCR negative result with clinical features suspicion for COVID-19, especially when only upper respiratory tract samples were tested, multiple sample types in different time points, including from the lower respiratory tract if possible, should be tested. Importantly, combination of real time RT-PCR and clinical features especially CT image could facilitate disease management. Proper sampling procedures, good laboratory practice standard, and using high quality extraction and real-time RT-PCR kit could improve the approach and reduce inaccurate results
Q: Given the 40% false negative rate from the NF antigen test, what can be done? E.g. multiple tests and/or combining it with AB testing, reconsidering reliability of testing asymptomatic etc
A: Doctors need better training and information on how to administer the tests, and when. People with serious symptoms who test negative need multiple tests, in order to ensure their diagnosis is certain. And most importantly, patients with symptoms that are consistent with COVID should still behave as though they are infected, no matter what their lab results suggest
Questions for hospitals and healthcare workers
Q: What recommendations are there for health workers to prevent them from infecting their families when they go home after treating COVID-19 patients?
A: They take off all of the scrubs from work. They put them directly into the washing machine. Shoes stay in a nearby plastic container. Walking into the house, they go directly to the shower. Only after a hot shower does he (or she) return to begin the laundry.
Q: What is the recommended approach to regular testing of asymptomatic medical staff given the increased hospital workload?
A: Asymptomatic Casual Contacts Can remain at Work.
Q: Is there a need of blood sample for corona PCR testing?
A: For RT_PCR, the specimen is usually collected from the upper respiratory tract using the nasopharyngeal swab and/or oropharyngeal swab technique ; a sample is gathered from the throat behind the nose, containing a mixture of mucous and saliva.
Q: How reliable is serological testing for COVID-19?
A: FDA still expects tests to be validated even under the emergency revised policy for tests. However, the EUA process or an evaluation by NIH supports greater confidence in test performance.
Q: What are the appropriate diagnostic tests for corona testing?
A: PCR is gold standard for COVID-19 testing.
Nucleic acid amplification tests (NAAT) for COVID-19 virus, Serological testing, viral sequencing
Q: What is the body’s own interferon release level in response to COVID-19?
A: Interferons have been shown to possess a crucial role in the defense against coronavirus diseases. The virus can impede the interferon induction in humans. Moreover, STAT1, a key protein in the interferon mediated immune response, is antagonized by the virus. This could explain the increased response threshold of immune cells to IFNs during CoV infections. A vivid correlation between the innate immune response threshold and the fatality rates in COVID-19 can be found.
Q: Can you get COVID-19 again? After how long?
A: CDC and partners are investigating to determine if you can get sick with COVID-19 more than once. At this time, we are not sure if you can become re-infected. Until we know more, continue to take steps to protect yourself and others.
We know that for similar coronaviruses, infected people are unlikely to be re-infected shortly after they recover. However, because the immune response to COVID-19 is not yet understood, it is not yet known whether similar immune protection will be observed for patients who have recovered from COVID-19
Q: When a patient or person spends 14 days in quarantine, will he/she be completely free of virus or can he still shed virus?
A: Quarantine means separating a person or group of people who have been exposed to a contagious disease but have not developed illness (symptoms) from others who have not been exposed, in order to prevent the possible spread of that disease. Quarantine is usually established for the incubation period of the communicable disease, which is the span of time during which people have developed illness after exposure. For COVID-19, the period of quarantine is 14 days from the last date of exposure because the incubation period for this virus is 2 to 14 days. Someone who has been released from COVID-19 quarantine is not considered a risk for spreading the virus to others because they have not developed illness during the incubation period.
Yes, provided quarantine is done properly a person can be declared virus free.
Q: What could be the best ways to tackle anxiety arising out of spread of mis-information?
A: First of all, read valid information sources instead of media. Use Meditation to soothe yourself. One must not rely totally on social and electronic media for information. Look at reliable resources of information;
National Action Plan for Preparedness and Response to COVID-19 Pakistan, https://www.nih.org.pk/novel-coranavirus-2019-ncov,
The Centers for Disease Control and Prevention https://www.cdc.gov/coronavirus/2019-ncov/index.html,
The World Health Organization, https://www.who.int/docs/default source/coronaviruse/situation-reports/20200216-sitrep-27-covid-19.pdf
NIH: US National Library of Medicine (MedinePlus), https://medlineplus.gov/coronavirusinfections.html, Elsevier Coronavirus Information Center https://www.elsevier.com/connect/coronavirus-information-center
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The Pakistan Biological Safety Association is a non-profit, non-governmental professional organization dedicated to the provision of comprehensive knowledge related to Biosafety issues in Pakistan.