Disaster Medicine and Public

Health Preparedness
Occupational Health and Safety Measures in
Healthcare Settings during COVID-19: Strategies
www.cambridge.org/dmp for Protecting Staff, Patients and Visitors
Isra Asma Ahmad1 and Ernest Osei2,3,4,5
Concepts in Disaster 1
Department of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada; 2Department
Medicine of Medical Physics, Grand River Regional Cancer Centre, Kitchener, ON, Canada; 3Department of Physics and
Astronomy, University of Waterloo, Waterloo, ON, Canada; 4Department of Systems Design Engineering,
Cite this article: Ahmad IA and Osei E. University of Waterloo, Waterloo, ON, Canada and 5Department of Clinical Studies, Ontario Veterinary College,
Occupational health and safety measures in University of Guelph, Guelph, ON Canada
healthcare settings during COVID-19: Strategies
for protecting staff, patients and visitors.
Disaster Med Public Health Prep. doi: https:// Abstract
doi.org/10.1017/dmp.2021.294. The COVID-19 (SARS-CoV-2) pandemic has profoundly impacted almost every aspect of
Keywords: healthcare systems worldwide, placing the health and safety of frontline healthcare workers
covid-19; sars-cov-2; infection control at risk, and it still continues to remain an important public health challenge. Several hospitals
measures; nosocomial transmission; have put in place strategies to manage space, staff, and supplies in order to continue to deliver
healthcare settings optimum care to patients while at the same time protecting the health and safety of staff and
Corresponding author: patients. However, the emergence of the second and third waves of the virus with the influx of
Ernest Osei, new cases continue to add an additional level of complexity to the already challenging situation
Email: [email protected]. of containing the spread and lowering the rate of transmission, thus pushing healthcare systems
to the limit. In this narrative review paper, we describe various strategies including adminis-
trative controls, environmental controls, and use of personal protective equipment, imple-
mented by occupational health and safety departments for the protection of healthcare
workers, patients, and visitors from SARS-CoV-2 virus infection. The protection and safeguard
of the health and safety of healthcare workers and patients through the implementation of effec-
tive infection control measures, adequate management of possible outbreaks and minimization
of the risk of nosocomial transmission is an important and effective strategy of SARS-CoV-2
pandemic management in any healthcare facility. High quality patient care hinges on ensuring
that the care providers are well protected and supported so they can provide the best quality of
care to their patients.

Introduction
The coronavirus disease (COVID-19) caused by the SARS-CoV-2 virus was declared a Public
Health Emergency of International Concern on January 30, 2020 and a pandemic on March 11,
2020 by the World Health Organization (WHO).1 Numerous studies have since reported that
SARS-CoV-2 is primarily transmitted through respiratory particles (such as droplets) falling
directly on individuals when an infected person who is unmasked, sneezes, coughs, or talks
and the infected secretions enter the mucous membranes of another person either through
the mouth, nose or eye.2–13 Furthermore, several studies have also reported that airborne trans-
mission of the virus can occur when particles float in the air for a prolonged period of time
(which is likely to occur during aerosol-generating procedures),2,6–9 and a person remains in
the environment for at least 15 minutes. According to Public Health Ontario,2 secondary trans-
mission of the virus can also occur if a person touches a contaminated surface and then proceeds
to touch the mouth, nose or eye. The Center for Systems Science and Engineering (CSSE) at
Johns Hopkins University,14 reported that there are currently over 191 million cases of
COVID-19 and over 4.1 million COVID-19 related deaths worldwide as at July 20, 2021.
The continual emergence of new SARS-CoV-2 variants has added an additional level of com-
plexity to the already challenging situation of containing the spread and lowering the rate of
transmissions.
© The Author(s), 2021. Published by Cambridge The SARS-CoV-2 pandemic still remains a significant public health challenge as most
University Press on behalf of Society for Disaster healthcare systems worldwide have limited capacity and resources to handle the influx of
Medicine and Public Health, Inc. new cases each day.15–17 Consequently, public health officials and policy makers worldwide
are constantly developing new strategies based on continuously changing evidence-based guide-
lines to manage the spread of the virus in order to help alleviate its burden on healthcare systems
and to save the lives of thousands of people. Furthermore, occupational health and safety depart-
ments and administrators in hospitals have been working closely with public health offices to
develop policies providing optimal protection for healthcare workers, patients, and visitors via
elimination of all possible transmission pathways to prevent nosocomial transmissions. One of
2 IA Ahmad and E Osei

the important tenets of effective pandemic management has been control measures (i.e. triaging procedures, limiting the number
the protection and safeguard of the health and safety of healthcare of people into the hospital, cohorting of patients and staff),
workers and patients through implementation of effective safety environmental control measures (i.e. effective surface cleaning,
measures at hospitals to avoid or minimize potential nosocomial adequate ventilation, and air filtration), engineering control mea-
transmissions.20,25,26,38,41 Numerous studies have reported that sures, the proper use of personal protective equipment (PPE) such
the establishment and implementation of robust infection preven- as face masks and respiratory hygiene, and the elimination of the
tion management policies in hospital settings are vital in minimiz- hazard.
ing the spread of SARS-CoV-2.18–21 Moreover, high quality patient
care hinges on ensuring that the care providers are very well pro- Administrative controls
tected and supported so they can provide the best quality of care to Administrative controls are modifications in work procedures
their patients. Therefore, the goal of this narrative review paper is including timing of work, policies, rules and regulations, work
to describe various infection control strategies implemented by practices (including training, supervision, housekeeping, personal
occupational health and safety departments in healthcare settings hygiene practices, equipment maintenance, and schedules) that are
and played paramount roles in reducing nosocomial spread for instituted to prevent or eliminate exposure of staff, patients, and
the protection of healthcare staff, patients and visitors against visitors to any hazards that may be present within the healthcare
the COVID-19 and prevent healthcare facilities from becoming the settings.32,35,36 Administrative controls are very effective in reduc-
epicenters of SARS-CoV-2 virus transmission. ing or limiting the transmission of infectious diseases in healthcare
settings through the identification of all the potential exposure
Protection of healthcare workers pathways and the implementation of practices and policies
required to prevent or eliminate the source of spread of exposures.
The public health and hospital-based Occupational Health and
The primary objective of administrative control measures imple-
Safety departments in several countries have collaborated using
mented in hospitals is to ensure that patients, visitors, and health-
the best available evidence-based guidelines to provide protection
care staff who may be infected with any infectious disease such as
for frontline healthcare workers, patients and visitors against
COVID-19 could be promptly identified, diagnosed, isolated, and
SARS-CoV-2, and COVID-19. The protection of healthcare
treated in an effort to prevent the spread of the infection to others
professionals is paramount to the sustainability of healthcare sys-
within the hospital.32,37,38 Several studies have reported that the
tems in any pandemic since they play a pivotal role in the delivery
success of any administrative control measures instituted within
of safe and effective treatment for patients while maintaining their
healthcare settings is heavily dependent on the careful guidance
safety.22–24 Healthcare professionals bear the brunt of the current
and directions provided by the occupational health and safety
pandemic with the management of various surges of new cases
departments and any infection prevention disease committees that
each day, working longer hours, frequent shifts, and possibly fewer
may have been established to manage and prevent the spread of the
breaks while potentially compromising their own health to support
infection.32,35,48 The occupational health and safety departments
COVID-19 patients. According to Abbas et al.,25 healthcare work-
within healthcare facilities serve to ensure that the organization
ers are at greater risk of contracting the virus since they work in
has the resource capacity, knowledge, training, policies and proce-
environments with active transmission and a myriad number of
dures to adequately implement any established infection control
exposure pathways through both indirect and direct contact with
measures. According to Su et al.,35 administrative control measures
patients who may be infected with the virus. Moreover, lessons
can be effective in reducing the transmission of infections if they
learnt from past epidemics such as the Severe Acute Respiratory
are well implemented, adequately enforced, and continually moni-
Syndrome (SARS) show that inadequate protection of healthcare
tored to better facilitate staff, patient, and visitor compliance.
staff could potentially lead to staff shortage as absenteeism may
Several studies have reported that administrative control measures
increase, and the few remaining staff may be required to complete
such as triage procedures at main entrances of the facility, limiting
additional care duties and work longer hours which could poten-
the number of patients and visitors to the facility, cohorting of
tially lead to occupational burnout.26–31 According to Temsah
patients and healthcare workers, and physical distancing practices
et al.,26 added work pressure on healthcare workers could take a
are all effective measures of preventing or limiting the spread of
toll on their mental well-being and potentially increase their
SARS-CoV-2 infection in hospitals.32,35–40,43–47,49–59,61 According
susceptibility to depression and post-traumatic stress disorder.
to Lu et al.,40 the establishment of infection control strategies such
Furthermore, inadequate protection and management of the
as material preparation and distribution, training on infection pre-
health of healthcare workers can have a ripple effect on patients
vention measures, a triage strategy, limiting traffic into the hospi-
and their families.26 Consequently, the design and effective imple-
tal, reorganization of hospital departments to minimize the
mentation of stringent and vigilant infection control policies and
number of people present at any particular time, and keeping
procedures aimed at the protection and care of healthcare workers,
the environment sanitized are very effective strategies to contain
is an important cornerstone for the prevention of nosocomial
the spread of the SARS-CoV-2.
SARS-CoV-2 infection and the sustainability of patient care.26
High quality patient care hinges on ensuring that the care provid-
Triaging procedures
ers are very well protected and adequately supported so that they
Triaging is a systematic process used to control patient flow in a
can provide the best quality of care to their patients.
clinic or a facility to ensure that those with urgent healthcare needs
are prioritized to receive immediate care.62 Studies have reported
Mitigation strategies to control the spread of sars-cov-2/
that the implementation of triaging processes within the healthcare
covid-19
system has significant potential to prevent the spread of nosoco-
Several studies have reported on effective strategies required to mial infection through prompt identification of patients, staff,
control the spread of SARS-CoV-2 within healthcare settings such and visitors who may be infected with SARS-CoV-2. Furthermore,
as staff vaccination,32–47 the implementation of administrative ensuring the triaging procedures are tailored towards prompt
Disaster Medicine and Public Health Preparedness 3

identification and detection of SARS-CoV-2 affected individuals possible surge in COVID-19 cases. Liu et al.,42 also reported
is very critical in reducing exposure by staff, patients, and that adding restrictions to the number of visitors, maintaining a
visitors.36,39,63–67 Lee et al.,68 reported that the implementation of visitor log, and limiting the number of entrances to the hospital
proper triage procedures is an important factor in helping to pre- are important access control strategies to limit the number of
vent the spread of SARS-CoV-2. According to Wong et al.,36 Wang people in the hospital, thereby reducing nosocomial spread of
et al.,39 and Lee et al.,68 an effective triaging process can be estab- SARS-CoV-2.
lished for early identification of patients, staff, and visitors who Lu et al.,40 described infection control measures that were estab-
may be infected with SARS-CoV-2, and should be set up only at lished in a West China Hospital in an Ear-Nose-and-Throat (ENT)
the main entrances of the healthcare facility to ensure that all department to protect healthcare workers and patients from poten-
patients, staff, and visitors entering the facility are screened using tial SARS-CoV-2 infection. They reported that in order to decrease
the same standard questionnaire. However, in order to minimize the number of patients present at the ENT clinic, they separated the
congestion at the facilities’ entrances, it is suggested that different waiting area from the treatment area, reduced the number of
triage stations should be established at 2 different main entrances; appointments, re-scheduled appointments at different times,
1 to be used by staff and the other by patients and visitors. restricted visitation to a single visitor, increased online consulting
Furthermore, it is important that all other access to the healthcare services, and initially suspended elective surgeries. They concluded
facility is inaccessible to all staff, patients, and visitors. Lee et al.,68 that the infection control measures that were implemented signifi-
reported that performing temperature checks, asking about cantly reduced the number of people in the clinic and were very
patients travel history, close contacts, and new symptoms, are very effective in preventing nosocomial SARS-CoV-2 infection in the
important information to gather as part of the triage process. They ENT department. Wang et al.,59 investigated the impact of imple-
reported the installation of infrared thermal cameras within hos- menting recommendations that were outlined by the National
pitals in Taiwan as part of the triaging process for prompt detection Cancer Center and Chinese Academy of Sciences for the protection
of patients, visitors, or staff with elevated body temperatures of patients and staff from contracting SARS-CoV-2. They reported
(fever) as an effective approach for temperature checks in hospitals. suspending elective surgeries, reducing inpatient and outpatient
Numerous studies have reported that the most common screening visits in the oncology department, suspending chemotherapy treat-
criteria questions used in most healthcare facilities at triaging sta- ments where possible, and using oral administration of anti-cancer
tions include the following: asking patients/ staff/ visitors if (i) they drugs for patients. They observed that the precautions employed
are experiencing any symptoms of upper respiratory infection, (ii) were very successful in preventing the spread of cross infection
travelled outside the country within the past 14 days, (iii) if they since no COVID-19 cases were reported among staff or patients
have visited any facility with known outbreak, and (iv) if they have in the department during the time of the study. They concluded
been in contact with any individual who has been diagnosed with that during the COVID-19 era, it is possible to continue to provide
COVID-19.36,39,69–72 If a patient, staff or visitor responds yes to treatment to patients with cancer who urgently require it, without
any of the questions, it is recommended that they be immediately compromising patients’ health, by implementing appropriate
placed in an airborne isolation room and tested for SARS-CoV-2. safety measures that can prevent cross infection. Al-Shamsi
According to Wang et al.,39 the implementation of the triage pro- et al.,48 investigated some practical approaches to manage cancer
cedures in various hospitals have been very effective in prompt treatment during the SARS-CoV-2 pandemic. They recommended
identification of patients, staff, and visitors with infection and thus that deferring elective surgeries and outpatient visits, postponing
has significantly reduced the risk of transmissions in several chemotherapy and radiation treatment on a case-by-case basis,
hospitals. using alternative treatments such as oral anti-cancer therapy where
possible, and utilizing telemedicine for patient follow-up and sup-
Limiting traffic in healthcare facilities port, are imperative measures that can help reduce the number of
Studies have reported that limiting the number of people present in people in the facility and help curb the spread of infection and pre-
the healthcare facility at any given time is an effective strategy for vent potential risk of exposure to SARS-CoV-2. They concluded
the prevention and minimization of potential exposure and spread that these measures have the potential to minimize the spread
of SARS-CoV-2 in the facility.32,40,41,73–76 Consequently, a number of COVID-19 in healthcare facilities and protect patients who
of hospitals worldwide cancelled, postponed, or severely reduced are immunocompromised from contracting the infection. Jindal
several healthcare services including elective surgeries, patient et al.,53 also investigated the management practices of cancer
follow-up, face-to-face patient consults, cancer screening/preven- patients during this pandemic and suggested similar approaches
tion services, and certain diagnostic and treatment services. in order to provide safe cancer care. They suggested the deferment
Furthermore, several hospitals shifted to telemedicine, restricted of cancer patients’ regimes if they are tested positive for COVID-
in-hospital visitations, and implemented strategies for some staff 19/SARS-CoV-2 and acknowledged that treatment centers pose a
to work from home in an effort to minimize potential pathways great risk of exposure to the infection. They concluded that
of exposure to SARS-CoV-2.32,36,41,77 Although these measures although deferring treatment could minimize the spread of
may potentially reduce the spread of SARS-COV-2, it is recom- SARS-CoV-2, it can potentially compromise the health of patients
mended that 1 should carefully weigh the benefits of patient care and their condition could progress from potentially curable (with
with both the risk of patients contracting SARS-COV-2, and the near-normal life expectancy) to likely incurable (with much
downstream consequences of delaying, modifying, or cancelling reduced life expectancy).
diagnostic and treatment activities.77 A study conducted by The
Lancet Digital Health reported that the use of telemedicine Cohorting of patients
increased from 10% to 75% in the UK during the height of The World Health Organization characterized cohorting patients
the COVID-19 lockdown.78 According to Lai et al.,41 the postpone- as the concept of separating patients who have been infected by the
ment of elective surgeries will also ensure that healthcare facilities same laboratory confirmed pathogen into 1 ward.33 There is suffi-
have adequate resources (beds, ventilators etc.) and staff for cient evidence that suggests that cohorting patients is an effective
4 IA Ahmad and E Osei

measure in containing and preventing the spread of infections such an effective control measure for reducing SARS-CoV-2 transmis-
as gastroenteritis in hospital settings,50,55,79,80 and has been sion in healthcare facilities. The CDC has recommended that
reported to be potentially effective to reduce the risk of transmis- healthcare workers should minimize the number of patient
sion and exposure to SARS-CoV-2.43,44,56 The World Health encounters by simultaneously performing some medical proce-
Organization and the US Centre for Disease Control and dures or examinations where possible.34 Additionally,52,58,61 other
Prevention guidelines recommended the cohorting of COVID- studies have reported that developing healthcare teams is an effec-
19 patients as it can potentially limit the number of patients and tive measure in minimizing the risk of hospital-acquired infections.
healthcare workers who could be exposed to the virus and will help There is sufficient evidence suggesting that the cohorting of health-
contain its spread in the healthcare settings. Cohorting of patients care workers is effective in minimizing cross-transmission of infec-
has been a common practice in infection control strategies that are tious agents,51,57,59 and could potentially reduce cross transmission
utilized to manage outbreaks and the prevention of the spread of of SARS-CoV-2. Chandy et al.,45 examined evidence-based mea-
nosocomial infection.43,44,56,68 sures needed to reduce the transmission of SARS-CoV-2 among
According to Lee et al.,68 cohorting patients is an effective patients and staff in healthcare-settings. They reported that
strategy to reduce nosocomial SARS-CoV-2 infection when cross-covering staff who have been caring for patients with
coupled with other measures such as triaging procedures and COVID-19 in other units, can lead to intra-hospital transmission,
the use of personal protective equipment. Patterson et al.,44 inves- thus, cohorting COVID-19 healthcare teams is imperative.
tigated measures needed to protect patients with comorbidities Furthermore, they suggested that multiple teams should be devel-
who have been admitted to the hospital to prevent them from being oped as COVID-19 is highly contiguous and if members of 1 team
exposed to SARS-CoV-2. They reported using clinical, laboratory, need to go into isolation, the alternative staff members can fill in.
and radiological markers to promptly identify and cohort patients They concluded that there are multiple pathways of transmission
with COVID-19 in order to minimize the risk of exposure to staff and formulating healthcare teams can potentially prevent the
and other patients. The implementation of the cohorting strategy transfer of SARS-CoV-2 to non-COVID-19 patients and staff.
ensured that patients who tested negative for COVID-19/SARS- In a systematic review by Abad et al.,46 they reported that cohorting
CoV-2 did not acquire the infection during their hospital visit, patients and healthcare workers is an effective strategy to reduce
as they were housed in single occupancy rooms distanced from intra-hospital transmission of infectious diseases. They observed
patients who were COVID-19 positive. Furthermore, they reported that about 88.5% of studies have reported a significant reduction
that cohorting patients helped alleviate the demand for single occu- in the spread of infection when cohorting healthcare workers
pancy rooms, as patients who are infected were grouped together in was implemented with other infectious disease measures such as
the same space. As a result, single rooms were then utilized for cohorting patients, and good hand hygiene practices. They con-
patients with comorbidities or at greater risk for complications cluded that although determining the effectiveness of cohorting
due to COVID-19. They concluded that cohorting patients, is an healthcare staff can be challenging as typically, other mitigation
effective measure in preventing healthcare-associated COVID-19 measures are usually implemented simultaneously, they reported
infection among patients with comorbidities. that cohorting staff strengthens the overall infection control
Congregate care settings such as long-term care homes or nurs- strategy.
ing homes are also highly susceptible to COVID-19 outbreaks.
Cohorting residents, can often be a mitigation strategy that is uti- Environmental controls
lized in congregate care settings as an outbreak management strat- Environmental controls, both primary and secondary, are mea-
egy. Montoya et al.,56 examined some of the interventions sures that are usually instituted with the intent to reduce the
implemented to manage COVID-19 outbreaks at 3 different nurs- amount of droplet nuclei containing infectious pathogens that
ing homes in Michigan to avert further transmission to other res- may be present in the air.32,34,41 The primary environmental con-
idents and staff. They reported using cohorting residents with trols involve the utilization of mechanical ventilation systems such
COVID-19 as 1 of the many reduction and control strategies as hoods, to remove or reduce infectious microorganisms that may
implemented to manage the outbreaks at each of the nursing be present in the air, whereas the secondary environmental con-
homes. They found that cohorting residents who were SARS- trols involve the use of either the HEPA filtration or/and ultraviolet
CoV-2 positive through prompt testing decreased asymptomatic germicidal irradiation systems to remove aerosol causing diseases
transmission to other staff and residents. They concluded that agents from the air.81–90 According to Lee,81 controlling the direc-
cohorting the residents is an effective method for outbreak man- tion of airflow in enclosed spaces can potentially reduce the pres-
agement and lowering the prevalence of COVID-19 in nursing ence of aerosol causing diseases and thus minimize the likely
home settings. spread of diseases to adjoining spaces. Evidence suggests that
SARS-CoV-2 can be transmitted from an infected person to others
Cohorting of healthcare workers through respiratory droplets and aerosols, created when an infected
Cohorting of healthcare workers is also considered an effective person coughs/sneezes, sings, shouts, or talks.11,13,32 Thus incorporat-
administrative control measure that can be employed to minimize ing environmental control measures that are capable of removing
the exposure and reduce the risk of transmission of SARS-CoV-2 SARS-CoV-2 from the air, into infectious disease control strategies,
since the approach could significantly limit the number of staffs is important to reduce its spread in healthcare facilities.32,34,82
who interact with potentially infected patients.32,34,45,46,52,58,61 In Several studies have demonstrated that the implementation of
this approach, a group of healthcare workers are assigned to be environmental control measures such as adequate ventilation,
responsible for the care of only patients who are diagnosed to installation of air dampers and HEPA filtration systems, the redis-
be SARS-CoV-2 positive, thus limiting the number of other health- tribution of airflow in facilities, and regular maintenance of the
care workers to any potential exposure to the virus.32,34,45,46,52,58 heating, ventilation and air-conditioning systems are effective mit-
According to the Centers for Disease Control and Prevention igation strategies to minimize the spread of nosocomial SARS-
(CDC),34 minimizing the number of patient-staff interactions is CoV-2,41,82,89,91–95 Evidence suggests that adequate utilization of
Disaster Medicine and Public Health Preparedness 5

the heating, ventilation, and air conditioning systems in healthcare of PPE. The proper use of PPE can potentially prevent
facilities is imperative to help minimize airborne transmission of self-contamination as well as transfer of infection from person
SARS-CoV-2.41,82–91,95 Somsen et al.,82 investigated how ventila- to person, and several studies have established the importance of
tion levels impact the amount of airborne droplets present at a PPE in protecting healthcare workers and in prevention of the
given time in various spaces, to gain a better insight of airborne spread of nosocomial SARS-CoV-2 in health care settings.98–107
transmission in order to suggest appropriate mitigation strategies However, according to Hoernke et al.,101 it is important for hospital
needed to prevent the spread of SARS-CoV-2. They observed that administrators and occupational health and safety departments to
in spaces with adequate ventilation, the quantity of aerosols understand some of the challenges that frontline workers experi-
present in the air decreased by about 50% within 30 seconds of ence when using PPE, so that when developing pandemic prepar-
adequate ventilation, whereas a greater amount of aerosols persist edness strategies, they could help implement tailored approaches
in the air for a prolonged period of time in poorly ventilated spaces. to address some of staff concerns.
They concluded that poorly ventilated areas could lead to the Kalantary et al.,98 conducted a narrative review to identify the
spread of SARS-CoV-2 via aerosol droplets as they remain sus- different pathways of exposure to COVID-19 among healthcare
pended in the air for a prolonged period. Consequently, proper workers and on the use of PPE to prevent SARS-CoV-2 transmis-
ventilation plays a vital role in preventing airborne transmission sion. They indicated that healthcare workers are more susceptible
of SARS-CoV-2 by removing aerosol particles in the air. Lai to the acquisition of SARS-CoV-2 since they are more likely to be
et al.,41 examined different infection control measures imple- in close contact with infected patients, and reported that aerosol
mented at an ophthalmology clinic to minimize the spread of generating procedures such as tracheal intubation, tracheotomy,
SARS-CoV-2. They reported that adding fresh air dampers to and manual ventilation, are activities that pose the greatest risk
the ventilation system and using high efficiency particulate air fil- of transmission to healthcare workers. Consequently, they recom-
ters to purify the air and to remove the infectious droplets, could mended that to ensure adequate protection of staff, healthcare
potentially reduce infectious droplets present in the air, thus low- workers should always wear full PPE, including N95 respirators,
ering the concentration of droplets by redistributing airflow. They eye protection, gown, gloves, and aprons during aerosol generating
concluded that the implementation of this environmental control procedures, although regular surgical masks could be used during
measure is imperative in preventing the spread of SARS-CoV-2. non-aerosol generating procedures. They concluded that the use of
Saran et al.,91 also reviewed several heating, ventilation, and air PPE is imperative in protecting healthcare workers from acquiring
conditioning system guidelines for information on how healthcare SARS-CoV-2 and is an effective infection control measure in low-
facilities could improve or maintain high indoor air quality to pre- ering viral transmission. Tan et al.,99 reviewed the inconsistencies
vent the spread of nosocomial transmission. They suggested that, that are reported in the literature pertaining to the recommended
for optimal safety and protection of staff, any suspected or con- PPE use among surgical staff. They reported that all patients with
firmed COVID-19 patient should be admitted in an airborne iso- COVID-19 pose a significant risk to healthcare workers, thus
lation room with an air exchange rate of at least 6 air exchanges per proper use of PPE is deemed necessary in all procedures for opti-
hour for older facilities, and at least 12 air exchanges per hour for mal protection. They suggested the use of surgical mask, disposable
newly built facilities. They reported that guidelines from several gown, gloves, eye protection, and a head covering during non-
professional bodies suggest that all aerosol generating procedures aerosol generating procedures and the use of N95 respirators, dis-
relating to COVID-19 should be performed in well ventilated neg- posable long-sleeved gown, apron, gloves, eye protection, head
ative pressure rooms to mitigate airborne transmission. Adjusting covering, and shoe covering for aerosol generating procedures.
the air distribution, air flow rate, and air exchange rates of the heat- Furthermore, they suggested that in order to ensure optimal pro-
ing ventilation and air condition systems in such spaces would tection and minimize the risk of cross-contamination, all health-
potentially minimize infectious particles from reaching non- care workers should receive proper training on the donning on
contaminated spaces. They concluded that the heating ventilation and off of PPE and if possible, should appoint a staff member
and air condition systems in healthcare facilities could play an inte- who ensures that all members are donning on and off the PPE
gral role to prevent the spread of airborne nosocomial transmission in the proper sequence. They concluded that PPE is an important
of SARS-CoV-2 and proper utilization and maintenance of such line of defense against SARS-CoV-2 and should be readily available
systems should be incorporated in any pandemic management to all healthcare workers. Jamieson et al.,100 reviewed the recom-
program. mended practices on the use of PPE to minimize the risk of
SARS-CoV-2 exposure and ensure optimal protection for obstetri-
Personal protective equipment (PPE) cians. The main purpose of their study was to inform and guide
Personal protective equipment (PPE) serves as a barrier between healthcare workers on selecting the appropriate PPE based on
the wearer and the environment, to prevent pathogens from enter- the pathway of exposure. They reported the odds of contracting
ing the body, and has been proven to effectively protect healthcare a respiratory infection (0.09%) with proper and consistent use
workers from exposure to various pathogens.32,34,36,96 Some exam- of gloves, gown, mask, and eye protection, coupled with other
ples of PPE include surgical masks, N95 respirators, medical infection-control measures such as appropriate donning on and
gloves, gowns, goggles, and face shields.96 According to Barratt doffing off practices, adherence to proper hand hygiene practices
et al.,97 it is imperative that every healthcare setting has a well- and continual cleaning of high touch surfaces. They concluded that
established PPE program which clearly outlines any hazards that consistent and proper use of PPE in conjunction with adhering to
pose illness within the working environment, ensures adequate adequate hand hygiene practices are important and effective in
selection and use of PPE, clearly outlines donning on and off prac- reducing the risk of acquiring SARS-CoV-2 infection. Hoernke
tices, regular testing of PPE for staff, regular inventory check of et al.,101 investigated some of the challenges healthcare workers
PPE to determine if they have an adequate amount of supply in the UK experienced regarding the use of PPE during the
in case of any emergency, and regular staff training on the use SARS-CoV-2 pandemic. They observed that several healthcare
6 IA Ahmad and E Osei

frontline workers reported inadequate supply of PPE, did not Conflict of interest. The authors declare that the research was conducted in
receive proper training in the use of PPE, and there was lack of the absence of any commercial or financial relationships that could be construed
guidance and protocols on the prolonged use of PPE. as a potential conflict of interest.
Furthermore, staff reported some inherent restrictions with
the use of PPE such as difficulties communicating with patients,
developing skin reactions, and the discomfort of feeling too hot. References
They suggested that as a good practice to help minimize PPE
fatigue, staff should be encouraged to take breaks. They con- 1. Ohannessian R, Duong TA, Odone A. Global telemedicine implemen-
cluded that the use of PPE is very instrumental to help protect tation and integration within health systems to fight the covid-19 pan-
demic: A call to action. JMIR Public Health Surveill. 2020;6(2):e18810.
frontline workers from acquiring SARS-CoV-2 infection and
2. Ontario Agency for Health Protection and Promotion (Public Health
in prevention of transmission to colleagues and patients.
Ontario). COVID-19 routes of transmission- what we know so far; 2020.
Furthermore, they emphasized the importance of ensuring Toronto, ON: Queen’s Printer for Ontario. [Internet]. www.public
adequate supply of PPE, training staff on its proper use, and healthontario.ca/-/media/documents/ncov/covid-wwksf/2020/12/routes-
approaches to combat PPE fatigue.101 transmission-covid-19.pdf?la=en.
3. World Health Organization (WHO). Modes of transmission of virus
causing COVID-19: implications for IPC precaution recommendations:
Conclusion scientific brief, 27 March 2020. No. WHO/2019-nCoV/Sci_Brief/
Transmission_modes/2020.1.
The SARS-CoV-2/COVID-19 pandemic has significantly impacted 4. Endersby RVW, Ho ECY, Spencer AO, Goldstein DH, Schubert E.
almost every aspect of healthcare systems worldwide, placing the Barrier devices for reducing aerosol and droplet transmission in covid-19
health and safety of frontline workers at risk and still remains patients: advantages, disadvantages, and alternative solutions. Anesth
an important public health challenge. Furthermore, healthcare Analg. 2020;131(2):e121-e123.
facilities could be a potential source of the spread of infection as 5. Morawska L, Tang JW, Bahnfleth W, et al. How can airborne transmis-
sion of COVID-19 indoors be minimized?. Environ Int. 2020;142:105832.
patients with active SARS-CoV-2 infection may visit such facilities
6. Howard BE. High-Risk aerosol-generating procedures in covid-19:
for treatment or consultation. Consequently, the establishment,
Respiratory protective equipment considerations. Otolaryngol Head
implementation and enforcement of robust infection prevention Neck Surg. 2020;163(1):98-103.
management controls and policies in hospital settings are para- 7. Klompas M, Baker M, Rhee C. What is an aerosol-generating procedure?.
mount to reduce the risk of nosocomial infection, decrease the like- JAMA Surg. 2021;156(2):113-114.
lihood of healthcare workers contracting the infection, and thus 8. Hamilton GS. Aerosol-generating procedures in the COVID era.
minimize the spread of SARS-CoV-2. The protection and safe- Respirology. 2021;26(5):416-418.
guard of the health and safety of frontline healthcare workers 9. Bolton L, Mills C, Wallace S, Brady MC; Royal College of Speech and
and patients through the implementation of effective safety mea- Language Therapists (RCSLT) COVID-19 Advisory Group. Aerosol gen-
sures, adequate management of possible outbreaks and minimiza- erating procedures, dysphagia assessment and COVID-19: A rapid review.
tion of nosocomial transmission is an important and effective Int J Lang Commun Disord. 2020;55(4):629-636.
10. Larsen JR, Martin MR, Martin JD, Kuhn P, Hicks JB. Modeling the
strategy of pandemic management used by occupational health
onset of symptoms of covid-19. Front Public Health. 2020;8:473.
and safety departments in healthcare settings.
11. Wan S, Xiang Y, Fang W, et al. Clinical features and treatment of
COVID-19 patients in northeast Chongqing. J Med Virol. 2020;92(7):
797-806.
12. Filatov A, Sharma P, Hindi F, Espinosa PS. Neurological complications of
Search Strategy
coronavirus disease (covid-19): Encephalopathy. Cureus. 2020;12(3):e7352.
The following databases; PubMed (National Library of Medicine 13. Krajewska J, Krajewski W, Zub K, Zatoński T. covid-19 in otolaryngolo-
Bethesda, MD), PMC (U.S. National Institutes of Health’s gist practice: a review of current knowledge. Eur Arch Otorhinolaryngol.
National Library of Medicine, Bethesda, MD), NCBI (National 2020;277(7):1885-1897.
Center for Biotechnology Information, U.S. National Library of 14. Johns Hopkins Coronavirus Resource Center, The Center for Systems Science
and Engineering (CSSE) at Johns Hopkins University (JHU). Covid-19 dash-
Medicine), PNAS (National Academy of Science, Washington,
board. https://coronavirus.jhu.edu/map.html. Accessed 20 July 2021.
DC), Springer Link (Springer Nature, London, U.K.), Wiley 15. Shen X, Zou X, Zhong X, Yan J, Li L. Psychological stress of ICU nurses
Online Library (John Wiley & Sons Inc., Hoboken, NJ), The in the time of COVID-19. Crit Care. 2020;24(1):200.
Lacent, Science Direct (Elsevier, Amsterdam, The Netherlands), 16. Iyengar K, Mabrouk A, Jain VK, Venkatesan A, Vaishya R. Learning
Medline (National Library of Medicine, Bethesda, MD) were opportunities from COVID-19 and future effects on health care system.
searched from December 2019 to March 2021, for relevant studies Diabetes Metab Syndr. 2020;14(5):943-946.
published in English between 2010 and 2021, reporting on strate- 17. Blumenthal D, Fowler EJ, Abrams M, Collins SR. Covid-19 -
gies for protection of healthcare workers, patients, and staff from Implications for the health care system [published correction appears
nosocomial COVID-19 infections. The literature search used the in N Engl J Med. 2020 Jul 23;:]. N Engl J Med. 2020;383(15):1483-1488.
following keywords: ‘COVID-19,’ ‘nosocomial transmission,’ ‘pan- 18. Reeves JJ, Hollandsworth HM, Torriani FJ, et al. Rapid response to
demic management,’ ‘COVID-19 infection in hospitals,’ COVID-19: Health informatics support for outbreak management in
an academic health system. J Am Med Inform Assoc. 2020;27(6):853-859.
‘Protection against COVID-19,’ ‘Healthcare staff management in
19. Chang CM, Tan TW, Ho TC, Chen CC, Su TH, Lin CY. COVID-19:
COVID-19,’ ‘Infection control during COVID-19,’ ‘COVID-19 out- Taiwan’s epidemiological characteristics and public and hospital
break in hospital,’ ‘Strategies to control COVID-19,’ ‘Triage and responses. PeerJ. 2020;8:e9360.
COVID-19,’ ‘Cohorting patients and COVID-19,’ ‘Cohorting staff 20. Liang XH, Tang X, Luo YT, Zhang M, Feng ZP. Effects of policies and
and COVID-19.’ The searches were not limited by study design containment measures on control of COVID-19 epidemic in Chongqing.
and included conference abstracts, full research articles, and reviews. World J Clin Cases. 2020;8(14):2959-2976.
Disaster Medicine and Public Health Preparedness 7

21. Ho HJ, Zhang ZX, Huang Z, Aung AH, Lim WY, Chow A. Use of a real- An experience from Hong Kong. Graefes Arch Clin Exp Ophthalmol.
time locating system for contact tracing of health care workers during the 2020;258(5):1049-1055. doi: 10.1007/s00417-020-04641-8.
covid-19 pandemic at an infectious disease center in Singapore: Validation 42. Liu SY, Kang XL, Wang CH, et al. Protection procedures and preven-
study. J Med Internet Res. 2020;22(5):e19437. tions against the spread of coronavirus disease 2019 in healthcare settings
22. Malik JS, Jenner C, Ward PA. Maximizing application of the aerosol box for nursing personnel: Lessons from Taiwan. Aust Crit Care. 2021;
in protecting healthcare workers during the COVID-19 pandemic. 34(2):182-190.
Anaesthesia. 2020;75(7):974-975. 43. Cho JH, Kang SH, Park HC, et al. Hemodialysis with cohort isolation to
23. Chan PS, Berg RA, Nadkarni VM. Code blue during the COVID-19 pan- prevent secondary transmission during a covid-19 outbreak in Korea. J
demic. Circulation: Cardiovascular Quality and Outcomes. 2020;13(5): Am Soc Nephrol. 2020;31(7):1398-1408.
e006779. 44. Patterson B, Marks M, Martinez-Garcia G, et al. A novel cohorting
24. Nayna Schwerdtle P, Connell CJ, Lee S, et al. Nurse expertise: A critical and isolation strategy for suspected COVID-19 cases during a pandemic.
resource in the covid-19 pandemic response. Ann Glob Health. 2020;86(1):49. J Hosp Infect. 2020;105(4):632-637.
25. Abbas M, Nunes TR, Martischang R, et al. Nosocomial transmission and 45. Chandy PE, Nasir MU, Srinivasan S, Klass D, Nicolaou S, B Babu S.
outbreaks of coronavirus disease 2019: The need to protect both patients Interventional radiology and COVID-19: Evidence-based measures to
and healthcare workers. Antimicrobial Resistance & Infection Control. limit transmission. Diagn Interv Radiol. 2020;26(3):236-240.
2021;10(1):1-13. 46. Abad CL, Barker AK, Safdar N. A systematic review of the effectiveness
26. Temsah MH, Al-Sohime F, Alamro N, et al. The psychological impact of of cohorting to reduce transmission of healthcare-associated C. difficile
COVID-19 pandemic on health care workers in a MERS-CoV endemic and multidrug-resistant organisms. Infect Control Hosp Epidemiol. 2020;
country [published correction appears in J Infect Public Health. 2020 41(6):691-709.
Oct;13(10):1599]. J Infect Public Health. 2020;13(6):877-882. 47. Palmore TN, Henderson DK. Managing transmission of carbapenem-
27. Cai H, Tu B, Ma J, et al. Psychological impact and coping strategies of resistant enterobacteriaceae in healthcare settings: a view from the
frontline medical staff in Hunan between January and March 2020 during trenches. Clin Infect Dis. 2013;57(11):1593-1599.
the outbreak of coronavirus disease 2019 (COVID-19) in Hubei, China. 48. World Health Organization. Infection prevention and control of epidemic-
Med Sci Monit. 2020;26:e924171. and pandemic-prone acute respiratory infections in health care; 2014.
28. Walton M, Murray E, Christian MD. Mental health care for medical staff 49. Al-Shamsi HO, Alhazzani W, Alhuraiji A, et al. A practical approach to
and affiliated healthcare workers during the COVID-19 pandemic. Eur the management of cancer patients during the novel coronavirus disease
Heart J Acute Cardiovasc Care. 2020;9(3):241-247. 2019 (covid-19) pandemic: An international collaborative group.
29. Billings J, Ching BCF, Gkofa V, Greene T, Bloomfield M. Experiences Oncologist. 2020;25(6):e936-e945.
of frontline healthcare workers and their views about support during 50. Barclay L, Park GW, Vega E, et al. Infection control for norovirus. Clin
COVID-19 and previous pandemics: A systematic review and qualitative Microbiol Infect. 2014;20(8):731-740.
meta-synthesis. BMC Health Serv Res. 2021;21(1):923. 51. Cooper BS, Stone SP, Kibbler CC, et al. Isolation measures in the hos-
30. Heath C, Sommerfield A, von Ungern-Sternberg BS. Resilience strate- pital management of methicillin resistant Staphylococcus aureus (MRSA):
gies to manage psychological distress among healthcare workers during Systematic review of the literature. BMJ. 2004;329(7465):533.
the COVID-19 pandemic: A narrative review. Anaesthesia. 2020; 52. French CE, McKenzie BC, Coope C, et al. Risk of nosocomial respiratory
75(10):1364-1371. syncytial virus infection and effectiveness of control measures to prevent
31. Mesa Vieira C, Franco OH, Gómez Restrepo C, Abel T. COVID-19: The transmission events: A systematic review. Influenza Other Respir Viruses.
forgotten priorities of the pandemic. Maturitas. 2020;136:38-41. 2016;10(4):268-290.
32. de Perio MA, Dowell CH, Delaney LJ, et al. Strategies for optimizing the 53. Jindal V, Sahu KK, Gaikazian S, Siddiqui AD, Jaiyesimi I. Cancer treat-
supply of N95 filtering face piece respirators during the coronavirus dis- ment during COVID-19 pandemic. Medical Oncology. 2020;37:1-3.
ease 2019 (COVID-19) pandemic. Disaster Med Public Health Prep. 54. Greig JD, Lee MB. A review of nosocomial norovirus outbreaks: Infection
2020;14(5):658-669. control interventions found effective. Epidemiol Infect. 2012;140(7):
33. World Health Organization (WHO). Infection prevention and control 1151-1160.
during health care when COVID-19 is suspected: Interim guidance; 19 55. MacCannell T, Umscheid CA, Agarwal RK, et al. Guideline for the pre-
March 2020 (No. WHO/2019-nCoV/IPC/2020.3). vention and control of norovirus gastroenteritis outbreaks in healthcare
34. Centers for Disease Control and Prevention. Infection Control: Severe settings. Infect Control Hosp Epidemiol. 2011;32(10):939-969.
acute respiratory syndrome coronavirus 2 (SARS-CoV-2); 2020. Infection 56. Montoya A, Jenq G, Mills JP, et al. Partnering with local hospitals and
Control Guidance. public health to manage COVID-19 outbreaks in nursing homes. J Am
35. Su CP, de Perio MA, Cummings KJ, McCague AB, Luckhaupt SE, Geriatr Soc. 2021;69(1):30-36.
Sweeney MH. Case investigations of infectious diseases occurring in work- 57. Nijssen S, Bonten MJ, Weinstein RA. Are active microbiological surveil-
places, United States, 2006-2015. Emerg Infect Dis. 2019;25(3):397-405. lance and subsequent isolation needed to prevent the spread of methicil-
36. Wong J, Goh QY, Tan Z, et al. Preparing for a COVID-19 pandemic: A lin-resistant Staphylococcus aureus?. Clin Infect Dis. 2005;40(3):405-409.
review of operating room outbreak response measures in a large tertiary 58. Bonten MJ, Austin DJ, Lipsitch M. Understanding the spread of antibi-
hospital in Singapore. Se préparer pour la pandémie de COVID-19: revue otic resistant pathogens in hospitals: Mathematical models as tools for
des moyens déployés dans un bloc opératoire d’un grand hôpital tertiaire control. Clin Infect Dis. 2001;33(10):1739-1746.
au Singapour. Can J Anaesth. 2020;67(6):732-745. 59. Said MA, Perl TM, Sears CL. Healthcare epidemiology: Gastrointestinal
37. Chang YT, Lin CY, Tsai MJ, et al. Infection control measures of a flu: norovirus in health care and long-term care facilities. Clin Infect Dis.
Taiwanese hospital to confront the COVID-19 pandemic. Kaohsiung J 2008;47(9):1202-1208.
Med Sci. 2020;36(5):296-304. 60. Wang Z, Wang J, He J. Active and effective measures for the care of
38. Sydnor ER, Perl TM. Hospital epidemiology and infection control in patients with cancer during the covid-19 spread in China. JAMA
acute-care settings. Clin Microbiol Rev. 2011;24(1):141-173. Oncol. 2020;6(5):631-632.
39. Wang Q, Wang X, Lin H. The role of triage in the prevention and control 61. Zhang Y, Sun Z, Latour JM, Hu B, Qian J. Hospital response to the
of COVID-19. Infect Control Hosp Epidemiol. 2020;41(7):772-776. COVID-19 outbreak: The experience in Shanghai, China. J Adv Nurs.
40. Lu D, Wang H, Yu R, Yang H, Zhao Y. Integrated infection control strat- 2020;76(7):1483-1485.
egy to minimize nosocomial infection of coronavirus disease 2019 among 62. FitzGerald G, Jelinek GA, Scott D, Gerdtz MF. Emergency department
ENT healthcare workers. J Hosp Infect. 2020;104(4):454-455. triage revisited. Emerg Med J. 2010;27(2):86-92.
41. Lai TH, Tang EW, Chau SK, Fung KS, Li KK. Stepping up infection con- 63. Chung HS, Lee DE, Kim JK, et al. Revised triage and surveillance pro-
trol measures in ophthalmology during the novel coronavirus outbreak: tocols for temporary emergency department closures in tertiary hospitals
8 IA Ahmad and E Osei

as a response to covid-19 crisis in Daegu Metropolitan City. J Korean Med A review [published online ahead of print, 2021 Jan 22]. Environ Chem
Sci. 2020;35(19):e189. Lett. 2021;1-7.
64. Fasola G, Pelizzari G, Zara D, et al. Feasibility and predictive perfor- 85. Dietz L, Horve PF, Coil DA, Fretz M, Eisen JA, Van Den Wymelenberg K.
mance of a triage system for patients with cancer during the covid-19 2019 novel coronavirus (covid-19) pandemic: Built environment considera-
pandemic. Oncologist. 2021;26(4):e694-e703. tions to reduce transmission [published correction appears in mSystems.
65. Oh J, Lee JK, Schwarz D, Ratcliffe HL, Markuns JF, Hirschhorn LR. 2020 May 5;5(3):]. mSystems. 2020;5(2):e00245-20.
National response to covid-19 in the republic of Korea and lessons learned 86. Ren C, Xi C, Wang J, et al. Mitigating Covid-19 infection disease trans-
for other countries. Health Syst Reform. 2020;6(1):e1753464. mission in indoor environment using physical barriers. Sustain Cities Soc.
66. Schaye VE, Reich JA, Bosworth BP, et al. Collaborating across private, 2021;74:103175.
public, community, and federal hospital systems: Lessons learned from 87. Kohanski MA, Lo LJ, Waring MS. Review of indoor aerosol generation,
the covid-19 pandemic response in NYC. NEJM Catalyst Innovations transport, and control in the context of COVID-19. Int Forum Allergy
in Care Delivery. 2020;1(6). Rhinol. 2020;10(10):1173-1179.
67. Wake RM, Morgan M, Choi J, Winn S. Reducing nosocomial transmis- 88. Rezaei N, Jafari M, Nazari A, et al. A novel methodology and new
sion of COVID-19: implementation of a COVID-19 triage system. Clin concept of SARS-CoV-2 elimination in heating and ventilating air con-
Med (Lond). 2020;20(5):e141-e145. ditioning systems using waste heat recovery. AIP Adv. 2020;10(8):
68. Lee IK, Wang CC, Lin MC, Kung CT, Lan KC, Lee CT. Effective strat- 085308.
egies to prevent coronavirus disease-2019 (COVID-19) outbreak in hos- 89. Shajahan A, Culp CH, Williamson B. Effects of indoor environmental
pital. J Hosp Infect. 2020;105(1):102-103. parameters related to building heating, ventilation, and air conditioning
69. Ornaghi S, Callegari C, Milazzo R, et al. Performance of an extended systems on patients’ medical outcomes: A review of scientific research on
triage questionnaire to detect suspected cases of Severe Acute hospital buildings. Indoor Air. 2019;29(2):161-176.
Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection in obstet- 90. Morawska L, Milton DK. It is time to address airborne transmission
ric patients: Experience from 2 large teaching hospitals in Lombardy, of coronavirus disease 2019 (COVID-19). Clin Infect Dis. 2020;71(9):
Northern Italy. PloS One. 2020;15(9):e0239173. 2311-2313.
70. Judson TJ, Odisho AY, Neinstein AB, et al. Rapid design and implemen- 91. Saran S, Gurjar M, Baronia A, et al. Heating, ventilation and air condi-
tation of an integrated patient self-triage and self-scheduling tool for tioning (HVAC) in intensive care unit. Crit Care. 2020;24:194.
COVID-19. J Am Med Inform Assoc. 2020;27(6):860-866. 92. Bhagat RK, Linden PF. Displacement ventilation: A viable ventilation
71. Silvery A, Nizami MI, Sharma A, Bhaskar L. Three tier screening tool strategy for makeshift hospitals and public buildings to contain
and second triage to minimize the spread of covid-19 in the emergency COVID-19 and other airborne diseases. R Soc Open Sci. 2020;7(9):200680.
department of a tertiary hospital in India. Frontiers in Emergency 93. Gu D, Zheng Z, Zhao P, Xie L, Xu Z, Lu X. High-efficiency simulation
Medicine. 2020;4(2s):e50-e50. framework to analyze the impact of exhaust air from covid-19 temporary
72. Quah LJJ, Tan BKK, Fua TP, et al. Reorganising the emergency hospitals and its typical applications. Applied Sciences. 2020;10(11):
department to manage the COVID-19 outbreak. Int J Emerg Med. 2020; 3949.
13(1):32. 94. Chirico F, Sacco A, Bragazzi NL, Magnavita N. Can air-conditioning
73. Falvey JR, Krafft C, Kornetti D. The essential role of home- and com- systems contribute to the spread of sars/mers/covid-19 infection?
munity-based physical therapists during the covid-19 pandemic. Phys Insights from a rapid review of the literature. Int J Environ Res Public
Ther. 2020;100(7):1058-1061. Health. 2020;17(17):6052.
74. Jones MS, Goley AL, Alexander BE, Keller SB, Caldwell MM, Buse JB. 95. Mousavi ES, Kananizadeh N, Martinello RA, Sherman JD.
Inpatient transition to virtual care during covid-19 pandemic. Diabetes COVID-19 Outbreak and hospital air quality: A systematic review of
Technol Ther. 2020;22(6):444-448. evidence on air filtration and recirculation. Environ Sci Technol. 2021;
75. De Simone V, Guarise P, Guardalben S, et al. Telecardiology during the 55(7):4134-4147.
Covid-19 pandemic: Past mistakes and future hopes. Am J Cardiovasc Dis. 96. Tomas ME, Kundrapu S, Thota P, et al. Contamination of health care
2020;10(2):34-47. personnel during removal of personal protective equipment. JAMA Intern
76. Singh J, Green MB, Lindblom S, Reif MS, Thakkar NP, Papali A. Med. 2015;175(12):1904-1910.
Telecritical care clinical and operational strategies in response to 97. Barratt R, Shaban RZ, Gilbert GL. Characteristics of personal protective
covid-19. Telemed J E Health. 2021;27(3):261-268. equipment training programs in Australia and New Zealand hospitals: A
77. Osei E, Francis R, Mohamed A, Sheraz L, Soltani-Mayvan F. Impact of survey. Infect Dis Health. 2020;25(4):253-261.
COVID-19 pandemic on the oncologic care continuum: Urgent need to 98. Kalantary S, Khadem M, Golbabaei F. Personal protective equipment for
restore patients care to pre-COVID-19 era. J Radiother Pract. 2021:1-11. protecting healthcare staff during covid-19 outbreak: A narrative review.
78. McCall B. Could telemedicine solve the cancer backlog?. The Lancet Front Emerg Med. 2020;4(2s):e61.
Digital Health. 2020;2(9):e456-e457. 99. Tan L, Kovoor JG, Williamson P, et al. Personal protective equipment
79. Rajagopalan S, Yoshikawa TT. Norovirus infections in long-term care and evidence-based advice for surgical departments during COVID-19.
facilities. J Am Geriatr Soc. 2016;64(5):1097-1103. ANZ Journal of Surgery. 2020;90(9):1566-1572.
80. Lopman BA, Andrews N, Sarangi J, Vipond IB, Brown DW, 100. Jamieson DJ, Steinberg JP, Martinello RA, Perl TM, Rasmussen SA.
Reacher MH. Institutional risk factors for outbreaks of nosocomial gas- Obstetricians on the coronavirus disease 2019 (COVID-19) front lines
troenteritis: Survival analysis of a cohort of hospital units in South-west and the confusing world of personal protective equipment. Obstet
England, 2002-2003. J Hosp Infect. 2005;60(2):135-143. Gynecol. 2020;135(6):1257-1263.
81. Lee JY. Tuberculosis infection control in health-care facilities: environ- 101. Hoernke K, Djellouli N, Andrews L, et al. Frontline healthcare workers’
mental control and personal protection. Tuberc Respir Dis (Seoul). experiences with personal protective equipment during the COVID-19
2016;79(4):234-240. pandemic in the UK: A rapid qualitative appraisal. BMJ Open. 2021;
82. Somsen GA, van Rijn C, Kooij S, Bem RA, Bonn D. Small droplet aero- 11(1):e046199.
sols in poorly ventilated spaces and SARS-CoV-2 transmission. Lancet 102. Mick P, Murphy R. Aerosol-generating otolaryngology procedures and
Respir Med. 2020;8(7):658-659. the need for enhanced PPE during the COVID-19 pandemic: a literature
83. Capolongo S, Gola M, Brambilla A, Morganti A, Mosca EI, Barach P. review. J Otolaryngol Head Neck Surg. 2020;49(1):29.
COVID-19 and healthcare facilities: A decalogue of design strategies for 103. Kim H, Hegde S, LaFiura C, et al. Access to personal protective equip-
resilient hospitals. Acta Biomed. 2020;91(9-S):50-60. ment in exposed healthcare workers and COVID-19 illness, severity,
84. Choi H, Chatterjee P, Lichtfouse E, et al. Classical and alternative dis- symptoms and duration: A population-based case-control study in six
infection strategies to control the COVID-19 virus in healthcare facilities: countries. BMJ Glob Health. 2021;6(1):e004611.
Disaster Medicine and Public Health Preparedness 9

104. Newby JC, Mabry MC, Carlisle BA, Olson DM, Lane BE. Reflections on 106. Torjesen I. Covid-19: Appropriate PPE prevents infections in doctors in
nursing ingenuity during the COVID-19 pandemic. J Neurosci Nurs. frontline roles, study shows. BMJ. 2020;369:m2330.
2020;52(5):E13-E16. 107. Suzuki T, Hayakawa K, Ainai A, et al. Effectiveness of personal protective
105. Muñoz-Leyva F, Niazi AU. Common breaches in biosafety during don- equipment in preventing severe acute respiratory syndrome coronavirus 2
ning and doffing of protective personal equipment used in the care of infection among healthcare workers. J Infect Chemother. 2021;27(1):
COVID-19 patients. Can J Anaesth. 2020;67(7):900-901. 120-122.