Applying the precautionary principle to personal protective equipment (PPE) guidance during the COVID-19 pandemic: did we learn the lessons of SARS?

Quality of clinical evidence and political justifications of ivermectin mass distribution of COVID-19 kits in eight Latin American countries

BACKGROUND

Several countries in Latin America conducted mass distribution of COVID-19 kits intended to treat mild COVID-19, thereby preventing excess hospitalisations. Many of the kits contained ivermectin, an antiparasitic medicine that was not approved at the time for the treatment of COVID-19. The study objective was to compare the timing of the publication of scientific evidence about the efficacy of ivermectin for COVID-19 with the timeline of distribution of COVID-19 kits in eight Latin American countries and to analyse whether evidence was used to justify ivermectin distribution.

METHODS

We conducted a systematic review of randomised controlled trials (RCTs) published on the efficacy of ivermectin or ivermectin as adjuvant therapy on mortality from, or as prevention for, COVID-19. Each RCT was assessed using the Cochrane Grading of Recommendations, Assessment, Development and Evaluations (GRADE). Information on the timing and justification of government decisions was collected through a systematic search of leading newspapers and government press releases.

RESULTS

After removing the duplicates and abstracts without full text, 33 RCTs met our inclusion criteria. According to GRADE, the majority had a substantial risk of bias. Many government officials made claims that ivermectin was effective and safe in the prevention or treatment of COVID-19, despite the lack of published evidence.

CONCLUSION

All eight governments distributed COVID-19 kits to their populations despite the absence of high-quality evidence on the efficacy of ivermectin for prevention, hospitalisation and mortality in COVID-19 patients. Lessons learnt from this situation could be used to strengthen government institutions' capacities to implement evidence-informed public health policies.

Behind the Counter: Exploring Pharmacists' Stressors and Lessons Learned During the Pandemic in Ontario, Canada

Background

The onset of the COVID-19 pandemic has contributed to increased stress among healthcare professionals. Among these healthcare providers are Ontario pharmacists, who are facing new and pre-existing challenges and new stressors since the pandemic.

Objectives

This study aimed to understand the stressors and lessons learned by Ontario pharmacists during the pandemic through their lived experiences.

Methods

In this descriptive qualitative study, we conducted semi-structured one-on-one interviews with Ontario pharmacists virtually to learn about their stressors and lessons learned during the pandemic. Interviews were transcribed verbatim, then analyzed using thematic analysis.

Findings

We reached data saturation after 15 interviews and identified 5 main themes: (1) Communication/miscommunication with the public and other care providers; (2) high workload due to staff shortage and low appreciation/acknowledgement; (3) mismatch in market demand and supply; (4) informational gaps pertaining to the COVID-19 pandemic along with rapid protocol changes; and (5) lessons learned to improve the future of pharmacy practice in Ontario.

Discussion

Our study helped us gain a better understanding of the stressors pharmacists faced, their contributions, and the opportunities that arose due to the pandemic.

Conclusion

Drawing on these experiences, this study provides recommendations to improve pharmacy practice and increase preparedness for future emergencies.

Multidisciplinary Student Groups Support Digital Education as a Public Health Precautional Action to Prevent Spread of COVID-19 Infection: A Mixed Methods Study

Background

Health personnel had greater odds of contracting COVID-19 during its first wave in Norway, compared with all working-age individuals. Students in health care, but also in social care and teacher education programs may be exposed to the risk of being infected themselves and to infect others through their mandatory practical training. Online education may reduce their risk of becoming patients and spreaders both in their private lives and during their mandatory training.

Aim

To explore the extent to which unvaccinated professional students fear transmission of SARS-CoV-2 from fellow students and from public transportation during the third wave.

Materials and Methods

In this cross-sectional study, 3148 students in health care, social care, and teacher education programs and 32 supervisors completed online questionnaires consisting of open and closed questions (mixed methods) after participating in digital interprofessional learning (IPL) small-group seminars (49.6% and 65% response rates, respectively). On a 6-point Likert scale (0–5), all means concerning fear were around 3, with overlapping confidence intervals. Fear of infecting high-risk individuals seemed higher than fear of contracting the virus themselves. High levels of loyalty to and trust in state and health authorities were expressed. Medical-related terminology was frequently used, such as the one-meter distance rule, infection tracking, national guidelines, and hand sanitizer, which implies high levels of health literacy. They expressed strong support for online course delivery (mean 4.5) ahead of practical training as a precautionary public health action.

Conclusion

These students did not have high levels of fear of contracting the virus from other students or public transport. They expressed a higher fear of infecting others than being infected themselves. The major implication for the public and the educational system is that students, even in a country with low death rates, support digital education as a public health precautional action to prevent the spread of infection.

Indonesian Anesthesiologists Preparedness for COVID-19 Surge Capacity in the Early Pandemic

Background: Anesthesiologists play a crucial role in every disaster event, including biological disasters by COVID-19. This medical specialty should be prepared for a surge in patients due to a pandemic. The present study aims to evaluate the preparedness of anesthesiologists in facing the surge in the number of COVID-19 patients at the beginning of the pandemic in Indonesia. Methods: This is a descriptive cross-sectional study using an online survey to Anesthesiologists in Indonesia, with snowballing sampling method. A distribution frequency was used to describe the univariate analysis results of the variables. Pearson correlation was used to test the correlation between perceived resource adequacy/availability and perceived preparedness to face the surge. Results: A total of 141 anesthesiologists participated in our online survey; 47% of responders said they do not have enough staff, while 53% said that their staff did not have sufficient knowledge of handling the critical COVID-19 patients. They also reported limited resources, especially the limited isolation space and N95 masks. The correlation analysis indicated a strong and significant relationship between limited resources and the preparedness of anesthesiologists. Conclusion: At the beginning of the pandemic, Indonesian Anesthesiologists felt that they still had very limited resources, leading to unpreparedness to deal with the surge in the number of COVID-19 patients with critical conditions.

Airway recommendations for perioperative patients during the COVID-19 pandemic: a scoping review

PURPOSE

Numerous guideline recommendations for airway and perioperative management during the COVID-19 pandemic have been published. We identified, synthesized, and compared guidelines intended for anesthesiologists.

SOURCE

Member society websites of the World Federation of Societies of Anesthesiologists and the European Society of Anesthesiologists were searched. Recommendations that focused on perioperative airway management of patients with proven or potential COVID-19 were included. Accelerated screening was used; data were extracted by one reviewer and verified by a second. Data were organized into themes based on perioperative phase of care.

PRINCIPAL FINDINGS

Thirty unique sets of recommendations were identified. None reported methods for systematically searching or selecting evidence to be included. Four were updated following initial publication. For induction and airway management, most recommended minimizing personnel and having the most experienced anesthesiologist perform tracheal intubation. Significant congruence was observed among recommendations that discussed personal protective equipment. Of those that discussed tracheal intubation methods, most (96%) recommended videolaryngoscopy, while discordance existed regarding use of flexible bronchoscopy. Intraoperatively, 23% suggested specific anesthesia techniques and most (63%) recommended a specific operating room for patients with COVID-19. Postoperatively, a minority discussed extubation procedures (33%), or care in the recovery room (40%). Non-technical considerations were discussed in 27% and psychological support for healthcare providers in 10%.

CONCLUSION

Recommendations for perioperative airway management of patients with COVID-19 overlap to a large extent but also show significant differences. Given the paucity of data early in the pandemic, it is not surprising that identified publications largely reflected expert opinion rather than empirical evidence. We suggest future efforts should promote coordinated responses and provide suggestions for studying and establishing best practices in perioperative patients.

STUDY REGISTRATION

Open Science Framework ( https://osf.io/a2k4u/ ); date created, 26 March 2020.

COVID-19-Positive Testing in Minnesota High School Fall and Winter Sports: A Guide for Sports Risk

OBJECTIVE

To assess the effectiveness of coronavirus disease 2019 (COVID-19) prevention strategies used during sports participation.

DESIGN

To analyze prospective reports of student-athletes with COVID-19-positive tests to assess prevention strategies and risk factors by sports and seasons.

SETTING

Minnesota high schools.

PARTICIPANTS

Fall 2020 (August 24-October 30) and winter 2021 (January 2-March 12) student-athletes.

ASSESSMENT OF RISK FACTORS

Sports, indoor location, mask use, physical distancing, and season.

MAIN OUTCOME MEASURES

COVID-19-positive test rates.

METHODS

Self-selected schools voluntarily reported, in 2-week intervals, the number of student-athletes with COVID-19-positive tests in each sport and the number of athletes participating in each sport during the fall and winter sports seasons. The positive testing rates per 100 000 athletes were calculated for participants in each sport and compared by sports type and risk variables.

RESULTS

The high school age community-positive testing rate was 1298 per 100 000 students in the fall and 2396 in the winter. The student-athlete positive testing rate was 1500 per 100 000 athletes during the fall and 2800 during the winter (χ2 = 1.98, df = 1, P = 0.350). Positive tests per 100 000 athletes ranged from 197 (girls alpine skiing) to 4151 (wrestling). The incidence rates comparing indoor with outdoor sports (P = 0.001) and close-contact with physically distanced sports (P = 0.023) were significantly different, but the incidence rates comparing indoor masked with unmasked sports (P = ns) were not different.

CONCLUSION

Athletes competing in outdoor individual sports have less risk of a COVID-19-positive test compared with age-matched individuals in the community and indoor sports participants either wearing or not wearing masks during competition. Unmasked athletes in close proximity have the highest positive test rates, and unenforced masking is not associated with lower positive testing rates. More study is needed to understand mask effectiveness.

Decision-Making in Sport During a Pandemic

OBJECTIVE

The COVID-19 pandemic has affected all elements of global society, and sport is not exempt. Many sporting events have been either postponed or canceled, and national sporting organizations have had to make highly complex decisions in the face of scientific uncertainty and risk. This article applies these lessons to the world of sport with the goal of assisting sporting organizations to make sound and reasoned decisions during a pandemic.

DATA SOURCES

A narrative approach using both academic literature sources and live examples from the authors' experience. We use Daniels and Sabin's accountability for reasonableness framework to facilitate decision-making in the face of such uncertainty.

MAIN RESULTS

Decision-making in the context of uncertainty has the potential to create conflict and disengagement from key stakeholders. Evidence from recent pandemics has illustrated that an ethical approach to decision-making results in reasoned decision-making and confers a legitimacy to decisions that ultimately supports engagement and satisfaction from stakeholders.

CONCLUSIONS

The incorporation of ethical considerations into risk assessment and management when making complex decisions, which incorporate high levels of uncertainty, will assist sporting organizations have positive outcomes.

A Pan-Canadian narrative review on the protocols for reopening dental services during the COVID-19 pandemic

The current coronavirus disease 2019 (COVID-19) pandemic is impacting the way in which dental services are provided. The aim of this narrative review was twofold: to summarize key areas from the Canadian protocols available for the reopening and restructuring of dental services across the country and to critically review these protocols based on existing evidence. A narrative review of the existing Canadian protocols, written in English and French, was undertaken between April 15 and July 13, 2020. The protocols were obtained by searching through regulatory bodies and websites from professional organizations, and from personal contacts through academic institutions and policy leaders. The data extraction form focused only on protocols related to dentistry, and the information was compiled by a hired assistant. Content was categorized via group discussions with the research team on eight areas: office management and procedures, patient and staff screening, treatment procedures, office layout, risk reduction, personal protective equipment, supporting information, and length and readability. Thirteen protocols were identified and offered substantial variation in the level of details provided. All but two protocols specified proper donning/doffing of personal protective equipment, while all protocols recommended daily monitoring of COVID-19 related signs and symptoms in staff and patients. They varied in terms of recommended mask types, eye and face shield protection, and head coverings. While all protocols aimed at restructuring emergency dental services, their recommendations were often not based on the published evidence. This narrative review summarized key areas from 13 provincial and territorial protocols in Canada to help oral health care providers plan the reopening of their services. The information conveyed across all documents was clear, but variance highlights the need for a coordinated effort to develop an evidence-based document for dental practitioners.