Risk Assessment, COVID-19

The Spread of the Disease

According to the CDC (1), Coronavirus (COVID-19) is an illness caused by a virus that can spread from person to person. The virus causes respiratory tract infections of differing impact from mild to severe and may lead to death. The disease may be spread through the touching of objects that have the virus on them and the close interaction with people who have the virus (recommended distancing measures at this time are six feet).

The virus is spread through respiratory droplets when an infected person sneezes, coughs or talks. However, there are some reputable studies that indicate that the virus may be completely aerosolized (2), (3). This may mean that the virus may be spread through the normal breathing of an infected person in close contact with someone. While there is no hard evidence of this type of transmission, the spread of the virus by asymptomatic people of which I will touch upon later may support it. With this in mind it would be best to move forward with that as a fact.

The Lifespan of the Virus

A study published in the LancetMicrobe (4) tested the virus’ life span in a 71-degree-Fahrenheit room at 65% relative humidity. After three hours, the virus had disappeared from printing and tissue paper. It took two days for it to leave wood and cloth fabric. After four days, it was no longer detectable on glass or paper money. It lasted the longest, seven days, on stainless steel and plastic.

With these figures in mind, and considering the possible aerosolisation of the virus, it is incumbent upon us to disinfect all surfaces in our rooms that any visitor may have come in contact with. We should also consider the removal of any furniture that has cloth fabric of any kind from both public areas and clinic rooms.

Asymptomatic Carriers

There is now ample reliable evidence that there are many asymptomatic carriers of the virus, and that they and pre-symptomatic carriers are infectious (5). There is also ample reliable evidence of the spread of infection by asymptomatic carriers (6), (7). While triaging any prospective face to face customers on the phone may help us ensure that we see no-one with an active infection, or who has been recently exposed to an active infection, it will not ensure that we will not come into contact with asymptomatic carriers.

The Efficacy of Masks

In a recent study detailed in the Annals of Internal Medicine, it was found that neither surgical nor cotton masks worn by infected patients effectively filtered the virus during coughs. This is of interest to us because some of our procedures such as otoscopy, impression taking and wax removal may cause a cough response and therefore may expose us. A further article on the website of the Centre For Evidence-Based Medicine looked at the use of masks in the healthcare setting.

It appears that surgical masks are useful for the general medical setting, however, it cautions that there are no studies at this stage on the efficacy of surgical masks with COVID-19 and all of the available guidance is based on other viral respiratory infections. It details that better protection is offered by so called N95 or FFP2 respirator masks and the very best protection is offered by FFP3 respirator masks.

Two things have been pointed out to me, the first is quite important, masks need to be fit-tested in order that you know they are offering the best protection. I omitted to mention that because I assumed, a stupid thing to do, that everyone knew that. You will have to excuse me, I spent many years researching and writing for a Health Surveillance website and took that as said. The second thing is that the new guidelines are out in the UK and that they don’t match what I am saying here. I want to make it clear, with the research I have done, the references you can see below, I would not feel comfortable in the clinic without the precautions I have set out. That doesn’t mean that I believe the guidelines are somehow problematic. It simply means that I see the guidelines as the minimum acceptable measures. I don’t see them as a clear instruction not to do more if I wish.

Interestingly, it says “Importantly, masks and respirators should not be considered as isolated interventions. Other protection includes hand hygiene, aprons or gowns, goggles or face shields, and gloves.” The evidence appears to support the fact that the FFP3 respiratory mask is of the highest protection, however, if we are close to the patient and there may be any chance of an aerosol producing event, we must also consider other precautions.

The Efficacy of Cleaning Products

Most household disinfectants and alcohol wipes of at least 70% alcohol can be used to disinfect your work area. It is important that the disinfectant used is specified to kill human corona virus. It is also important to note that many of the disinfectants available have wet times on the label. For instance, a simple bleach mix with water needs to be wet on a surface for one minute to kill the virus. Therefore when using any disinfectant we need to follow the instructions.

Physical Practice Changes

With the risk of infection and cross-infection through the touching of surfaces in mind, we will remove all chairs and coffee tables from the appointment area. We will ensure that all high touch areas such as tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, sinks, etc are cleaned with appropriate disinfectant procedures on a regular basis. We will ensure that appropriate instructions for wet time will be followed.

In our clinic rooms, we will remove any chairs with cloth insets or made from cloth and replace them with plastic chairs. We will completely clear the desktop and any surrounding furniture of any and all extraneous equipment such as receiver wire boxes, dome containers and anything else that we do not need to undertake any appointment. We will pack them away in cupboards and drawers and keep a completely clean desk policy.

Any equipment that can not be packed away will be part of our post-appointment cleaning checklist.

Appointment Query

All appointment queries whether they are online or offline will be triaged by phone. The guideline questions will be asked in relation to possible exposure. We will also ask questions about the issue or issues that need to be solved. If we believe that the issue may be resolved without a face to face appointment, we will do so. If for instance, we are to offer a roadside appointment or drop-off, we will adhere to a different risk assesment and risk mitigation steps. For the purpose of this assesment, we will work on the basis that it is an emergency ear wax removal.

We will establish the emergency through simple questioning such as:

• Is your ear completely blocked?
• Have you tried over the counter solutions available from a pharmacist?
• How long have you used the solution without success?
• Is their pain or discomfort?

If the answers meet our criterion which will be yes, yes, over a week and yes. We will then move forward to instruction on attending the clinic.

Attending The Clinic

All patients who attend the clinic will be instructed that they need to attend the clinic at the appointed time. If they are late, they will not be seen. This criterion is to ensure that there is adequate time between appointments to ensure complete disinfection. This will be explained to them clearly. We will also explain to them clearly that in order to meet all our guidelines at this time, we will be closely documenting the needs and each step of the appointment. We will print the documentation and ask them to review it and sign it.

They will be informed that they will be met at the door, when they are met, they will be asked to use hand sanitiser and don a mask. They will be instructed in the proper process for donning the mask. If we are able to source enough FFP3 masks we will ensure that we supply said masks to the patient. However, if we are not, we will endeavour to try to supply FFP2 (N95), if we can’t, the least acceptable mask will be a surgical mask.

PPE For Staff

Our staff will wear FFP3 masks, or will not be undertaking face to face appointments. Once the patient has donned their mask, they will be taken straight through through to the clinic room. We will undertake the standard procedure for wax removal including the usual questions and waiver mechanism.

PPE For Wax Removal

Before we move to otoscopy and the wax removal procedure, we will don goggles, or a visor (preferably goggles meeting the WHO standards) and a disposable apron or gown. We will explain the reason for this to the patient including the possible cough response and the ensuing aerosolisation possibilities.

We shall undertake otoscopy using video otoscopy equipment in order to increase distance. We shall then undertake the wax procedure as normal, being careful in order that we minimise the risk of cough response as much as possible. Because we are unsure whether their ear wax may contain either blood or puss, we will use gloves during any procedure that may involve contact with cerumen.

Doffing and Disposing

Once the process is finished and we are happy that the ear canal is cleared we will then move towards doffing of the personal protection equipment. Doffing of possibly infected equipment will be undertaken following the health authority guidelines (10).

We will dispose of the PPE, micro-suction canula and specula in a clinical waste bag following all of the clinical guidelines from our local health authority. We will then print off our documentation of the decision to move forward with the appointment and the steps we have taken during the process and have the patient sign it. We will then escort the patient off the premises.

Cleaning The Premises

At this stage, we will begin our disinfectant procedure. That procedure will include:

• The disinfection of all surfaces in the clinic room, including
• The desk and anything on it
• The chairs in the clinic room
• The micro-suction pump and tubing
• The table or trolley that the micro-suction pump is on
• Any surface in the clinic room including cupboards, cupboard handles, sound booth exterior etc
• Surfaces in the reception area
• Surfaces in the hallway between the reception and clinic room if any
• Surfaces in the toilet if they have used it

I have based this assesment and process on the best possible evidence that is available to me at this stage. This document may change when new information becomes available.

1. CDC Factsheet: https://www.cdc.gov/coronavirus/2019-ncov/downloads/2019-ncov-factsheet.pdf
2. New England Journal of Medicine, Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1:https://www.nejm.org/doi/10.1056/NEJMc2004973
3. CDC, Aerosol and Surface Distribution of Severe Acute Respiratory Syndrome Coronavirus 2 in Hospital Wards, Wuhan, China, 2020: https://wwwnc.cdc.gov/eid/article/26/7/20-0885_article
4. The Lancet Microbe, Stability of SARS-CoV-2 in different environmental conditions: https://www.thelancet.com/journals/lanmic/article/PIIS2666-5247(20)30003-3/fulltext
5. New England Journal of Medicine: Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility: https://www.nejm.org/doi/full/10.1056/NEJMoa2008457
6. JAMA Network Research Letter, Presumed Asymptomatic Carrier Transmission of COVID-19: https://jamanetwork.com/journals/jama/fullarticle/2762028
7. Oxford Academic, Clinical Infectious Diseases, COVID-19 Transmission Within a Family Cluster by Presymptomatic Carriers in China: https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa316/5810900
8. Annals of Internal Medicine, Effectiveness of Surgical and Cotton Masks in Blocking SARS–CoV-2: A Controlled Comparison in 4 Patients:https://annals.org/aim/fullarticle/2764367/effectiveness-surgical-cotton-masks-blocking-sars-cov-2-controlled-comparison
9. The Centre for Evidence-Based Medicine, What is the efficacy of standard face masks compared to respirator masks in preventing COVID-type respiratory illnesses in primary care staff?: https://www.cebm.net/covid-19/what-is-the-efficacy-of-standard-face-masks-compared-to-respirator-masks-in-preventing-covid-type-respiratory-illnesses-in-primary-care-staff/
10. ECDC, Guidance for wearing and removing personal protective equipment in healthcare settings for the care of patients with suspected or confirmed COVID-19: https://www.ecdc.europa.eu/sites/default/files/documents/COVID-19-guidance-wearing-and-removing-personal-protective-equipment-healthcare-settings-updated.pdf