Universal Pandemic Precautions

As of June 19, 2020, the COVID-19 pandemic has led to 2,201,399 infections and 118.458 deaths in the United States. The CDC has reported that HCP account for ~11% of COVID-19 infections. ³ Increasing evidence has provided a roadmap for protecting HCP from the acquisition of COVID-19. Systematic reviews and meta-analyses have demonstrated the effectiveness of masks ^{Reference Offeddu, Yung, Low and Tam4,Reference Chu, Akl and Duda5} and eye protection ^{Reference Chu, Akl and Duda5} to protect HCP. As with HIV and HBV, multiple measures need to be implemented in healthcare facilities to prevent SARS-CoV-2 transmission, including (1) screening of patients, visitors, and HCP for symptoms of COVID-19 prior to entry; (2) routine use of source control masks by patients, visitors, and HCP ^{Reference Leung, Chu and Shiu6} ; (3) frequent hand hygiene and surface disinfection of shared equipment and devices; (4) enhanced personal protective equipment for HCP performing aerosol-generating procedures and during care of known or suspected patients with COVID-19; and (5) prompt testing of persons with signs or symptoms of COVID-19 and institution of appropriate isolation precautions. Screening of asymptomatic patients at the time of admission may be of benefit in several circumstances, among them: (1) testing prior to admission to a congregate setting (eg, psychiatry, rehabilitation, post-surgery recovery units); (2) testing prior to admission to the labor and delivery unit to protect the nursery; and, (3) testing to identify presymptomatic patients because they are clearly infectious. Testing may also be useful for screening HCP who have had COVID-19 exposure as defined by CDC. Testing strategies are changing rapidly, and increased testing of asymptomatic patients and staff may be more practical in the near future, depending on infection prevalence and test availability. ^{Reference Henderson, Hayden and Wright7}

To protect HCP, patients and visitors from acquisition of COVID-19 and other respiratory pathogens, we propose a paradigm shift; implementation of universal pandemic precautions (UPPs): Use of a mask and eye protection for all direct patient contacts or at a minimum, use of a mask and eye protection for direct patient contact when the patient is unable (eg, children) or unwilling to wear a mask. We propose this paradigm shift based on the following: (1) transmission of SARS-CoV-2 has been well described from presymptomatic and likely occurs from asymptomatic COVID-19 patients; (2) A negative COVID-19 test in an asymptomatic patient does not exclude incubating COVID-19, and such patients may become infectious shortly after the test; (3) the use of masks ^{Reference Offeddu, Yung, Low and Tam4,Reference Chu, Akl and Duda5} and eye protection ^{Reference Chu, Akl and Duda5} by HCP protects against acquisition of SARS and SARS-CoV-2; and (4) the use of universal pandemic precautions would prevent HCP from an exposure that, per the CDC, would lead to exclusion from work for 14 days. ⁸ We also suggest that the implementation of universal pandemic precautions will likely also offer a potential beneficial effect on the prevention of transmission of other droplet-spread respiratory pathogens in the healthcare setting (eg, influenza A and B, respiratory syncytial virus, seasonal coronaviruses, etc), especially during seasons in which these and other respiratory viruses are circulating.

We understand that implementation of universal pandemic precautions will require careful messaging for our colleagues and patients. We expect that the rationale for aforementioned universal pandemic precautions will persuade our colleagues to accept them. Messaging to patients should focus on describing the rationale for universal pandemic precautions, including noting that their use is one of several precautions that protect patients. In addition, patients should be informed that this routine practice is not specifically focused on them individually. Finally, we realize that institution and discontinuation of universal pandemic precautions should be based on current local case numbers (or rates or burden) and local prevalence of infection in asymptomatic populations (eg, preprocedural test positivity rates because symptom screening cannot detect these potentially infectious patients.

We realize that paradigm shifts are difficult and, as demonstrated by Semmelweis, ^{Reference Kadar9} may not be accepted. Ultimately, however, the use of hand hygiene as advocated by Semmelweis became a keystone of infection prevention. We believe that universal pandemic precautions will be accepted by patients and staff and that it will ultimately result in a safer healthcare environment for all.