Novel Coronavirus: A Wake-up Call for Best Practices in Preventing Pathogen Transmission
By David Levine, PT, DPT, PhD, FAPTA, Henry Spratt, PhD, June Hanks, PT, DPT, PhD, and Charles Woods, MD, MS
Novel human coronavirus disease (COVID-19), now moving towards pandemic status, represents one of the great concerns of modern life – the rapid evolution of new human viruses that can be spread via the respiratory tract. As with other pathogens, physical therapists, physical therapist assistants, and administrative staff can take tangible steps to help prevent the spread of disease that could harm our most vulnerable populations. The Centers for Medicare and Medicaid Services has issued guidelines for infection control and is calling on health care providers to activate infection control practices.
COVID-19 is caused by severe acute respiratory syndrome coronavirus 2, abbreviated as SARS-CoV-2. As a positive-strand, enveloped RNA virus, SARS-CoV-2 is another coronavirus like the severe acute respiratory syndrome (SARS) virus that first appeared in China in 2002, infecting around 8,000 people worldwide and resulting in about 750 deaths in total. The major lesson learned from the SARS outbreak was how easily these coronaviruses can spread. To avoid additional spread of these viruses requires effective detection, protection of caregivers (eg. hand washing, protective clothing, and masks for infected individuals), and disinfection of health care facilities and equipment. These measures are a must for all physical therapy clinics.
There is still much to learn about the new virus, including how easily it spreads. Based on what we currently know about other coronaviruses, SARS-CoV-2 is spread mainly from person to person through respiratory droplets among close contacts, especially under crowded conditions. It is easy to see how the first cases of COVID-19 appeared in Wuhan, China, a large city about the size of Chicago last December. However, this new virus is not the only airborne virus that can cause epidemics — think influenza.
In addition to taking precautions to avoid aerosolization (the production of airborne particles containing an infectious virus or bacteria), we must disinfect surfaces touched by infected people. Thus, in physical therapy clinics, in anticipation of future patients being infected by the SARS-CoV-2 virus, we must think holistically in terms of clinic disinfection and protection.
What Should We Be Doing in Physical Therapy to Prevent Pathogen Transmission?
Most people infected by the virus — around 80% — show mild symptoms, much like having the common cold, from which they will recover over the course of several weeks. It is the remaining 20% of people who are most at risk of more severe symptoms and potential critical outcomes. This latter group includes older individuals, the very young, and immunocompromised patients. Keeping individuals with mild symptoms away from the most susceptible persons is paramount in reducing serious complications and even death.
By the nature of our profession, physical therapists and physical therapist assistants use our hands and therapeutic equipment extensively and have frequent direct patient contact. We also work in crowded environments and with individuals that may be immunocompromised. While there are many precautions we can take that are specific to SARS-CoV-2, the virus serves as a reminder for all health care providers and administrators to be vigilant in preventing the spread of any transmissible disease or infectious bacteria.
1. Practice proper hand and wrist hygiene.
When you don't know what you don't know, then do what you do know: Wash your hands—and your wrists! Hand and wrist hygiene should occur before and after each patient encounter.
With the very short time between this writing and actual publication, researchers will learn more about COVID-19 and recommendations are likely to expand. That said, the practice of appropriate handwashing remains as the most basic strategy to prevent the spread of SARS-CoV-2, the influenza virus, and the common cold. Proper hand/wrist hygiene using soap and water or alcohol-based hand sanitizers (ABHS) significantly impacts microbe transmission and should be incorporated into routine patient care.
Handwashing with soap and water is recommended after treating patients with known or suspected norovirus or Clostridium difficile, since ABHS are not effective against these pathogens, and is recommended for SARS-CoV-2 as well. While soap doesn't kill the virus, it does wash it away if done properly: Wash hands with soap and water, place the hands under running water, apply the soap, and vigorously rub all surfaces of the hands and wrists together for 15-20 seconds (sing "Happy Birthday" twice), rinse, use a disposable towel to dry, and use the towel to turn off the water faucet. Make sure you clean under your fingernails, as well.
ABHS are the most efficacious method to reduce bacteria on the hands and wrists. ABHS should be used according to manufacturer recommendations, which generally include putting the product on and rubbing all surfaces together for at least 20 seconds until dry. If it is dry before 20 seconds, you have not used enough ABHS.
Fingernails should be kept less than ¼ inch long, and excessive jewelry should be avoided. Frequent use of hand lotions that do not interfere with hand sanitizing products may help reduce hand dryness from frequent cleansing.
2. Cover your coughs and sneezes with a tissue.
Cover your mouth and nose with a tissue when coughing or sneezing. If no tissue is available, sneezing or coughing into a bent elbow is recommended. It may prevent those around you from getting sick. Flu and other serious respiratory illnesses, like respiratory syncytial virus (RSV), whooping cough and SARS, are spread by cough, sneezing, or unclean hands.
3. Stay home when you are sick.
If possible, stay home from work, school, and running errands when you are sick. This will help prevent spreading your illness to others.
4. Avoid touching your eyes, nose, or mouth.
Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.
Cleaning and Disinfection in the Clinic and Other Settings
This is an area that we don't emphasize enough within the physical therapy profession. No matter what type of practice setting, we all have objects and equipment — tables, walkers, wheelchairs, goniometers, pulse oximeters, crutches, gait belts, exercise equipment, countertops, treadmills, light switches, doorknobs, cabinet handles, etc. — that are frequently touched and contaminated. We don't yet know how easily SARS-CoV-2 can be transmitted by objects, but as a rule surfaces should be cleaned between each patient encounter using an appropriate disinfectant. The Environmental Protection Agency has released a list of disinfectants approved for use against the SARS-CoV-2 virus.
It is beyond the purpose of this blog to discuss the numerous types of disinfectants that have advantages and disadvantages in terms of effectiveness, kill time, safety, cost, and ease of use. For example, hydrogen peroxide wipes are commonly used in health care, but take one minute of contact/wet time to kill methicillin resistant staphylococcus aureus (MRSA), three minutes of contact/wet time to kill norovirus, and five minutes to kill mycobacterium bovis. How often do we achieve a wet time of even 30 seconds when cleaning equipment? The bottom line: Read the labels and learn about the products.
For more information on where bacteria commonly grow in the clinic and how to prevent its spread, see this blog post.
PTs who work in home health don't have as much control over their environment, but should still practice hand and wrist hygiene, "distancing" (avoiding droplets from a patient's cough) as much as possible, and avoiding patient visits when they are ill.
What If My Patient Is the One Coughing/Sneezing, or Exhibits COVID-19 Symptoms?
Advise patients who are sick to call their primary care providers and stay at home. It is hard to know how to tell people when and when not to go see their doctor, urgent care center, or minute clinic. The Centers for Disease Control and Prevention currently recommends that you call your physician if you develop a fever, cough, and shortness of breath AND have been in close contact with a person diagnosed with COVID-19 or have recently traveled from an area with ongoing spread of SARS-CoV-2.
Request patients who are coughing or sneezing to wear a mask while in the clinic and, if possible, move them into an individual room for treatment. Provide alcohol-based hand sanitizer and face masks at all facility entrances. Educate your patients on proper hand and wrist hygiene and the other preventive practices outlined above.
Make a plan for how you will educate your front desk and clinical staff about protecting themselves and cleaning their workspace frequently.
The World Health Organization website includes the following helpful resources:
David Levine is professor in the department of physical therapy at The University of Tennessee at Chattanooga (UTC) and a board-certified clinical specialist in orthopaedic physical therapy. June Hanks is associate professor in the department of physical therapy at UTC. Henry Spratt is a microbiology professor in the UTC department of biology, geology, and environmental science. Charles Woods is chair of the department of pediatrics of the UT College of Medicine Chattanooga and professor of pediatric infectious diseases.