key: cord-0714584-wqs1k0os authors: Assadi, Majid; Gholamrezanezhad, Ali; Jokar, Narges; Keshavarz, Mohsen; Picchio, Maria; Seregni, Ettore; Bombardieri, Emilio; Chiti, Arturo title: Key elements of preparedness for pandemic coronavirus disease 2019 (COVID-19) in nuclear medicine units date: 2020-04-21 journal: Eur J Nucl Med Mol Imaging DOI: 10.1007/s00259-020-04780-4 sha: 38df2eec78989870b2819dfc940be8aa13a26809 doc_id: 714584 cord_uid: wqs1k0os nan # Springer-Verlag GmbH Germany, part of Springer Nature 2020 Coronaviruses are enveloped, positive-sense, single-stranded RNA viruses (27-32 kb genome length) belonging to the Nidovirales order, which cause infection in the respiratory and intestinal tract [1] . This family is genetically divided into four genera, namely alpha, beta, gamma, and delta coronavirus. The first two genera infect mammals, while the latter two spread the disease to birds [2] . To date, seven coronaviruses have been identified as human pathogens, including CoV-229E, CoV-NL63, CoV-HKU1, CoV-OC43, SARS, MERS, and 2019 novel coronavirus (2019-nCoV). According to phylogenetic analysis, the novel coronavirus (SARS-CoV-2) is located in the beta coronavirus genus. This new coronavirus causes severe respiratory tract infection and is also highly contagious [3] . The transmission route of the 2019-nCoV is mostly through close contact, respiratory droplets, and persistence of the virus on inanimate surfaces [4] . However, some studies have shown that the fecal-oral route may be a possible pathway of transmission [5, 6] . The attachment of the virus to the receptor expressed by cells is an essential step in the occurrence of persistent infection in the host. Owing to the structural similarities between spike surface glycoproteins of 2019-nCoVand SARS-CoV-2, virus entry is reportedly mediated by angiotensin-converting enzyme 2 (ACE2) receptor [7] . Furthermore, the tissue tropism and pathogenesis of SARS-CoV-2 infection would be determined by the distribution of ACE2 as a receptor. High expression of ACE2 on various tissues such as respiratory tract cells, the urinary system, and the testes can account for the involvement of several organs in SARS-CoV-2 infection [8, 9] . Owing to the lack of adequate treatment and a vaccine, as well as the asymptomatic incubation period of this emerging virus, every procedure that could rapidly and accurately detect infection is important for the management of this disease, including patient isolation and effective public health surveillance [10] . According to the guidelines published by the Chinese government, samples suspected to be SARS-CoV-2 should be confirmed by a real-time reverse transcriptase polymerase chain reaction (RT-PCR) test [11] . Limitations in collecting a specimen from patients and the performance of laboratory kits mean that quantitative RT-PCR has a high specificity but a low sensitivity (60-70%) for SARS-CoV-2 detection. The low sensitivity can lead to poor identification of patients and thus increase the chance of contamination in the community [12] . Imaging, including computed tomography (CT), plays a major role in the diagnosis and assessment of the severity and progression of the disease in COVID-19 infection. An accurate and fast diagnosis of COVID-19-infected patients through a CT scan is possible with computer-aided methods such as deep learning [13] . The reported sensitivity of chest CT has been found to be more than that of RT-PCR (98% vs 71%, respectively) [14] . As it cannot be excluded that infected and suspected COVID-19 patients will be referred to nuclear medicine units, among other health services, special prevention and protection measures for healthcare workers and other patients are essential. Like any similar circumstances, the most logical way to handle a potential risk is to be informed and systematically prepared. In line with this, the readiness of units is of great importance, as this could cause decreased problem. This document aims to present precautionary and safety recommendations at the time of the COVID-19 outbreak for healthcare workers and to provide the most appropriate information about personal protective equipment (PPE) for nuclear medicine units. Healthcare workers are at risk of coronavirus infection in the workplace because of human-to-human transmission and the contagious nature of viral infection. Thus, prevention and control strategies to reduce secondary infections among close contacts and healthcare workers are vital. Previously, international organizations such as the WHO and the Centers for Disease Control and Prevention (CDC) produced useful documents about effective strategies for preventing and treating viral infections including MERS-CoV, Ebola, SARS, and avian flu [15] [16] [17] [18] . The WHO-based guidelines on the most effective preventive measures for health workers who have been exposed to a confirmed coronavirus patient in a healthcare facility are illustrated in Table 1 [19] . Notably, the risk of contagion for health workers in nuclear medicine units is high because of the referral of non-symptomatic patients and inadequate protection equipment. The medical director and the security officer should have delivered the right infection control training and evidence-based framework for both patients and healthcare workers, based on the accepted prevention and protection guidelines. Health workers should wear PPE appropriate to their profession or specialty. This equipment consists of a mask (surgical and respiratory), gloves, gowns, shoes, head cover, and eye protection. If the PPE is reusable, it has to be correctly cleaned and decontaminated before and after each use. Details of PPE usage are elaborated next. There are two main types of masks, "surgical" and "respiratory." The surgical masks protect against infectious agents transmitted via droplets of saliva or secretions from the upper respiratory tract. Nonetheless, protective or respiratory masks also protect against the inhalation of infectious agents transmitted by airborne paths. Individuals who must wear face masks include every person with respiratory symptoms such as sneezing, coughing, and difficulty breathing, people who are caregivers in their families, and healthcare employees who have been exposed to individuals with confirmed or suspected COVID-19. Surgical masks are disposable, while respirators can be reused by replacing the filter once it becomes full. These two types of masks should not be worn for more than three (for surgical mask) to eight (for respiratory mask) hours at a time, according to the manufacturers' guidelines. The respiratory mask prevents the wearer from inhaling aerosols, as well as mist or gases, which are health hazards. It also protects the person from airborne infectious pathogens such as coronavirus, SARS, or H1N1. In the USA, respirators are produced based on the NIOSH (National Institute for Occupational Safety and Health) standard protocols, which divide them into several classes according the degree of oil resistance: classes N, R, and P. On the other hand, European standard EN 149:2001 identifies three classes of disposable particulate respirators: FFP1, FFP2, and FFP3. Various types of respiratory masks are shown in Table 2 (http://emag. medicalexpo.com/which-masks-actually-protect-againstcoronavirus/, http://www.safeticorp.com/data/train_img_ normal/Respiratory_Protection.pdf, https://www. rogerwjones.co.uk/tsc28938-ffp1-disposable-mask-10) [20] . Therefore, for the contagious patient, a surgical mask must be worn as soon as contagion is suspected. For caregivers caring for a patient with confirmed or suspected coronavirus, SARS, or H1N1, it is imperative to wear a protective mask of at least classes FFP2 or FFP3 (classes N, R, or P in the USA) for the greatest filtration of particles and aerosols. N95 masks are the most favored mask for health workers in a COVID-19 infected situation (http://guide.medicalexpo.com/choosing-asurgical-mask-or-respirator/) [21] . These masks should be replaced when changing the bowl-shaped mold and the soiled filter. Before touching the mask, hands should be washed with soap and water for at least 20 s, then dried with a clean paper towel. Gloves are made of different materials and differ according to the type of work undertaken. Patients, caregivers, and healthcare workers must use gloves to protect themselves from infections during examinations. Details of the most appropriate professional gloves for healthcare w o r k e r s a r e s u m m a r i z e d i n Ta b l e 3 ( h t t p s : / / avacaremedical.com/medical-gloves-guide, https:// mercatormedical.eu/products/gloves) [22] , along with their properties. The first stage in determining which type of gloves would be suitable is identifying the dangers and the corresponding hand protection measures. The best gloves for healthcare workers are, first, latex and, second, nitrile [20] . Wearing a face mask and gloves cannot definitely block infections in any of these circumstances and should be combined with other PPE and regimes, such as hand hygiene, maintaining a distance from people with symptoms, and respiratory hygiene (or cough etiquette). The correct order for donning and removing PPE is also important. The relevant steps are shown in Figs. 1 and 2 (https://www.cdc.gov/HAI/ pdfs/ppe/ppeposter1322.pdf). Perform hand hygiene immediately after removing all PPE. Suitable for particles between 2 and 5 μm with a minimum 94% filtration and maximum 8% leakage to the inside, mainly used in construction, agriculture, and healthcare professionals against influenza viruses. They are currently used for protection against the coronavirus FFP3 The most filtering mask of the FFPs, suitable for particles smaller than 2 μm with a minimum 99% filtration and maximum 2% leakage to the inside, using against very fine particles such as asbestos N class No oil resistance. A distinction is made between N95, N99, and N100 suitable for particles larger than 0.3 μm, and the number after the letter indicates the percentage of filtration of suspended particles R class Resistant to oil for up to 8 hours. Similar to the N class, a division is made between R95, R99, and R100, suitable for particles larger than 0.3 μm P class Class P: a completely oil-resistant mask. There are also P95, P99, and P100 Eur J Nucl Med Mol Imaging The two principal measures to prevent transmission of infectious diseases, namely elimination or removing the risk physically and substitution of the risk, are not applicable to the healthcare setting. Nevertheless, contagion can be reduced by decreasing exposure to transmissible respiratory particles in these units. Therefore, strategies including environmental hygiene, administrative regulations, high work performance, and the correct use of PPE are essential to prevent the spread of infections in a healthcare setting. It has shown that the factors that increase the risk of death in COVID-19 patients include cardiovascular disease (10.5%), diabetes (7.3%), chronic respiratory disease (6.3%), high blood pressure (6%), cancer (5.6%), and certain other underlying diseases (0.9%) [23] . It is recommended that health workers with these risk factors should stop work immediately and take time off away from the unit. Moreover, personnel must be aware of the latest COVID-19 information and recommendations and should check themselves for any signs of disease (subjective fever, cough, or difficulty breathing) before presenting to the . & Try to make regular appointments for imaging and carry out the procedure only at the allocated time. If the timetable has changed, it can be suggested that patients wait at home or in their car. & As much as possible, portable imaging in emergency wards should be performed in a room with appropriate ventilation. & For cases admitted to hospitals, before referring the patient to the nuclear medicine unit, the relevant ward should coordinate with the imaging unit regarding probable infection. & Maintain a spatial distance of at least 1 m between noninfected, potential, and verified infected COVID-19 patients and also between patients and health workers to decrease the transmission of pathogens. & Consider the use of patient cohorting, such as scheduling potential infected and confirmed infected patients at the same time for examination or imaging and non-infected patients at a different time, to reduce the transmission of COVID-19 pathogens to healthcare workers and other non-infected patients. The pandemic SARS-CoV-2 disease is spreading rapidly. Healthcare workers and others must take protective and preventive measures to reduce the probability of contagion. All staff in nuclear medicine units must follow the national and local official recommendations and guidelines to lower the risk of transmission. Recording and assessing all our experiences and lessons about COVID-19 daily will be a valuable exercise, helping to guide the management of the coronavirus pandemic. Case designations are dynamic, and consequently, frontline doctors are strongly urged to seek updates from public health and infection control authorities as our understanding of this disease matures. One more important point that we should not forget in this situation is this fact that this situation confines people to a small area and limits normal activity out of doors, which may lead to increased stress levels, restlessness, and the adverse consequences of physical inactivity. Psychological and behavioral supports could be helpful for the reduction of anxiety and negative moods, which could be important for increasing resilience during this disease outbreak. Finally, it should be kept in mind that like other similar conditions, the most proper way to deal with any crisis is to be widely prepared. Up to now, it may believe that the performance of the healthcare system in nuclear medicine units is limited to radiation issues. This fact intensifies the necessity of nuclear medicine unit preparedness before an infection outbreak in addition to radiation accident. The development of an individualized management model for each nuclear medicine unit based on staffs, instruments, kind of services, crowding, physical space, hospital base unit, or outpatient clinic that could consider all managerial aspects of a crisis is of pivotal importance. The proposed response mode should have internal and systemic integrity and coherence among the included items in two intra-and inter-unit management categories. Besides, continuous training of different occupational staffs are among the key parameters in keeping the readiness and appropriate response of units to rare but extremely important probable infection outbreak. This article does not contain any studies with human participants or animals performed by any of the authors. 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