key: cord-0825740-lbwpb0d0 authors: KOCH, Lionel; NESPOULOUS, Olivier; TURC, Jean; LINARD, Cyril; MARTIGNE, Patrick; BEAUSSAC, Madeleine; MURRIS, Sophie; FERRARIS, Olivier; GRANDADAM, Marc; FRENOIS-VEYRAT, Gaelle; LOPES, Anne-Aurélie; BOUTONNET, Mathieu; BIOT, Fabrice title: Risk analysis by Failure Modes, Effects and Criticality Analysis (FMECA) and biosafety management during collective medical air medical evacuation of critically ill COVID-19 patients date: 2021-10-21 journal: Air Med J DOI: 10.1016/j.amj.2021.10.006 sha: ddb26246b75b5f86317483d4d92ab8aeaa0f99b4 doc_id: 825740 cord_uid: lbwpb0d0 In March 2020, COVID-19 caused an overwhelming pandemic. To relieve overloaded Intensive Care Units in the most affected regions, French Ministry of Defence triggered collective Air Medical Evacuations (MEDEVAC) on-board of an Airbus A330 Multi Role Tanker Transport of the French Air Force. Such collective air MEDEVAC is a big challenge regarding biosafety, as until now, only evacuations of a single symptomatic patient with an emergent communicable disease, like Ebola virus disease, have been conducted. However, the COVID-19 pandemic required collective MEDEVAC for critically ill patients and involved a virus still little known. Thus, we performed a complete risk analysis using a process map and an FMECA (Failure Modes, Effects and Criticality Analysis) to assess the risk and implement mitigation measures for health workers, flight crew as well as for the environment. We reported the biosafety management experienced during six flights with a total of 36 critically ill COVID-19 positive patients transferred with no casualties whilst preserving both staffs and aircraft. In March 2020, the world faced an unprecedented outbreak of Coronavirus called COVID-19 (1) . In some French regions, especially in the East, an overwhelming influx of critically ill patients overloaded Intensive Care Units (ICU) while many other regions were less affected and had available capabilities. Collective Air Medical Evacuations (MEDEVAC) were conducted onboard an Airbus A330 Multi Role Tanker Transport (MRTT) from the French Air Force to relieve those ICUs and to ensure the best prognosis for patients (2, 3) . Air MEDEVAC of single symptomatic patients with a communicable disease like Ebola Virus Disease (EVD) had already been performed (4) , but never multiple patients on an A330-MRTT. The situation during the COVID-19 outbreak was different as it required numerous MEDEVAC for critically ill patients with Acute Respiratory Distress Syndrome (ARDS) involving a virus still little known. Such collective air MEDEVAC of contagious critically ill patients is a big challenge regarding biosafety. In this work, we reviewed the risk assessment and the situational awareness including both aeronautic and medical constraints. We established a risk map and proceeded to a risk assessment using an FMECA (Failure Modes, Effects and Criticality Analysis) method. We described the measures implemented to mitigate biohazard for health workers and flight crew on board as well as for the aircraft cabin environment to reach an acceptable risk. We also controlled the efficiency of our measures by staff health and environmental monitoring. We reported here the biosafety management experienced during six flights with a total of 36 COVID-19 critically ill patients transferred. Biosafety and biosecurity experts from the French Armed Forces Biomedical Research Institute (IRBA) and chemical, biological, radiological, nuclear and explosive (CBRNE) specialists from the French Air Force assessed the risk and considered the feasibility to evacuate critically ill COVID-19 patients with minimal risk of contamination for medical staff, flight crew and environment, mostly the aircraft cabin. Despite the operational emergency, we conducted a risk analysis based on an FMECA method already in use in some health facilities (5) to assess and mitigate the COVID-19 transmission risk. We first determined a process map, which listed of all actions undertaken during the mission. Then we established a risk cartography based on a review of the literature to evaluate the risk of transmission of a communicable disease in an aircraft and the specificity of SARS-CoV-2 transmission. On-site inspections with the manufacturer, Airbus, helped us to understand the air circulation in the cabin and how it was renewed. Thus, we also considered the need for flight safety and security as well as the medical constraints induced by the care of ARDS patients in an aircraft during a flight. The risk of working with a highly pathogenic infectious agent has been evaluated based on guidelines from the French Agency for Food, Environmental and Occupational Health and Safety (Agence nationale de sécurité sanitaire de l'alimentation --ANSES) (6) . The "MoRPHEE" (MOdule de Réanimation Pour Haute Elongation d'Evacuation -Resuscitation Module for High Elongation Evacuation) medical kit (7) transform the A330 MRTT's cabin into a flying ICU. Our analysis, integrating aeronautical and infectious data, resulted in a set of measures aimed to mitigate the infectious risk in this peculiar environment. The equipment and procedures that we implemented mitigated the risk until reaching an acceptable level previously defined. We chose a step by step approach close to the field, which allowed us to check our hypothesis with the already established cabin's configuration. Once we considered that the risk was acceptable, we performed the medical evacuations. The entire staff was medically monitored for early and late symptoms of infection. Environmental samplings using sterile moistened swabs were collected in different spots before and after full decontamination ( Figure S1 ). Specific reverse transcriptase real-time polymerase chain reaction (RT-qPCR) targeting RNA-dependent RNA polymerase (RdRp) was used to detect the presence of SARS-CoV-2. We listed all actions undertaken by the staff to perform an air MEDEVAC of COVID-19 severely ill patients to create a process map ( Table 1) . This includes actions performed before, during and after patient transportation from the preparation of the aircraft to the reconditioning. Aircraft transportation has been described as a cause of tuberculosis (8), measles (9) or SARS (10) infection spread between travellers. Thus, in 2007, the U.S. authorities published a public health "Do Not Board" (DNB) list to avoid people who are at risk to be contagious from boarding commercial flights (11) . As a result, in 2015, almost 400 passengers have been placed on federal Public Health Travel Restrictions (PHTR) for getting tuberculosis or measles (12) and between January 2014 and December 2016, 160 passengers had travel restricted because of documented high risk exposure to EVD, Lassa fever or the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) (13) . However, while the risk of infectious disease transmission has been described between passengers during commercial flights, there is less scientific data for medical transportation related to massive evacuations of contagious patients. Nevertheless, during the West-Africa EVD outbreak, at least 33 patients were evacuated to the U.S. or Europe as two patients with Lassa fever from Togo in 2016, but, to the best of our knowledge, all were medical evacuations performed in a dedicated confinement unit, with a unique symptomatic patient on-board (4, 14, 15) . including aerosolisation while passing through these same areas (18) . The similar airborne transmission was also observed in a large housing complex in Hong Kong due to a hydraulic action inside drainage pipes (19) . Nosocomial clusters have also been described, notably in Toronto where 128 cases were described in a hospital (20) . These events, especially those related to airborne transmission are also described in the current outbreak (21) such as in the Diamond Princess cruise ship where all transmission modes might have been involved (22) . Indeed, the persistence of the coronavirus in the environment has been tested in experimental conditions. Under certain temperature and humidity conditions, the SARS-CoV-2 responsible for COVID-19 might remain viable in aerosols for more than three hours with a half-life of one hour. It has also found to be viable on plastic and stainless steel up to 72 hours with a half-life of several hours (23) . These data are corroborated by studies on previous human coronaviruses SARS-CoV-1, Middle East Respiratory Syndrome (MERS) coronavirus and endemic human coronaviruses (HCoV) which can persist on inanimate surfaces up to 9 days but remain sensitive to disinfection procedures (24). The Airbus A330-MRTT is an aerial refuelling tanker aircraft used by the Strategic Air Force and based on the civilian Airbus A330-200. Part of the aircraft cabin can be transformed into a medical zone (7) . This capability of collective strategic medical evacuation (MEDEVAC), known as "MoRPHEE", was designed to evacuate severely injured war casualties and originally employed the Boeing KC-135. The A330-MRTT with the MoRPHEE kit was conceived to be able to adapt to multiple scenarios, including contamination by CBRNE agents. The A330-MRTT with the MoRPHEE kit provides the level of care of a flying ICU and complies with the aeronautical security regulations. Six critically ill patients in addition to eight other patients can be transported simultaneously with a medical crew composed of 3 ICU physicians, 2 flight surgeons, 3 anaesthetic nurses, 3 flight nurses and 2 nurses trained in emergency care (25) . However, it was not designed to take care of patients with a communicable disease whereas the COVID-19 pandemic was its first use in operational conditions ever. The missions aimed to evacuate COVID-19 critically ill patients needing permanent monitoring without any information about their capability for the SARS-CoV-2 dissemination. Despite the presumed or potential patient's contagiousness imposing biosafety measures, medical and aeronautic standard security procedures had to be followed. Clinical parameters and aeronautic data are detailed in separated publications (2, 3) . Pilots should not be exposed to infectious risk and should fly the aircraft as usual. The cabin flight crew had to be able to secure the aircraft, especially during the boarding and disembarking phases. Health workers had to be able to perform technical interventions and to control patient stability for several hours despite the infectious risk. Both health workers and flight crew should have the possibility to rest in a "clean" area. We have adapted the Airbus A330 MRTT by creating different areas in the aircraft cabin ( Fig. 1) . The MoRPHEE medical area was considered as "dirty" and separated by a vinyl partition from the front of the aircraft including the cockpit and the back of the cabin. Air processed by HEPA (High-Efficiency Particulate Air) filters entered the cabin from overhead distribution outlets and left the cabin towards the ground outflow grills ( Fig. 2A) with minimal forwards and backwards airflow (26) . The air was renewed every three minutes. The airflow in the cabin was advantageous to contain the possible dissemination of viral particles. The front and the back of the aircraft were considered as "clean". We used the "clean" area in the back as a safety zone to allow the medical staff and the flight crew to rest. Thus, we created an intermediary area with an airlock to allow the personnel to go out the "dirty" area using biosafety procedures (doffing PPE) and to return. For that purpose, we used the disabled toilet to create a vacuum airlock in which the air was renewed every 34 seconds thanks to the mechanical ventilation system (Fig. 2B) . We have blocked all the apertures in the door on the "dirty" side of the airlock so that the air entering only came from the "clean" area. Decontamination of the "dirty" area was performed in two steps with aircraft approved products. First manual cleaning disinfection of all surfaces, focusing on the most frequently touched areas, followed by an application of disinfectant by a fogging machine. All personnel in the "dirty" area were equipped with standard PPE notably with Filtering Face Piece 2 (FFP2, similar to N95) masks. However, before the first evacuations, neither health workers nor the flight crew was used to wearing such equipment even if the flight crew had already been trained in CBRNE procedures. We had to set up dedicated procedures especially for the use of the airlock and to train all personnel to work with this constraint. These PPE and procedures also raised safety issues by reducing the ergonomics of routine medical procedures and increasing staff stress. Therefore, we set up specific training and debriefing after every mission. Actions involving the respiratory system as cardiopulmonary resuscitation are known to be high-risk situations for transmission of coronavirus (27) . Thus we followed the French guidelines (28) to transfer patients with minimum risk of aerosolisation (patients intubated under curare administration, ventilated and aspirated only with closed and filtered systems, shut-off and clamping mechanical ventilation systems during patient transfer). Throughout the MEDEVAC, a dedicated biosafety team was present to ensure that procedures were followed. Our risk analysis was limited to the management of patients by our flying team and separated between occupational risks and environmental contamination risks. It excluded the ground teams as well as the analysis related to aeronautical risks. All risks were quantified in the FMECA ( Table 2 ) using the risk rating scale ( Table 3) , before and after mitigation. The coefficients for each risk modality were assigned by a consensus of at least three experts. A risk priority index at 20 or less was considered as low and did not require any further mitigation. An index between 21 and 40 was considered as middle and needed some supplementary measures whereas an index superior at 40 was considered as not acceptable and prevented the continuation of the mission. Despite several risks initially identified as not acceptable with index values up to 80 (for a maximum at 125), we managed to reduce all risks to an acceptable level. The higher residual risk concerned mostly contamination (especially by contagious personnel) and injuries by fall. The first flight occurred on March 18 th followed by five other flights on March 21 th , 24 th , 27 th , 31 th and April 3 rd . Six ICU patients were transported in each flight for a total of 36 patients. During the second flight, 68 environmental samples were collected and all of them were negative. These results were especially important for the safety zone, where health workers and flight crew had the possibility to rest. Because of the unprecedented nature of this zoning, we choose a step-by-step implementation with a prototype in the first flight before a definitive version during the second mission. Finally, we used this safety area to rest after patients have been disembarked only from the third MEDEVAC when we received the results of our samplings. All in all, fourteen people had been exposed only in the "clean" zone and 28 in both the "dirty" and "clean" zone during several hours per mission (4h30-6h30). Fourteen days after the last flight, none of them experienced any symptoms and hence, none were tested by PCR (not indicated for massive and systematic testing at that time). Here we presented the implemented biosafety measures for the first ever collective air MEDEVAC of critically ill COVID-19 patients. Our objective was to establish working conditions as close as usual for health workers while protecting them and the aircraft from SARS-CoV-2. The challenge was the absence of recommendations or guidelines to evacuate multiple patients with an emerging communicable disease (15) and the operational emergency, which forced us to quickly develop an innovative solution, even if we did not know a lot about the virus or its propagation. Thus, we performed a risk analysis based on FMECA method by assessing the published data on infectious risk and air transportation as well as coronaviruses' specific mode of transmission. The literature published after our missions confirmed the increased risk of COVID-19 transmission during air travel (29) . Even if simulations in several aircraft have shown a low risk of aerosol dispersal during the flight (30), multiple outbreaks have occurred during flights, especially long ones and despite low occupancies and prevention measures including wearing masks in some of them (31) (32) (33) (34) (35) . Clusters have also been described in other confined spaces like restaurants (36) , conference rooms or public transportation (37) and health care facilities have been proven to be among the most contaminated areas by aerosol or contamination transfer (38) (39) (40) (41) (42) . Moreover, the virus can survive up to days on surfaces, depending on the conditions (43) (44) (45) (46) . However, by integrating some contextual data from the aircraft configuration and the constraints of health workers and flight crew work, we set up dedicated biosafety procedures and trained all staffs to efficiently mitigate the risk and protect both, the staffs and the aircraft. The most innovative measure was without contest the compartmentalisation of the aircraft with the creation of different areas in the cabin to separate the working zone considered as "dirty" from a "clean" zone which was considered as a safety area. We implemented it step by step and used it only after some adjustments and receiving the results of the environmental samplings, to ensure that the risk in this area was not higher than the risk in general population. We completed this (52) (53) (54) (55) . In an airplane, wearing a mask appears to provide a certain degree of protection (56, 57) . Thus, wearing a surgical mask for awake patients in all circumstance and for all staff in the safety area contributed to mitigate the spreading risk. The initial assessment identified high risks for staff and for the environment with several risks priority indexes exceeding 60 for a maximum possible at 125. The highest risk was a possible contamination of the staff or the environment by the patient or by other staff members, which is highly problematic on a military air base (58) . The mitigation measures we implemented managed to lower the risk to an acceptable level with all risk priority indexes less than or equal to twenty. We maintained this assessment even if we did not study the dispersion of the virus in the air of the cabin by atmospheric sampling while the spread by aerosol is one of the most difficult to contain (59) . Moreover, in the current situation, RT-qPCR tests should have been considered before the mission for all staff but at this time in France they were reserved for symptomatic patients with severe forms of the disease. Thus, the highest residual risk was a contamination of the environment, especially the airport facilities by an infected staff. This risk was identical to that of staff who have no professional exposure, for example airport staff member. This meant that we managed to efficiently mitigate all additional risk due to the unusual nature of the mission. As a result of the measures we put in place, especially due to PPE wearing, certain risks increased notably for occupational risk such as traumatic injuries, illness or stress. Despite our efforts, traumatic injuries were the second residual risk index but fortunately, none of our staff experienced any injury. We evacuated 36 patients over a long distance with no casualties while preserving both staff and aircraft. We did not find any sign of infection among all personnel present in the aircraft after monitoring them from the first flight and during fourteen days. The negativity of all samplings validated our biosafety measures, especially decontamination procedures. This was especially important as after this MEDEVAC, the aircraft had to pursue all its others missions ranging from aircraft refuelling to strategic MEDEVAC of injured soldiers. However, critically ill patients are suspected to have lower viral charges than mild-to-moderate cases (60) and might be at lower risk than patients with an early form of the disease (61) . Indeed, it has already been described that on three resuscitation rooms only one among the three patients had contaminated his environment (62) . Fortunately, the SARS-CoV-2 remains very susceptible to a wide range of disinfectant (63) and their persistence could affect the virus survival on surfaces (64) as confirmed in China where SARS-CoV-2 RNA was only found in the sewage of hospital isolation wards routinely wiped (65) . However, we recommend performing supplementary sampling in case of transportation of symptomatic and conscious patients, which could be more at risk of environmental dissemination. We did not test our organisation in a long-range flight with staff turnover implying multiple back and forth in the "clean" zone and more risk of contamination. Zoning the aircraft and developing appropriate operating procedures created a safe work environment in the A330 MRTT during the evacuation of COVID-19 critically ill patients. Both medical staff and aircraft have been preserved during these missions. Furthermore, the existence of a "clean" zone, which allows the medical staff to rest, makes repeated flight or long-range flights possible with maximum safety. The methodology of infectious risk assessment used could be extended to any situation at risk of contamination especially with an emergent pathogen. As previously evoked (66) , this article illustrates the contribution of infectious risk management specialists in the conduct of operations related to a major biological crisis. The staff put PPE on and was briefed by the staff leader The staff leader coordinated the arrival of the patients on the aircraft The staff transferred on the aircraft stretcher and put all medical devices in place The staff assessed the patients and prepared them to take off The staff prepared to take off (sit down and lock the belt) After take-off, the staff took care of patients (moving from one patient to another, patients monitoring, ICU treatments including possible high risk gestures on respiratory tract) At the end of the flight, the staff prepared the patients for landing The staff prepared for landing (sit down and lock the belt) After landing, the staff prepared the patients for transfer The staff leader coordinated the departure of the patients from the aircraft The staff transferred from the aircraft stretcher to the ambulance stretcher and put all medical devices off The staff decontaminate all medical devices The staff undressed PPE and left the aircraft A specialised team decontaminated the aircraft cabin and managed wastes After full decontamination, staff was debriefed and reconditioned all material Risks are classified and characterised by modality and possible effects. Risk priority indexes are calculated using the risk rating scale in Table 3 and defined as followed: ≤20, marked : low, the analysed process could be applied; 21-40 marked : middle, supplementary measures are necessary; >40 marked : not acceptable, the analysed process could not be applied before and after application of mitigation measures. Mitigation measures can affect likelihood (L), severity (S) and detectability (D) to decrease (↘) or increase (↗) them. Certainly that the failure will frequently occur 5 Likely Frequent failure 4 Occasional Failure occurred occasionally with a similar process 3 Rare Could occur and has been observed once 2 Unlikely Could occur, but has never been observed 1 Severity Deadly Can cause death for human or global exposure/dissemination 5 Serious Can cause very serious or irreversible injuries for human or mass exposure/dissemination 4 Average Can cause significant injuries for human or very likely exposure/dissemination 3 Benin Can cause mild injuries for human or a very limited risk ok exposure/dissemination 2 Unlikely Could unlikely cause mild injuries for human or no risk of exposure/dissemination 1 Detectability Detection is not possible 5 An experienced person needs to verify several parameters and interpret a complex situation to highlight the possible occurrence of the event 4 Moderate An experienced person or a measurement/test can detect that the event could occur 3 Easy There are multiple factor that could alert the personnel before the event occurs 2 Obvious A novice could easily detect the event before it occurs 1 Table 3 : risk rating scale for likelihood, severity and detectability. Risk priority indexes are calculated by multiplying the coefficient for likelihood (L), severity (S), detectability (D). Epidemiological data from the COVID-19 outbreak, real-time case information Oxygen Management During Collective Aeromedical Evacuation of 36 COVID-19 Patients With ARDS Collective aeromedical transport of COVID-19 critically ill patients in Europe: A retrospective study Aerial medical evacuation of health workers with suspected Ebola virus disease in Guinea Conakry-interest of a negative pressure isolation pod-a case series Evaluating the application of failure mode and effects analysis technique in hospital wards: a systematic review Methodological guide to the assessment of biological safety and security risks Morphée Tuberculosis and air travel: a systematic review and analysis of policy Patterns of measles transmission among airplane travelers Transmission of the severe acute respiratory syndrome on aircraft Federal air travel restrictions for public health purposes--United States Federal travel restrictions to prevent disease transmission in the United States: An analysis of requested travel restrictions US Federal Travel Restrictions for Persons with Higher-Risk Exposures to Communicable Diseases of Public Health Concern. Emerg Infect Dis Airborne Medical Evacuation Review of Literature for Air Medical Evacuation High-Level Containment Transport Guidance on Air Medical Transport (AMT) for Patients with Ebola Virus Disease (EVD) | Emergency Services | Clinicians | Ebola (Ebola Virus Disease) | CDC Assessing and planning medical evacuation flights to Europe for patients with Ebola virus disease and people exposed to Ebola virus European Centre for Disease Prevention and Control Progress in Global Surveillance and Response Capacity 10 Years after Severe Acute Respiratory Syndrome. Emerg Infect Dis Evidence of airborne transmission of the severe acute respiratory syndrome virus Investigation of a nosocomial outbreak of severe acute respiratory syndrome (SARS) in Toronto, Canada COVID-19 may transmit through aerosol SARS-CoV-2 and COVID-19: The most important research questions Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1 Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents Ten Years of En Route Critical Care Training Guidelines for Prevention and Control Possible SARS Coronavirus Transmission during Cardiopulmonary Resuscitation. Emerg Infect Dis Recommandations d'experts portant sur la prise en charge en réanimation des patients en période d'épidémie à SARS-CoV2 Société Française d'Anesthésie et de Réanimation Risk of COVID-19 During Air Travel TRANSCOM/AMC Commercial Aircraft Cabin Aerosol Dispersion Tests Assessment of SARS-CoV-2 Transmission on an International Flight and Among a Tourist Group A large national outbreak of COVID-19 linked to air travel, Ireland, summer 2020 Asymptomatic Transmission of SARS-CoV-2 on Evacuation Flight. Emerg Infect Dis Transmission of SARS-CoV 2 During Long-Haul Flight. Emerg Infect Dis In-flight transmission cluster of COVID-19: a retrospective case series COVID-19 Outbreak Associated with Air Conditioning in Restaurant Airborne Transmission of COVID-19: Epidemiologic Evidence from Two Outbreak Investigations Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals Environmental contamination of SARS-CoV-2 in healthcare premises Detection of air and surface contamination by SARS-CoV-2 in hospital rooms of infected patients Aerosol and Surface Distribution of Severe Acute Respiratory Syndrome Coronavirus 2 in Hospital Wards Toilets dominate environmental detection of severe acute respiratory syndrome coronavirus 2 in a hospital Modeling the Inactivation of Viruses from the Coronaviridae Family in Response to Temperature and Relative Humidity in Suspensions or on Surfaces Experimental aerosol survival of SARS-CoV-2 in artificial saliva and tissue culture media at medium and high humidity Stability of SARS-CoV-2 and other coronaviruses in the environment and on common touch surfaces and the influence of climatic conditions: A review The effect of temperature on persistence of SARS-CoV-2 on common surfaces Aerosol transmission of SARS-CoV-2? Evidence, prevention and control Efficacy of face mask in preventing respiratory virus transmission: A systematic review and meta-analysis Association between 2019-nCoV transmission and N95 respirator use Effectiveness of Face Masks in Preventing Airborne Transmission of SARS-CoV-2. mSphere Respiratory virus shedding in exhaled breath and efficacy of face masks Absence of Apparent Transmission of SARS-CoV-2 from Two Stylists After Exposure at a Hair Salon with a Universal Face Covering Policy Large SARS-CoV-2 Outbreak Caused by Asymptomatic Traveler Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility Transmission of SARS-CoV-2 by inhalation of respiratory aerosol in the Skagit Valley Chorale superspreading event. Indoor Air Absence of in-flight transmission of SARS-CoV-2 likely due to use of face masks on board In-flight Transmission of SARS-CoV-2: a review of the attack rates and available data on the efficacy of face masks Gestion de la COVID-19 au sein d'une base aérienne militaire. Presse Médicale Form Uncertainties about the transmission routes of 2019 novel coronavirus. Influenza Other Respir Viruses SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient Transmission of SARS and MERS coronaviruses and influenza virus in healthcare settings: the possible role of dry surface contamination Antiseptics and Disinfectants: Activity, Action, and Resistance SARS-CoV-2 RNA detection of hospital isolation wards hygiene monitoring during the Coronavirus Disease 2019 outbreak in a Chinese hospital Natural outbreaks and bioterrorism: How to deal with the two sides of the same coin? J Glob Health We thank the French Air Force CBRNE teams, flight crews and firefighters and the Infectiology Department of French Armed Forces Biomedical Research Institute for providing support during this mission. The authors received no financial support for the authorship of this article. The authors received no financial support for the authorship of this article.