Challenges and countermeasures in the prevention of nosocomial infections of SARS-CoV-2 before resumption of work: Implications for the dermatology department
Authors: Yamin Zhang, Jingjing Wen, Cai Chen, Lingling Zeng, Liu Yang, Changzheng Huang, Aiping Feng, Xiaoping Miao, Mahin Alamgir, Babar Rao, Yan Li, Juan Tao
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: Recently, the number of new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in China has been decreasing. At manuscript preparation, new cases had not been reported in Wuhan since March 18, 2020.1The Novel Coronavirus Pneumonia Emergency Response Epidemiology TeamThe epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) — China, 2020.China CDC Weekly. 2020; 2: 113-122Crossref Scopus (1278) Google Scholar As health care systems resume routine clinical activities, implementation of robust infection control measures to prevent nosocomial transmission of SARS-CoV-2 remains a top priority.2Bowdle A. Munoz-Price L.S. Preventing infection of patients and healthcare workers should be the new normal in the era of novel coronavirus epidemics.Anesthesiology. 2020; 132: 1292-1295Crossref PubMed Scopus (46) Google Scholar Our dermatology department is in Wuhan, the area first and worst affected by coronavirus disease 2019 in China. We aim to share our experiences in this unique position by outlining our infection control plan. We hope that it can serve as guidance for dermatology departments and the health agencies overseeing them. In the early days of the outbreak, high rates of nosocomial SARS-CoV-2 infections were observed in health care workers. More than two-thirds of infected health care workers had contracted the virus in units without known coronavirus disease 2019 patients.3Wang D. Hu B. Hu C. et al.Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China.JAMA. 2020; 323: 1061-1069Crossref PubMed Scopus (16038) Google Scholar We suspect that covert carriers of the virus may have contributed to this unchecked nosocomial spread; Qiu4Qiu J. Covert coronavirus infections could be seeding new outbreaks.Nature. 2020 Mar 20; (Online ahead of print)https://doi.org/10.1038/d41586-020-00822-xCrossref Scopus (157) Google Scholar reported that 60% of infections may be asymptomatic. By remaining cognizant of this risk, even in departments not directly involved in treatment of coronavirus disease 2019, we devised the following infection control plan for our dermatology clinic: First, an experienced infection control expert team was established. This team took responsibility for training and managing health care workers, including hand hygiene and the proper use of personal protective equipment (Supplemental Material 1 available via Mendeley at https://data.mendeley.com/datasets/s3ncfct2z8/1), as well as monitoring their state of health. We also held emergency simulations outlining protocols for inpatient dermatology admissions and consultations, as well as contingency plans for exposure to SARS-CoV-2–infected patients or health care workers in dermatology clinics. Next, the department was divided into clean, potentially contaminated, and contaminated zones. The potentially contaminated and contaminated zones were separated by 2 buffer zones (Fig 1). Patients and staff were to use separate passageways. Before entering the designated patient care area (contaminated zone), staff would don personal protective equipment in the clean zone. On exiting the contaminated zone, they would follow a series of transitions before returning to the clean zone. In the first buffer zone, they doffed personal protective equipment (except working clothes, N95 masks, goggles, and caps). Then they entered the potentially contaminated zone to remove the remaining items. Next, they transitioned to the second buffer zone, where they donned a new surgical mask. Only then did they enter the clean zone. This functional and geographic division of the clinics and wards was designed to minimize the risk of cross contamination. By sanitizing and washing hands in each zone and using adequate personal protective equipment for all patient encounters, we lessened the risk of nosocomial transmission. Finally, all employees were required to achieve 100% on a written examination (Supplemental Material 2). Thirty-five staff members completed the test (response rate 100%). Because of the relatively low accuracy rate of personal protective skills (82.04%) and division of work area (84.28%) (Fig 2), some dermatology staff received additional training. In the fight against future outbreaks, infection-prevention strategies take precedence.2Bowdle A. Munoz-Price L.S. Preventing infection of patients and healthcare workers should be the new normal in the era of novel coronavirus epidemics.Anesthesiology. 2020; 132: 1292-1295Crossref PubMed Scopus (46) Google Scholar Dermatologists should be trained in these measures, and clinics should be modified to minimize the risk of nosocomial transmission. We want to express our deep respect for all the first-line health care workers for their dedication in the fight against SARS-CoV-2 and thank the health care workers who participated in this study.