CC BY
9https://doi.org/10.32921/2225-9929-2020-3-38-17-20
Review article
Prerequisites for Improving the Anti-epidemic Regime in Medical Organizations in the Context of the COVID-19 Pandemic
Assel Khassenova 1, Zaituna Khamidullina 2, Zhuldyz Danbayeva 3, Gulnoza Aldabekova 4, Luka Bruzzati 5
1 Senior Lecturer, Department of Public Health and Hygiene, Astana Medical University,
Nur-Sultan, Kazakhstan
2 Vice-Director of the multifunctional hospital No.3 for the obstetric and gynecological block, Kazakhstan 3 Director of the multifunctional hospital No.3 of Nur-Sultan city, Kazakhstan 4 Senior Lecturer, Department of Public Health and Epidemiology, Astana Medical University,
Nur-Sultan, Kazakhstan 5 Professor of Public Health of the Bocconi University, Milan, Italy
Abstract
The pandemic of COVID-19 remained the central issue for public health due to the rapid spread and high contagiousness of the virus. In Kazakhstan, anti-epidemic measures developed and implemented came as sufficient prevention, which provides the prevention of airborne and contact mode of transmission. However, there are studies that indicated the existence of a fecal-oral mode of transmission due to the presence of angiotensin converting enzyme 2 (ACE2) on the surface of cells of the gastrointestinal tract.
Health care workers are at a significantly increased risk of infection because they are in constant contact with potential sources of viral infection. The personnel of medical organizations play a leading role in the fight against the pandemic; the task of the health care system is to create conditions for maintaining and strengthening their health. Considering persisting risks, it is necessary to foresee possible routes of transmission of infection and strengthen the anti-epidemic measurements, taking into account the fecal-oral mode of transmission.
Key words: COVID-19, anti-epidemic measures, nosocomial infection, fecal-oral transmission, angiotensin converting enzyme 2 (ACE2), Kazakhstan.
COVID-19 пандемиясы кезшде медицинальщ уйымдардагы эпидемияга карсы ic-шараларды жетmдiрудщ алгышарттары
Хасенова А.Ж.1, Хамидуллина З.Г.2, Данбаева Ж.С.3, Алдабекова Г.У.4, Luka Bruzzati 5
1 Когамдыц денсаулыц жэне гигиена кафедрасынын ага оцытушысы, Астана медициналын; yHueepcumemi, Нур-Султан, Казахстан
2 Нур-Султан цаласынын N°3 цалалыц кепбей/ндi ауруханасы директорынын акушерл/к-
гинекологиялыц блок бойынша орынбасары, Казахстан
3 Нур-Султан цаласынын N°3 цалалыц кепбей/'нд/' ауруханасынын директоры, Казахстан
4 Когамдыц денсаулыц жэне эпидемиология кафедрасынын ага оцытушысы, Астана медициналыц
университетi, Нур-Султан, Казахстан
5 Боккони университет/мн цогамдыц денсаулыц сацтау профессоры, Милан, Италия
Тушндеме
COVID-19 пандемиясы тез таратуы мен жугу жи/'л/'г/'н/'н тым жогары болуына байланысты когамныц ж1тi назарында болып отыр. Казакстанда аталмыш вирустыц ауа-тамшы жэне байланыс бойынша таралу жолдарыныц алдын алу максатында эпидемияга карсы ic-шаралар курастырылып, тэж/'рибеге енг/'зтген. Алайда, соцгы кездерi вирустыц нэж/'с-ауыз кууысы аркылы таралуын дэлелдейт1н зерттеу жумыстары бар екен1 назар аударады. Вирустыц нэж/'с-ауыз куысы аркылы таралуы асказан-шек жолдары жасушыларыныц беткей/'нде ангиотензинге алмастырушы ферментт1ц (ACE2) болуымен байланыстыратын зерттеу нэтижелер1 де кездеседi.
Медициналык кызметкерлер вирусты жукпаныц квзi болуы мYмкiн наукастармен Yнемi байналыста болатындыктан, олардагы ауруды жуктыру катерi вте жогары болып саналады. Сондыктан медициналык уйымдардыц кызметкер/'н/'н пандемиямен ку^ресудег/' рвл1 мацызды екен/'н ескере отырып, денсаулык сактау жYйесi олардыц денсаулыгын сактау мен ныгайтуына кажеттi жагдай жасауы керек. Жукпалы аурудыц тарауы кауп жогары болгандыктан, вирустыц нэж/'с-ауыз кууысы аркылы косымша таралуына карсы эпидемиялык режимд1 кушейткен жвн.
Tyüíh свздер: COVID-19, эпидемияга карсы iс-шаралар, аурухана1ш1л1к инфекция, нэж/'с-ауыз кууысы аркылы таралу жолы, ангиотензинге алмастырушы фермент (ACE2), Казакстан.
Предпосылки к усовершенствованию противоэпидемического режима в медицинских организациях в условиях пандемии COVID-19
Хасенова А.Ж.1, Хамидуллина З.Г.2, Данбаева Ж.С.3, Алдабекова Г.У.4
1 Старший преподаватель кафедры общественного здоровья и гигиены, Медицинский университет
Астана, Нур-Султан, Казахстан 2 Заместитель директора многопрофильной больницы №3 города Нур-Султан по акушерско-
гинекологическому блоку, Казахстан 3 Директор многопрофильной больницы №3 города Нур-Султан, Казахстан 4 Старший преподаватель кафедры общественного здоровья и эпидемиологии, Медицинский университет Астана, Нур-Султан, Казахстан 5 Профессор общественного здравоохранения Университета Боккони, Милан, Италия
Резюме
Пандемия COVID-19 остается в центре внимания общества, ввиду быстрого распространения и высокой контагиозности вируса. В Казахстане для предотвращения заражения, разработаны и внедрены противоэпидемические меры, предусматривающие профилактику воздушно-капельного и контактного путей передачи вируса. Однако, имеются исследования, указывающие на существование фекально-орального пути вирусного заражения, что связано с наличием ангиотензин-превращающего фермента 2 (АСЕ2) на поверхности клеток желудочно-кишечного тракта.
Медицинские работники подвергаются значительно повышенному риску заражения поскольку находятся в постоянном контакте с потенциальными источниками вирусной инфекции. Персоналу медицинских организаций принадлежит ведущая роль в борьбе с пандемией, задачей системы здравоохранения является создание условий для сохранения и укрепления их здоровья. На фоне сохраняющихся рисков, следует учесть данные о возможных путях передачи инфекции и усилить противоэпидемический режим с учетом фекально-орального пути распространения дополнительно.
Ключевые слова: COVID-19, противоэпидемические мероприятия, внутрибольничная инфекция, фекально-оральный путь передачи, ангиотензин-превращающий фермент 2 (АСЕ2), Казахстан.
Corresponding author: Assel Khassenova, Senior Lecturer, Department of Public Health and Hygiene, Astana Medical University, Nur-Sultan, Kazakhstan. Postal code: 010000
Address: Beibitshilik str., 49 a, Nur-Sultan, Kazakhstan Phone: + 7(7172) 53-94-59; 439, 438 E-mail: assel1165@mail.ru
J Health Dev 2020; 3 (38): 17-20 UDC 616-036.22 Recieved: 17-08-2020 Accepted: 06-09-2020
kSI^^I^J This work is licensed under a Creative Commons Attribution 4.0 International License
Introduction
The global COVID-19 pandemic has become a serious problem for the health system, with emergency to mobilize resources and transition to new standards. In a relatively short time period, extensive knowledge of the pathophysiology of the disease was obtained and measures were developed to prevent mass infection [1,5,7].
Health care workers are at the forefront of the battle against coronavirus infection, being in direct contact with potentially infected patients. The high risk of infectioning among healthcare workers is a major challenge facing the healthcare system. According to official data, the number of infected medical workers in
Modes of transmission of COVID-19
Airborne and contact modes of transmission considered as the main and the most frequent ways of infectioning that provided the rapid spreading of virus. Later studies found that the penetration of the virus into a human cell occurs with the participation of the ACE2 enzyme, which is present in many tissues, including the cells of the gastrointestinal tract. A viral effect on the gastrointestinal tract manifests gastrointestinal symptoms such as diarrhea, anorexia, nausea and vomiting [4]. Diarrhea may be the earliest sign of COVID-19 infection, but due to its non-specificity, diagnosis and identification of the virus may be delayed, increasing the risk of nosocomial infection.
Data on diarrhea symptoms remained in the shadows of severe respiratory symptom for several months, and amounted to no more than 3.8% [5]. According to various authors, the gastrointestinal
Kazakhstan amounted to more than 8.5 thousand people in 6 months [2]. Airborne and contact transmission routes of infection were identified, the patients had clinical manifestations of severe respiratory syndrome. Taking into account the modes of transmission of infection, measures for prevention and control of infection in medical organizations have been developed, including disinfection to reduce contamination, use of personal protective equipment (PPE), isolation and distancing [3].
The aim: to analyze the available literature on improving the anti-epidemic regime in medical organizations in the context of the COVID-19 pandemic, focusing on the fecal-oral transmission routes.
symptoms of coronavirus infection were recorded 2.4% to 5.1% [6, 7]. Later, the rate of patients with diarrhea increased significantly, and viral particles were found in feces of 11% to 49.5% patients [8-10]. Positive results for the virus in feces were found in 69% of patients without diarrhea symptoms [11]. Authors' report shows 20% of COVID-19 patients feces were tested positive on viral RNA even after the eliminating respiratory symptoms [12, 13]. Research outcomes indicated diarrhea as common in patients with COVID-19, but also confirmed the possibility of transmission of COVID-19 through the digestive tract. Results obtained give better understanding of the evolution and clinical manifestations of disease, and highlights the need for new measures to prevent the spread of the pathogen.
Infection control in medical organizations
One of the most serious hazards to the healthcare system is the high incidence of coronavirus infection among healthcare workers. Medical staff at the forefront of the fight against the pandemic continue to provide care to infected patients and non-COVID-19 patients. The risk of infection has rapidly increased due to the high capacity of intensive care units to redeploy clinical staff to frontline positions (for example, intensive care units or COVID-19 wards).
Healthcare workers can contract COVID-19 at work through direct or indirect contact with infected patients or other healthcare professionals, or through ongoing community transmission. According to the Ministry of Health of the Republic of Kazakhstan, positive tests for coronavirus were confirmed in 8,518 medical workers. Given the possibility of false negative results and asymptomatic casemix, it can be expected that the number of infected is much higher. It is known that in Kazakhstan, feces are not currently being tested for the presence of the virus. Also, Kazakhstan studies do not report cases of gastrointestinal symptoms in patients with COVID-19.
Hospitals implemented anti-epidemic regime, which provides for the following measures: distance of at least 1 meter in accordance with the marking of working areas, control of patient flows to prevent crowding. Personal protective equipment clarified by 3 levels in dependence on the frequency of their contact with a potential source of infection. The measures taken made it possible to take control of the possibility of infection by
airborne and contact transmission of infection. However, international guidelines say that the clinical manifestations of coronavirus infection may change, and the results of recent foreign studies should be taken into account.
Most of medical staff have full-time jobs, are exposed to frequent contact with infected people, as well as psychological stress, long hours of work, and fatigue. To maintain a normal regimen, staff needs time and space for at least one food intake. According to the order of the Ministry of Health of the Republic of Kazakhstan, a strict division of the hospital into «clean» and «infected» zones is established. All health care organizations provide zoning for «conditionally infected» and «conditionally clean» zones [14].
"Conditionally infected zone" includes:
1) Admission unit that distributes patients according to infection status;
2) Isolation boxes for infection positive or infection suspected.
Other hospital units considered as "Conditionally
clean".
Transmission between two zones is supported by inspection rooms with division into 2 flows:
1) from a "Conditionally clean" zone to a «Conditionally infected» one when entering a shift;
2) from the «Conditionally infected» zone to the "Conditionally clean" one when leaving the shift.
The «Conditionally clean» area includes a
dressing room, a PPE distribution room, a sanitary facility;
The «Conditionally infected» area includes a PPE removal room, a PPE collection room, shower cabins and sanitary facilities.
The «Conditionally clean» zone includes the ordinatory room, nurse room, sanitary unit, and utility rooms. These «Conditionally clean» rooms are located inside the departments. Staff has the following activities in «Conditionally clean» zone as e-medicine documentary,
professional disputes, leisure time, food and beverage intake. The medical staff is provided with a sufficient amount of PPE and disinfectants in the hospital, taking into account the movement of personnel between «Conditionally clean» and «Conditionally infected» areas. Administrative, technical and support personnel do not enter «Conditionally infected» zones without PPE. Such approach considered as efficient because hospitals implemented did not report cases of gastrointestinal disorders among staff [15].
Conclusion
It is evidenced that ACE2 serves as a receptor for the entry of the virus into human cells on which this enzyme is expressed. Thus, the point of application of the virus can be both lung tissue and the gastrointestinal tract. Therefore, the possibility of fecal-oral contamination should also be considered when developing anti-epidemic measures. Creation of a site for the transition from a
conditionally infected area to conditionally clean one for eating purposes of medical workers, should reduce the risks of fecal-oral infection of a nosocomial infection. In the face of a re-outbreak of COVID-19, these measures look timely.
References
1. Shadmi E., Chen Y., Dourado I., Faran-Perach I. et al. Health equity and COVID-19: global perspectives. International journal for equity in health, 2020; 19(1): 1-16.
2. Semenova Y., Glushkova N, Pivina L., Khismetova Z. et al. Epidemiological Characteristics and Forecast of COVID-19 Outbreak in the Republic of Kazakhstan. Journal of Korean medical science, 2020; 35(24): e227.
3. World Health Organization, 2020. Rational use of personal protective equipment (PPE) for coronavirus disease (COVID-19): interim guidance, 19 March 2020. №.WHO/2019-nCoV/IPC PPE_use/2020.2. Website. [Cited 21 Sep 2020]. Available from URL: https://apps.who.int/iris/bitstream/handle/10665/331498/WHO-2019-nCoV-IPCPPE_use-2020.2-eng.pdf.
4. Zhang H.K.H., Gong H.X.D., Wang J.L.Z. Digestive system is a potential route of COVID-19: an analysis of single-cell coexpression pattern of key proteins in viral entry process. Gut, 2020; 69: 1010-1018.
5. Guan W.J., Ni Z.Y., Hu Y., Liang W.H. et al. Clinical characteristics of coronavirus disease 2019 in China. N. Engl. J. Med., 2020; 382: 1708-1720.
6. Xiao F., Tang M., Zheng X., Liu Y. et al. Evidence for gastrointestinal infection of SARS-CoV-2. Gastroenterology, 2020; 158: 1831-1833.
7. Young B.E., SWX O., Kalimuddin S., Low J.G. et al. Epidemiologic features and clinical course of patients infected with SARS-CoV-2 in Singapore. JAMA, 2020; 323(15): 1488-1494.
8. Wan Y., Li J., Shen L., Zou Y., Hou L., Zhu L. Enteric involvement in hospitalised patients with COVID-19 outside Wuhan. Lancet Gastroenterol Hepatol., 2020; 5: 534-535.
9. Wei X.S., Wang X., Niu Y.R., Ye L.L. et al. Diarrhea is associated with prolonged symptoms and viral carriage in corona virus disease 2019. Clin. Gastroenterol. Hepatol., 2020; 18: 1753-1759.
10. Pan L., Mu M., Yang P., Sun Y. et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. Am. J. Gastroenterol., 2020; 115: 766-773.
11. Liu M., He P., Liu H.G., Wang X.J. et al. Clinical characteristics of 30 medical workers infected with new coronavirus pneumonia, JAMA, 2020; 43; 209-214.
12. Xiao F., Tang M., Zheng X., Liu Y. et al. Evidence for gastrointestinal infection of SARS-CoV-2., Gastroenterology, 2020; 158(6), 1831-1833.
13. Kopel J., Perisetti A., Gajendran M. et al. Clinical Insights into the Gastrointestinal Manifestations of COVID-19. Digestive Diseases and Sciences, 2020; 65: 1932-1939.
14. Приказ Министра здравоохранения Республики Казахстан. О некоторых вопросах организации и проведения санитарно-противоэпидемических и санитарно-профилактических мероприятий; утв. 5 июля 2020 года, № ЦР ДСМ-78/2020.
Order of the Minister of Health of the Republic of Kazakhstan. On some issues of organizing and conducting sanitary-anti-epidemic and sanitary-preventive measures (Order of the Minister of Health of the Republic of Kazakhstan. On some issues of organizing and conducting sanitary-anti-epidemic and sanitary-preventive measures) [in Russian]; approved July 5, 2020, No. H,R DSM-78/2020.
15. Huang C., Wang Y., Li X., Ren L. et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet, 2020; 395: 497-506.
