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Letters to the Editor

Reply to “Protecting against COVID-19 aerosol infection during intubation”

Wu, Yi-Chia; Chen, Ching-Sunga; Chan, Yu-Jiuna,b,c,*

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Journal of the Chinese Medical Association: June 2020 - Volume 83 - Issue 6 - p 583
doi: 10.1097/JCMA.0000000000000331
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Dear Editor,

We appreciate the comments by Tseng et al1 on our recent article Wu et al2 published in the current issue of the Journal of the Chinese Medical Association. Indeed, it is very crucial to protect health care workers (HCWs) in this pandemic. Not only HCWs safeguard patient care, but also they are at high risk of contracting this contagious disease. Studies indicate that 3.8% (1716/44 672) of HCWs during the outbreak in China (as of February 11, 2020) were infected and 14.8% of confirmed cases were classified as severe or critical.3,4 A random sample survey in March 2020, in Noord-Brabant, Netherlands, revealed nearly 4% of the hospital staff is infected with this novel coronavirus, but the percentages vary per hospital (0%-10%).5 Mortality did happen even among young doctors. As we emphasized in previous overview and the authors concur that “stringent protection procedures should be conducted for high-risk procedures.”2 Endotracheal tube intubation by all means is one of the most dangerous maneuver. It has been shown that aerosol might be generated during intubation and viral-containing droplets can floating or contaminate different surfaces for many hours.6 Particularly, viral loads are high in the early stage of symptom onset and lung-derived samples (such as sputum or aspirate) contain high viral load when the patient’s condition deteriorates and need intubation.7,8

It has been shown that surgical face masks can effectively prevent viral spreading of many respiratory viruses, including the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).9 However, surgical face masks need to be removed during intubation. The authors invented a transparent acrylic “aerosol box” to protect the person who conducts intubation from aerosol spreading or droplet contamination. This device seems promising in reducing the chance of infection during intubation. It would be very informative if the authors could demonstrate or show experimental data that how effective “the box” can contain viral-containing droplets inside the box and protect people from infection.

References

1. Tseng YJ, Lai HY. Protecting against COVID-19 aerosol infection during intubation. J Chin Med Assoc 2020;83:582.
2. Wu YC, Chen CS, Chan YJ. The outbreak of COVID-19: an overview. J Chin Med Assoc 2020;83:217–20.
3. Chang D, Xu H, Rebaza A, Sharma L, Cruz CSD. Protecting health-care workers from subclinical coronavirus infection. Lancet Respir Med 2020;8:e13.
4. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China. JAMA 2020. [Epub ahead of print]
5. Results of Random Sample Test: 4% of Hospital Staff Infected With Coronavirus. RIVM Committed to health and sustainability. 2020. Available at https://www.rivm.nl/en/news/result-of-random-sample-4-hospital-staff-infected-with-coronavirus
6. Doremalen NV, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med 2020;382:1564–7.
7. Wolfel R, Corman VM, Guggemos W, Seilmaier M, Zange S, Muller MA, et al. Virological assessment of hospitalized patients with COVID-2019. Nature 2020. [Epub ahead of print]
8. Liu Y, Yan LM, Wan L, Xiang TX, Le A, Liu JM, et al. Viral dynamics in mild and severe cases of COVID-19. Lancet Infect Dis 2020. [Epub ahead of print]
9. Leung HL, Chu KW, Shiu YC, Chan KH, McDevitt JJ, Hau JP, et al. Respiratory virus shedding in exhaled breath and efficacy of face masks. Nat Med 2020;26:676–80.
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