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National Nurses United Response To COVID-19

About the Novel Coronavirus (COVID-19) Outbreak

In December 2019, a newly identified coronavirus, known as COVID-19, emerged in Wuhan, Hubei Province, China causing illness in humans. Multiple clusters of COVID-19 have since been reported across China and in more than 70 other countries including Italy, Iran, Japan, South Korea, and the United States.
 
The U.S. Department of Health and Human Services declared the virus to be a nationwide health emergency following the World Health Organization’s (WHO) declaration of a public health emergency of international concern on January 30, 2020.
 
On January 21, 2020, China announced for the first time that health care workers have been infected- at least fourteen by recent counts. In recent days, dozens of U.S. health care workers have been exposed due to their employer’s lack of protections.

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About COVID-19

While much has been learned about COVID-19 in a few weeks, there is still a lot we don’t know:

 

What is known: It is a coronavirus, which is a large family of viruses that can infect animals and/or humans. COVID-19 is similar to the viruses that cause SARS (Severe Acute Respiratory Syndrome) and MERS (Middle East Respiratory Syndrome). 

 

 

What is known: Several published reports have established a basic picture of clinical symptoms and outcomes for those infected with COVID-19. These symptoms can include fever, cough, muscle soreness, weakness, diarrhea, headache, and other symptoms. While some symptoms appear to be common, there is also diversity in how COVID-19 manifests (Table 1).

Table 1: Symptoms of COVID-19 Reported in the Scientific Literature

Symptom

Huang et al. (Feb 15-21, 2020), report on 41 admitted hospital patients with laboratory-confirmed COVID-19 infection in Wuhan, Hubei Province, China[1]

Wang et al. (Feb 20, 2020), report on 105 patients with COVID-19 infections in North Shanghai, China [2]

Liang et al. (Feb 28, 2020), report on 457 patients with lab-confirmed COVID-19 identified from 7 studies[3]

Fever

98%

82.9%

89%

Cough

85%

62.9%

63%

Fatigue or weakness

44%

17.1%

51%

Headache

8%

Muscle soreness 6.7%

8%

Diarrhea

3%

8.6%

7%

Several additional reports underline the potential seriousness of a COVID-19 infection, including damage to lung tissue that has become characteristic to COVID-19. Shi et al. (Feb 24, 2020) describe this damage:

“COVID-19 pneumonia manifests with chest CT imaging abnormalities, even in asymptomatic patients, with rapid evolution from focal unilateral to diffuse bilateral ground-glass opacities that progressed or co-existed with consolidations within 1-3 weeks.”[4]

The Chinese Centers for Disease Control and Prevention (Chinese CDC) reported recently that approximately 20% of COVID-19 cases are classified as severe or critical.[5] COVID-19 infections may result in life-threatening conditions including acute respiratory distress syndrome, acute kidney injury, cardiac injury, and liver dysfunction (Table 2) and may require hospitalization, intensive care, intubation, or other significant life-saving interventions. In some cases COVID-19 may lead to death; the Chinese CDC reported that 2.3% of confirmed COVID-19 cases died.[6] The World Health Organization’s reports indicate that 3.4% of reported cases have died.[7] There is currently no cure, only supportive treatment, and no vaccine.

 

Table 2: Clinical Outcomes of COVID-19 Reported in the Scientific Literature

Clinical progression/outcome

Yang et al. (Feb 24, 2020), report on 52 critically ill patients with COVID-19 who were admitted to an intensive care unit (ICU) in Wuhan, China[8]

Liang et al. (Feb 28, 2020), report on 457 patients with lab-confirmed COVID-19 identified from 7 studies[9]

Acute respiratory distress syndrome

67%

12%

Acute kidney injury

29%

2%

Cardiac injury

23%

3%

Liver dysfunction

29%

-

Death

61.5% at 28 days

8%
 

[1] Huang et al. (Feb 15-21 2020), “Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.” The Lancet, 395(10223): 497-506

[2] Wang, Changhui, et al. (Feb 20, 2020), “The Epidemiologic and Clinical Features of Suspected and Confirmed Cases of Imported 2019 Novel Coronavirus Pneumonia in North Shanghai, China.” Preprints with The Lancet, published online at https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3541125.

[3] Liang, Bo et al. (Feb 28, 2020), “Clinical Characteristics of 457 Cases with Coronavirus Disease 2019.” Preprints with The Lancet, published online at https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3543581.

[4] Shi, Heshui et al. (Feb 24, 2020), “Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study.” The Lancet Infectious Diseases, published online, https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30086-4/fulltext.

[5] Wu, Zunyou and Jennifer M. McGoogan (Feb 24, 2020), “Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention.” JAMA, published online at https://jamanetwork.com/journals/jama/fullarticle/2762130.

[6] Wu, Zunyou and Jennifer M. McGoogan (Feb 24, 2020).

[7] The World Health Organization’s Situation Report from March 4, 2020 indicates that 2,984 deaths have been reported in China and 214 deaths have been reported outside of China for a total of 3,198 deaths. 3,198 deaths ÷ 93,090 total cases = 3.4%. World Health Organization (March 4, 2020), “Coronavirus disease 2019 (COVID-19), Situation Report-44.” Online at https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200304-sitrep-44-covid-19.pdf?sfvrsn=783b4c9d_6.

[8] Yang, Xiaobo et al. (Feb 24, 2020), “Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study.” The Lancet Respiratory Medicine, published online, https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30079-5/fulltext.

[9] Liang, Bo et al. (Feb 28, 2020).

 

 

What is known: The virus is spread through human to human transmission. Asymptomatic cases are occurring and can be infectious. Two studies indicate that the most infectious period may actually be the first four days or so after exposure. Researchers found very high levels of the virus in upper respiratory tract samples before clinical symptoms occurred.[1,2]

 

What is unknown: All modes of transmission for COVID-19 have yet to be established.

However, current epidemiological evidence supports aerosol transmission of COVID-19. Aerosols, particles suspended in air, can be transmitted by an infected person through breathing, talking, coughing, and sneezing.[3] They can also be generated during medical procedures such as intubation and bronchoscopy. Particles vary in size; larger aerosol particles can remain suspended in the air for several minutes, while smaller or lighter ones can linger in the air for hours and travel through the room and ventilation systems. Perfume spray demonstrates the extent of aerosol distribution as it can be smelled from a distance for quite some time as the particles disperse throughout the room.

Similar to SARS (severe acute respiratory syndrome), researchers have found that SARS-CoV-2, the virus that causes COVID-19, can survive and stay infectious in aerosols for at least 3 hours.[4] SARS-CoV-2 can also survive on surfaces for an extended period of time. For example, genetic material from SARS-CoV-2 was detected on a number of surfaces in the Diamond Princess cruise cabins of both symptomatic and asymptomatic infected passengers 17 days after they vacated.[5] Asymptomatic virus shedding and viability in the air and on surfaces may explain the rapid person-to-person transmission. As such, all contact and airborne precautions must be maintained to protect healthcare workers.

[1] Woelfel, Roman et al. Clinical Presentation and Virological Assessment of Hospitalized Cases Of Coronavirus Disease 2019 In A Travel-Associated Transmission Cluster. MedRxiv, Cold Spring Harbor Laboratory Press, 2020. https://doi.org/10.1101/2020.03.05.20030502

[2] Nishiura, Hiroshi, et al. Serial Interval of Novel Coronavirus (COVID-19) Infections. International Journal of Infectious Diseases, Elsevier, 2020. https://doi.org/10.1016/j.ijid.2020.02.060

[3] Jones, R.M. and L.M. Brosseau, Aerosol transmission of infectious disease. Journal of Occupational and Environmental Medicine, 2015. 57(5): p. 501-8.

[4] N van Doremalen, et al. Aerosol and surface stability of HCoV-19 (SARS-CoV-2) compared to SARS-CoV-1. The New England Journal of Medicine, 2020. DOI: 10.1056/NEJMc2004973.

[5] Moriarty, et al. Public Health Responses to COVID-19 Outbreaks on Cruise Ships — Worldwide, February–March 2020. MMWR Morb Mortal Wkly Rep. DOI: http://dx.doi.org/10.15585/mmwr.mm6912e3

 

 

The following case definition is proposed. This definition would be more protective than the CDC’s current case definition.

Suspected: Any patient with respiratory symptoms should be considered a suspected COVID-19 case.

Probable: If the patient tests negative for influenza and other respiratory viruses, s/he should be considered a probable COVID-19 case.

If the patient has clinical symptoms that match the characteristics of COVID-19 cases, s/he should be considered a probable COVID-19 case regardless of test results.

Confirmed: If the patient tests positive for COVID-19.

Any suspected COVID-19 case should be investigated further, and all protections and precautions taken until ruled out.

All protections should be implemented for any probable or confirmed COVID-19 case. This means that precautionary leave (minimum of 14 days) should be implemented for any nurse exposed to a probable or confirmed COVID-19 case.

 

 

The situation is evolving rapidly. Please see the links below for the most up-to-date information.

World Health Organization (WHO)’s Dashboard
https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd

 

Employers Must Prepare to Keep You Safe

In situations like this one where knowledge is lacking about a health threat, there is often debate about what actions to take and when. Too often healthcare employers prioritize saving money over safe care and wait to act— this is unacceptable.  

Hospitals and other healthcare employers have the duty and responsibility to prepare ahead of time to protect staff and patients. And in situations like the current outbreak, to follow the precautionary principle. The precautionary principle states that we should not wait until we know for sure that something is harmful before we take action to protect people’s health. Full precautions mean anticipatory or protective action must be taken to prevent possible or further harm.

Following the precautionary principle is necessary to protecting nurses and other healthcare workers from the hazard posed by an emerging infectious disease like COVID-19. Nurses and other healthcare workers have a fundamental right to a safe and healthful workplace and infectious diseases should be no exception. Full protection of healthcare workers is a fundamental and necessary part of limiting the spread of viruses.  

Of employers, NNU is asking the following:

  1. Employers shall implement plans and protocols in response to COVID-19 based on the precautionary principle, which holds that lacking scientific consensus that a proposed action, policy, or act is not harmful – particularly if that harm has the potential to be catastrophic – such action, policy, or act should not be implemented and the maximum safeguards should be pursued.
  2. Employers shall clearly communicate with all RNs/health care workers, including notifying nurses when there is a possible or confirmed COVID-19 case.
  3. Employers shall provide education and training for all RNs/health care workers, including on protective gear, donning and doffing, and all other protocols relating to COVID-19.
  4. Employers shall provide the highest level of protection, including functioning negative pressure rooms and personal protective equipment for nurses providing care to possible and confirmed COVID-19 cases. Employers must ensure negative pressure rooms remain functional at all times during use. Highest level of PPE must include PAPR (powered air-purifying respirator), coveralls meeting ASTM (American Standard for Testing and Materials) standard, gloves, temporary scrubs, and other protections.
  5. Employers shall plan for surge of patients with possible or confirmed COVID-19, including plans to isolate, cohort, and to provide safe staffing.
  6. Employers shall conduct a thorough investigation after a COVID patient is identified to ensure all staff and individuals who were exposed are identified and notified. Any nurse/health care worker who is exposed to COVID-19 will be placed on precautionary leave for at least 14 days and will maintain pay and other benefits during the full length of that leave.

Documents:

Nurses' Statements

Letters to Officials