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[Music].um.we shall start now uh good evening one.and all i'm apollo.state coordinator i am a tamil nadu i.take inman's pleasure in welcoming you.all to med infinite.2020. med infinite 2020 is an online.medical conference.conducted by the ima msn and jd and.tamil nadu.for the medical students all over the.country it started from july 16.and it will go on till september 15th.it's the third day of the conference.and it's been going really well thank.you everyone for supporting and.participating.now we have the session on the topic of.the heart.on the very important and much needed.topic.prevent preventing the transmission of.covalent in healthcare providers.to talk to us about such an important.topic we have on board.two eminent and great speakers i take.utmost privilege.in welcoming dr valen and dr daniel.vander on.thank you so much sir for accepting our.invite to share your wisdom and.enlightening us.before you before i introduce you to the.speakers i would like you to like to.thank our sponsors.iris need pg a great online platform for.free pg preparation you can check out.their content their website for some.amazing content.and apipola mobile accessories and.electronics company.let us now begin the session without any.further ado.i would like to start it off with a.small introduction.of our speakers for the day dr valen and.dr daniel andre.dr es bal is a public health specialist.of infectious diseases for the division.of global health protection centers for.disease control and prevention cdc.india country office new delhi he.supports infectious disease surveillance.with focus on activities.including prevention deduction and.response to antimicrobial resistance.and survival the violence of healthcare.associated infections in india.dr valin is a medical doctor with wide.range of technical.and preventive health program public.health program management.experience in communicable and.non-communicable diseases.he has previous previously worked with.the national aids control organization.napo international training and.education center for health.itec he has also worked as a trainee.india epidemic intelligence service.officer.national center for disease control.india at national institute of research.in tuberculosis.indian indian council of medical.research and national program for.cancer diabetes cardiovascular diseases.and stroke.at mohfw newton new england.he has also worked as technical.consultant for wkhu india country office.and who ceo offices in bhutan and india.dr valen has many national and.international scientific publications to.his credit.and has also co-authored chapter on.health care assisted infections.in the national guidelines for infection.prevention and control in health care.facilities.ministry of health and family welfare.dr valen is a life member of indian.medical association.and the indian red cross society i take.a great privilege in welcoming you sir.thank you.for our second speaker we have doctor.daniel.van der hon is dr daniel wonder on.is a medical officer international.infection control program.office of the director division of.healthcare quality promotion.cdc.doctor vander aan received his.bachelor's degree at breton college.betting illinois and his md at case.western reserve university.cleveland ohio he completed his clinical.residency in internal medicine.at the vanderbilt university nashville.tennessee.and is mph from roland school of public.health atlanta georgia.he also completed a public policy.fellowship at the satcher health.leadership institute and morehouse.school of medicine.dr vanderhaan has practiced medicine and.directed quality improvement initiatives.in domestic.and international healthcare facilities.prior to joining cdc in 2015 he directed.communicable disease programs.as the medical program administrator for.the fulton country department of health.and wellness.starting in 2015 he has served as a.medical officer.for the international infection control.program supporting efforts in africa.asia the caribbean and the middle east.to build sustainable capacity to prevent.detect and respond to health care.associated infections globally.these efforts have included the.provision of technical assistance.to develop policy guidelines and.programs to improve surveillance systems.infection prevention and control.and the microbial stewardship at the.national state and facility levels.since 2018 dr van der aan has worked.to support efforts to build sustainable.capacity to prevent deduct and respond.to healthcare associated infections in.india.he also has many scientific and.international publications to his credit.and is a principal investigator on.multiple research projects.seeking to add new knowledge to the.field i take a.great immense android and immense.pleasure in welcoming you sir.thanks a problem.uh so we can now start the session uh so.uh before beginning the session i would.like to tell that the audience please.refrain from asking questions.in the middle and you can keep your.questions at the end of the session.where you we will have a q and a section.so we uh over to user.thank you dr aburva first of all i would.like to acknowledge uh the support.provided by my colleague dr.dan and trendy for preparation of this.slides and.uh headquarters like the most of the.slides which we are going to talk about.today.are from the cdc's archives for the.infection prevention control from our.headquarters team.and uh there was immense support from.our country office and especially from.dr dan van trenty for preparing these.slides.so today we will be going to discuss.about.uh protecting healthcare workers from.kovite 19.in during this pandemic in the health.care facilities.so to talk about the preventive measures.we should understand the basics of.epidemiology what all of the revised.symptoms.which has been enlisted by international.agencies.how the scovit 19 transmission happens.and like what a lot of the surveillance.case definitions.available in india and internationally.for like documenting these cases and the.strategies for.preventing infections among the.outpatients in the healthcare facilities.in patients and healthcare workers.so if you uh look at the pandemic.situation.as on date so 216 countries.and territories are affected by this.pandemic.and more than um like 13 million like uh.confirmed cases we have and we have like.more than.half a million uh confirmed deaths.happen.so the map here on the right side.shows uh the situation of.19 for the past seven days by countries.you can see india united states brazil.and all like they are like very much.dark in color reporting.uh more than one lac cases if you see.the indian scenario.35 states and union territories out of.36 like they have reported cases.so more than million confirmed cases.have been reported.and out of those like the.good thing is more than 6 lakh 77 000.has been discharged or like they have.been declared queued.and we have lost 36 000 people uh uh.like due to kobe in our country as for.the reports of ministry of health and.family welfare.uh us on date like this is as per the.ministry of health health and family.welfare website.uh access today morning so if you see ma.the states maharashtra tamil nadu and.delhi has most number of cases with.maharashtra more than three lakh pieces.tamil nadu with more than one lag fifty.thousand cases and.daily also like above one lakh cases.the least uh reported cases are from.mandaman.mizoram these three have.less than a thousand cases um like.reported a sound date.so we should be aware of the symptoms.before starting the session like.unless we are aware of the symptoms we.won't be able to.detect and like prevent our healthcare.providers.from covid19 so the symptoms you all.know it can appear.between like two to 14 days after.exposure to the virus and the median.time is like four to five days so.the people with these symptoms are.combination of symptoms.with 19 the classical symptoms are fever.or chill.cough shortness of breath or difficulty.in breathing.so additional symptoms which can.accompany this or like which can.like without this classical symptom also.you may just have a.fatty muscle or body ache headache new.loss of taste.or smell sore throat congestion or runny.nose.nausea or vomiting and diarrhea so this.is as for the.latest centers for disease control.guidance and this has been adopted by.like many international bodies also.so india has also revised uh the um.guidelines based on the latest symptoms.prescribed by centers for the systems.so um how kobe 19 gets transmitted.so the spread people in like the it is.currently believed based on the evidence.that.it can happen through direct indirect or.close contact with infected people.via mouth or no secretion so this.includes saliva respiratory secretion of.secretion droplets.released from mouth or nose with an.infected.whenever infected person coughs sneaks.sneezes.uh speaks or sings people who are in.close contact within one meter with an.infected person can catch covet 19 when.those infectious droplets get.touched uh like into the mouth or nose.directly.so are like also through indirect you.can contact through surfaces by touching.like when the droplets are there on the.surfaces.you touch that and then you touch your.nose or mouth or eyes like then you can.get in.so now there are a lot of uh talking.about.uh the airborne transmission of.subscribe.so what does the world health.organization say about.the airborne transmission of sarsko v2.and we will be hearing more from our.expert.dr dan van buren regarding airborne.transmission during the question and.answer sessions.so the airborne transmission is defined.as the spread of an infectious agent.caused by dissemination of.dropped nuclei that remain infectious.when suspended in air over long distance.and time.the airborne transmission of suscob2 can.occur.during medical procedures that generate.aerosols that those are called.agps or aerosol generating procedures.a number of respiratory droplets.generate microscopic aerosol by.evaporating.and normal breathing and talking can.result in exhale aerosols.a susceptible person could inhale.aerosol and could become infected if the.aerosol contain the virus in sufficient.quantity again how much is the.sufficient quantity it is still being.expedited.which can cause infection within the.recipient however.as i mentioned like the.uh study like how what is the quantity.required for infecting.through um this aerosol procedures.so what are the current evidences.regarding airborne transmission of.cobit 19 as mentioned.[Music].in the world health organization.latest infection prevention for document.the recent clinical reports of health.care workers exposed to covet 19 index.cases.not in the presence of aerosol.generating procedures found there is no.nosocomial transmission when contact and.droplet precautions were appropriately.used.including wearing a medical mask as a.component of personal protective.equipment.further studies are needed to determine.whether it is possible to detect.viable suscob2 in air samples from.settings where no procedures that.generate aerosols are performed and the.role of aerosol might play a.transmission so this is still under a.study and ass off date who says.there might be but currently there is no.evidence so maybe.late the evidence may evolve in the.future.so what are the evidences of airport.transmission of stars kobe 2.in non-technical settings like has been.which has been reported as on date.so outside of medical facilities some.outbreak reports related to indoor.crowded spaces.suggested the possibility of aerosol.transmission combined with droplet.transmission.so this has happened during a choir.practice.and there are published report about.this happened in an enclosed restaurant.from.people got infected in a closed resort.where the air condition was suspected to.be the source of.infection so and also a fitness center.uh where the people who attended the.fitness classes like they also got.infected so these three reports.are available and the references.mentioned below these slides will be.available.will be provided to you so you can refer.to the study later and i would like to.hear more from my colleague.during the subsequent session after me.so in all this events short-range.aerosol transmission particularly in.specific indoor locations such as.crowded.and inadequately ventilated spaces over.a prolonged period of time with infected.persons.cannot be ruled out so the thing is like.still it can.it can be debated that like carrot be.still be a droplet.infection not not due to airborne.transmission.so now coming to the healthcare.facilities uh what ppe should be used in.healthcare facilities so many people.have asked this question.uh when apoorva shared the questionnaire.with.with us so the personal protective.equipments must be.rationally used for activities commonly.performed by.healthcare workers the use of ppe should.be based on the transmission based.precautions.and like bp is not recommended for like.each and everything so based on like.what is the skin wall those pps.has to be selected like appropriately.healthcare workers involved in direct.care care of kobit 90 patients should be.our appropriate ppe they should be a.glass non-steroidal examination.browser enough so medical mask so that.is a triple layer.mask eye protection goggles are facials.because like splashes should not happen.to the eye and again through conjecture.you can get infections so.eye protection is the must and gown or.long-sleeve non-steroid.the gowns can be used so this uh.the picture shown here is based on the.um.who recommended ppe for managing covet 9.so now you can you can ask like if you.don't recommend any mask.like.[Music].where there is an aerosol generation.like for common uh patient.care and things like that so seeing the.patient in opd medical mass is enough.like when.uh like what are all are the procedures.which generate aerosol like.where people should be opting for like.more um.like more personal productive equipments.like respirators and all.so for that we should understand like.what all are the examples of some.aerosol generating procedures which can.happen in a healthcare facility.aerosols can be generated by medical.procedures.in or and it can be root of transmission.for with 19 virus.so uh and these aerosols can be.potentially infected like if this from a.kobit 19 patient it can be potentially.infectious.so you have to be careful like any.intubating.procedure or extubation or related.procedures can generate a lot of.aerosols.tracheostomy or tracheostomy procedures.can generate.aerosols manual ventilation so when you.are.ventilating a patient using an ample bug.or something like it can.again cause aerosol generation within.the.space or in and around the patient open.suctioning.bronchoscopy surgery and postmortem.procedures in which high speed devices.are.you are used like for example when you.are using automated.your electro electric saw or something.or you are splashing the liquid or.something it can generate a lot of.errors.so this can occur both in surgical.procedures are also when you are.providing like medical legal autopsy and.when you are.dissecting so when you are using these.type of equipment you have to use it.cautiously or.you have to uh use it with the.protection.with the vacuum suctioning unit and all.so.other procedures which can generate.aerosol involved non-invasive.ventilation.by by for example pipe.high frequency oscillating ventilations.high flow nasal oxygen also can generate.because like you are passing the oxygen.through a.humidifier like which can generate a lot.of aerosols.so and when you are inducing a sputum.like for example you all.know that like uh for diagnosis of tb.and all like induced is.one of the method in pediatric.population so.when you are inducing a sputum for a for.some diagnostic procedures like it can.generate a lot of aerosols and if the.patient was.having a virus he can spread to others.dental procedures again like.where they use high speed drilling and.they will be pumped like flushing the.water and all.so it can generate a lot of parasols and.the healthcare provider.or the person who is assisting the.healthcare provider can get infected.if the patient who is undergoing.procedure.had the infection so certain other.procedures.equipments may generate an aerosol from.material other than.patient secretions but are not.considered to represent a significant.infectious risk.procedure in this category include.administration of pressurized humidified.oxygen.administration of medication by a.nebulization but you have to be careful.when you are mobilizing the patient.so what should we do for aerosol.generating procedures.aerosol generating procedures.induced coughing should be performed.cautiously and avoided if possible.if performed the following should occur.the healthcare provider in the room.should bear an n95 or a high level.respirator.high protection gloves and gown so mass.are considered highly contaminated post.procedure and should be discarded.immediately.the number of healthcare providers.present during the procedure should be.limited to only those who are essential.for the patient care and supportive for.the procedure support.and visitors should not be present in.the procedure and aerosol generating.procedures should ideally take place in.an.airborne infection isolation room if.available.and clean and disinfect procedure room.surfaces immediately after the procedure.so that.from the format you you won't be getting.transmitted with kobe.so for any aerosol generating procedures.it requires additional personal.protective equipment as.i had mentioned earlier so uh you though.you should perform the aerosol.generating procedure in an adequate.ventilated room.which has at least 12 air exchanges per.hour.and you should be wearing appropriate.ppe.so you should be using particulate.respirator.not less than n95 or ffp2 as per the.european standard or ffp3.which provides at least 94 protection.against.this respiratory virus.so uh you have to be really really very.careful like.while you don and off the.personal protective equipments so this.is very very important because like most.of the time.healthcare providers get infected while.they are doffing so you have to follow.the steps like there are very clear.procedures.and videos available from centers for.disease control and.from who so you can watch those videos.and.you have to follow the appropriate.sequence so that bearing ppe is fine but.unless you doff it.with all uh following the necessary.steps like you may get infected the.chances of infection because.your whole pp is contaminated with a lot.of body fluids and infectious material.so doffing is very very important and.you have to follow the.current how to prevent.transmission of sasko v2 in healthcare.facilities.so for what patient can do is like they.can use telemedicine facility to inform.health care providers if they are.seeking care for respiratory.symptoms so they should wear a face.cover or a face mask.necessarily and they should notify the.registration desk about like what.symptoms they are having whether they.are respiratory symptomatic.or like they are having some other.symptoms they should be washing hands at.healthcare facility entrance and.touching the surfaces.i like and do not not to touch the.surfaces unnecessarily.and they should carry a tissue or other.alternative to cover the mouse like if.face covers are not available and.they should they should not be spitting.outside so at least.one meter like again it is being debated.like one meter or two meters so.minimum one meter uh distance should be.uh.maintained between like any at all times.like either.whether it is a registration dispersion.or.another person a patient who's coming to.the health care facility so one meter.minimum distance should be maintained so.if it is more than one.like more than one meter or like two.meters like it is.well and good the more distance you.maintain the chances of infections.uh are getting the infection is very.less because like you know very well.like thus we had seen like even.loud speaking and um uh like.singing you know like loud speaking can.generate a lot of droplets and you can.splash it outside and.like when we hear from dan like we will.be hearing more about that.so how to manage ill patient seeking.care use clinical triage in all health.care facilities for early.identification of patients with acute.respiratory infection.to prevent transmission of pathogens to.health care workers and others.so uh first like if you want to do.trials.like what all are the case definitions.which has been given by who and which.has currently adopted by ministry of.health and family welfare also so we.have the same definition the w cho and.ministry of health has the same health.definition for a suspected case probable.case under confirmed case.a suspected case you know very well uh.that any patient with acute respiratory.illness fever or at least one.sign of symptom of respiratory disease.exam like shortness of.a residence in br reporting community.transmission of covid 19.during the last 14 days prior to the.symptom or a patient with.acute respiratory illness and having.been in contact with the confirmed or a.probable case or a patient with acute.respiratory illness who.are who is requiring care and you cannot.establish other diagnosis so these are.the.definitions for the suspected case and.the this.has to be followed like at all times.like every health care facility when you.are.doing.so in the outpatient department.you have to do uh triaging of any.patient entering into a healthcare.facility so you should ensure like.everyone wearing.face mask or a face cover so if they are.not.having like there should be they should.be it should be made available at the.registration desk.and there should be if you see here uh.in the first picture so the.person in the registration desk and uh.the patient like both are having at.least one meter distance.so in the in the initial phase and there.can be.physical barriers also like between the.registration.desk person and the patient like it can.be using a glass.or using a plastic like a sheet like.makeshift arrangements can be made but.if the barrier is there again this will.limit your ppe use.and also it will protect the healthcare.worker who's at the registration desk.from contracting the infection like if.at all the patient was.like having the disease you know so then.uh after that like uh if you see like um.there should be appropriate.wastage bins for collecting the disposal.of like masks and like tissue paper.all those things and uh there should be.place for washing the hands.or alcoholic rub should be provided near.the registration desk.so again like if you enter like if.anyone who is symptomatic they will be.immediately separated.and they will be made told to wait in.the room like that is respiratory.symptomatics.even the non-symptomatic they would be.advocated for.maintaining a distance of at least one.meter between them and.like they will be like moved separately.so in the respiratory waiting area.please.and if you see this picture in the.orange color box like uh.even while waiting even if they are.symptomatic after bearing mask also.you should ensure that patients are.sifting sitting at one meter distance.apart.so the chair should be put like only at.one meter distance length.there should be a minimum one meter.distance between two chairs placed in.the waiting area of.whether it is for respiratory or.non-respiratory symptomatics so.identification of.inpatients with suspected kovit-19 cases.this is very very important.the objective of this process is to.identify in patients.with suspected kobit 19 and guide.infection prevention control strategies.to prevent transmission so.you can adapt a passive strategy or.enhance passive strategy or active.strategy.so in the passive strategy the.clinicians are kept informed of the.current clinical definitions.case definitions which has been provided.uh by the ministry of health and family.welfare.and clinicians must be made aware of.what to do if they suspect.anyone with covet 19 in a hospitalized.patient this can happen like.the patient may come and get admitted.for surgery but.unless the surgeon knows like what all.of the.definitions latest definitions available.and what all are the latest symptoms.available um so then like he won't be.able to pick up.the case at the earliest you know like.so you.we all like all clinicians who are.managing all pgs all junior doctors who.are working.they should be aware of what all are the.symptoms other than the classical.symptoms.and they should be aware of the case.definitions provided by the ministry of.health and family welfare.so earlier there were a lot of different.many difference between the indian.case definitions and the who but now.it's one and the same.the passive strategy considerations um.are.and like so uh it depends on the.participation and skill of available.clinicians and understanding of local.epidemiology and clinical presentation.of kobit 19.may differ in different populations so.one size doesn't fit for all like.because.you know very well like some states are.having more cases some districts are.having more cases if you.take tamil nadu chennai is having a lot.of cases.and uh like in in more than 10.50 000 cases are there in chennai so if.you see other districts it is less than.10 10 000. so it it based on the local.unless the cognition understands.the local epidemiology and things like.it won't be very effective.to do like it may vary from place to.place that's what.i would like to mention so in.enhanced positive strategy.can be done by establishing systems that.prompt or require clinicians to.regularly review.all patients for likelihood of kovit19.for example incorporating consideration.of covet 19 into sign out reporting so.before.anyone goes out you should make you can.make it mandatory that like how.did you suspect anyone with covet and.that has to be documented also it's not.only.just by conveying while you are handing.over the duty and going out but you can.create a system for documenting that.so this is an enhanced passive strategy.where you ensure.that is documented and the cases are.identified early.so that the transmission can be.prevented inside the healthcare facility.in active strategy a targeted data.collection and review of patient.information by groups.specifically responsible and trained for.identification of suspected coping cases.so these groups can be a facility in ipc.committee.or like hospital infection control team.so it can be a.like public health authorities like who.has been assigned as a team from the.deputy director of health services like.for tamil nadu you have like they.they may assign a team in each health.facility identify a team and assign a.team for doing.actively finding the cases among the.non-copied.facilities you know like there are a lot.of other hospitals which.may not be having covet case but like.but you.there are chances that some of the.patients who are.mildly symptomatic are like.pre-symptomatic they can get admitted.and later they may.develop symptoms or develop the disease.so.actively you will be identifying them in.the non-profit facilities are like it.can be.other local public health authorities.also uh can be included as part of this.team.so are healthcare workers in kobet areas.more at risk.so if you see like a study proactively.swapped at rp pcr.over 1200 nhs staff.and asked about kobe 19 symptoms 1000.staff members reporting fit for duty.during the study period.with three percent tested positive for.the coronavirus of those testing.positive one in five reported no.symptoms.two in five reported mild symptoms and.two in five reported coveting symptoms.that had stopped more than a.week previously again even if you are.doing actively following up.so the persons who are asymptomatic.are if the people those who have had.symptoms like two weeks back like they.can still be positive so this is what we.infer from the study.which was conducted in gland so.uh our healthcare workers in kobe 19.areas.more at risk so like where like.in this study like where infections are.greater among staff.bearing appropriate ppe uh in red areas.these people during the study they have.categorized.the areas into three three different.colors.so uh like there is a green color that.is in the opd where it is less risk.so then amber color and the red color so.the red area staffs were three times.more likely to be.covet 19 positive than a green area so.there are still many unanswered.questions in the study.transmission acquired from patients to.staff in red areas did staff get it from.home.did stab get it from colleagues because.like they all are wearing appropriate pp.and.they know whom they are dealing with or.it is unclear if.representative like this can be.extrapolated to all healthcare.facilities in the country or.even outside the country like that's our.outsiding.the implications that hospital need to.introduce screening programs across the.workforce.testing important uh tool to uh stop.infection spreading within the hospital.setting.so how early identification of.symptomatic healthcare.providers can be done so the it can be.done through.again through passive strategy or.enhanced passive strategy.or through active strategy as we.did for inpatient care so all health.care workers.uh self-assessing the passive strategy.you will be assessing for yourself so.they will be doing self-assessment for.fever.and or a defined set of newly.symptomatic.symptom symptoms indicative of covid19.if the healthcare worker has a fever or.respiratory symptom they should not.report to the facility.and remotely report their condition to.the authorized or.the coordinating person in the.healthcare facility and they should be.provided with immediate medical.assessment and follow-up.from home so in enhanced passive.strategy like apart from like.this they can also utilize.the remainders and prompt messages for.workers like through sms messages or.whatsapp message.or group messages about uh like a.self-assessment.of their symptom and you can also make.phone calls to remind the workers like.all the healthcare workers including.nurse all other paramedicals and medic.the doctors can be reminded of so in.active strategy.uh all health care workers coming to the.healthcare facility.should be screened prior to each shift.like for like you can ask these.questions and also you can.do screening of temperature and things.like that so you can also follow and.enhance like there is a remote active.strategy that all health care workers.require to report.presence or lack of symptoms remotely.prior to so before coming to the.healthcare facility.you make it a system in your health.facility that.they should be reporting so i don't have.fever i don't have any symptom.so i am coming to work today so then.they come and they will be assessed.in the healthcare facility also that is.like active strategy includes like.in-person active strategy that is.done at the health facility and also you.can.complement that using a remote active.strategy.before coming to work like everyone does.an assessment and report.and they then they come so you are you.are doing a.double double layer uh protection and.ensuring that the healthcare workers.doesn't have uh.illness uh before coming to the.healthcare facility so what is the.ministry of health and family welfare.risk categorization for healthcare.workers.who have contact with positive cases so.it has been categorized into.the risk category has been categorized.into a high risk exposure and a low risk.exposure.the healthcare worker or other person.providing care to kovid 19 case or a lab.worker.handling respiratory specimens from a.kovit 19 case without recommended ppe.or with possible breach in ppe is the.highest exposure.or else if the person has performed an.aerosol generating procedure without.appropriate ppe.or like a healthcare worker without a.face mask or face shield or global.having uh face-to-face contact with the.whole comet 19 patient.within one meter for more than 15.minutes then it is categorized as a.high risk exposure lower exposure is.contact who do not meet the criteria of.a high risk are called.uh low risk exposure so and there is a.form for identifying this and this has.to be reported.to the nodal officer of the healthcare.facility who has been.assigned as a coordinating authority for.that particular health facility so what.is the guideline for healthcare worker.who have contact with positive.case though all the high-risk contact.will be quarantined tested.as per icmr testing protocol they will.be actively monitored for development of.symptoms and.managed as per the laid out if they test.positive but remain asymptomatic they.will follow the protocol for.very mild mild or pre-symptomatic case.so.again like there is a criteria for.clinical management of cases so.they you can refer to those guidelines.which are mentioned below.if they test positive and remain.asymptomatic as per icmr guideline.they complete 14-day quarantine but.again please be informed this may vary.from.state to state like your state may like.tamilnadu may be following a different.guidelines.so please get the latest guidance from.your health facility uh from the state.government authorities.and uh like the same the state.government content guidelines will be.followed for this.and loris contact shall continue to work.and they will self-monitor.their health for development of symptoms.so.that's all i would like to.mention about the prevention strategies.and some surveillance methods.in for the healthcare provider um.and here are some of the forms like.which we.sharing with you so these are self.monitoring forms for asymptomatic.healthcare worker.and this is for active monitoring you.can uh utilize this formula originally.from your centers for disease control.which can be adapted and used.if at all some exposure happens there is.a risk assessment.for the exposed forces.so this can be really.used this is very this will be very.helpful.if there is an outbreak or if there is.recovery in your health capacity if you.want to identify like where the exposure.happened you can use.this standard forms which are available.thank you so much and uh.now over to dr dan for.further discussion of the questions.raised during the registration.thanks dr vaughn.thank you so much sir thank you for the.very.clear concise presentation uh now i.shall be.putting forward the questions.which were which you got in the.registration.form.is my screen visible.yes that's good so the first question.was.are the current measures sufficient to.control the spread among health workers.so the current measures that are being.advocated.you know mask wearing social distancing.uh you know if they're done correctly.can and should protect health care.workers.the issues come into.uh are they being done correctly are.does everyone wear their mask as.prescribed.is there current uh ventilation uh.to limit any chance of in an.aerosolized virus in the air is that.being.carried out are people washing their.hands.to limit any potential fomite or.neck transmission if it's all done.correctly.the current measures should protect.health care workers.you know are they taking off their ppe.appropriately so they don't.self-contaminate.based on the evidence that we have if a.healthcare facility and a healthcare.worker.applies all recommended measures.then the risk is sufficient.the risk is low.over so the next question is.do people who get exposed to the virus.frequently like healthcare professionals.develop some kind of resistance or.immunity to the virus.so immunity to the virus is something.that has not yet.been completely understood.we know that individuals who are.diagnosed with covid do develop.antibodies how long those antibodies.remain.is average around two weeks but we don't.really know.what the protection is for healthcare.providers who.have gotten the virus if we look at.coronaviruses.and we look at the common cold.coronaviruses we know that.individuals can be re-infected with the.same coronavirus.like the common cold we also know that.sars.and mers which are also coronaviruses.have been shown in prior studies to have.limited immunity one to two years.you know a few days ago the the cdc.updated one of their web pages and.on there they have not documented anyone.that's been reinfected.with a sars cov2 virus that does not.mean that it's not.possible or not happening it's just that.to date.when we haven't been able to find.documented evidence that a healthcare.worker.or an individual who acquired in the.community.has when re-exposed developed.a subsequent infection although it's.something that is an.unanswered question that definitely.needs more.to the work question are there work.restrictions recommended for hexip.with underlying health conditions who.may care for covert 19 patients.so individual facilities states or.governments.may choose to engage work restrictions.for healthcare providers who are.older who have comorbidities.or immunocompromised because these are.the patients that have a higher risk.for death so i know that there.are health care facilities who have.reassigned health care workers based on.risk.to lower risk situations to avoid.the potential of them contracting.sars kobe 2 and getting coronavirus and.then.dying but a lot of these work.restrictions.are facility dependent state dependent.but based on the evidence they are.increased risk if they have underlying.health conditions.the next question is what are the.instructions of precautions for the.safety of pregnant health care provider.who is treating cold patients.so at this point from the literature we.know that.pregnant individuals.may be an increased risk for severe.illness.from covid19 compared to non-pregnant.and there may be an increased risk of.adverse outcomes such as preterm birth.again a lot of this evidence is being.evolved i've also seen a study where.even though the pregnant individuals may.be an increased risk for severe illness.there was an.increased risk for death so.you know this is again where facilities.and states and governments.may have their own rules and regulations.for health care providers who are taking.care of cova patients.but just to know the evidence to date is.that if.someone is pregnant and contracts covid.they may be an increase for more severe.illness.what is the type of ppe to be owned by.an health care provider during.transporting covert patients.or suspected coal patients.so um again.there may be something that's india.specific guidance for ministry of health.and family welfare and boeing i don't.know if you.know of any specific guidance on this.but in general any ppe.is designed to to protect the healthcare.worker and also the patient.so someone who's transporting someone.with covid needs to have.a mask usually a face.covering or some kind of goggles if.they're going to be close to that.patient.if there's a risk for them coughing on.that.healthcare worker and then gowns and.and gloves and also the root.that is taken by the covet patient needs.to be mapped out.to avoid unnecessary exposure of that.covid patient.to non-covet patients so this is where.covet wards that have dedicated routes.to surgical suites or.radiology suites that avoid non-covet.wards or non-coveted patients.is something that healthcare facilities.should look at.so what are the precautions to be.followed while disposing dead bodies.over infected patients volun do you want.to take this one.ah sure man so uh the the.ministry of health and family welfare.from emr.ncdc has divisions has given uh clear.guidelines on dead body management.okay like this is different from wh you.know like who doesn't recommend any.additional precaution like only thing.what they mention is do not embalm the.body and.uh like and you have to ensure that.there is no leaking.don't touch or hug the body or kiss the.body unnecessarily.so indian guidelines are mentioned that.like you have to.once the patient dies uh like uh due to.kovat like and you have the established.diagnosis.so keep the body inside inside a bag.that is a leak-proof bag and uh it has.to be closed and the outside of the body.should be disinfected.with one percent hyperchrome before uh.keeping the closing the body inside the.bag like you have to.ensure that there is nothing leaking for.example if you are renewing a catheter.or if you are removing a.central vein cannula like something like.that so you have to ensure.that uh like no body fluid or blood or.something is leaking so that has to be.you can keep the gauze and stop like.stop it bearing appropriate.personal protective equipment and close.the body and disinfect with the.hypochlor one person hypothesization.and transport the body and what indian.guidelines recommend is even the.ambulance which is.a mercury van which is uh transporting.the body has to be disinfected with.combustion.and you can dispose of the body so again.like uh.disposing you have to follow the.religious customs like if their.religious practices to cremate the body.it can be cremated.or you can go for a deep barrier like us.as per the what their religious faith.demands you know so but all times you.have to ensure like not only.uh caring for the uh people but also.to be respectful with the dead like the.dead person also like he was.he was a like respectable person like.before then that has to be continued and.you have to.respect of the uh the people who were.dead to covet and.appropriate respect has to be given like.while transportation.or during the period so i.hope this answers your question yes.uh do you want to take this question sir.it asks.do's and don'ts of health care workers i.think this has been extensively.discussed yeah.yes so you can i can skip it yes.and uh what are some of the iris and.relatively lowest medical procedures.also we.risk yeah we have discussed okay so.this question says if pp runs out what.are some of the best ways.with which you can prevent exposure so.dan like do you want me to show the ppe.slides.sure okay.so you can just stop sharing.so this we.so uh ppe if you're running out of ppe.uh you know one is calculating when am i.going to run out of ppe.and both cdc and who have forecasting.tools so your healthcare facility.should have a system in place where.they're forecasting if they have enough.ppe.and these are two different tools.i think uh initially it's the who tool.might be where we would start.to calculate it but this is something.your facility should be doing.next.one way that you can minimize ppe.is to engage staff.in using telemedicine can use physical.barriers.such as glass or plastic between the.patient.your general staff people that are.checking in but also health care workers.so that you don't have to give them ppe.also if you cohort staff not involved.in direct patient care from covet.patients.is a way that you can maximize the use.of ppe.now i would say that this is very.contingent.on a screening program of health care.providers.and patients for symptoms.of covet as bone was explaining in his.slides.and what we've seen in several case.studies.is that health care workers who work in.areas.that are deemed to be not covet wards.may have a higher risk if they're not.washing their hands doing appropriate.ppe use because they have this false.sense of security that they're okay.and there was a nice study in durban.south africa that was published that.clearly showed that healthcare workers.who felt like they were.not dealing with covet patients actually.facilitated the transfer.and also patients were able to give it.to healthcare workers in those wards.next slide.if you do not have ppe consider.reuse of ppe and when you reuse a ppe.you should have things like goggles and.face shields now this is.outside of general recommendations.and not recommended if there's an.adequate supply of ppe.if you're reprocessing equipment you.need dedicated staff.to oversee ppe to make sure that you're.not putting ppe.out that hasn't been cleaned.appropriately.or could pose a risk because it has.holes it's ripped or it's.not appropriate.next so n95s.isn't the ppe that most commonly were.questioned about that can we reuse it.and if we look at the sars kobe 2 it has.needs a host to survive it can survive.on surfaces.and you know n95s are made out of.plastic steel cardboard and.if you put those together 72 hours is.really the limit.so um there are different ways to.reprocess ppe.but in our experience in talking with.sites.both in india and in different parts of.the world.reuse with a.time between you so you're using.a uh respirator an n95 and.letting it set for five days and then.reusing it in that time period.the sars kobe 2 is dying and that.keeps you safe over.her next slide yeah.so uh yeah and also dan like you can.mention about like what all are the some.strategies.in fact.so there are different ways different.strategies that have been.used and all of them have limited.research.some of which are not recommended some.of which are more promising and we'll go.through these.quickly next slide.so we've kind of touched on periodic.reuse.based on the surface.there is a limited evidence on.how much sars kobichi comes in the mask.so a small study in singapore that.didn't find a lot of.sars kobe 2 on ppe this room was.appropriately ventilated at 12 extra.exchanges per hour.in situations where you're using.aerosolized generating procedures.that may be a higher rate and in.when you're doing an air slot generating.procedures generally you.are not supposed to reuse that n95 mask.but should immediately get a new one.other ways that contamination could be.sterilized is heat treatment.the sars kobe 2 can't survive at high.temperatures so 65 degrees for 30.minutes.so there's a protocol here on this.that allows you to safely reuse the mask.although it does potentially damage the.mask and you can't keep doing this.forever.next slide also there's been use of.steam.sterilization again you're looking at.the filtration efficacy these masks.have these electrostatic charges.that are degraded by some of these.treatment methods.and have limited evidence next.if you're looking at soaking in alcohol.or chlorine.these definitely are not recommended you.can see from this stanford study.that you have a really marked decrease.in the filtration efficacy.and you're looking at n95s that function.more as.a good surgical mask rather than an n95.because of the decreased filtration.efficacy.next slide and then chlorine.of course it you know is very irritating.to the lungs.and so that's also not good for.healthcare workers.ethylene oxide is definitely not.recommended it can be.teratogenic carcinogenic and so this was.used by some facilities really early but.since.should be abandoned.hydrogen peroxide has.some promise and.again limited evidence we get into how.often they can be used.and next slide.you know at the bottom of this is a very.nice website where all the evidence is.summarized.again moist heat.uv light so here uv light.this is a protocol out of nebraska and.there are different protocols.and this particular website here at the.bottom you can find the protocol.on how to do this again each.individual uv light has its own.strength distance from the mass that you.need to do it.so you may not be able to do a.one-to-one.uh use of this particular protocol and.again the evidence is limited but if you.have it and you.can potentially use it and that's all.you have at least you have some guidance.and a place you can look.yeah thank you dan so then.go to the next question you can share.so the next question goes as or empiric.antibiotics recommended for healthcare.workers suspected of having covered 19..so at this point who and cdc have no.recommendations for empiric use of.antibiotics or other.antimicrobials for healthcare workers.you know this may.differ from states or other countries.but that's i'm just giving you who and.cdc recommendations.based on current evidence okay.so the next question is how long does an.examination.run need to be awakened after being.occupied by a patient with.confirmed or suspected covet 19..so a patient with confirmed or suspected.cove covid19.should be wearing a mask in a health.care facility associates.provider we know that studies from.nebraska and singapore.when they've sampled the environment of.rooms that have loaded 19 patients they.become heavily contaminated with.coronation.but we also know that a room when it's.cleaned.with an appropriate disinfectant is this.easily kills the virus so i would say.one it needs to be cleaned.after the patient enters the room and.has suspected.covid uh if they are in there for a.period of time and you're also looking.at the ventilation.you're looking for ventilation between 6.and 12 air exchanges per hour.and if you're not sure what that could.mean.if you're looking at a room that has an.open window an open door.and the room is a fair size your air.exchange rate is around.42 so picking a room.as an examination room that's well.ventilated or a negative pressure.is also important how long that room.needs to be vacant is dependent on.the ventilation in that room.okay.the next question is how do you see.increasing cases of forward amongst.healthcare workers how do you document.it so if you're going to look at.document.increasing cases you would have to have.some surveillance system and this is.what mullen.had described in his presentation you.need a systematic way.where you're constantly assessing and.monitoring your healthcare workers.when we look at studies from um.[Music].new england the public health england.the us.you know this varies between three and.ten percent from the studies i've seen.but it could also be in your.facility if you have lots of coronavirus.higher than that it really is going to.be dependent on.cases in the community and also how well.a particular facility.is engaging in ppe and also how well.they're able to screen.and identify those workers so this is.kind of a difficult question.you need a lot of information to answer.this question.yeah so unless to complement and like.you have to have a strong surveillance.system like.um either it can be passive or active.but uh.surveillance and documentation and.analyzing of the report.very important not only at the facility.level but at the.district state and the national level to.understand have a better understanding.about.like whether it is increasing or.decreasing and why it is increasing to.know the cause.next okay.um so this question i think we have a.cube.to a doctors and paramedical staff with.protection they mean like in the state.the arrangement region why is that.that's what the question is.uh pointed at.do you want me to speak sir yeah you can.uh so next question goes is which field.amongst doctors are most vulnerable to.covered according to you.which field in the sense.okay so i think that you know this gets.into.um fields that.deal a lot with patients so.pulmonologists that are working with.doing a lot of intubations and aerosol.generating procedures or emergency room.doctors that are seeing a lot of.patients come through.or ear nose and throat surgeons or.dentists.all those are fields where they're very.close to an airway.and because many patients are.asymptomatic and we have many.cases of documented asymptomatic.transmission.those providers are at higher risk.because they're closer.but i would also say that fields where.doctors.do not take appropriate precautions.are also at risk and we do have many.cases.where doctors who are taking care of.patients.in the community who are not really.taking standard precautions and wearing.their appropriate ppe are likely to get.infected because they don't.take the risk seriously they don't take.infection prevention control seriously.and so sometimes what we also see is.that.those that are working in high-risk.situations with covet patients in.intensive care units.are actually safer because there's a.higher.awareness of what ppe they should be.using and a higher adherence to that ppe.as opposed to where they feel that.there's less risk so.i would just say for you as as doctors.you should take all standard precautions.and wear a ppe appropriately for all.patients at all times not also for them.but also for you because we have many.cases where doctors are transmitting.covid to their patients.and doctors can be asymptomatic and.transmit to the patients just as much as.patients can be asymptomatic and.transfer it to unit.okay.it is rising cases and healthcare.manpower in equity.of it is a concern.i mean i mean in in a pandemic situation.in a pandemic situation when you have.rising cases and it overwhelms a health.care system.and you have few staff to take care of.those patients.i would agree that this is a concern in.any country.in any situation and.in those situations i think it's also a.concern on what kind of.care we can provide to patients and.whether it's a high resource setting low.resource setting.when you are overwhelmed with patients.and you are just trying to get through.the day.and trying to provide care to everyone.sometimes and there's an acknowledgement.in public health and in the medical.profession that you.sometimes have to um do the best you can.um and this is also where i think that.we need to.prepare our systems for these type of.situations.regardless of situation so that we have.enough health care we have enough.manpower.to deal with these kind of conditions.not only.just in india but around the world.the next question is kind of in line.with this so.uh it's specific to india india so do.you think.students need to be open for additional.support in your consumer opinion.i'm not sure what additional support is.can you explain that to me uh in the.sense.uh they in the sense like final year.medical students or.medical students in general uh in in the.the setting of lack of staff to care for.patients should they be.do you think it's a good option for them.for open students.so this is again a facility.or a state or a government's decision on.how they.allocate their students i know that.there.are students who graduated early so they.could put them into.uh places where they could be used.i know that even in in countries like.england.where they were overwhelmed they were.asking.tech staff who are not physicians and.not medical students.to man ventilators they were training.them how to use ventilators and asking.demand ventilators because they just.didn't have enough.people so not only students are being.asked to provide.care it is non-traditional.medical providers that are being asked.to do much more.than their training in order to provide.care for the vast numbers of people that.are presented.okay so.uh i think this this question also can.be skipped.uh due to time time constrained i think.it's better to skip.similar questions okay.yeah you can move on total there were 30.questions yes.so in this question it says what is your.opinion on administering healthcare.workers with flu vaccines will it be.effective.so flu vaccines are effective against.flu.and we haven't really entered flu season.to know.how flu administration.is going to affect covid there has been.many documents that.have shown that sars kobe 2 virus can.co-exist with flu.it can co-exist with other viruses.so there's also a concern that you know.it's in in a population not only.healthcare providers.that when flu season comes it could be.very.uh problematic if someone has flu.and coronavirus um.so i think that the recommendation is is.still that health care workers should be.getting flu vaccines.but i don't know uh you know what the.effect will be on sars kobe 2.because those studies haven't been done.because it's it's uh.it's still early okay so.this is the next question is coaxing a.covert vaccine is currently under trial.in india.and will be out in the market within a.year can it be assumed to be safe enough.when most other vaccines take a minimum.of 10 years of safety trial.i mean vaccines are being developed.and are in trial at a much faster pace.than we've had in.other situations and all vaccines.have risks and benefits and much is.unknown.so a lot of vaccine work is is underway.if a particular vaccine is safe or not.that's why you have to.have trials to understand if it's safe.or if it.is not safe and you can only do that by.just having some trials and if it's.unsafe to stop.and pursue a different direction and if.it does appear safe.then you end up with larger populations.being exposed and again that safety.profile being assessed.but because of the concern that the.potential high.high impact of a virus a viral vaccine.for coronavirus.you know this again is something that.we want to do but we also want to be.safe and we just have to.look at the data when it comes in.okay um.since covet has been declared airport.does this put healthcare workers at a.higher risk of.intra-hospital infections do you want uh.to comment on.a code being declared airborne or not do.you want to clarify that.i'll talk a little bit about it you know.the the issue with.coronavirus is airborne versus.non-airborne.and i think it's it's a matter of.what the degree is you know there was a.jama article that came out.relatively recently and i can share that.with you to share with them.that kind of summarizes it and you know.what we're seeing is that in the.laboratory setting.you can make the virus airborne and you.can detect it in the air.in the real world there are some cases.where it seems like.there is some element of it being.airborne.but it is not felt.to be a primary means of transmission.it can contribute to transmission but if.we look at some.airborne virus like measles which is.truly airborne.the are not for measles is between 13.and 18.and if somebody with measles walks into.a room.a closed room and.makes it airborne.that virus will stay in the air for 30.minutes.and anyone walking into that room.is has a high probability of getting.that virus.we are not seeing that same situation in.the epidemiology for corona virus.although we have this restaurant in in.china where you have the air conditioner.kind of recirculating the air.although we have uh an incident in.washington where you have a choir.practice that went two and a half hours.what we're seeing is that the.epidemiology is.not having an r naught of 13 to 18. it's.more like 2.5.and also in those situations we're.looking at the duration of time.in the case in china that duration of.time was 50 to 70.some minutes in the case of the the.choir it was two and a half hours and.they were.also in close proximity in settings.where they were.sharing tea and cookies so.you can't put it all on airbornes i.would say that.that evidence is still very much.evolving.it's possible that it's contributing.but it's not something that if you wear.a mask.if you're working in ventilated.conditions.those seem to be very protective for.healthcare workers.uh and it's it's something that we'll.get more evidence on but i would say for.you.if you're concerned about it always wear.a mask.an n95 if you're working in close.proximity with patients.and work in well-ventilated areas and.also you know wear a face shield if.if you're working in close proximity as.well as per the recommendations.okay the next question is what advice.would you give to families with.healthcare healthcare workers.caring for food.the family members of the healthcare.workers.so families of healthcare workers the.healthcare worker has a responsibility.to take care of.him or herself and wear the appropriate.ppe.and then when they're coming home be.very cautious.we know that healthcare workers are at.higher risk because they're seeing.patients with coronavirus but we also.know that.in families and when the community.many healthcare workers are bringing.into the hospital so in the study that.was in.england you know 40 40.to close to 50 percent of the healthcare.workers were not getting in the hospital.they were getting it from their own.family units and friends and family.so i think that here.it's everyone needs to be aware you need.to do some self monitoring.this is what vollen had presented are.you having symptoms.are your family having symptoms if.anyone's having symptoms that you're.aggressive and getting testing getting.treatment.so that you are not exposing either your.family.or your co-workers.or patients that you take care of.i don't know well and you have anything.you want to add to that but.yeah and and also you know like when you.come home.you have to you can wash your.clothes and separately in hot water.with usual detergent like separately you.can wash your.clothes you are wearing for the um.facility when you are visiting and uh.also you know uh like uh don't take like.too many things.take your lunch or something and in a.disposable.packet or like in a package thing and.just dispose it off.and like unnecessarily like don't bring.bring.to the facility and back from their.like unnecessary bag bags or like any.baggages and all.and now mainly the mobile phones which.you are using like there is a very.beautiful guideline.from the newsland like health department.which we will be able to share like we.have some frequently asked questions.we have.this will be very very helpful you know.like my very minor things but this will.go a long way.in protecting the families of the.healthcare providers.uh so the next question is there has.been an overcrowding of cold hospitals.especially in major.cities like chennai do you think this.would place healthcare workers at a.higher risk of infection are there any.additional ways.in which they can protect themselves.from infection again this has been.discussed yeah.so the next question is there has been a.recent wake of patients.with other complaints being tested.positive for code 90.even though they initially tested.negative for infection could this be a.reason that go with testing among.doctors or inadequate.and could be potential carriers of.infection to their patients.so i think that if you stop sharing i'll.i'll.share my slides okay i'll share some.slides because i think that this is kind.of.an area where i think that we need to.have.some clarity.so when we're talking about um.transmission.most of the transmission that's.happening is in the first.period when somebody becomes symptomatic.there's cases of pre-symptomatic and.then somebody develops symptoms.in the first five to six days.after someone has symptoms is when most.of the transmission happens it's also.when most of the virus.is being shed from the upper.airway and there was just a taiwanese.study that was published.a few days ago that did not find.cases in healthcare providers or.contacts that happen six days after.symptoms.and if we look at the difference between.being able to detect the virus.and the virus actually being a viable.virus so.uh this is documentation of asymptomatic.transmission we've kind of talked about.that.so this particular study which was.you know this is a nice site here at the.bottom of the slide on cdc.but let's answer the question how long.does a person remain.infectious and shed live virus after.they become infected.and the answer is between 7 and 10 days.the evidence that we have so far is.seven to ten days.so that means for most individuals.who get sars cov2 it affects them and.they have coronavirus.seven to ten days after they have.symptoms.is when the virus can no longer be.isolated as a live virus.but you can continue to detect the virus.up to.six weeks out the average being around.two weeks.so in individuals who continue to test.positive using rt pcr so.the test that's most often being used is.rtpcr so they're continuing to test.positive.but again this is a different.because just because i can detect the.virus does not mean.that it's causing or can cause an.infection i need live virus to do that.and in that case going back to this.earlier slide that is.typically 7 to 10 days now i will say.that there's a caveat to this.and the caveat is that in severe.infections.in patients who have very severe.infections they're able to find the live.virus.sometimes up to 20 days after.so this does not apply to everybody and.this is where evidence is still needed.so in cases where you have a severe.infection.that patient may actually shed live.virus much longer than the seven today.period which is for most individuals so.i think you have to look at the.kind of infection the severity of.symptoms and know that evidence is still.evolving but.um that's the answer to that answer that.question.over.ames delhi has recently deployed robots.to avoid transmission from patients to.healthcare workers.how effective in the long run do you.think this measure might be.yeah i don't know much how the robots.are actually being deployed but.i think the principle is that if there.is.uh distance between.healthcare providers and patients that.limits transmission it also limits.the patient's ability to transmit it to.the healthcare worker.and you know we don't know how long.coronavirus is going to be around.it could be that it's.you know a season and then it kind of.goes away it could be with us for a long.long time.so how effective in the long run.i think i think it depends on how these.robots are used.in their particular situations but the.principle is.limiting that transmission and if they.can limit transmission.from healthcare provider to patient from.patient to healthcare provider it could.be effective.okay.actually they are using it for two.purpose like one main for disinfecting.and also like in the mainly in the.for serving the patients uh so.mainly in the kobit words.okay so.uh due to kovid our supply chains have.been compromised as a result even the.ppe is having made.do not reach the required places what is.your take on this.yeah i don't have a take because um.you know i think this is a kind of a.question for your hospital administrator.or your state on how they can.can help with that yeah so this would be.please.monitor the current stock of pps at all.time like you.can use the calculators for the burn.rate and things like that.so that you can ensure adequate stock.is available in your health facility in.your department like.because that will be very helpful you.know like if you are using the bond rate.calculators of.wh will be very helpful to monitor your.pp's stop position.okay.do you think treatment costs for covered.in private hospitals should be regulated.by government.given it serves as a major concern for.overcrowding and government code.hospitals.yeah i can't comment on what a country.can do for.treatment or no treatment i i can say.that.there has been an effort by governments.in.other places around the world to make.coronavirus testing and treatment.affordable because.if you limit uh testing.especially you end up with widespread or.more widespread community transmission.because people aren't coming to the.hospital for testing so if they don't.know they have coronavirus because they.i don't have it available then they.feel that maybe they don't have it and.they can go.and transmit it to others or they don't.seek medical care so.there are arguments for making.coronavirus.treatment and testing affordable for.everyone from many different places.around the world.now and the actual implementation of.that has to be local.and fit with uh local government.policies guidelines and.feasibility.even this question has been.addressed so i will skip it.do you think a deficient contact tracing.among healthcare workers.has been one of the causes of increased.infections among them.so i'll give you the the case study that.was from south africa in that particular.case there was a woman who came to the.emergency room.from a foreign country to south africa.and she tested positive.and in the emergency room she.[Music].was seen by a healthcare provider that.then went over and saw a patient from a.nursing home.that patient in the nursing home was.also very close to the triage area.now the woman who was tested positive.she went home.but the woman from the nursing home got.coronavirus.and then entered the hospital.that patient eventually caused an.outbreak in five wards in two outpatient.the dialysis unit and back at the.nursing.widespread transmission and in that.there was no health care screening.for health care workers for coronavirus.that was routine.and because it wasn't routine and.because the healthcare worker wasn't.tested.and found to be positive.there was transmission but it also was.for healthcare.for the patients too so this is why.surveillance of healthcare workers and.patients is very important to limit.transmission.that's just one example but there are.many many other cases that i've heard.okay so we have come to the end of the.session.this is the final question.we have seen an increasing trend of.violence against.frontline doctors recently from the.general public and this is attributed to.having a direct impact.on their mental health which in turn.affects their job efficacy.how do you think we can deal with this.so the mental health of healthcare.workers is extremely important.you know you as medical providers do a.difficult job day in and day out.you work long hours you take risks with.your own health.you also are risking bringing it back to.your friends.and family and loved ones and.you know if you are also exposed to.any kind of attacks from.the general public or others it.definitely.can have a negative effect and so.working with your administrator to.make this known i think that you can't.hold this in i think you have to make it.known.to people that can message this as a.concern.within your own facility and up in your.government because.they are the ones that ultimately can.put public health messaging out wherever.you're at.in whatever country you're at.i think that also taking advantage of.mental health counseling i know that.many.facilities have mental health counseling.that's available.and don't be afraid to reach out for.help in that.as well.well any do you want to add anything or.uh yeah and also there are recent.guidelines from.nimhan's bangalore regarding.supporting the counselings and things.like that and counseling numbers.are available for healthcare workers.because like this is extremely.stressful situation as dr dan has.mentioned so you can use those like.there are videos.available from your health and family.welfare.you can they can utilize those uh and.like.i don't know like um like even in tamil.nadu.they have ev every district they have a.mental health program.and now they are offering support to the.healthcare professionals like.so i know like one of my colleagues is.involved in all potential district.so uh so you you can utilize all this.opportunities yeah.i do agree it is a very very stressful.and.like really mental health is an.important.thing which has to be taken care of.and so that was the last question and.everything almost has been extensively.very extensively covered.uh so um for those who.who are watching guys they have come to.the end of the session.so if you have any questions please put.it in the put it up in the live chat.we shall wait for a few couple of.minutes and if we.uh don't have any questions then we can.end the session.people watching put up your questions in.the live chat.in the comment box.so uh people want uh you to share their.ppt your presentation uh later if that.is possible.sure like we will be sharing the.presentation and additional materials.uh the dr dan and the case studies what.dr dan was mentioning so all those.things we shared along with the.surveillance forms and things like that.okay.dan will be sharing to you you can share.with the participants because you should.be having.their registration ids.we don't have any questions.so we can.prove the session sir.yes yeah.thank you thank you so much sir thank.you for accepting our invite.and making time and putting in the.effort to come and present to us.and that was so expensive you had almost.covered every possible aspect.of the topic it was very useful.and and i also take a moment to thank.our sponsors either sneak pg.and online pg preparation platform and.apipola a mobile accessories and.electronics companies.thank you thank you so much.thank you sir.you.

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