BLOG: The new 'universal precautions'
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At this time, we don’t have a firm grip on the true prevalence of COVID-19. Testing is not yet widely available, and the most common swab test has limited sensitivity, especially for early infection.
But even if the prevalence of actively infected patients is 1%, we are all probably encountering patients in our practices and at the grocery store who are shedding the virus.
Most of our practices are welcoming back patients for routine care, with the admonition that if they have fever, cough, fatigue or other symptoms, they should stay home. Some surgery centers and hospitals are requiring testing before admitting patients. Should we do the same? After all, in eye care, we get very close to patients’ faces. Even with masks and barriers, we are all breathing the same air in our cramped exam rooms.
I think the answer to whether we should test everyone lies in our history. When I was in medical school in the late 1980s and early 1990s, HIV and AIDS were a terror. Being infected was a death sentence, and it carried a social stigma of suspicion as an IV drug abuser or someone with a then-stigmatized sexual orientation. Antibody testing was widely available and 99% sensitive and specific. This meant we could identify 99% of infected patients if we tested everybody. We could know the risky population — those with “the scarlet letter” in their chart — and alter our health care worker precautions accordingly. This sounded promising, but it also meant that 1% of truly negative patients had a positive test result, with all the baggage this implied and no HIPAA laws to protect privacy, until retesting could set the record straight. Ultimately, we stopped routine testing, and health care adopted “universal precautions” for all patients, regardless of their disease status. This would lessen the stigma of HIV and also protect workers from other bloodborne diseases like hepatitis B and C. It worked. Transmission of bloodborne illnesses in the health care setting became a rarity, and to most of us, those precautions are now a second nature.
During the COVID-19 pandemic, we are observing a new level of “pandemic precautions,” and they, too, are working. Donning masks, using barriers, minimizing personal contact, and reducing both the number of patients and the time they spend in the office have helped us resume care and isolate both ourselves and our staff from disease and harm. To date, no reported case of an outbreak of COVID-19 has been reported in an eye care office, despite thousands of patient visits and surgeries. In the face of a disastrous pandemic, this is quite an accomplishment, and testing has played little or no part in this success.
There is one place that testing should probably be expanded in eye care: patients who present with signs and symptoms of episcleritis, unexplained conjunctivitis and perhaps any type of uveitis as well. Although fewer than 5% of COVID-19 cases present with eye-related signs, they have been known to be the harbinger of infection. Although testing is not 100% sensitive, it might uncover cases in which lives can be saved by earlier identification, at least during this phase of the disease in which the population burden of disease is expanding.
With hope, none of us will experience another pandemic like COVID-19 during our careers. But if nothing else, our experience should teach us to be better prepared if there is a next time, with adequate personal protective equipment and a state of mind to implement “pandemic precautions.” Should they be needed, these steps could make all the difference in delaying spread of disease and protecting ourselves, our employees and the public.
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