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  • Writer's pictureLouie Romanos

Protecting your dental clinic against the asymptomatic COVID patient

I would like to begin by emphasizing that the presence of COVID-19 in the pediatric population is RARE however, there have been confirmed cases in the literature. In comparison to adults, children have minor flu-like symptoms and rarely require hospitalization.


  • On May 26, the ministry of health published its’ Directive #2 which outlines the operational requirements that health care professionals or persons who operate a group practice of regulated health professionals must follow in order to practice health care delivery during the COVID epidemic.


It’s imperative that these measures be FOLLOWED as no single strategy on its own can protect health care professionals from the asymptomatic COVID patient. Without question, this patient exists although the prevalence of this disease state is unknown.


Case 1: a 22-year old male returned from Wuhan to Hefei on Jan 19

  • He visited with his 16-year old cousin on the evening on his return

  • Met 15 previous classmates on Jan 21

  • Sample size between 16-23 years of age

  • He reported being totally asymptomatic and was described by all his contacts as healthy between Jan 19-21

  • His very first symptoms included itchy eyes and a fever, developing on Jan 22

  • 7 youngsters (his cousin and 6 classmates) became infected with COVID after a few-hours-of-contact with this individual

  • None of the contacts has visited Wuhan, or had any exposure to wet-markets, wild-animals, or medical institutes within 3-months

  • Median incubation period was 2-days for this sample


Limitations: case number is low so the generalizability of these findings should be taken cautiously (Huang et al., 2020)


Case 2: a 20-year old woman lives in Wuhan and travelled to Anyang on Jan 10

  • she met with patients 2 and 3 on Jan 10

  • she accompanied 5 relatives (patients 2-6) to visit another hospitalized relative in Anyang on Jan 13

  • after the development of disease in her relatives, patient 1 was isolated

  • as of Feb 11, she was asymptomatic and out of 4 RT-PCR testing, only 1 ever came back positive

  • patients 2-6 developed COVID. 4 were woman, and ages ranged from 42-57

  • none had visited Wuhan or been in contact with any other people who had travelled to Wuhan

  • incubation period for pt. 1 was 19 days, which is long but within the reported range of 0-24 days

  • her first RT-PCR test was negative; false-negative results have been observed related to the quality of the kit, the collected sample, or performance of the test

Limitations: case number is low so the generalizability of these findings should be taken cautiously (Bai et al., 2020)



Figure 1: nasopharyngeal swab position for an effective swab. Note how deep the clinician has actually advanced the instrument.


  • These case reports conclude that screening alone may not protect your staff or patients from exposure to COVID.


  • Each health care entity should conduct an organizational risk assessment as a precondition to restarting a service. This is a systematic approach assessing the efficacy of control measures that are in place to mitigate the transmission of infections in a health care setting (Ministry of Health, COVID-19 Operational Requirements, 2020)


The types of hazard control used at your dental practice can significantly reduce the risk of COVID exposure. These controls include:


  1. Engineering and Systems Control Measures: these measures help reduce the risk of exposure to a pathogen by implementing methods of isolation or ventilation. i.e a plexiglass barrier between admin staff and patients; physical distancing or 2 meters





Figure 2: designing a medical office waiting area with 2-meters distance in-between seating.



  1. Administrative Control Measures: The use of policies, procedures, training, and education for reducing the risk of disease transmission between staff and patients. i.e- the use of ACTIVE SCREENING. A process where patients and visitors are screened over the phone for symptoms of COVID 19 prior to attending their appt.





Figure 3: an example of a passive screening initiative. A signage that can be posted at the entrance of facility delivering health care.



  1. PPE controls: the last tier in the hierarchy of hazards controls and should not be relied on as a stand-alone primary prevention program (Ministry of Health, COVID-19 Operational Requirements, 2020)




Figure 4: an example of PPE that should be worn when performing an aerosol generating medical procedure on a confirmed COVID-positive patient.


The Royal College of Dental Surgeons of Ontario has created an excellent document, “COVID-19: Managing infection risks during in-person dental care”, as a guideline for going about re-opening your dental practice WITH the ultimate goal being minimizing the likelihood of disease transmission between staff and patients.


There are several educational resources available to health care professionals or persons who operate a group practice of regulated health care professionals that are designed for making this transition easier and with more confidence.


If you have any questions about COVID-19 or required additional training in infant and child airway management/resuscitation contact:


louie@streamlinepalscertification


www.streamlinepalscertification.com



References:


  1. Bai, Y., Yao, L., Wei, T., Tian, F., Jin, Dong-Yan, Chen, L., Wang, M. (2020). Presumed Asymptomatic Carrier Transmission of COVID-19. JAMA,323(14), 1406-1407.

  2. Huang, L., Zhang, X., Zhang, X., Wei, Z., Zhang, L., Xu, J., Liang, P., Xu, P., Zhang, C., Xu, A. (2020). Rapid asymptomatic transmission of COVID-19 during the incubation period demonstrating strong infectivity in a cluster of youngsters aged 16-23 years outside Wuhan and characteristics of young patients with COVID-19: a prospective contact-tracing study. Journal of Infection, 80, 1-13.

  3. COVID-19 Operational Requirements: Health Sector Restart. http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/operational_requirements_health_sector.pdf

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