Recommendations for clinical and endoscopic examination
The risk of contamination is very high in upper respiratory examinations. In Chinese patients, SARS-Cov-2 was detected in 63% of nasopharyngeal swabs, in 46% of the fiberoptic bronchoscopic brush biopsies and in 93% of bronchoalveolar lavage fluid specimens.28 Higher viral loads were detected after symptoms onset of COVID-19, with higher viral load in the nose than in the throat.29 In spite of that, recommendations for clinical and endoscopic examination can be very controversial because adequate PPE to all staff involved in patient care cannot be available everywhere. For sure, at least “WHO infection prevention and control (IPC) standards” should be in place at international level. Disruption of supply chains and depletion of stock of PPE can drive anxiety in health professionals.30
The Working Group of 2019 Novel Coronavirus, Peking Union Medical College Hospital,21 criteria for the selection of front-line medical personnel included passing physical examinations and professional training  for COVID-19. Candidates were excluded if they were pregnant, aged over 55 years, had history of chronic diseases such as chronic hepatitis, renal diseases, diabetes mellitus, autoimmune diseases, and tumors. All individuals with acute fever were also excluded. For those who are working with COVID-19 suspicious or infected patients, isolation or observation was compulsory in the following conditions: a) those with close unprotected contact with COVID-19 pneumonia patients (health workers should be relatively isolated, “avoiding walking around and extensive contact with others”); b) onset of fever, cough, shortness of breath and other symptoms (medical personnel should be isolated immediately and receive appropriate care); c) when work in the COVID-19 infection ward is finished, nasopharyngeal or oropharyngeal swabs for COVID-19 and a full blood count should be carried out. Those who have abnormal test results should undergo strict isolation and observation; while others will be generally isolated for observation and resume work after one week. However, there are no consensus on these recommendations as to how long COVID-19-positive healthcare professionals should refrain from patient care. Viral secretion was found in hospitalized Chinese patients who recovered to last from 8 to 37 days with a median of 20 days.5
During the COVID-19 pandemic status, effective biosafety precautions must be implemented in all clinics and hospitals because most infected patients are not symptomatic and may have been examined only with inadequate protection. Medical and dental examinations and procedures can produce aerosols. Even subsequent patients in the same room or suite are at elevated risk.1 3132. Consequently, healthcare professionals are at high risk of contamination.
Aiming to preserve and ensure staff and patient safety, the USA Center for Diseases Control (CDC) recommends that healthcare facilities cease elective care and restrict their activities to providing urgent and emergency visits and procedures for several weeks. All elective and non-time sensitive, non-urgent surgical procedures and admissions must be rescheduled as necessary.33 In other parts of the world, like Hong Kong, and, and most recently, Italy, France and Belgium, there has also been a reduction in elective clinics and operations, with the aim of prioritizing the use of personnel and available facilities to the diagnostic and therapeutic pathways of COVID-19 management. However, most oncologic interventions are still proceeding in the belief that cancer surgery is time-sensitive. It would be prudent to confirm that the patient is SARS-CoV-2 free through swab testing. This recommendation must change when the situation becomes critical and the whole healthcare facility is under strain from COVID-19 patients.8 This may ensue even in more-developed countries.
Working in the epicenter of the current pandemic,1 169 staff workers involved in a dental emergency unit at the School and Hospital of Stomatology, Wuhan, China, have treated >700 patients with emergent dental care since January 24 under using adequate protection measures. Since February 3, they have also provided consultations to >1,600 patients on an online platform. No COVID-19 infection has been reported among the staff, confirming the effectiveness of the established infection control measures in COVID-19 prevention within dental settings. They established triage stations to measure and record the temperature of all staff and patients. Patients and accompanying persons were provided with medical masks and temperature measurement once they entered the hospital. All the dentists undertook strict personal protection measures and avoided techniques that could produce aerosols. Rubber dams and high-volume saliva ejectors were used to minimize aerosol or spatter during the surgical procedures. Face shields and goggles were considered essential with use of drilling with water spray. A 4-handed technique and saliva ejectors were considered beneficial.