Work Characteristics, Workplace Support, and Mental Ill-Health in a Canadian Cohort of Healthcare Workers During the COVID-19 Pandemic.

OBJECTIVE: The aim of the study was to identify determinants of mental health in healthcare workers (HCW) during the COVID-19 pandemic. METHODS: A cohort of Canadian HCW completed four questionnaires giving details of work with patients, ratings of workplace supports, a mental health questionnaire, and substance use. Principal components were extracted from 23 rating scales. Risk factors were examined by Poisson regression. RESULTS: A total of 4854 (97.8%) of 4964 participants completed ratings and mental health questionnaires. Healthcare workers working with patients with COVID-19 had high anxiety and depression scores. One of three extracted components, 'poor support,' was related to work with infected patients and to anxiety, depression, and substance use. Availability of online support was associated with feelings of better support and less mental ill-health. CONCLUSIONS: Work with infected patients and perceived poor workplace support were related to anxiety and depression during the pandemic.

Excess risk of COVID-19 infection and mental distress in healthcare workers during successive pandemic waves: Analysis of matched cohorts of healthcare workers and community referents in Alberta, Canada.

OBJECTIVES: To investigate changes in risk of infection and mental distress in healthcare workers (HCWs) relative to the community as the COVID-19 pandemic progressed. METHODS: HCWs in Alberta, Canada, recruited to an interprovincial cohort, were asked consent to link to Alberta's administrative health database (AHDB) and to information on COVID-19 immunization and polymerase chain reaction (PCR) testing. Those consenting were matched to records of up to five community referents (CRs). Physician diagnoses of COVID-19 were identified in the AHDB from the start of the pandemic to 31 March 2022. Physician consultations for mental health (MH) conditions (anxiety, stress/adjustment reaction, depressive) were identified from 1 April 2017 to 31 March 2022. Risks for HCW relative to CR were estimated by fitting wave-specific hazard ratios. RESULTS: Eighty percent (3050/3812) of HCWs consented to be linked to the AHDB; 97% (2959/3050) were matched to 14,546 CRs. HCWs were at greater risk of COVID-19 overall, with first infection defined from either PCR tests (OR=1.96, 95%CI 1.76-2.17) or physician records (OR=1.33, 95%CI 1.21-1.45). They were also at increased risk for each of the three MH diagnoses. In analyses adjusted for confounding, risk of COVID-19 infection was higher than for CRs early in the pandemic and during the fifth (Omicron) wave. The excess risk of stress/adjustment reactions (OR=1.52, 95%CI 1.35-1.71) and depressive conditions (OR=1.39, 95%CI 1.24-1.55) increased with successive waves during the epidemic, peaking in the fourth wave. CONCLUSION: HCWs were at increased risk of both COVID-19 and mental ill-health with the excess risk continuing late in the pandemic.

RéSUMé: OBJECTIFS: Étudier l'évolution du risque d'infection et de problèmes de santé mentale (PSM) chez les travailleurs de la santé (TdS), comparé à la population générale, au cours de la pandémie de COVID-19. MéTHODES: Certains TdS de l'Alberta (Canada) participant à une cohorte interprovinciale, ont consenti à ce que la base administrative de santé de l'Alberta (AHDB) nous transmette leurs données de vaccination contre la COVID-19 et de tests d'amplification des acides nucléiques (TAAN). Ceux ayant consenti ont été appariés à un maximum de cinq témoins de population générale. Les diagnostics médicaux (par médecins) de COVID-19 ont été identifiés dans l'AHDB du début de la pandémie jusqu'au 31 mars 2022. Les consultations médicales pour PSM (anxiété, stress/troubles de l'adaptation, dépression) ont été identifiées entre le 1er avril 2017 et le 31 mars 2022. Les rapports de cotes (RC) comparant les TdS aux témoins de la population générale ont été estimés pour chaque vague d'infection. RéSULTATS: Quatre-vingts pourcent (80 %; 3050/3812) des TdS ont donné leur consentement à ce que leurs données nous soient transmises par l'AHDB; 97 % d'entre eux (2959/3050) ont été appariés à 14 546 témoins. Dans l'ensemble, les TdS étaient plus à risque de COVID-19, avec une première infection identifiée soit par les TANN (RC=1,96, IC de 95% 1,76-2,17), soit via les dossiers médicaux (RC=1,33, IC de 95% 1,21-1,45). Ils étaient également plus à risque pour chacun des trois problèmes de SM. Le risque de COVID-19 ajustés pour les facteurs de confusion était plus élevé que chez les témoins au début de la pandémie et durant la cinquième vague (variant Omicron). Les excès de risque de stress/troubles de l'adaptation (RC=1,52, IC de 95% 1,35-1,71) et de dépression (RC=1,39, IC de 95% 1,24-1,55) ont augmenté au fil des vagues de l'épidémie, avec un pic à la quatrième vague. CONCLUSION: Les TdS étaient plus à risque d'infection de COVID-19 et de troubles de santé mentale avec cet excès de risque se prolongeant plus tard dans la pandémie.

Determinants of SARS-CoV-2 IgG response and decay in Canadian healthcare workers: A prospective cohort study.

INTRODUCTION: Healthcare workers (HCWs) from an interprovincial Canadian cohort gave serial blood samples to identify factors associated with anti-receptor binding domain (anti-RBD) IgG response to the SARS-CoV-2 virus. METHODS: Members of the HCW cohort donated blood samples four months after their first SARS-CoV-2 immunization and again at 7, 10 and 13 months. Date and type of immunizations and dates of SARS-CoV-2 infection were collected at each of four contacts, together with information on immunologically-compromising conditions and current therapies. Blood samples were analyzed centrally for anti-RBD IgG and anti-nucleocapsid IgG (Abbott Architect, Abbott Diagnostics). Records of immunization and SARS-CoV-2 testing from public health agencies were used to assess the impact of reporting errors on estimates from the random-effects multivariable model fitted to the data. RESULTS: 2752 of 4567 vaccinated cohort participants agreed to donate at least one blood sample. Modelling of anti-RBD IgG titer from 8903 samples showed an increase in IgG with each vaccine dose and with first infection. A decrease in IgG titer was found with the number of months since vaccination or infection, with the sharpest decline after the third dose. An immunization regime that included mRNA1273 (Moderna) resulted in higher anti-RBD IgG. Participants reporting multiple sclerosis, rheumatoid arthritis or taking selective immunosuppressants, tumor necrosis factor inhibitors, calcineurin inhibitors and antineoplastic agents had lower anti-RBD IgG. Supplementary analyses showed higher anti-RBD IgG in those reporting side-effects of vaccination, no relation of anti-RBD IgG to obesity and lower titers in women immunized in early or mid-pregnancy. Sensitivity analysis results suggested no important bias in the self-report data. CONCLUSION: Creation of a prospective cohort was central to the credibility of results presented here. Serial serology assessments, with longitudinal analysis, provided effect estimates with enhanced accuracy and a clearer understanding of medical and other factors affecting response to vaccination.

Cohort profile: recruitment and retention in a prospective cohort of Canadian healthcare workers during the COVID-19 pandemic.

PURPOSE: Healthcare workers were recruited early in 2020 to chart effects on their health as the COVID-19 pandemic evolved. The aim was to identify modifiable workplace risk factors for infection and mental ill health. PARTICIPANTS: Participants were recruited from four Canadian provinces, physicians (medical doctors, MDs) in Alberta, British Columbia, Ontario and Quebec, registered nurses (RNs), licensed practical nurses (LPNs) and healthcare aides (HCAs) in Alberta and personal support workers (PSWs) in Ontario. Volunteers gave blood for serology testing before and after vaccination. Cases with COVID-19 were matched with up to four referents in a nested case-referent study. FINDINGS TO DATE: Overall, 4964/5130 (97%) of those recruited joined the longitudinal cohort: 1442 MDs, 3136 RNs, 71 LPNs, 235 PSWs, 80 HCAs. Overall, 3812 (77%) were from Alberta. Prepandemic risk factors for mental ill health and respiratory illness differed markedly by occupation. Participants completed questionnaires at recruitment, fall 2020, spring 2021, spring 2022. By 2022, 4837 remained in the cohort (127 had retired, moved away or died), for a response rate of 89% (4299/4837). 4567/4964 (92%) received at least one vaccine shot: 2752/4567 (60%) gave postvaccine blood samples. Ease of accessing blood collection sites was a strong determinant of participation. Among 533 cases and 1697 referents recruited to the nested case-referent study, risk of infection at work decreased with widespread vaccination. FUTURE PLANS: Serology results (concentration of IgG) together with demographic data will be entered into the publicly accessible database compiled by the Canadian Immunology Task Force. Linkage with provincial administrative health databases will permit case validation, investigation of longer-term sequelae of infection and comparison with community controls. Analysis of the existing dataset will concentrate on effects on IgG of medical condition, medications and stage of pregnancy, and the role of occupational exposures and supports on mental health during the pandemic.

Determinants of Sickness Absence Duration After Mild COVID-19 in a Prospective Cohort of Canadian Healthcare Workers.

OBJECTIVE: The aim of the study is to identify modifiable factors associated with sickness absence duration after a COVID-19 infection. METHODS: Participants in a prospective cohort of 4964 Canadian healthcare workers were asked how many working days they had missed after a positive COVID-19 test. Only completed episodes with absence ≤31 working day and no hospital admission were included. Cox regression estimated the contribution of administrative guidelines, vaccinations, work factors, personal characteristics, and symptom severity. RESULTS: A total of 1520 episodes of COVID-19 were reported by 1454 participants. Days off work reduced as the pandemic progressed and were fewer with increasing numbers of vaccines received. Time-off was longer with greater symptom severity and shorter where there was a provision for callback with clinical necessity. CONCLUSIONS: Vaccination, an important modifiable factor, related to shorter sickness absence. Provision to recall workers at time of clinical need reduced absence duration.

Occupation and SARS-CoV-2 seroprevalence studies: a systematic review.

OBJECTIVE: To describe and synthesise studies of SARS-CoV-2 seroprevalence by occupation prior to the widespread vaccine roll-out. METHODS: We identified studies of occupational seroprevalence from a living systematic review (PROSPERO CRD42020183634). Electronic databases, grey literature and news media were searched for studies published during January-December 2020. Seroprevalence estimates and a free-text description of the occupation were extracted and classified according to the Standard Occupational Classification (SOC) 2010 system using a machine-learning algorithm. Due to heterogeneity, results were synthesised narratively. RESULTS: We identified 196 studies including 591 940 participants from 38 countries. Most studies (n=162; 83%) were conducted locally versus regionally or nationally. Sample sizes were generally small (median=220 participants per occupation) and 135 studies (69%) were at a high risk of bias. One or more estimates were available for 21/23 major SOC occupation groups, but over half of the estimates identified (n=359/600) were for healthcare-related occupations. 'Personal Care and Service Occupations' (median 22% (IQR 9-28%); n=14) had the highest median seroprevalence. CONCLUSIONS: Many seroprevalence studies covering a broad range of occupations were published in the first year of the pandemic. Results suggest considerable differences in seroprevalence between occupations, although few large, high-quality studies were done. Well-designed studies are required to improve our understanding of the occupational risk of SARS-CoV-2 and should be considered as an element of pandemic preparedness for future respiratory pathogens.

The evolution of workplace risk for Covid-19 in Canadian healthcare workers and its relation to vaccination: A nested case-referent study.

BACKGROUND: During the early months of the Covid-19 pandemic, studies demonstrated that healthcare workers (HCWs) were at increased risk of infection. Few modifiable risks were identified. It is largely unknown how these evolved over time. METHODS: A prospective case-referent study was established and nested within a cohort study of Canadian HCWs. Cases of Covid-19, confirmed by polymerase chain reaction, were matched with up to four referents on job, province, gender, and date of first vaccination. Cases and referents completed a questionnaire reporting exposures and experiences in the 21 days before case date. Participants were recruited from October 2020 to March 2022. Workplace factors were examined by mixed-effects logistic regression allowing for competing exposures. A sensitivity analysis was limited to those for whom family/community transmission seemed unlikely. RESULTS: 533 cases were matched with 1697 referents. Among unvaccinated HCWs, the risk of infection was increased if they worked hands-on with patients with Covid-19, on a ward designated for care of infected patients, or handled objects used by infected patients. Sensitivity analysis identified work in residential institutions and geriatric wards as high risk for unvaccinated HCWs. Later, with almost universal HCW vaccination, risk from working with infected patients was much reduced but cases were more likely than referents to report being unable to access an N95 mask or that decontaminated N95 masks were reused. CONCLUSIONS: These results suggest that, after a rocky start, the risks of Covid-19 infection from work in health care are now largely contained in Canada but with need for continued vigilance.

Automated Coding of Job Descriptions From a General Population Study: Overview of Existing Tools, Their Application and Comparison.

OBJECTIVES: Automatic job coding tools were developed to reduce the laborious task of manually assigning job codes based on free-text job descriptions in census and survey data sources, including large occupational health studies. The objective of this study is to provide a case study of comparative performance of job coding and JEM (Job-Exposure Matrix)-assigned exposures agreement using existing coding tools. METHODS: We compared three automatic job coding tools [AUTONOC, CASCOT (Computer-Assisted Structured Coding Tool), and LabourR], which were selected based on availability, coding of English free-text into coding systems closely related to the 1988 version of the International Standard Classification of Occupations (ISCO-88), and capability to perform batch coding. We used manually coded job histories from the AsiaLymph case-control study that were translated into English prior to auto-coding to assess their performance. We applied two general population JEMs to assess agreement at exposure level. Percent agreement and PABAK (Prevalence-Adjusted Bias-Adjusted Kappa) were used to compare the agreement of results from manual coders and automatic coding tools. RESULTS: The coding per cent agreement among the three tools ranged from 17.7 to 26.0% for exact matches at the most detailed 4-digit ISCO-88 level. The agreement was better at a more general level of job coding (e.g. 43.8-58.1% in 1-digit ISCO-88), and in exposure assignments (median values of PABAK coefficient ranging 0.69-0.78 across 12 JEM-assigned exposures). Based on our testing data, CASCOT was found to outperform others in terms of better agreement in both job coding (26% 4-digit agreement) and exposure assignment (median kappa 0.61). CONCLUSIONS: In this study, we observed that agreement on job coding was generally low for the three tools but noted a higher degree of agreement in assigned exposures. The results indicate the need for study-specific evaluations prior to their automatic use in general population studies, as well as improvements in the evaluated automatic coding tools.

Arsenic Speciation and Metallomics Profiling of Human Toenails as a Biomarker to Assess Prostate Cancer Cases: Atlantic PATH Cohort Study.

Chronic exposure to inorganic arsenic and trace metals has been linked to prostate cancer, and altered arsenic methylation capacity may have an important role in arsenic carcinogenesis. Biomarkers may be able to elucidate this role. Our objectives were to characterize profiles of arsenic species and metallome in toenails and urine samples, compare profiles between prostate cancer cases and controls, and determine the discriminant ability of toenail and urine biomarkers. Toenail samples (n = 576), urine samples (n = 152), and questionnaire data were sourced from the Atlantic Partnership for Tomorrow's Health (PATH) cohort study. Healthy controls were matched to prostate cancer cases (3:1 ratio) on sex, age, smoking status, and the province of residence. Metallome profiles and proportions of arsenic species were measured in toenail and urine samples. Analysis of covariance (ANCOVA) was used to compare the mean percent monomethylarsonic acid (%MMA), dimethylarsonic acid (%DMA), inorganic arsenic (%iAs), primary methylation index (PMI, MMA/iAs), and secondary methylation index (SMI, DMA/MMA). Multivariate analysis of covariance (MANCOVA) was used to compare selected metal concentrations. Mean %MMA was significantly lower and SMI was significantly higher in toenails from prostate cancer cases compared to controls in unadjusted and adjusted models. Proportions of arsenic species were correlated with total arsenic in toenails. Arsenic speciation in urine was not different between cases and controls, nor were metallome profiles in toenails and urine. Our results indicate that toenails are a viable biomarker for altered arsenic speciation in prostate cancer cases and may have greater utility than urine in this context.

Primary Care Physicians' Learning Needs in Returning Ill or Injured Workers to Work. A Scoping Review.

Primary care physicians are uniquely positioned to assist ill and injured workers to stay-at-work or to return-to-work. Purpose The purpose of this scoping review is to identify primary care physicians' learning needs in returning ill or injured workers to work and to identify gaps to guide future research. Methods We used established methodologies developed by Arksey and O'Malley, Cochrane and adapted by the Systematic Review Program at the Institute for Work & Health. We used Distiller SR©, an online systematic review software to screen for relevance and perform data extraction. We followed the PRISMA for Scoping Reviews checklist for reporting. Results We screened 2106 titles and abstracts, 375 full-text papers for relevance and included 44 studies for qualitative synthesis. The first learning need was related to administrative tasks. These included (1) appropriate record-keeping, (2) time management to review occupational information, (3) communication skills to provide clear, sufficient and relevant factual information, (4) coordination of services between different stakeholders, and (5) collaboration within teams and between different professions. The second learning need was related to attitudes and beliefs and included intrinsic biases, self-confidence, role clarity and culture of blaming the patient. The third learning need was related to specific knowledge and included work capacity assessments and needs for sick leave, environmental exposures, disclosure of information, prognosis of certain conditions and care to certain groups such as adolescents and pregnant workers. The fourth learning need was related to awareness of services and tools. Conclusions There are many opportunities to improve medical education for physicians in training or in continuing medical education to improve care for workers with an illness or injury that affect their work.

The association between mental health and shift work: Findings from the Atlantic PATH study.

We evaluated the relationship between mental health and shift work in the Atlantic Partnership for Tomorrow's Health (PATH) cohort study. In a matched study with 12,413 participants, including 4155 shift workers and 8258 non-shift workers, we utilized general linear models and logistic regression models to assess the differences in depression, anxiety, and self-rated health. Shift workers reported higher levels of each of the mental health-related domains compared to non-shift workers. There was a significant increased risk of depression (OR = 1.13, 95% CI, 1.00-1.27) and poor self-rated health (OR = 1.13, 95% CI, 1.14-1.55) among shift workers compared to non-shift workers. Shift workers were more likely to have increased rates of depression and poor self-rated health, as well as depressive and anxiety symptom scores compared to non-shift workers. As a result, shift workers may be at increased risk of comorbidity, poor quality of life, missed work, and early retirement.

Politics of disease control in Africa and the critical role of global health diplomacy: A systematic review.

Background: Africa is facing the triple burden of communicable diseases, non-communicable diseases (NCDs), and nutritional disorders. Multilateral institutions, bilateral arrangements, and philanthropies have historically privileged economic development over health concerns. That focus has resulted in weak health systems and inadequate preparedness when there are outbreaks of diseases. This review aims to understand the politics of disease control in Africa and global health diplomacy's (GHD's) critical role. Methods: A literature review was done in Medline/PubMed, Web of Science, Scopus, Embase, and Google scholar search engines. Keywords included MeSH and common terms related to the topics: "Politics," "disease control," "epidemics/ endemics," and "global health diplomacy" in the "African" context. The resources also included reports of World Health Organization, United Nations and resolutions of the World Health Assembly (WHA). Results: African countries continue to struggle in their attempts to build health systems for disease control that are robust enough to tackle the frequent epidemics that plague the continent. The politics of disease control requires the crafting of cooperative partnerships to accommodate the divergent interests of multiple actors. Recent outbreaks of COVID-19 and Ebola had a significant impact on African economies. It is extremely important to prioritize health in the African development agendas. The African Union (AU) should leverage the momentum of the rise of GHD to (i) navigate the politics of global health governance in an interconnected world(ii) develop robust preparedness and disease response strategies to tackle emerging and reemerging disease epidemics in the region (iii) address the linkages between health and broader human security issues driven by climate change-induced food, water, and other insecurities (iv) mobilize resources and capacities to train health officials in the craft of diplomacy. Conclusion: The AU, Regional Economic Communities (RECs), and African Centres for Disease Control should harmonize their plans and strategies and align them towards a common goal that integrates health in African development agendas. The AU must innovatively harness the practice and tools of GHD towards developing the necessary partnerships with relevant actors in the global health arena to achieve the health targets of the Sustainable Development Goals.

Performance and impact of disposable and reusable respirators for healthcare workers during pandemic respiratory disease: a rapid evidence review.

OBJECTIVES: To synthesise evidence concerning the range of filtering respirators suitable for patient care and guide the selection and use of different respirator types. DESIGN: Comparative analysis of international standards for respirators and rapid review of their performance and impact in healthcare. DATA SOURCES: Websites of international standards organisations, Medline and Embase, hand-searching of references and citations. STUDY SELECTION: Studies of healthcare workers (including students) using disposable or reusable respirators with a range of designs. We examined respirator performance, clinician adherence and performance, comfort and impact, and perceptions of use. RESULTS: We included standards from eight authorities across Europe, North and South America, Asia and Australasia and 39 research studies. There were four main findings. First, international standards for respirators apply across workplace settings and are broadly comparable across jurisdictions. Second, effective and safe respirator use depends on proper fitting and fit testing. Third, all respirator types carry a burden to the user of discomfort and interference with communication which may limit their safe use over long periods; studies suggest that they have little impact on specific clinical skills in the short term but there is limited evidence on the impact of prolonged wearing. Finally, some clinical activities, particularly chest compressions, reduce the performance of filtering facepiece respirators. CONCLUSION: A wide range of respirator types and models is available for use in patient care during respiratory pandemics. Careful consideration of performance and impact of respirators is needed to maximise protection of healthcare workers and minimise disruption to care.

Twitter Analytics to Inform Provisional Guidance for COVID-19 Challenges in the Meatpacking Industry.

The COVID-19 pandemic raised considerable challenges to obtain reliable guidance to help occupational health practitioners, workers, and stakeholders building up efficient prevention strategies at the workplace, between the constant increase of publications in the domain, the time required to run high-quality research and systematic reviews, and the urgent need to identify areas for prevention at the workplace. Social Media and Twitter, in particular, have already been used in research and constitute a useful source of information to identify community needs and topics of interest for prevention in the meatpacking industry. In this commentary, we introduce the methods and tools we used to screen relevant posts on Twitter. Twitter analytics is a way to capture real-time concerns of the community and help ensure compliance with the notion of social accountability. As such research has limitations in terms of exhaustiveness and level of evidence, it should be considered as provisional guidance to direct both actions at the workplace and further conventional research projects.

Assessing arsenic in human toenail clippings using portable X-ray fluorescence.

Arsenic is a toxic metalloid which has been associated with a wide range of health effects in humans including skin abnormalities and an elevated risk of skin, bladder, kidney, and lung cancer, diabetes, and cardiovascular disease. The measurement of arsenic concentration in nail clippings is often used in population studies as an indicator of arsenic exposure. Portable X-ray fluorescence (XRF) is an emerging technique for measuring arsenic in nail clippings. In the current study, single toenail clippings from 60 Atlantic Canadian participants were assessed for arsenic using a new portable XRF approach. A mono-energetic portable XRF system using doubly curved crystal optics was used to measure each clipping for a total of 900 s. Energy spectra from each clipping were analyzed for arsenic characteristic X-rays to provide a normalized arsenic signal. The same clippings were then analyzed for arsenic concentration using a "gold standard" method of inductively coupled plasma mass spectrometry (ICP-MS). Nail clipping arsenic concentrations measured by ICP-MS ranged from 0.030 µg/g to 2.57 µg/g, with a median result of 0.14 µg/g. Portable XRF results for arsenic were compared against ICP-MS arsenic concentrations, with a linear equation of best fit determined between the two variables. A correlation coefficient of r = 0.77 was found from the 59 nail clippings returning an ICP-MS arsenic concentration above the limit of quantitation. When the comparison was limited to the 20 clippings having an XRF normalized signal at least twice as large as the associated uncertainty of measurement, the correlation coefficient was r = 0.89. With the selection of an arsenic concentration of 0.1 µg/g as a cut-off value between "exposed" and "non-exposed" individuals, the XRF method provided a test sensitivity of 76% and a specificity of 81%. The corresponding positive predictive value was 88% and the negative predictive value was 65%. The portable XRF technique used in this study shows promise as a means of assessing arsenic concentration in toenail clippings.

Extended use or reuse of single-use surgical masks and filtering face-piece respirators during the coronavirus disease 2019 (COVID-19) pandemic: A rapid systematic review.

BACKGROUND: Shortages of personal protective equipment during the coronavirus disease 2019 (COVID-19) pandemic have led to the extended use or reuse of single-use respirators and surgical masks by frontline healthcare workers. The evidence base underpinning such practices warrants examination. OBJECTIVES: To synthesize current guidance and systematic review evidence on extended use, reuse, or reprocessing of single-use surgical masks or filtering face-piece respirators. DATA SOURCES: We used the World Health Organization, the European Centre for Disease Prevention and Control, the US Centers for Disease Control and Prevention, and Public Health England websites to identify guidance. We used Medline, PubMed, Epistemonikos, Cochrane Database, and preprint servers for systematic reviews. METHODS: Two reviewers conducted screening and data extraction. The quality of included systematic reviews was appraised using AMSTAR-2. Findings were narratively synthesized. RESULTS: In total, 6 guidance documents were identified. Levels of detail and consistency across documents varied. They included 4 high-quality systematic reviews: 3 focused on reprocessing (decontamination) of N95 respirators and 1 focused on reprocessing of surgical masks. Vaporized hydrogen peroxide and ultraviolet germicidal irradiation were highlighted as the most promising reprocessing methods, but evidence on the relative efficacy and safety of different methods was limited. We found no well-established methods for reprocessing respirators at scale. CONCLUSIONS: Evidence on the impact of extended use and reuse of surgical masks and respirators is limited, and gaps and inconsistencies exist in current guidance. Where extended use or reuse is being practiced, healthcare organizations should ensure that policies and systems are in place to ensure these practices are carried out safely and in line with available guidance.

Telemedicine Across the Globe-Position Paper From the COVID-19 Pandemic Health System Resilience PROGRAM (REPROGRAM) International Consortium (Part 1).

Coronavirus disease 2019 (COVID-19) has accelerated the adoption of telemedicine globally. The current consortium critically examines the telemedicine frameworks, identifies gaps in its implementation and investigates the changes in telemedicine framework/s during COVID-19 across the globe. Streamlining of global public health preparedness framework that is interoperable and allow for collaboration and sharing of resources, in which telemedicine is an integral part of the public health response during outbreaks such as COVID-19, should be pursued. With adequate reinforcement, telemedicine has the potential to act as the "safety-net" of our public health response to an outbreak. Our focus on telemedicine must shift to the developing and under-developing nations, which carry a disproportionate burden of vulnerable communities who are at risk due to COVID-19.

Telemedicine as the New Outpatient Clinic Gone Digital: Position Paper From the Pandemic Health System REsilience PROGRAM (REPROGRAM) International Consortium (Part 2).

Technology has acted as a great enabler of patient continuity through remote consultation, ongoing monitoring, and patient education using telephone and videoconferencing in the coronavirus disease 2019 (COVID-19) era. The devastating impact of COVID-19 is bound to prevail beyond its current reign. The vulnerable sections of our community, including the elderly, those from lower socioeconomic backgrounds, those with multiple comorbidities, and immunocompromised patients, endure a relatively higher burden of a pandemic such as COVID-19. The rapid adoption of different technologies across countries, driven by the need to provide continued medical care in the era of social distancing, has catalyzed the penetration of telemedicine. Limiting the exposure of patients, healthcare workers, and systems is critical in controlling the viral spread. Telemedicine offers an opportunity to improve health systems delivery, access, and efficiency. This article critically examines the current telemedicine landscape and challenges in its adoption, toward remote/tele-delivery of care, across various medical specialties. The current consortium provides a roadmap and/or framework, along with recommendations, for telemedicine uptake and implementation in clinical practice during and beyond COVID-19.

Classification of aerosol-generating procedures: a rapid systematic review.

In the context of covid-19, aerosol generating procedures have been highlighted as requiring a higher grade of personal protective equipment. We investigated how official guidance documents and academic publications have classified procedures in terms of whether or not they are aerosol-generating. We performed a rapid systematic review using preferred reporting items for systematic reviews and meta-analyses standards. Guidelines, policy documents and academic papers published in english or french offering guidance on aerosol-generating procedures were eligible. We systematically searched two medical databases (medline, cochrane central) and one public search engine (google) in march and april 2020. Data on how each procedure was classified by each source were extracted. We determined the level of agreement across different guidelines for each procedure group, in terms of its classification as aerosol generating, possibly aerosol-generating, or nonaerosol-generating. 128 documents met our inclusion criteria; they contained 1248 mentions of procedures that we categorised into 39 procedure groups. Procedures classified as aerosol-generating or possibly aerosol-generating by ≥90% of documents included autopsy, surgery/postmortem procedures with high-speed devices, intubation and extubation procedures, bronchoscopy, sputum induction, manual ventilation, airway suctioning, cardiopulmonary resuscitation, tracheostomy and tracheostomy procedures, non-invasive ventilation, high-flow oxygen therapy, breaking closed ventilation systems, nebulised or aerosol therapy, and high frequency oscillatory ventilation. Disagreements existed between sources on some procedure groups, including oral and dental procedures, upper gastrointestinal endoscopy, thoracic surgery and procedures, and nasopharyngeal and oropharyngeal swabbing. There is sufficient evidence of agreement across different international guidelines to classify certain procedure groups as aerosol generating. However, some clinically relevant procedures received surprisingly little mention in our source documents. To reduce dissent on the remainder, we recommend that (a) clinicians define procedures more clearly and specifically, breaking them down into their constituent components where possible; (b) researchers undertake further studies of aerosolisation during these procedures; and (c) guideline-making and policy-making bodies address a wider range of procedures.