Wednesday, March 11, 2020

"Be (Better) Prepared": What Alexander Might Have Done Differently

This is a conversation with an EMT about quarantining vehicles, among other thing, and proper travel protocol for newly repatriated Americans who need to quarantine.

Becca is a first responder and a nature lover. When there is a sick bird of prey, she works with NH Fish & Game to deliver it to the vet in a safe way. When someone has contaminated an ambulance or a vehicle, she wipes it down best she can. She worked on Superfund sites in the past and wore hazmat suits to prevent spreading contaminants from those sites to the outside world. She and I have been talking incessantly for the last three weeks about everything from foam soap to what New Hampshire residents would do if Seabrook Nuclear Plant had a release. We knew each other through Project Laundry List, the nonprofit organization that I ran for 15 years.

When she let me know that she was disappointed in me for driving a rental car from JFK International Airport to my quarantine location in Seneca County, NY, I told her that I could do better now, but when I arrived in New York that was the best I knew how to do without breaking the bank. What follows is an edited conversation that we both agreed to publish together as a way to be part of the solution, instead of part of the problem.

This is a wide-ranging conversation about practical considerations for Americans returning from China, Italy, South Korea, and a growing list of nations and the steps they should take to quarantine.

Alexander: Absent any resources from the state, like a van that takes you to designated quarantine quarters--a hotel maybe, what is the best way for an individual or a family returning to the US and facing quarantine to get from an international airport to their expected quarters?

Becca: That depends whether they're symptomatic or asymptomatic. If they're symptomatic, they'll likely be flagged at the airport's CDC checkpoint. I strongly suspect that the CDC has been arranging ambulance transports for the symptomatic to the hospital or the home depending on the severity of the signs or symptoms.

With regard to how the asymptomatic are supposed to travel away from the airport, the CDC has been surprisingly mum. That is my understanding, anyway. For that reason, individuals and families returning to the United States are using rideshares, car rentals, and public transportation. Should the CDC be arranging transportation for the asymptomatic? In my opinion, it should, especially if they're returning from CDC Level 3 travel advisory countries, and the CDC is instructing them to isolate for two weeks after leaving the airport.

Right now many rideshare contractors can't afford to quit although many have and many would if they could afford to do so. In a statement to Business Insider on March 6th, an Uber spokesperson announced that drivers diagnosed with the virus or otherwise affected by coronavirus quarantines would be able to receive compensation for up to 14 days to make up for lost revenue. But rideshare contractors are saying this isn't enough. Many worry that compensation will only be provided to rideshare contractors who have been diagnosed with COVID-19, and many have no health insurance (or limited health insurance) and can't go to see a doctor. Due to the absence of CDC guidance, I'd take a rental car if I was asymptomatic, because I could clean it before driving away from the airport. Not to throw shade at rideshare contractors, but how do I know that I'm stepping into a rideshare that is cleaned properly, especially if someone that may have been symptomatic was riding in it prior to me? A rental car might be the more expensive option however. And a rental car may not be practical for those living in urban or suburban areas near the airport. Now I'm sure you'll ask me how to properly clean a vehicle...

The CDC has also been surprisingly mum with regard to guidance for cleaning personal vehicles, especially those used for commercial purposes. That is my understanding, anyway. That said, the CDC has issued guidance regarding the cleaning of ambulances and aircraft. Ambulances are designed to be cleaned. So are commercial airplanes. Personal vehicles cannot be cleaned as easily, although there may be some takeaways here. And again these takeaways are probably more useful for rentals and rideshares that are used commercially. First of all, we're not really sure how long coronavirus can live on soft surfaces like fabric or carpet, and according Havard Medical School these soft surfaces may be difficult to wash. There is no carpeting and relatively few soft surfaces in the patient compartments of ambulances outside of the cots, and the sheets and blankets on the cots are sent to the laundry immediately after the patients are dropped off at the hospital. CDC recommends routine operating procedures for cleaning aircraft unless potentially symptomatic passengers have been identified.

If potentially symptomatic passengers have been identified, enhanced cleaning procedures are recommended, which include cleaning all porous (soft) and non-porous (hard) surfaces within 6 feet of the symptomatic passengers in all directions with EPA-approved cleaners that are effective against COVID-19 (SARS-CoV-2); additionally, items that cannot be cleaned (i.e. pillows, passenger safety placard, and other similar items) should be disposed of properly. Airlines are expected to ensure that workers are trained on the hazards of the cleaning chemicals in accordance with OSHA's Hazard Commmunication Standard, 29 CFR 1910.1200. Airlines are also expected to properly train cleaning crews to demonstrate an understanding of how to use personal protective equipment (PPE), when PPE is necessary, and how to properly don (put on), use, and doff (take off) the PPE.

Here is a list of EPA's registered antimicrobial products for use against novel coronavirus SARS-CoV-2, the cause of COVID-19. These products are also used regularly on ambulances to clean equipment and surfaces that are porous and non-porous alike after the patients are dropped off at the hospital. They are also frequently used by car rental agencies. One of them, Clorox Healthcare Bleach Germicidal Cleaner Spray, can be purchased on Amazon by anyone including a rideshare contractor. Are Lyft and Uber drivers being taught how and when to use them properly? My best guess is that taxi services are held to a higher level of service in this regard. Legislators might consider looking into this.

Alexander: I decided to isolate myself in an Airbnb away from anybody that I knew in the countryside and return my rental car so that I could not even go for hikes along the gorges nearby. You told me that you were very disappointed that I drove the car and did not keep it for two weeks. This whole five-week trip is likely to cost more than a month's salary for me. What should I have done?

Becca: Initially that was true, yes. However, if you attempted to clean the vehicle before returning it, I couldn't be, could I? I say this because of the position that the CDC has been putting us in. How did you clean the vehicle?

Alexander: I wiped down the steering wheel with a wet wipe and told the rental agency that I had just returned from China.

We are both furious that there were reputedly high school students working at Market Basket in Warner, NH, who just returned from Italy and should be in quarantine.  That is where you do your shopping, right? Healthy young kids and their parents probably have little to fear if they catch COVID-19, right? Why should they quarantine?

Becca: They were observed working at the Market Basket in Warner, and yes, I do my shopping there. They were also observed drinking coffee at Grounds in New London.  Several members of my local community and the surrounding area called the N.H. Department of Health & Human Services (DHHS) hotline for COVID-19 to report them.  On one hand, yeah, I'm furious. On the other? I sympathize. There may have been a communication disconnect between the school district and the students initially over whether the students in question were returning from a CDC level 2 or 3 travel advisory country. As they were returning home from Italy, Italy was considered a CDC level 2. After they arrived home, the CDC upgraded Italy from a level 2 to a level 3. A two-week isolation at home is required for the level 3s. Teenagers pay attention and they generally dislike inconsistency. This was an inconsistency. They've been asking many of the same questions we have some of which center around other inconsistencies. Teenagers are less likely to comply with austere measures, such as the type of isolation required for level 3s, when there are inconsistencies. Above all else, isolation isn't easy for teenagers due to their high energy level. Regardless, isolation works. And I don't think anybody wants to spread the coronavirus.  It doesn't help that we may feel fine and may be capable of spreading before we feel sick. Hopefully rapid-screening tests are in our foreseeable future. And maybe one of these very teenagers will design one. 

Alexander: The state can do nothing, you tell me. But some people have said that it is a misdemeanor. Does that vary state-to-state? What sort of power should and does the state have before declaring a state of emergency?

Becca: I don't believe that the State of New Hampshire has declared a state of emergency yet. Last week, a Dartmouth-Hitchcock Medical Center employee defied instructions from DHHS advising him to stay home after returning from Italy. Concerned members of his community reported him to DHHS, and the State of New Hampshire issued him "an official order" of isolation under RSA Section 141-C:11. He had tested positive for coronavirus though. Another man who had been in close contact with him had also tested positive for coronavirus. Violating RSA Section 141-C is a misdemeanor under RSA 141-C:21. Obviously the State of New Hampshire has the power to issue official orders of isolation and to enforce them. However it would appear as though this power has only been exercised against individuals with positive test results and any individuals who may have closely associated with them. The State of New Hampshire's power may also be limited in other ways. For example, a family in my community runs a daycare out of the family home. Asymptomatic family members who returned from the high school field trip to Italy are isolating at home on a volunteer basis per the DHHS advisory.  Several members of my community want the DHHS to shut the daycare down temporarily. The DHHS claims that it does not necessarily have the power to do so, so long as the asymptomatic family members who are isolating on a volunteer basis are isolating properly. I think that asking the state to issue official orders of isolation for the asymptomatic may be a heavy lift. I'm not sure how I feel about the day care situation though. How do you feel about orders of isolation and the day care situation, having been through isolation yourself?

Alexander: I am very concerned that it is ineffective if not done well and that it is a harrowing mental experience, akin to isolation or solitary, but not as extreme. The insecurity of not knowing when I would be reunited with my girlfriend and kids, the lack of support from some friends and family for my decision to return (which the government said we should do!), and being in the Finger Lakes without a car or a single soul that I know was hard.

New York has recalled all the college students living abroad and declared a state of emergency. When Governor Cuomo made the announcement of the money they would be spending, he said that the people in quarantine need to be visited once a day. Maybe that is true if they are sick with mild symptoms, but that was not my experience. As a healthy individual, I just had to call in my temperature readings from morning and evening once per day, after an initial visit from the county's health workers. How would you recommend the nurses visiting an asymptomatic patient dress for meeting an asymptomatic patient?

Becca: I am not sure what nurses visiting asymptomatic patients are required to wear although the  CDC has issued guidance for public health officials conducting evaluations. The CDC has also issued guidance for first responders. Per the CDC, any patients requiring emergency medical services and who are exhibiting signs or symptoms of a respiratory infection should be given a facemask. If COVID-19 is suspected regardless of whether a patient is symptomatic or asymptomatic, first responders are encouraged to wear a single pair of disposable patient examination gloves, a disposable isolation gown, respiratory protection (i.e., N-95 or higher-level respirator), and eye protection. How did the visiting nurses dress for their visit with you, the asymptomatic patient? Does it match up with the CDC's guidance for public health officials conducting evaluations? If they didn't take your temperature and stayed 6 feet away from you, they may have been dressed appropriately.

Alexander: They were very professional and followed the guidance.

It is important to think of the environmental impact of overkill. I am thinking of the now billions of masks that are headed for the landfill or the incinerators in China. Can you talk a bit about the mask buying frenzy, what are reasonable preparations people should be making, and the sorts of decisions that we as a society need to make to preserve financial and natural resources for their highest and best purpose?

Becca: I am worried that the frenzy may create both unnecessary waste and a shortage. Handwashing and voluntary isolation appear to be the most successful means of reducing the spread. Although facemasks catch droplets, it would appear as though they may not catch tiny particles a/k/a tiny aerosols not to mention that viruses can transmit through the eyes. Most of the folks we see wearing masks to protect themselves are not wearing eye protection. I find that puzzling. It may be an indication of where we're at so far as public health education opportunities go. I really love CDC's hand-washing campaign. I first learned about it through your blog!

Alexander: Do you know what the quarantine agreement looks like in NH? My "gentleman's agreement" in New York only restricted me to the town, but the visiting RNs from the Health Department told me to stay only on the property. I asked for special permission to go on an abandoned graveyard that abutted the place and they granted it. I was unlikely to see any living people there. Do you think I was given too much latitude?

Becca: According to an advisory that DHHS has been distributing to schools in New Hampshire, asymptomatic travelers returning from countries with a Level 3 travel advisory (such as Italy) are to be advised to stay home and monitor their health for 14 days after returning to the United States. Family members including children of quarantined individuals are not required to quarantine and long as they remain asymptomatic, they can leave the home and can go to public places like school and work. If the person being quarantined develops illness, household members must then also stay home on quarantine. Do I think you were given too much latitude? No. And further, I would have less concerns about walking around in the graveyard after you left then I have had about shopping at the Market Basket in Warner for the past week. I know your voluntary quaranitine a/k/a isolation wasn't easy. Quarantine is especially hard on children and teenagers. I would love to know more about this through the eyes of your children and your students, if you were to blog about it in the future. It doesn't surprise me that students in my community have been violating the terms of their quarantine agreement and it raises questions for me with regard to how we as a state might better handle pandemics and quarantines moving forward. There are far too many inconsistencies right now, which is understandable, and there are also the psychological ramifications, which we haven't really begun to look at yet.  I'm glad you were given permission to visit the abandoned graveyard. Not everybody has been that lucky, if you'd call that lucky?

Alexander: Can you tell me something about the ranking of different types of products to clean hands? Am I right in thinking that liquid soap (without anti-bacterial) is king and that foam soap is better than bar soap, but pretty much everything is better than Purell and other alcohol-based hand-sanitizers?

Becca: That is an excellent question and everybody will probably have a different opinion and that's understandable. I will share mine with you, and the reasoning behind it. What's your take? I'm sure during your isolation, you spent a lot of time thinking about soap.

Foam Soaps

Foam soaps (a/k/a aerosolized liquid soaps) are all the rage in New Hampshire where I live. They are fun and often cheaper than the other types of liquid soaps, and until a couple of years ago there were no studies comparing liquid soap with foam soap in regard to the efficacy of reducing hand microbial burden a/k/a "germs."  According to a study published in 2017 by the American Journal of Infection Control, foam soap is not as effective as liquid soap in eliminating hand bacterial load. The study authors indicated this may be due to the fact that one must build up lather with liquid soap, whereas foam soap is already dispensed as lather. In addition, the amount of soap dispensed per pump is less with foam soap compared with liquid soap. For these reasons the study authors suggested that the use of foam soaps for handwashing may give a false sense of hand decontamination and eventually lead to the spread of resistant bacteria. As you may have guessed, the CDC is mum with regard to the efficacy of the various types of liquid soaps. That is my understanding, anyway. In my personal opinion, foam soaps are better than nothing if we're aware of their limitations.

Bar Soaps

Those little lavender soaps are fun for adults and children just love soaps embedded with toys. But are they sanitary? There has been a lot of buzz about that. Dermatologists generally seem to agree that it's not a big deal to deposit microorganisms from your skin onto your soap, and then back onto your skin. There may be a few exception to this general agreement however. One is, if you have an open cut they may allow pathogens to more easily enter your body causing conditions such as athlete's foot. You may also be more likely to pick up some sort of illness or infection if you share your bar soap, because bar soaps may allow germs to transfer from one person to another. For this last reason, I don't personally keep bar soap in my guest bathroom. Also, I change washcloths and towels frequently and absolutely abhor loofahs. Washlcloths and loofahs are porous and may collect skin cells upon which pathogens may feed. They are considered unsanitary if used repeatedly, especially if they remain wet in between uses.


Surprisingly, CDC isn't mum with regard to sanitizers. And I quote the CDC: "Alcohol-based hand sanitizers can quickly reduce the number of microbes on hands in some situations, but sanitizers do not eliminate all types of germs." Especially if our hands are really dirty or greasy. According to ProPublica, we may be buying hand sanitizers that won't work for coronavirus, because many made by the Purell and Germ-X brands rely on benzalkonium chloride instead of alcohol as the active ingredient. Non-alcohol antiseptics may not work as well for many types of germs or may just reduce the growth of germs rather than killing them. They may be better than nothing but people are buying them without knowing the difference. The CDC recommends hand sanitizers with at least 60% alcohol when we aren’t able to wash our hands. For that reason, I've always carried a bottle of pure 60%+ rubbing alcohol in my car along with a roll of sturdy paper towel. Since the winter flu season started, I have used both after shopping at the Market Basket. I saw a toddler sitting in a shopping cart a couple of days ago. He had a runny nose, and after rubbing at the rheum a/k/a liquid on his nose, he rubbed his fingers on the shopping cart handle. After I'm done grocery shopping, I douse the paper towel with the rubbing alcohol, and then vigorously scrub my hands with the paper towel. I like scrubbing with paper towel, because doing so creates some friction to help remove the germs. The great thing about rubbing alcohol is that it generally has a freezing point well below 0°C, and won't freeze in the car during the winter flu season.

Alexander: Thank you for taking the time to talk to me today and over the last three weeks since I have been home.

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