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Evidence Check

A rapid review outlining the available evidence on a discrete topic or question relating to the current COVID-19 pandemic. Evidence includes grey and peer review literature. View all Evidence Checks by date of publication.

Homelessness and COVID-19

Added: 22 May 2020

What guidance is available to support health systems respond to COVID-19 and associated risks for people experiencing homelessness?
  • Homelessness is a significant social determinant of health. Expert opinion is that people experiencing homelessness may find it difficult to effectively quarantine, practice distancing measures or perform proper hand hygiene. This may exacerbate and amplify the spread of COVID-19
  • Opinion suggests that people experiencing homelessness often have pre-existing medical conditions and limited access to healthcare, which may increase the impact of COVID-19 compared to general populations.
  • Evidence suggests that infection control, isolation and quarantine were challenges in previous pandemics and epidemics. Lessons can be applied from HIV/AIDS, Tuberculosis, H1N1 and SARS, including the need to establish rapid communication between public health and homelessness service providers, ensuring providers have access to personal protective equipment, and identifying where and how people will be isolated and treated.
  • Centers for Disease Control and Prevention (CDC) reported high proportions of positive COVID-19 test results upon universal testing in some shelters in the USA, suggesting the need for broader testing to prevent the spread of COVID-19 in these settings. Two USA studies also saw high proportions of people positive for COVID-19 after testing in homeless shelters.
  • Guidance from CDC includes implementing infection control practices, applying distancing measures and promoting use of cloth face coverings within homelessness services.
  • Guidance based on expert opinion suggests: - widespread distribution of accessible and up-to-date information on COVID-19 for people experiencing homelessness. Distribution can be through community partners including law enforcement. - providing providers of homelessness services with training to ensure effective screening and implementation of infectious disease protocols. - prioritising testing and flagging older people accessing services as a high risk for COVID-19.
  • Western Australia State Government is conducting scenario planning to develop strategies to respond to potential outbreaks of COVID-19 in people experiencing homelessness including cluster outbreaks.

Guidance and underlying evidence about personal protective equipment (PPE) use during COVID-19

Added: 20 May 2020
Updated: 21 May 2020

What is the current guidance on the use of PPE in COVID-19?
What is the evidence base for that guidance?
  • Personal protective equipment refers to specialised clothing or apparatus worn by an employee for protection against infectious materials or other hazards.
  • Occupational health and safety guidance asserts PPE should be considered in the context of broader, more effective hazard reduction approaches such as elimination, engineering and administrative controls
  • The core principles underpinning the use of PPE for infection control are: the safety of staff and patients is a priority at all times
  • PPE selection is informed by the anticipated contact with body substance or pathogens and the evidence base about transmission
  • a risk assessment approach is used to guide decisions about appropriate use.

Sanitising and covering large medical imaging equipment

Added: 8 May 2020
Updated: 20 May 2020

Which method is most effective in sanitising large medical imaging equipment for COVID-19?
Which method is most effective in covering or protecting large medical imaging equipment for COVID-19?
Which method is most effective in sanitising linear accelerators and radiotherapy bunkers for COVID-19?
  • There is a variety of options for disinfectants to use on medical imaging equipment. Most guidelines suggest compliance with equipment vendor guidance to find the safest disinfectant for each piece of equipment.
  • Regulatory agencies (such as the Therapeutic Goods Agency) publish lists of approved disinfectants (Table 4).
  • Specific disinfectants for machines during COVID-19 have included: isopropyl alcohol 70%, diluted bleach solution (6mg chlorine releasing disinfectant tablet to 1,000ml water), 2,000mg/L chlorine-containing disinfectant
  • 500 to 1,000mg/L chlorine containing disinfectant
  • and alcohol-containing disposable disinfectant wipes.

Renal replacement therapies for COVID-19 positive patients in ICU

Added: 12 May 2020
Updated: 20 May 2020

What is the current evidence on the use of renal replacement therapies in intensive care units for patients with COVID-19?
  • COVID-19 most frequently presents as mild respiratory illness and can generally be managed outside the hospital. About 20% of patients require hospitalisation, and of those, a quarter require intensive care.
  • ICU patients typically require management of hypoxaemic respiratory failure or hypotension requiring vasopressor support. Acute kidney injury is a less common complication but is associated with a significant risk for mortality.
  • Available data suggests that the prevalence of acute kidney injury in COVID-19 patients is around 3-9% and is more common in patients with severe disease, reported in up to 30% of critically ill or deceased patients.

Telehealth and COVID-19

Added: 7 May 2020
Updated: 19 May 2020

What evidence or published standards are available to guide telehealth implementation during the COVID-19 pandemic?
What safety and quality issues regarding the use of telehealth have been identified?
  • For COVID-19 patients, most primary care services be managed remotely. A visual summary to guide management has been published (Figure 1).
  • Key issues for the integration of telehealth into the public health response to COVID-19 include regulatory frameworks, strategic and operational planning, communication toolkits, data sharing mechanisms and evaluation.

Immunosuppression and COVID-19

Added: 30 Apr 2020
Updated: 19 May 2020

What is the evidence for the risk and management of people with immunosuppression and COVID-19?
  • A systematic review showed that people with immunosuppression showed favourable disease course when compared to the general population. Cancer patients experienced more severe COVID-19 infections but did not necessarily have a poor prognosis. The review is subject to bias due to the limited number of included papers and small sample size.
  • Additional small case series suggest that patients with immunosuppression generally have similar risk profiles to the general population in terms of COVID-19 outcomes and severity, however patients with cancer have been shown in some studies to have more severe disease. Results for transplant patients regarding disease severity varies and is based on small numbers.
  • People with cancer provide the majority of the evidence on immunosuppression during COVID- 19. Expert opinion varies on whether cancer patients with a diagnosis of COVID-19 should continue cancer treatment. However there is agreement that decisions should be based on balancing risks and benefits of treatment in the context of the pandemic and infection control principles.
  • A systematic review showed that there is no definitive evidence that specific cytotoxic drugs, low-dose methotrexate for autoimmune disease, NSAIDs, Janus kinase (JAK) kinase inhibitors or anti-TNFα agents are contraindicated in people with COVID-19.
  • The National Institute for Health and Care Excellence (NICE) recommends continuing systemic anticancer treatment only if it is needed for urgent control of the cancer, and if possible, defer treatment until the patient has at least one negative test for COVID-19.
  • NICE have also released guidance on children and young people who are immunocompromised with COVID-19.

NIPPV and requirements

Added: 11 May 2020
Updated: 14 May 2020

Has the increasing use of NIPPV to manage suspected or confirmed COVID-19 patients led to any additional guidance regarding the physical requirements and engineering services (e.g. negative pressure rooms or where positive pressure rooms vent to)?
  • In negative pressure rooms, consider using NIV therapy for patients with hypoxaemia associated with COVID-19, ensuring it is used with caution and strict attention is paid to staff safety.
  • In single rooms or shared ward spaces with a cohort of confirmed COVID-19 patients only, consider using NIV therapy for patients with hypoxaemia associated with COVID-19, ensuring it is used with caution and strict attention is paid to staff safety.
  • In shared wards or emergency department cubicles, do not use NIV therapy for patients with hypoxaemia associated with COVID-19.
  • During inter-hospital patient transfer and/or retrieval, do not use NIV therapy for patients with hypoxaemia associated with COVID-19.
  • In patients with COVID-19 who are deteriorating, consider endotracheal intubation and invasive mechanical ventilation. In patients with COVID-19 for whom NIV is appropriate for an alternate clinical presentation (e.g. concomitant chronic obstructive pulmonary disease with type 2 respiratory failure and hypercapnoea), ensure airborne and other infection control precautions are optimised.
  • In adults with COVID-19 on high-level respiratory support, monitor for worsening respiratory status. If worsening occurs, undertake early in the disease course endotracheal intubation in a controlled setting. Patients can deteriorate rapidly 5-10 days after symptom onset.

Pulmonary rehabilitation and COVID-19

Added: 7 May 2020
Updated: 12 May 2020

What is the guidance for the provision of pulmonary rehabilitation for people recovering from COVID-19?
  • A small quasi-randomised trial of elderly patients with COVID-19 showed respiratory rehabilitation can improve respiratory function, quality of life and anxiety.
  • Recommendations from international researchers for physiotherapy in acute hospital settings cover post COVID-19 mobilisation, exercise and rehabilitation interventions. They recommend early rehabilitation after the acute phase of acute respiratory distress syndrome, which is of particular value to those admitted to intensive care unit (ICU) to limit the severity of ICU-acquired weakness and promote rapid functional recovery.
  • Expert opinion suggests pulmonary rehabilitation could relieve the symptoms of dyspnoea, anxiety and depression, and eventually improve physical function and quality of life.
  • One article lists a range of common practices used in respiratory physiotherapy that are not recommended in with patients with COVID-19 in the acute phase including diaphragmatic breathing, pursed lips breathing, manual mobilisation or stretching of the rib cage, respiratory muscle training, exercise training and mobilisation during clinical instability. Other guidance suggests early mobilisation and physical exercises to improve respiratory and diaphragmatic muscle strength and promote recovery.
  • A living guideline for allied health professionals recommends that case prioritisation consider the potential impact on critical outcomes of a patient not receiving immediate rehabilitation.
  • Guidance suggests continuing rehabilitation care in the outpatient setting, and at home through ongoing therapy either in-person or via telehealth.
  • The American Thoracic Society does not endorse a specific approach to pulmonary rehabilitation during COVID-19. However a patient education factsheet has been published suggesting some ways to continue pulmonary rehabilitation at home. The British Thoracic Society released a resource kit with guidance to support pulmonary rehabilitation remote assessment during COVID-19.
  • The Lung Foundation Australia is facilitating an at-home exercise series through the initiative COVID-19 - Maintaining Movement.

Daily Evidence Digest

Rapid evidence checks are based on a simplified review method and may not be entirely exhaustive, but aim to provide a balanced assessment of what is already known about a specific problem or issue. This brief has not been peer-reviewed and should not be a substitute for individual clinical judgement, nor is it an endorsed position of NSW Health.