National Medical Association Annual Convention
National Medical Association Annual Convention
Source/Disclosures
Source: Frieden T. Fighting the COVID pandemic and prioritizing populations most at risk. Presented at: National Medical Association Annual Meeting; July 31-Aug. 4, 2020 (virtual meeting).
Disclosures: Bryce, Flick, Ourselin and Salata report no relevant financial disclosures. Frieden is president and CEO of Resolve to Save Lives, an initiative of Vital Strategies.
August 19, 2020
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Ex-CDC director Tom Frieden provides strategies for protecting HCWs amid COVID-19

Source/Disclosures
Source: Frieden T. Fighting the COVID pandemic and prioritizing populations most at risk. Presented at: National Medical Association Annual Meeting; July 31-Aug. 4, 2020 (virtual meeting).
Disclosures: Bryce, Flick, Ourselin and Salata report no relevant financial disclosures. Frieden is president and CEO of Resolve to Save Lives, an initiative of Vital Strategies.
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Former CDC director Tom Frieden, MD, MPH, recently described a hierarchy of controls — elimination, substitution, engineering, administration and personal protective equipment — that may help prevent COVID-19 among health care workers.

His remarks came during the National Medical Association’s Annual Meeting, held virtually due to the pandemic.

Hierarchy of controls to prevent COVID-19 among HCWs (from most effective to least effective): 1.	Elimination 2. Substitution 3. Engineering 4. Administration 5.	Personal protective equipment
Reference: Frieden T. Fighting the COVID pandemic and prioritizing populations most at risk. Presented at: National Medical Association Annual Meeting; July 31-Aug. 4, 2020 (virtual meeting).

Hierarchy of controls

Frieden said the “most effective” step is eliminating the hazard or infection. This can be accomplished by not allowing people who are ill to enter nursing homes and other congregate facilities. It can also be accomplished by ensuring that all hospitals and nursing home staffs have paid sick leave, so that there is no economic incentive to work while ill.

Examples of Frieden’s other steps, include:

  • substitution: using telehealth to provide health care;
  • engineering: improving building ventilation, installing partitions and reducing the number of high-touch surfaces such as doorknobs;
  • administration: determining safe occupancy, staggering shifts and holding virtual meetings; and
  • personal protective equipment (PPE): gloves, goggles, face masks and N95 respirators.

If patients with COVID-19 cannot be separated from other patients and staff by engineering and substitution, PPE becomes necessary, Frieden said. When PPE is necessary, supply has to be ensured.

Tom Frieden

“Positive air pressure respirators and facepiece respirators are not ideal PPE products,” Frieden said. “But we're not living in an ideal world, so we likely need to increase the safe use of reusable PPE.”

The magnitude of the current pandemic necessitates that physicians follow these steps, said Conrad L. Flick, MD, a family physician in North Carolina.

Conrad Flick
Conrad Flick

“We have to assume COVID-19 is like the influenza epidemic of 1917-1918,” he said in an interview.

Flick, who was not involved in Frieden’s presentation, offered other ways physicians can modify their workspaces.

“Patients with COVID-19 symptoms enter my office through a side door,” he said. “Patients wait for us to call them before entering the office. Staff members escort patients and keep office doors open to minimize surface touching.”

Frontline physicians weigh in

Family physician Richard L Bryce, DO, said his employer, Henry Ford Health System in Detroit, has implemented Frieden’s model with varying levels of success.

Richard Bryce
Richard L. Bryce

“We've done a good job in some ways, and there's other ways that we're still learning and trying to improve,” he said. “His strategy is realistic, so long as physicians understand that going from one step to the next step in order may not necessarily be important.”

Robert Salata, MD, chair of the department of medicine at University Hospital Cleveland Medical Center and professor at Case Western Reserve University's School of Medicine, expressed concern regarding Frieden’s decision to classify PPE as least effective.

Robert Salata
Robert Salata

“The concept of these interwoven issues is very important to control the pandemic,” he added.

COVID-19’s ‘t remendous impact’

Frieden’s presentation came amid reports showing the early repercussions of COVID-19 on the health care workforce.

As of May 13, at least 1,004 physicians worldwide, most of them general practitioners, family medicine physicians or primary care physicians (26.9%), have died from COVID-19, according to an analysis in the Journal of the American Board of Family Medicine.

Also, a review of COVID-19 symptom data through April 23 in The Lancet Public Health found that among nearly 100,000 frontline U.S. and U.K. health care workers, those with inadequate PPE who cared for patients with documented COVID-19 had an increased risk for COVID-19 vs. those with adequate PPE who were not caring for patients with suspected or documented COVID-19 (adjusted HR = 5.91; 95% CI, 4.53–7.71).

"The findings of our study have tremendous impact for health care workers and hospitals,” Sebastien Ourselin, professor at King's College London and author of the Lancet Public Health paper, said in a press release.