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Coronavirus Pandemic - What Pregnancy Centers Need to Know

Posted by Sandy Christiansen, MD, FACOG on Mar 27, 2020 9:30:00 AM

Updated 3/27/2020 to reflect enhanced screening recommendations for all clients and center personnel and to add additional sample policies and forms.

 

Sample Policies and Forms - To edit these sample policies and forms, download them and edit them on your own computer using Word. Guidance for using each form can be found in the "Pregnancy Center Response" section of this article.

Coronavirus Response Policy [Revised 3/27/20]

In-Center Coronavirus Screening Form

Phone Call Screening Tool [Revised 3/27/20]

Coronavirus Door Sign

Coronavirus Information Sheet - Door Sign Companion

Coronavirus Referral Handout for Positive Screens

Coronavirus Operational Accommodations Policy (re: mail and deliveries)

Coronavirus Material Assistance Notice

As with all policies, these sample documents should be approved per your center's processes; if this approval is likely to be delayed for any reason, the executive director or clinic manager should seek verbal permission to implement these recommendations pending formal approval of the policy.

What Pregnancy Centers Need to Know About COVID 19

In December 2019, the Chinese government announced an outbreak of a novel coronavirus.[i] Since then, the virus has spread to over 100 countries and infected thousands of people. As everyone is well aware, this situation is changing on an hourly basis, by region. Use this article as a guide, but check the CDC website, or other reliable outlet for the latest information. In addition, contact your local or state health department to obtain region-specific information.

Background

Coronaviruses are common and cause garden variety colds and flus. This virus is termed “novel” because it is a type of coronavirus that has never been seen in humans. A novel virus is one that typically starts out in animals (camels, cattle, cats, and bats) —but it evolves and “jumps” into humans (this rarely occurs).[ii] Other such viruses include the beta coronavirus that caused Middle East Respiratory Syndrome (MERS) and the beta coronavirus that causes severe acute respiratory syndrome, or SARS. SARS-CoV-2 is the virus that is now causing Coronavirus Disease, or COVID-19.

SARS-CoV-2 Basics

Spread: Investigators are still learning how it is spread. It appears the most common way is through close contact with an infected individual, through airborne droplets, but this is not the only way it is spread.[iii]

1.    Primary method: airborne droplets—direct contact with an infected person from coughs, sneezes.

2.    Secondary: inanimate objects (doorknobs, etc.) to face, eyes, nose

3.    Community: Per the CDC, this means people have been infected with the virus in an area, including some who are not sure how or where they became infected. This makes it more difficult to identify at risk individuals.

Symptoms of COVID-19:

·      Fever (over 100.4 degrees Fahrenheit)

·      Cough

·      Shortness of breath

Incubation Period (based on MERS data)

·      from 2 days to 14 days after an exposure

How the Disease Manifests

As with any viral infection, how it affects individuals varies widely. Some people will have the virus in their system without obvious symptoms. For others, it causes severe illness including respiratory failure, septic shock and death.[iv] The majority of people contract symptoms similar to the seasonal flu and recovery fully.

Who is at Greatest Risk?

The elderly and individuals with severe chronic underlying medical conditions such as heart disease, diabetes, and lung disease appear to contract the most severe cases.[v]

How does COVID-19 Affect Pregnant Women?[vi]

Currently, there is no data on how this virus affects pregnant women. Pregnancy is a state of relative immunocompromise compared to the non-pregnant state.  This may make pregnant women more susceptible to some infections, including flu viruses. Based on experience with MERS and SARS, pregnant women may be at risk for more severe cases. Adverse pregnancy outcomes (such as miscarriage and stillbirth) were more prevalent in women infected with MERS and SARS outbreaks in the past).

It is unknown if vertical transmission occurs in an infected pregnant (in utero, during delivery). Limited reports of infected pregnant woman did not detect the virus in amniotic fluid or breast milk.

*Pregnancy Center Response *

Pregnancy centers are places of compassion and respite and are wonderful community resources. However, evaluating and managing patients who are sick and may have been exposed to the COVID-19 is beyond the scope of most medical pregnancy centers. The Center’s role becomes one of triage and referral, not direct care. Since this virus may be especially harmful to pregnant women, it is all the more vital that this population be protected, as with the elderly and infirm.

Care Net recommends centers follow a three-pronged approach:

1.    Prepare

2.    Screen

3.    Refer

1. Prepare 

Determine how you will respond. Create policies and procedures to reflect your planned response. Educate center personnel. Implement policies and procedures. This is also a good time to update personnel manuals to reflect infectious disease policies.[vii]  Refer to this sample Coronavirus Response Policy. 

2. Screen 

- identify individuals who may be sick with COVID-19, do not see them, and refer them promptly for appropriate care. See In-Center Coronavirus Screening Form. See Phone Call Screening Tool. (To use these sample policies and forms, download them from Google Docs and edit them on your own computer.) 

Consider placing a sign at your entrance, or on your front door that requests all visitors to call the listed phone number and not enter the center. This gives the center an opportunity to apply the phone call procedure and avoid potential exposure for clients and center personnel within the building. See Coronavirus Door Sign.

Another option is to admit one person at a time to the center, verbally screen them and if they screen positive, give them the resource page and ask them to depart and call back in 2-3 weeks to schedule an appointment. Here is a sample Coronavirus Information Sheet - Door Sign Companion that may be placed outside the entrance for those who are waiting their turn to read. 

Just because a person does not complain of fever, cough, or shortness of breath that they are not infected with the virus - thus Care Net strongly recommends centers adopt these enhanced screening measures. It is possible that they are still in the incubation phase which ranges from 2-14 days, with an average of 6 before the manifestation of symptoms. In the healthcare setting, it has been noted that some people in the initial phase of COVID-19 have reported additional mild symptoms including:
  • a sore throat, muscle aches, feeling fatigued, nausea, and diarrhea.
Because many Care Net affiliates function as medical clinics, it makes sense to consider implementing other safety measures.
 
Other safety measures to employ when seeing clients who have screened “negative” for symptoms of COVID-19:
  1. Ask further questions: In addition to screening everyone for fever, cough, shortness of breath, recent contact with a potential/active case of COVID-19, and/or recent travel to a hotspot; Ask them if they feel like they are "coming down with something." Although this is not part of the everyday screening protocol, in healthcare settings, medical professionals are asking more questions. If they ask for clarification, you may ask have you been recently* experiencing: a sore throat, muscle aches, feeling fatigued, nausea, and diarrhea? (*within past 2 weeks).
2. Take their temperature: If the client verbally screens "negative," a medical professional should come to the lobby and take their temperature using a forehead thermometer. If their temperature is 100 degrees Fahrenheit or over, do not provide services. Give them appropriate referrals and tell them the center is not equipped to serve them at this time. The lower screening temperature of 100 degrees is being used within healthcare facilities in an effort to identify positive cases sooner. A medical professional should be the one to take the potential client's temperature.
3.Conduct the entire visit in one room, if possible, limiting the number of spaces and surfaces that the client may encounter.
4. Maintain social distancing as much as possible: complete intakes with at least 6 feet between personnel and the client
5. Limit the duration of the intake: the longer the time spent in a closed room with a potentially infectious individual, the greater the risk of contracting the virus. Ideally, spend between 15-30 minutes or less at a distance of less than six feet. Consider alternatives to face-to-face consultations.

6. Medical personnel handling urine, performing ultrasound exams, and drawing blood should wear a facemask with a built-in eye shield, or wear goggles, and gloves, per CDC guidelines.

All center personnel should likewise be screened according to these guidelines, including having their temperatures taken, either before coming to the center, or immediately upon arrival.
Any client or center personnel that passes the screening including temperature check, but begins to feel unwell should be asked to leave the center and not return in-person for 14 days. Clients in this circumstance may be offered virtual consultations if the center is offering those. 

3. Refer - when a client screens "positive," that does not automatically mean they are infected with coronavirus, but they do need to be given clear information about what steps they should take next. Create a simple handout (like this Coronavirus Referral Handout for Positive Screens) that may be read to a client who calls asking about an appointment, texted to clients (potential and existing), or given to a walk-in client who screens positive. The referral list will vary from region to region, but will likely include a recommendation to contact their own physician, or other physicians, contact the local health department, or, if they are very ill, refer directly to the nearest hospital. learn how your community has planned to respond to this crisis. Find out what to tell potentially infected individuals and where to send them.

People with symptoms should call their doctor for further advice. If they don’t have a doctor, they should call their local health department for instructions. People are being asked to call ahead to their doctor’s office, or other clinic, before just coming in to be seen. This will help the healthcare provider prepare so they may limit exposure to other people. 

Regular physician offices are currently developing strategies for handling potential patients sick with COVID-19. The following is from a large multi-specialty clinic in New York:

1. Social distancing: Please stand 6 feet away from the front desk when checking in or sit 6 feet from other patients in the waiting room when possible. 
2. Plan to attend any appointments alone, unless it is critical for someone to accompany you. Any guests of patients will also be asked screening questions for Coronavirus and, if deemed positive for risk factors, will be asked to wait outside the building. If a patient or guest refuses to wear a mask when asked by staff, they will also be asked to leave or wait outside the office. 
3. For patients with cold symptoms or who are severely ill: If you are not short of breath, stay home. You can contact your provider for advice or schedule an urgent care virtual visit online.
4. If you are feeling more severely ill, and are having trouble breathing, go to a local emergency room or call 911. Warn 911 if you have risks for having the coronavirus (recent travel or exposure to a known case).
5. For patients with no symptoms and possible exposure:
If you are not seriously ill and have been in close contact with a person confirmed with Coronavirus in the last 14 days OR feel you have been exposed to the Coronavirus, PLEASE stay home. We urge you to call your provider prior to coming into the office. If your local Department of Health has asked you to stay home on isolation, that’s what you should do. You will likely have to be home for at least 14 days after your potential exposure.

Remember, these recommendations apply to ALL people, including center staff and volunteers. 

What About Banquets and Fundraising Events?

 

Pregnancy centers with upcoming banquets or other large events will need to likewise choose how they will proceed. As more state and local governments limit the number of people allowed at gatherings, some pregnancy centers may have this decision made for them. 
 
Centers in locations where no explicit prohibition has been put in place will need to decide on a case by case basis whether to still hold their events. Boards should develop several contingency plans to consider when making this decision (for example, what happens if a prohibition is put in place the day of the event? Could a modified event be held remotely, as a live Podcast, or other virtual scenario? Could the event be postponed till much later in the year?). 
 
If a center chooses to proceed with an event, it should put extra precautions in place to protect attendees, especially given that many center supporters are older and are thus more vulnerable to coronavirus. 
 
Centers should also be in contact with their event insurance company as centers may be able to recoup some costs of canceling an event, especially if the event must be canceled due to a government ban.

All center personnel should follow the CDC recommendations for handwashing and use of alcohol based hand sanitizers, avoid touching one's face, avoid shaking hands, etc. The following is from the CDC website, Steps to Prevent Illness: 

Take steps to protect yourself

1. Clean your hands often

  • Wash your hands often with soap and water for at least 20 seconds especially after you have been in a public place, or after blowing your nose, coughing, or sneezing.
  • If soap and water are not readily available, use a hand sanitizer that contains at least 60% alcohol. Cover all surfaces of your hands and rub them together until they feel dry.
  • Avoid touching your eyes, nose, and mouth with unwashed hands.

2. Avoid close contact

Take steps to protect others

 

1. Stay home if you’re sick

2. Cover coughs and sneezes

  • Cover your mouth and nose with a tissue when you cough or sneeze or use the inside of your elbow.
  • Throw used tissues in the trash.
  • Immediately wash your hands with soap and water for at least 20 seconds. If soap and water are not readily available, clean your hands with a hand sanitizer that contains at least 60% alcohol.

3. Wear a facemask if you are sick

  • If you are sick:  You should wear a facemask when you are around other people (e.g., sharing a room or vehicle) and before you enter a healthcare provider’s office. If you are not able to wear a facemask (for example, because it causes trouble breathing), then you should do your best to cover your coughs and sneezes, and people who are caring for you should wear a facemask if they enter your room. Learn what to do if you are sick.
  • If you are NOT sick: You do not need to wear a facemask unless you are caring for someone who is sick (and they are not able to wear a facemask). Facemasks may be in short supply and they should be saved for caregivers.

4. Clean and disinfect

  • Clean AND disinfect frequently touched surfaces daily. This includes tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, and sinks.
  • If surfaces are dirty, clean them: Use detergent or soap and water prior to disinfection.

To disinfect:
Most common EPA-registered household disinfectants will work. Use disinfectants appropriate for the surface.

Options include:

  • Diluting your household bleach.
    To make a bleach solution, mix:
    • 5 tablespoons (1/3rd cup) bleach per gallon of water
      OR
    • 4 teaspoons bleach per quart of water

Follow manufacturer’s instructions for application and proper ventilation. Check to ensure the product is not past its expiration date. Never mix household bleach with ammonia or any other cleanser. Unexpired household bleach will be effective against coronaviruses when properly diluted.

  • Alcohol solutions.
    Ensure solution has at least 70% alcohol.
  • Other common EPA-registered household disinfectants.
    Products with EPA-approved emerging viral pathogens pdf icon[7 pages]external icon claims are expected to be effective against COVID-19 based on data for harder to kill viruses. Follow the manufacturer’s instructions for all cleaning and disinfection products (e.g., concentration, application method and contact time, etc.).

 

 To disinfect:

Most common EPA-registered household disinfectants will work. Use disinfectants appropriate for the surface.

Options include:

  • Diluting your household bleach.
    To make a bleach solution, mix:
    • 5 tablespoons (1/3rd cup) bleach per gallon of water
      OR
    • 4 teaspoons bleach per quart of water

    Follow manufacturer’s instructions for application and proper ventilation. Check to ensure the product is not past its expiration date. Never mix household bleach with ammonia or any other cleanser. Unexpired household bleach will be effective against coronaviruses when properly diluted.

  • Alcohol solutions.
    Ensure solution has at least 70% alcohol.
  • Other common EPA-registered household disinfectants.
    Products with EPA-approved emerging viral pathogens [7 pages] claims are expected to be effective against COVID-19 based on data for harder to kill viruses. Follow the manufacturer’s instructions for all cleaning and disinfection products (e.g., concentration, application method and contact time, etc.).

Care Net's recommendations are in step with CDC guidelines and adapted from other clinical practices such as the one above. 

Recognize that this crisis is going to continue to change which will require ongoing updates to your materials, reflecting the most recent available information.

What Else Can Centers Do?

As this situation evolves, some medical pregnancy centers may be positioned to be part of the medical response effort, should existing resources become overwhelmed. We have seen heroic efforts made by pregnancy centers in the past in response to tornados, floods, and hurricanes. Clinics who are called to offer assistance with this current crisis would need to prepare their facility to handle PUI (persons under investigation for COVID-19).

Per the Centers for Disease Control:

“Infection control procedures including administrative rules and engineering controls, environmental hygiene, correct work practices, and appropriate use of personal protective equipment (PPE) are all necessary to prevent infections from spreading during healthcare delivery. Prompt detection and effective triage and isolation of potentially infectious patients are essential to prevent unnecessary exposures among patients, healthcare personnel, and visitors at the facility. All healthcare facilities must ensure that their personnel are correctly trained and capable of implementing infection control procedures; individual healthcare personnel should ensure they understand and can adhere to infection control requirements.”

They would need to obtain test kits, and all the personal protective gear required for first responders. This scenario is beyond the scope of this article. The CDC has published detailed information specifically for healthcare facilitates.

This guidance is subject to change. It is not intended to be a comprehensive analysis of how best to respond to COVID-19. Please discuss your center's approach with local physicians, your board, and if you are a medical pregnancy center, with your medical director. 

We walk by faith, not be sight. Let us recall the Word of the Lord in Zephaniah 3:16-17: In that day it shall be said to Jerusalem: “Do not fear Zion, let not your hands be weak. The Lord your God is in your midst, The Mighty One, will save; He will rejoice over you with gladness, He will quiet you with His love, He will rejoice over you with singing.”

Now to Him who is able to do exceedingly abundantly above all that we ask or think, according to the power that works in us, to Him be glory in the church by Christ Jesus to all generations, forever and ever. Amen. Ephesians 3:20-21.

May God bless and keep you.

What About Banquets and Fundraising Events?

Pregnancy centers with upcoming banquets or other large events will need to likewise choose how they will proceed. As more state and local governments limit the number of people allowed at gatherings, some pregnancy centers may have this decision made for them. 
 
Centers in locations where no explicit prohibition has been put in place will need to decide on a case by case basis whether to still hold their events. Boards should develop several contingency plans to consider when making this decision (for example, what happens if a prohibition is put in place the day of the event? Could a modified event be held remotely, as a live Podcast, or other virtual scenario? Could the event be postponed till much later in the year?). 
 
If a center chooses to proceed with an event, it should put extra precautions in place to protect attendees, especially given that many center supporters are older and are thus more vulnerable to coronavirus. 
 
Centers should also be in contact with their event insurance company as centers may be able to recoup some costs of canceling an event, especially if the event must be canceled due to a government ban.

COVID 19 and pregnant women

EPA approved disinfectants


Sample Policies and Forms - To use these sample policies and forms, download them from Google Docs and edit them on your own computer

Coronavirus Response Policy

In-Center Coronavirus Screening Form

Phone Call Screening Tool

Coronavirus Door Sign

Coronavirus Information Sheet - Door Sign Companion

Coronavirus Referral Handout for Positive Screens

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