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ECDC. Personal protective equipment (PPE) needs in healthcare settings for the care of patients suspected or confirmed with 2019-nCoV https://www.ecdc.europa.eu/sites/default/files/documents/novel-coronavirus-personal-protective-equipment-needs-healthcare-settings.pdf
It is likely that the true number of infections, including those that are unreported and unrecognised due to mild symptoms or being asymptomatic, is much higher [6].
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6. Wu JT, Leung K, Leung GM. Nowcasting and forecasting the potential domestic and international spread of the 2019-nCoV outbreak originating in Wuhan, China: a modelling study. The Lancet. 2020.
China changed the case definition several times during the course of the outbreak, which caused uncertainty regarding the exact number of cases and the extent of the spread of the virus As of 1 March, local transmission has been reported in 13 countries outside of China: South Korea, Japan, Singapore, Australia, Malaysia, Vietnam, Italy, Germany, France, United Kingdom, Croatia, San Marino, Iran, the United Arab Emirates, and the United States of America [7].
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7. World Health Organization (WHO). Coronavirus disease 2019 (COVID-19) - Situation Report - 40 2020 [cited 2020 2 March]. Available from: https://www.who.int/docs/default-source/coronaviruse/situationreports/20200229-sitrep-40-covid-19.pdf?sfvrsn=7203e653_2
JAMA (American Medical Association (AMA))
Alexandra L. Phelan et al. 2020
During the following weeks, multiple countries implemented entry screening measures [11] for passengers arriving from China.
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11. Phelan AL, Katz R, Gostin LO. The novel coronavirus originating in Wuhan, China: challenges for global health governance. Jama. 2020.
MMWR. Morbidity and Mortality Weekly Report (Centers for Disease Control MMWR Office)
Daniel B. Jernigan et al. 2020
Thereafter, several major airlines suspended flights from China [12] and several countries repatriated citizens who lived in Wuhan [13].
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13. Jernigan DB. Update: Public Health Response to the Coronavirus Disease 2019 Outbreak—United States, February 24, 2020. MMWR Morbidity and Mortality Weekly Report. 2020;69.
As of 27 February 2020, 705 passengers had tested positive for COVID-19 [15].
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15. World Health Organization (WHO). Coronavirus disease 2019 (COVID-19) - Situation Report - 38 2020 [cited 2020 1 March]. Available from: https://www.who.int/docs/default-source/coronaviruse/situationreports/20200227-sitrep-38-covid-19.pdf?sfvrsn=9f98940c_2.
Transmission events have been reported in hospitals, with COVID-19 cases identified among healthcare workers and patients [16,17].
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16. European Centre for Disease Prevention and Control (ECDC). Outbreak of novel coronavirus disease 2019 (COVID-19): situation in Italy 2020 [cited 2020 1 March]. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/novel-coronavirus-threat-assessment-brief-23-feb-2020.pdf.
During the following week, several European countries reported cases of COVID-19 [18] in travellers from the affected areas in Italy [19,20], as well as cases without epidemiological links to Italy, China or other countries with ongoing transmission [21].
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18. World Health Organization (WHO). Coronavirus disease 2019 (COVID-19) - Situation Report - 39 2020 [cited 2020 1 March]. Available from: https://www.who.int/docs/default-source/coronaviruse/situationreports/20200228-sitrep-39-covid-19.pdf?sfvrsn=aa1b80a7_4.
Based on a large dataset from cases in China, the overall case fatality risk (CFR) among laboratory-confirmed cases was higher in the early stages of the outbreak (17.3% for cases with symptom onset from 1-10 January) and has reduced over time to 0.7% for patients with symptom onset after 1 February [25].
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25. World Health Organization (WHO). Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) 2020 [cited 2020 1 March]. Available from: https://www.who.int/docs/defaultsource/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf.
Eurosurveillance (European Centre for Disease Control and Prevention (ECDC))
Jantien A Backer et al. 2020
A recent modelling study confirmed that it remains prudent to consider the incubation period of at least 14 days [26,27].
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RAPID RISK ASSESSMENT Outbreak of novel coronavirus disease 2019 (COVID-19): increased transmission globally – fifth update The virus was initially isolated in bronchoalveolar lavage fluid samples [29], and viral RNA has thereafter been detected in nasopharyngeal and throat swabs as well as in serum [26,27], blood [32], rectal swabs, saliva, urine [33] and stool [29,30].
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27. Backer JA, Klinkenberg D, Wallinga J. Incubation period of 2019 novel coronavirus (2019-nCoV) infections among travellers from Wuhan, China, 20–28 January 2020. Eurosurveillance. 2020;25(5).
Eurosurveillance (European Centre for Disease Control and Prevention (ECDC))
Julien Riou et al. 2020
Some reports suggest there is the potential for clinical deterioration during the second week of illness [26,28,54].
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28. Riou J, Althaus CL. Pattern of early human-to-human transmission of Wuhan 2019 novel coronavirus (2019- nCoV), December 2019 to January 2020. Eurosurveillance. 2020;25(4).
New England Journal of Medicine (Massachusetts Medical Society)
Na Zhu et al. 2020
RAPID RISK ASSESSMENT Outbreak of novel coronavirus disease 2019 (COVID-19): increased transmission globally – fifth update The virus was initially isolated in bronchoalveolar lavage fluid samples [29], and viral RNA has thereafter been detected in nasopharyngeal and throat swabs as well as in serum [26,27], blood [32], rectal swabs, saliva, urine [33] and stool [29,30].
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Genetic analysis revealed that COVID-19 is closely related to SARS-CoV and genetically clusters within the genus Betacoronavirus, forming a distinct clade in lineage B of the subgenus Sarbecovirus together with two bat-derived SARS-CoV-like strains [29,35].
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29. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. New England Journal of Medicine. 2020.
RAPID RISK ASSESSMENT Outbreak of novel coronavirus disease 2019 (COVID-19): increased transmission globally – fifth update The virus was initially isolated in bronchoalveolar lavage fluid samples [29], and viral RNA has thereafter been detected in nasopharyngeal and throat swabs as well as in serum [26,27], blood [32], rectal swabs, saliva, urine [33] and stool [29,30].
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30. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. 2020 Feb 7.
Journal of Korean Medical Science (Korean Academy of Medical Sciences (KAMJE))
Jin Yong Kim et al. 2020
31. Kim JY, Choe PG, Oh Y, Oh KJ, Kim J, Park SJ, et al. The first case of 2019 novel coronavirus pneumonia imported into Korea from Wuhan, China: implication for infection prevention and control measures. Journal of Korean Medical Science. 2020;35(5).
RAPID RISK ASSESSMENT Outbreak of novel coronavirus disease 2019 (COVID-19): increased transmission globally – fifth update The virus was initially isolated in bronchoalveolar lavage fluid samples [29], and viral RNA has thereafter been detected in nasopharyngeal and throat swabs as well as in serum [26,27], blood [32], rectal swabs, saliva, urine [33] and stool [29,30].
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While it seems that the risk of COVID-19 transmission through SoHO is theoretical, uncertainties about viremia during the incubation period, during an asymptomatic course of infection, or after symptom resolution continue to be of concern in relation to the safety of SoHO [32].
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32. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet. 2020;395(10223):497-506.
New England Journal of Medicine (Massachusetts Medical Society)
Michelle L. Holshue et al. 2020
34. Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H, et al. First case of 2019 novel coronavirus in the United States. New England Journal of Medicine. 2020.
Biochemical and Biophysical Research Communications (Elsevier BV)
Yun Chen et al. 2020
This partly explains why COVID-19 virus appears to be more transmissible than SARS-CoV [37].
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37. Chen Y, Guo Y, Pan Y, Zhao ZJ. Structure analysis of the receptor binding of 2019-nCoV. Biochemical and Biophysical Research Communications. 2020.
Nature Microbiology (Springer Science and Business Media LLC)
Michael Letko et al. 2020
A number of specific mutations were identified, which increase the affinity of the RBD to the ACE2 receptor [38].
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38. Letko M, Marzi A, Munster V. Functional assessment of cell entry and receptor usage for SARS-CoV-2 and other lineage B betacoronaviruses. Nature Microbiology. 2020:1-8.
European Centre for Disease Prevention and Control
It follows the ECDC rapid risk assessment methodology with relevant adaptations [42].
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42. European Centre for Disease Prevention and Control (ECDC). Operational tool on rapid risk assessment methodology: ECDC; 2019. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/operational-tool-rapid-risk-assessmentmethodolgy-ecdc-2019.pdf.
Containment measures intended to slow down the spread of the virus in the population are therefore extremely important as outlined below in the ‘Options for response’ and recent ECDC guidance documents [44].
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All these measures will facilitate effective treatment of infected patients [44].
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Non-pharmaceutical interventions may reduce and interrupt transmission, based on evidence from influenza and other respiratory viruses [44].
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Community measures ECDC guidelines for the use of non-pharmaceutical countermeasures to delay and mitigate the impact of the epidemic of COVID-19 include a description of the measures that can be applied in the community: infection prevention and control, social distancing, travel-related and screenings of travellers [44].
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There is no evidence on the usefulness of face masks worn by persons who are not ill, therefore this is not advisable [44].
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Due to the significant secondary effects (social, economic, etc.) of social distancing measures, the decision on their application should be based on a case-by-case risk assessment, depending on the impact of the epidemic and the local epidemiological situation [44].
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Although some imported COVID-19 cases have been detected through entry screening at destination airports, the available evidence suggests that entry screening is not effective in delaying or mitigating a pandemic [44,62] or detecting incoming travellers with infectious diseases.
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Quarantine, including voluntary quarantine, may be considered for high-risk exposure contacts [44].
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44. European Centre for Disease Prevention and Control (ECDC). Guidelines for the use of non-pharmaceutical measures to delay and mitigate the impact of 2019-nCoV 2020. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/novel-coronavirus-guidelines-non-pharmaceuticalmeasures_0.pdf.
The plan should also include policies and recommendations for employees with symptoms of acute respiratory illness, separation of sick employees, routine environmental cleaning and travel health advice [45] based on the objectives of the business continuity plan.
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45. Centers for Disease Control and Prevention (CDC). Interim Guidance for Businesses and Employers to Plan and Respond to Coronavirus Disease 2019 (COVID-19), February 2020 2020 [updated 26 February 2020; cited 2020 1 March]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/guidancebusiness-response.html.
Due to the rapid increase in the number of COVID-19 cases outside of China, the relevant authorities in EU/EEA countries are encouraged to plan for sufficient PPE supplies for their health professionals [46,47].
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ECDC provides information on laboratory testing of suspected cases of COVID-19 using RT-PCR for EU/EEA Member States, addressing issues such as how to identify suspected cases and when to initiate testing [35,46,47].
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Infection prevention and control in healthcare settings ECDC has published a technical report on IPC for the care of patients with COVID-19 in healthcare settings as well as a technical report on personal protective equipment needs in healthcare settings for the care of patients with suspected or confirmed COVID-19 [46,54].
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46. European Centre for Disease Prevention and Control (ECDC). Personal protective equipment (PPE) needs in healthcare settings for the care of patients with suspected or confirmed novel coronavirus (2019-nCoV) 2020. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/novel-coronavirus-personalprotective-equipment-needs-healthcare-settings.pdf.
Due to the rapid increase in the number of COVID-19 cases outside of China, the relevant authorities in EU/EEA countries are encouraged to plan for sufficient PPE supplies for their health professionals [46,47].
On page 8
ECDC provides information on laboratory testing of suspected cases of COVID-19 using RT-PCR for EU/EEA Member States, addressing issues such as how to identify suspected cases and when to initiate testing [35,46,47].
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Member States should establish national laboratory diagnostic capacity for coronaviruses and have developed procedures for adequate transportation of samples [47].
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47. European Centre for Disease Prevention and Control (ECDC). Health emergency preparedness for imported cases of high-consequence infectious diseases 2019 [17 January 2020]. Available from: https://www.ecdc.europa.eu/en/publications-data/health-emergency-preparedness-imported-cases-highconsequence-infectious-diseases.
Science (American Association for the Advancement of Science (AAAS))
Seth Berkley 2018
RAPID RISK ASSESSMENT Outbreak of novel coronavirus disease 2019 (COVID-19): increased transmission globally – fifth update Healthcare system (laboratory, primary care, hospital) Laboratory testing of COVID-19 virus Laboratory diagnostic capacity weakness at national and community levels of healthcare can greatly reduce the effectiveness of outbreak containment [48].
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Based on a mapping of laboratory capacity, 38 laboratories in 24 EU/EEA countries had diagnostics in place for COVID-19 (as of 29 January 2020) [48]; and several countries have already rolled-out the tests to the regional and local laboratories.
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48. Berkley S. Health security's blind spot: Science; 2018. Available from: https://science.sciencemag.org/content/359/6380/1075.
Eurosurveillance (European Centre for Disease Control and Prevention (ECDC))
Chantal B.E.M. Reusken et al. 2020
52. Reusken C, Broberg EK, Haagmans B, Meijer A, Corman VM, Papa A, et al. Laboratory readiness and response for novel coronavirus (2019-nCoV) in expert laboratories in 30 EU/EEA countries, January 2020. Euro Surveill. 2020;25(6).
Infection prevention and control in healthcare settings ECDC has published a technical report on IPC for the care of patients with COVID-19 in healthcare settings as well as a technical report on personal protective equipment needs in healthcare settings for the care of patients with suspected or confirmed COVID-19 [46,54].
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Suspected patients should be asked to wear a surgical mask in order to reduce the spread of respiratory droplets [54].
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Some reports suggest there is the potential for clinical deterioration during the second week of illness [26,28,54].
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54. European Centre for Disease Prevention and Control (ECDC). Infection prevention and control for the care of patients with 2019-nCoV in healthcare settings 2020. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/nove-coronavirus-infection-prevention-controlpatients-healthcare-settings.pdf.
When using PPE, the correct donning and doffing process should be followed; further information on the donning and doffing procedures can be found in the ECDC Technical Document ‘Guidance for wearing and removing personal protective equipment in healthcare settings for the care of patients with suspected or confirmed COVID-19’ [55].
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55. European Centre for Disease Prevention and Control (ECDC). Guidance for wearing and removing personal protective equipment in healthcare settings for the care of patients with suspected or confirmed COVID-19 2020 [cited 2020 1 March]. Available from: https://www.ecdc.europa.eu/en/publications-data/guidancewearing-and-removing-personal-protective-equipment-healthcare-settings.
In this case, infection prevention and control measures as outlined in the WHO guidance for home care of patients with COVID-19, including, should be followed [57].
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Other reasons for home health care include symptomatic patients no longer requiring hospitalisation, where inpatient care is unavailable or unsafe (i.e. limited capacity and resources unable to meet demand for healthcare services) or in a case of informed refusal of hospitalisation [57].
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57. World Health Organization (WHO). Home care for patients with suspected novel coronavirus (nCoV) infection presenting with mild symptoms and management of contacts. Interim guidance. 2020 [updated January 20]. Available from: https://www.who.int/publications-detail/home-care-for-patients-with-suspected-novelcoronavirus-(ncov)-infection-presenting-with-mild-symptoms-and-management-of-contacts.
Guidance for clinical care of severe cases is available from WHO [59] and from the US CDC [58].
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58. Centers for Disease Control and Prevention (CDC). Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease 2019 (COVID-19) 2020 [updated 25 February 2020; cited 2020 1]. March]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-managementpatients.html.
School and day care measures or closure Evidence originating from seasonal and pandemic influenza modelling studies have shown that proactive school closures before the peak of influenza virus activity have had a positive impact in reducing local transmission and delaying the peak of the influenza activity [60].
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This is especially the case for COVID-19 because the symptoms are common to other respiratory diseases, and there is concurrent increased seasonal influenza activity in the affected areas [60].
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Although there is no evidence of effectiveness of mechanical or natural air ventilation to reduce COVID-19 transmission, there is mechanistic plausibility, and it should be applied, and enhanced especially in settings where people gather regularly [60].
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60. World Health Organization (WHO). Non-pharmaceutical public health measures for mitigating the risk and impact of epidemic and pandemic influenza 2019 [cited 2020 1 March]. Available from: https://apps.who.int/iris/bitstream/handle/10665/329438/9789241516839-eng.pdf?ua=1.
BMC Medicine (Springer Science and Business Media LLC)
Vernon J Lee et al. 2009
These measures could include for example: flexible working schedules/shifts for employees, the opportunity of distance working/teleworking, encouraging physical distancing measures within the workspace, increased use of email and teleconferences to reduce close contacts, reduced contact between employees and customers, reduced contact between employees, adoption of flexible leave policies and promoting the use of other personal protective countermeasures [61].
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61. Lee VJ, Lye DC, Wilder-Smith A. Combination strategies for pandemic influenza response-a systematic review of mathematical modeling studies. BMC medicine. 2009;7(1):76.
Eurosurveillance (European Centre for Disease Control and Prevention (ECDC))
Billy J Quilty et al. 2020
Although some imported COVID-19 cases have been detected through entry screening at destination airports, the available evidence suggests that entry screening is not effective in delaying or mitigating a pandemic [44,62] or detecting incoming travellers with infectious diseases.
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62. Quilty BC, S; et al. Effectiveness of airport screening at detecting travellers infected with novel coronavirus (2019-nCoV). Eurosurveillance. 2020.
Contact tracing and surveillance Contact tracing, quarantine and monitoring ECDC has published a technical report and algorithm on public health management of persons having had contact with probable and confirmed cases of COVID-19 infection [64].
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If symptoms of illness occur, the contacts should then self-isolate and seek medical advice [64], preferably by phone first.
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64. European Centre for Disease Prevention and Control (ECDC). Public health management of persons, including healthcare workers, having had contact with COVID-19 cases in the European Union 2020 [updated 25 February 2020; cited 2020 1 March]. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-public-health-management-contactnovel-coronavirus-cases-EU.pdf.
ECDC have also produced a technical report for EU/EEA countries public health authorities with an estimation of resources required for contact tracing, quarantine and monitoring activities [65].
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65. European Centre for Disease Prevention and Control (ECDC). Resource estimation for contact tracing, quarantine and monitoring activities in the EU/EEA 2020. Available from: https://www.ecdc.europa.eu/en/publications-data/resource-estimation-contact-tracing-quarantine-andmonitoring-activities-covid-19.
70. Hashem AM, Hassan AM, Tolah AM, Alsaadi MA, Abunada Q, Damanhouri GA, et al. Amotosalen and ultraviolet A light efficiently inactivate MERS-coronavirus in human platelet concentrates. Transfus Med. 2019 Dec;29(6):434-41.
71. Hindawi SI, Hashem AM, Damanhouri GA, El-Kafrawy SA, Tolah AM, Hassan AM, et al. Inactivation of Middle East respiratory syndrome-coronavirus in human plasma using amotosalen and ultraviolet A light. Transfusion. 2018 Jan;58(1):52-9.
72. Pinna D, Sampson-Johannes A, Clementi M, Poli G, Rossini S, Lin L, et al. Amotosalen photochemical inactivation of severe acute respiratory syndrome coronavirus in human platelet concentrates. Transfus Med. 2005 Aug;15(4):269-76.
73. Keil SD, Bowen R, Marschner S. Inactivation of Middle East respiratory syndrome coronavirus (MERS-CoV) in plasma products using a riboflavin-based and ultraviolet light-based photochemical treatment. Transfusion. 2016 Dec;56(12):2948-52.
Transfusion Medicine Reviews (Elsevier BV)
Le Chang et al. 2020
Considering that transmission of COVID-19 has not been reported, that levels of detected RNA in plasma are very low [75] and coincide with clinical symptoms and that screening policy has not been implemented for other respiratory transmitted viral illnesses in which transfusion transmission remains theoretical, including influenza, it seems that laboratory screening of blood, cells and tissues donors/donations is not well grounded.
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75. Chang L, Yan Y, Wang L. Coronavirus Disease 2019: Coronaviruses and Blood Safety. Transfusion Medicine Reviews. 2020.