Covid-19 Mizan guidelines for returning to work

let-get-back-to-work

Guidelines for Mizan practitioners, written by Bushra Finch, Founder and Director of The Mizan Foundation.

The Mizan Foundation oversees Mizan standards and Mizan practitioners. It is its own governing body and as such I have decided to produce guidelines for practitioners returning to work. I have read guidelines from several organisations and taken inspiration from them. 

I am steering a course that will maintain safety for everyone while still keeping the core of what makes Mizan what it is. We need to be able to make our clients feel safe – not just safe from infection, but we need to provide a safe environment for clients to build a relationship of trust so that they can open up to all that Mizan has to offer in terms of emotional, physical and spiritual healing.

The guidelines are written to cover those with a clinic-type therapy room as for those working from a room at home. Simply implement those that make sense and apply to your circumstances.

Given the scientific evidence – or rather lack of it – regarding the benefits of face masks, I will not be including the wearing of them as part of the guidelines. You and your clients are adults and can make up your own minds. Please see the document specifically regarding face masks.

General considerations

  • Think about what areas need to be regularly cleaned, what surfaces are frequently touched and how they can be cleaned. 
  • If you provide water for your client, make sure you thoroughly wash all glassware. Or you could ask clients to bring their own water.
  • Ask clients to wait in their car until the time of their appointment.

Waiting area

  1. Declutter and remove items from the reception/waiting area, e.g. magazines, pamphlets, decorations, refreshments
  2. Organise the area to enable physical distancing
  3. It would be even better not to use the waiting area and escort clients directly to treatment rooms
  4. Have hand sanitiser or hand washing facilities easily accessible to clients 
  5. Clients who arrive wearing gloves must remove them as they present a contamination risk
  6. Offer surgical masks to those who want them and offer to wear a mask. Please see the other document on the use of face masks
  7. Clean/disinfect surfaces that are touched frequently by numerous people, e.g. door handles, counters, pens, desks, light switches, payment machines
  8. Ventilate the room as much as possible – open doors and windows to circulate air
  9. Clean floors at the end of each day – mop hard floors, vacuum carpeted floors

Bathrooms

  1. Clean/disinfect surfaces between clients: door handles, light switches, toilet seat, handle and toilet paper holder, sink and taps 
  2. Either provide a clean towel for each client or use paper towels
  3. Display signs on the correct method of hand washing
  4. At the end of the day, a thorough cleaning of the toilet and sink area
  5. Ventilate the room as much as possible

Hallways

  1. Clean/disinfect all high-touch surfaces between clients, e.g. handrails, door handles, light switches, banisters
  2. Clean floors at the end of the day

Therapy room

  1. Declutter the room and remove items that could become contaminated. This may include knick knacks, book shelves, extra tables, chairs etc.
  2. Have hand sanitiser available
  3. Offer a mask to the client and offer to wear one (see my other document on face masks)
  4. Between clients, clean/disinfect surfaces such as door handles, lights switches, massage oil bottles – anything that either you or the client might touch
  5. Remove all linens as soon as the client has left and wash them in hot water and if possible use a drier
  6. Clean/disinfect the massage table between clients
  7. Wash hands before putting fresh linen on the table
  8. Ventilate the room as much as possible between clients and at the end of the day by opening doors and/or windows to circulate the air
  9. Clean floors at the end of the day, either mopping or vacuuming

Risk assessment before the appointment

  1. Have you been asked to self-isolate or quarantine by a doctor or health official in the last 14 days?
  2. Have you experienced any cold or flu-like symptoms in the last 14 days: fever, cough, shortness of breath or other respiratory problem?
  3. Have you had close contact with, or cared for, someone diagnosed with Covid-19 or someone exhibiting cold or flu-like symptoms within the last 14 days?
  4. Have you been tested for Covid-19? If so, when? What was the result?

Informed Consent at the appointment

  1. Assume your client knows nothing about Covid or infection transmission
  2. Inform clients of the risk of infection through close contact
  3. Obtain a signature that they understand the risk and wish to continue
  4. Repeat the questions above. If you are at all concerned about the responses, end the session and send them home
  5. Follow up to check on them and ask that they contact you should their symptoms develop 

After the appointment

  1. Ask clients to contact you should they develop symptoms or test positive for Covid in the next 14 days
  2. Check up on any clients that you sent home without treating

Guidelines for Practitioner Hygiene

  1. Long hair must be pulled back and secured.
  2. Clean teeth between sessions and after eating.
  3. Keep fingernails short and natural (no nail polish or artificial nails)
  4. Remove rings, bracelets and watches from hands, wrists and forearms while working

Hand hygiene

How to correctly wash hands:

  1. Wet the hands and using soap wash hands for 20-30 seconds
  2. Use friction on every surface of your hands: palms, backs of the hands, between the fingers, knuckles, sides of the hand
  3. Wash forearms up to the elbows with soap and water for 20 seconds
  4. Rinse and dry the hands
  5. Consider using paper towels to turn off the tap and open any doors. Or use hand sanitiser on entering the treatment room

NHS video on correct hand washing procedure https://www.nhs.uk/live-well/healthy-body/best-way-to-wash-your-hands/

When to wash hands:

  1. Immediately before and after performing a treatment
  2. After using the toilet
  3. After handling used sheets for the wash
  4. Before putting clean linen on the table
  5. Before and after eating
  6. After coughing or blowing your nose

Respiratory hygiene

  1. Cover the mouth and nose with a tissue when coughing or sneezing
  2. If a tissue is not available, cough or sneeze into an elbow
  3. Dispose of used tissues immediately
  4. Wash your hands thoroughly or use hand sanitiser

Health monitoring

  1. Self monitor for signs and symptoms of Covid-19 every day
  2. Take your temperature at the beginning of a workday
  3. Treat all new symptoms as suspicious
  4. If you develop a temperature or symptoms, cancel all appointments and either self-isolate for 14 days or take a test for Covid-19
  5. If you suspect you have been exposed to Covid-19, self isolate for 14 days or until you have a test and can be cleared of infection
  6. If a client reports that they have tested positive for Covid-19 within two weeks of a massage you must self-isolate until you can be clear of infection

Face masks

With the introduction of recommendations for wearing face masks in public, I decided to look into face masks, what they did and didn’t do and also if there was any evidence. Here are some of the findings.

Filtering face masks (N95) : They are classed as respirators so different guidelines apply than for face masks. 

  • They are used to prevent the inhalation of small particles, including airborne transmissable or infectious agents. 
  • Require training in use, fit testing, medical evaluations, monitoring and cleaning by a trained person; i.e. to be effective, you need to know how to use them

How they work: They prevent environmental toxins being breathed in by the person wearing the mask, but because they are designed for use in contaminated areas they provide no filtering of the out breath. 

Conclusion: If you’re in Sainsburys and someone with Covid is wearing an N95 mask, his/her breath is unfiltered and being exhaled all around the store. You are not being protected by his/her mask. The wearer is only protected if they know how to properly use, fit and clean them.

Surgical masks : 

  • Classed as medical devices
  • Not all masks that look like surgical masks are medical-grade, so are actually cloth masks
  • Used to protect against splashes and sprays 
  • Used to contain the wearer’s respiratory droplets to avoid contaminating surgical sites

How they work: they are designed for use in sterile environments to protect those in contact with the wearer from large droplets. They afford no protection to the wearer from being in contact with someone who has an infection transmissible by droplets. In non-sterile environments they should be worn for no more than 30 minutes.

Conclusion: In everyday wear, particles and contaminants quickly build up and clog the masks. The moisture from your breath, combined with the clogged mask, make it useless; if you come into contact with Covid and your mask traps it, you become a walking virus dispenser. If you don’t change it frequently (every 20-30 minutes) you are breathing in and shedding the germs from everywhere you have been.

Cloth face coverings :

  • Either commercially produced or improvised
  • Contain the wearer’s respiratory droplets 
  • Do not class as PPE
  • Will not protect the wearer against airborne transmissible agents

How to use them: They need to have multiplet layers of fabric, preferably four; they should be changed every 20-30 minutes and need washing after every use. Wash by hand in a bleach solution, 5 tablespoons household bleach per gallon of room temperature water. Soak for 5 minutes, rinse thoroughly. They are best dried in a drier at high temperature or in the sun.

Conclusion: They may provide limited protection, but only for a maximum of 30 minutes. Prolonged use of face masks can reduce blood oxygen, increase carbon dioxide. 

The WHO have indicated there are advantages and disadvantages to wearing masks but seem to have come down on the side of wearing them despite the lack of scientific evidence of benefit.

Several randomized controlled trials with verified outcomes (infections) were specifically designed to detect a benefit of wearing face masks and did not find any measurable benefit, for any viral respiratory disease. This includes the many randomized controlled trials that find no difference between open-sided surgical masks and respirators. There are links to the research articles quoted.

● Xiao, J et al. (2020) “Nonpharmaceutical Measures for Pandemic Influenza in Nonhealthcare Settings—Personal Protective and Environmental Measures”, Emerg Infect Dis. 5 May 2020;26(5):967- 975.

https://dx.doi.org/10.3201/eid2605.190994

[“Although mechanistic studies support the potential effect of hand hygiene or face masks, evidence from

14 randomized controlled trials of these measures did not support a substantial effect on transmission of

laboratory-confirmed influenza. We similarly found limited evidence on the effectiveness of improved

hygiene and environmental cleaning.”]

● Rancourt, DG (2020) “Masks Don’t Work: a Review of Science Relevant to Covid-19 Social Policy”,

ResearchGate, 11 April 2020, now at viXra : https://vixra.org/abs/2006.0044

● Long, Y et al. (2020) “Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and meta-analysis”, J Evid Based Med. 2020; 1-9. https://doi.org/10.1111/jebm.12381

[“A total of six RCTs involving 9171 participants were included. There were no statistically significant differences in preventing laboratory-confirmed influenza, laboratory-confirmed respiratory viral infections, laboratory-confirmed respiratory infection and influenza-like illness using N95 respirators and surgical masks. Meta-analysis indicated a protective effect of N95 respirators against laboratory-confirmed bacterial colonization.”]

● Bartoszko, JJ et al. (2020) “Medical masks vs N95 respirators for preventing COVID-19 in healthcare workers: A systematic review and meta-analysis of randomized trials”, Influenza Other Respir Viruses, 2020;14(4):365-373, https://doi.org/10.1111/irv.12745

[“Four RCTs were meta-analyzed adjusting for clustering. Compared with N95 respirators; the use of medical masks did not increase laboratory-confirmed viral (including coronaviruses) respiratory infection or clinical respiratory illness.”]

● Radonovich, LJ et al. (2019) “N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel: A Randomized Clinical Trial”, JAMA. 2019; 322(9): 824–833. doi:10.1001/jama.2019.11645,

https://jamanetwork.com/journals/jama/fullarticle/2749214

[“Among 2862 randomized participants, 2371 completed the study and accounted for 5180 HCW-

seasons. … Among outpatient health care personnel, N95 respirators vs medical masks as worn by

participants in this trial resulted in no significant difference in the incidence of laboratory-confirmed

influenza.”]

● Offeddu, V et al. (2017) “Effectiveness of Masks and Respirators Against Respiratory Infections in Healthcare Workers: A Systematic Review and Meta-Analysis”, Clinical Infectious Diseases, Volume 65, Issue 11, 1 December 2017, Pages 1934–1942, https://doi.org/10.1093/cid/cix681

[“Self-reported assessment of clinical outcomes was prone to bias. Evidence of a protective effect of

masks or respirators against verified respiratory infection (VRI) was not statistically significant”; as per

their Figure 2c]

● Smith, JD et al. (2016) “Effectiveness of N95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis”, CMAJ, Mar 2016, cmaj.150835; DOI: 10.1503/cmaj.150835, https://www.cmaj.ca/content/188/8/567

(I found these references on: http://ocla.ca/ocla-letter-who/)

According to the WHO, the likely disadvantages of the use of masks by healthy people in the general public include:

• potential increased risk of self-contamination due to the manipulation of a face mask and subsequently touching eyes with contaminated hands

• potential self-contamination that can occur if non-medical masks are not changed when wet or soiled. This can create favourable conditions for micro-organisms to amplify

• potential headache and/or breathing difficulties, depending on the type of mask used

• potential development of facial skin lesions, irritant dermatitis or worsening acne, when used frequently for long hours

• difficulty with communicating clearly

• waste management issues; improper mask disposal leading to increased litter in public places, risk of contamination to street cleaners and environmental hazard

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