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\begin{document}

\title{Performing the nasopharyngeal and oropharyngeal swab for 2019-Novel
Coronavirus (SARS-CoV-2) safely: how to dress, undress, and technical
notes}



\author[1]{Pasquale Di Maio, MD}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 19, 2024}


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\selectlanguage{english}
\begin{abstract}
Background: To show how to safely perform nasopharyngeal and / or
oropharyngeal swabs for 2019-Novel Coronavirus.

Methods: The video describes in detail the dressing and undressing
procedures of health personnel, with the appropriate personal protective
equipment. Technical notes for the execution of the nasopharyngeal and
oropharyngeal swab are also provided, to avoid sampling errors.

Results: The undressing phase is the procedure with the highest risk of
self-contamination for the health worker. Following the various steps as
shown in the video, there were no cases of contagion among the
otolaryngology team appointed to perform the swabs for SARS-CoV-2
testing.

Conclusions: This study demonstrates the technical feasibility of safely
performing nasopharyngeal and/or oropharyngeal swabs for identification
of SARS-CoV-2 viral RNA.%
\end{abstract}%



\sloppy


\textbf{Authors}

Pasquale Di Maio, M.D.,\textsuperscript{1} Oreste Iocca, M.D.,
D.D.S.,\textsuperscript{2} Antonio Cavallero M.D.,\textsuperscript{1}
Marco Giudice M.D.\textsuperscript{~}

\textsuperscript{1}Giovanni Borea Civil Hospital, Department of
Otolaryngology-Head and Neck Surgery, Sanremo, Italy
\textsuperscript{2}Humanitas Clinical and Research Center -- IRCCS -,
via Manzoni 56, 20089 Rozzano (MI)

\textbf{Corresponding author:} Pasquale Di Maio, M.D.~ Giovanni Borea
Civil Hospital,~Via Giovanni Borea, 56, 18038, Sanremo (IM), Italy~+39
3930200889 email: {dimaio.p86@aliceposta.it}

\textbf{Acknowledgments}

The authors would like to thank Dr. Giuseppe Garo, Dr. Cristina Ghirardi
and Dr. Carlotta Tola for participating in the video recording. In
addition, we are grateful to Ms. Rachel A. Elliott and Ms. Cristina
Marconi for their support in editing the manuscript and video.

\par\null

\textbf{INTRODUCTION}

Since its first appearance in Wuhan, China, in December 2019, the
SARS-CoV-2 virus responsible for coronavirus disease 2019 (COVID-19) has
progressively spread around the world.\textsuperscript{1} And to date
(April 15, 2020), according to the Johns Hopkins Coronavirus Resource
Center, the outbreak involved 185 countries worldwide, with 128,011
people dead.\textsuperscript{2} Healthcare workers were among the
hardest hit by this infection. This was evident from reports, both from
China and Italy, which revealed infection rates between medical staff
between 3.8 and 20\%.\textsuperscript{1}

The tests currently used for the direct identification of SARS-CoV-2 are
mainly aimed at detecting viral RNA through nucleic acid amplification,
generally using the polymerase chain reaction (PCR). The nasopharynx
and/or oropharynx are the most tested sampling sites using swabs, with a
slightly greater sensitivity shown by the nasopharyngeal
swab.\textsuperscript{3} This video shows the step-by-step procedure for
properly dressing and undressing, demonstrates how to wear the personal
protective equipment (PPE), and provides some technical notes on the
execution of the nasopharyngeal and oropharyngeal swab for COVID-19. All
of this serves to avoid the risk of contagion of the health worker. The
video is based on our experience at the Giovanni Borea Civic Hospital in
Sanremo, where in the last month, strictly following the CDC and WHO
guidelines,\textsuperscript{4,5} the otolaryngology team has performed
about 900 nasopharyngeal (95\%) and oropharyngeal (5\%) swabs. Following
these steps, none of the operators have been infected as of the present
date.

\par\null

Rich media available at \url{https://youtu.be/JhJu7\_0BVTw}

\textbf{VIDEO DESCRIPTION}

\textbf{Dressing phase}

The dressing phase takes place in a changing room, close to the entrance
of the COVID area but separate from it. It requires the execution of the
following steps: 1) remove all jewelry and personal items; 2) practice
good hand hygiene with soap and water or alcohol solution; 3) put on a
first pair of gloves; 4) put on the disposable full body scrubs; 5) put
on the cap 6) wear a Filtering Facepiece Particles mask, FFP2 or FFP3
(possibly covered with a surgical mask); 7) wear protective goggles
and/or a protective visor; 8) wear the shoe covers; 9) put on the second
pair of gloves (which must cover the wrist of the full body scrubs).
Figure 1 shows the healthcare professional at the end of the dressing
phase.

\textbf{Nasopharyngeal swab}

The patient wears a surgical mask. She is informed about the procedure
that is about to be performed. The patient must be seated in a
comfortable position with his head resting on the back of the chair. The
patient's head must be placed on a horizontal plane parallel to the
floor. The patient is asked to lower the mask by uncovering only her
nose and keeping the mouth closed. After opening the swab in a sterile
manner, the operator positions the patient laterally in order to avoid
direct droplet from sneezing or coughing. The swab is inserted gently
into the nostril. The insertion must be parallel to the floor of the
nasal fossa. The swab is kept medial and facing the nasal septum (do not
insert the swab upwards, as in this case the swab stops at the level of
the nasal turbinates and the viral RNA sampling may not be significant).
It is important to use the mark on the swab stick as a depth reference
(Figure 2). However, when the operator feels an obstacle to further
introduction, it means that the swab will have reached the posterior
wall of the nasopharynx. With clockwise and counterclockwise movement,
repeatedly rub the swab against the posterior wall of the nasopharynx
(Figure 3), for about 10-15 seconds. Extract the swab from the nostril
taking care not to contaminate it upon exit, introduce it into the test
tube and break it at the mark on the stick. In case of difficulty in
introducing the swab into a nasal fossa due to deviation of the nasal
septum or hypertrophy of the inferior turbinates, proceed with the same
technique in the contralateral nasal fossa. The endoscopic vision shown
in the video has a didactic purpose only, the nasopharyngeal swab should
not be performed with the aid of the endoscope.

\textbf{Oropharyngeal swab}

If it is impossible to perform the nasopharyngeal swab (for unfavorable
anatomical nasal conditions or because it is not tolerated by the
patient), the oropharyngeal swab can be performed as a second choice.
The patient is asked to lower the mask by exposing the mouth and to
fully open it. The swab is inserted into the oral cavity until it
reaches the level of the oropharynx. The sampling is carried out on the
uvula, the palatine tonsils and/or the posterior wall of the oropharynx.
The contact with the tongue and other areas of the oral cavity should be
carefully avoided.

\textbf{Undressing phase}

We recommend that the undressing phase takes place in a dedicated
changing room, located immediately upon leaving the COVID area. It
involves the following steps: 1{]} remove the second pair of gloves and
replace it with a pair of clean gloves; 2{]} remove the disposable full
body scrubs and dispose it in the appropriate container (the front and
sleeves of the dress are contaminated, so open the zipper or untie the
laces, move it away from the neck and shoulders, touching only inside
the garment , turn the lab coat upside down, fold or roll it up and
throw it away); 3{]} remove the first pair of gloves (the outside of the
gloves is potentially contaminated, therefore first remove one glove by
grasping and pulling it from the outside, then remove the other glove by
inserting a finger into the cuff of the glove and thus remove it, taking
care not to touch its external part); 4{]} remove the glasses and/or the
protective visor (their front is potentially contaminated, therefore to
remove them, grasping the side sections, and place them in a bag for
disinfection); 5{]} remove the mask: first the surgical mask, and then
the FFP2 or FFP3, (the front of the mask is potentially contaminated,
therefore after having loosened the rear laces, grasp the front of the
mask, move it away from the face and remove it); 6{]} remove cap and
shoes covers if not already removed upon removal of the full body
scrubs; 7{]} remove the second pair of gloves; 8{]} practice good hand
hygiene with soap and water or alcohol. For technical reasons, the
undressing phase in the video takes place in the same area where the
dressing took place, but we remark the importance of undressing in a
separate, dedicated area. Figure 4 shows the path that the operator
should follow to avoid contamination of the rooms, starting from the
dressing phase until returning to the clean common area.

\textbf{CONCLUSION}

This report details the indications that should be followed by the
healthcare professional during the execution of the nasopharyngeal
and/or oropharyngeal swab for COVID 19. Particular attention must be
paid during the undressing phase, due to the high risk of contagion if
this phase is not correctly performed. We hope that this manuscript and
related video can serve as a guide to safely perform high airway
sampling for COVID 19.

\textbf{REFERENCES}

\begin{enumerate}
\tightlist
\item
  Kowalski LP, Sanabria A, Ridge JA, et al. COVID-19 Pandemic: Effects
  and Evidence-Based Recommendations for Otolaryngology and Head and
  Neck Surgery Practice. \emph{Head Neck} . 2020 Apr 9. doi:
  10.1002/hed.26164. Online ahead of print.
\item
  Johns Hopkins Coronavirus Resource Center.
  https://coronavirus.jhu.edu/map.html.
\item
  Patel R, Babady E, Theel ES, et al. Report From the American Society
  for Microbiology COVID-19 International Summit, 23 March 2020: Value
  of Diagnostic Testing for SARS-CoV-2/COVID-19. \emph{mBio} .
  2020;11(2):00722-20.
\item
  World Health Organization. Rational Use of Personal Protective
  Equipment for Coronavirus Disease 2019 (COVID-19).; 2020.
  https://apps.who.int/iris/bitstream/handle/10665/331215/WHO-2019-nCov-IPCPPE\_use-2020.1-eng.pdf.
\item
  CDC PPE Sequence. Centers for Disease Control and Prevention.
  https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf.
\end{enumerate}

\textbf{Figure legends}

\textbf{Figure 1:} The health worker with a full body gown and all PPE
for the safe execution of nasopharyngeal and/or oropharyngeal swabs.

\textbf{Figure 2:} The mark on the swab stick indicates the correct
insertion depth.

\textbf{Figure 3:} Endoscopic view of the swab on the posterior wall of
the nasopharynx.

\textbf{Figure 4:} The path that the healthcare professional should
follow to avoid contaminating the rooms. A) Changing room for dressing;
B) COVID area for the execution of the swabs; C) Changing room for
undressing; D) Clean external common area

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\includegraphics[width=0.70\columnwidth]{figures/HED-26230-Figure-1/HED-26230-Figure-1}

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\includegraphics[width=0.70\columnwidth]{figures/HED-26230-Figure-3/HED-26230-Figure-3}

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\end{figure}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/HED-26230-Figure-4/HED-26230-Figure-4}

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