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Table 2 Study characteristics of included studies (n = 38)

From: Risk of transmission of respiratory viruses during aerosol-generating medical procedures (AGMPs) revisited in the COVID-19 pandemic: a systematic review

Author (Year), Country Design/setting Recruitment period HCW population (n; role) Patient population (age; disease status; symptoms; or stage of illness) Aerosol-generating medical procedures (as described in the studies) Viral respiratory infection/ laboratory tests Outcome Data analysis presentation
*Alraddadi (2016), Saudi Arabia [54] Retrospective cohort/Single Centre – Medical intensive care unit, emergency department, neurology unit May to June 2014 n = 283; radiology technicians, nurses, respiratory therapists, physicians, clerical staff, patient transporters NR; MERS-positive; NR; NR Specific AGMPs and AGMPs Combined: Airway suctioning, bronchoscopy, CPR, intubation, extubation, non-invasive ventilation, manual ventilation, HFOV, nebulizer treatments, insertion of nasogastric tubes, insertion of peripheral line insertion of central venous line, chest physiotherapy, manipulating face mask or tubing, tracheostomy care, chest tube insertion/removal MERS/ELISA Number of events, stratified RR by mask type
Brown (2021), USA [43] Retrospective cohort/Multicentre – Emergency medical services February 16 to July 31, 2020 n = 1592; EMS providers Adults; COVID-19-positive; fever, cough, shortness of breath, sore throat, nasal congestion, gastrointestinal symptoms, body aches, altered mental status, fatigue/weakness, headache, chest pain; NR AGMPs Combined: Endotracheal intubation, supraglottic airway insertion, bag-valve-mask (BVM) ventilation (with or without chest compressions for CPR), continuous positive airway pressure nonrebreather mask oxygen (high-flow oxygen 15L/min), nebulizer medication therapy, CPR COVID-19/ RT-PCR Number of events, unadjusted IRR
Caglayan (2021), Turkey [34] Cross-sectional/Multicentre -thoracic societies March 11 to May 15, 2020 n = 15; physicians NR; confirmed or suspected COVID-19-positive; fever and other COVID-19 symptoms; NR Specific AGMP: Bronchoscopy COVID-19/ Self-reported (type of diagnostic test not reported) Number of events, statistical comparison of groups (i.e. p-values)
Celebi (2020), Turkey [29] Case–control/Single Centre – all units March 20 and May 20, 2020 n = 181; physicians, nurses, cleaning personnel, and other occupations NR; suspected or confirmed COVID-19-positive; NR; NR Specific AGMPs: CPR, intubation, bronchoscopy, endoscopy, mechanical ventilation COVID-19/ RT-PCR Number of events, statistical comparison of groups (i.e. p-values)
*Chano (2021), Japan [46] Prospective cross-sectional/Multicentre – COVID-19 designated hospitals February 15 to February 26, 2021 n = 1237; doctors, nurses, office workers, and others NR Not specifically identified in the paper but list of AGMPs combined received from personal communication with the author: Tracheal suction, tracheal intubation, extubation, bronchoscopy, nebulizer therapy COVID-19/ Serology Number of events, unadjusted OR
Chatterjee (2020), India [28] Case–control/Multicentre – all units April to May 2020 n = 751; doctor, nurses, housekeeping, security, lab techs, other NR Specific AGMPs: Respiratory suctioning, endotracheal intubation, nasopharyngeal swab collection COVID-19/ RT-PCR Number of events, unadjusted and adjusted OR
Chen (2009), China [65] Retrospective/Multicentre – all units involved in the care of SARS patients 2003 n = 758; doctors, nurses, health attendant, lab technician, other NR; suspected or confirmed SARS-positive; NR; ‘caring for super spreading patient(s)’ Specific AGMPs; Tracheal intubation, tracheotomy SARS/ ELISA Unadjusted and adjusted OR
Cheng (2015), Hong Kong [53] Retrospective cohort/Single Centre – adult ICU and general medical ward April 1, 2013 to May 31, 2014 n = 70; NR One, 36-year old, female with verified influenza A H7N9; 6-days after onset of symptoms (fever, cough, sputum production, sore throat, dyspnoea); one 65-year old male with verified influenza A H7N9; 4-days after onset of community-acquired pneumonia AGMPs Combined: Endotracheal intubation, CPR, bronchoscopy, open suction of respiratory tract, sputum induction, use of nebulizer therapy, non-invasive positive pressure ventilation, high-frequency oscillatory ventilation Influenza A H7N9/ Serology Number of events, statistical comparison of groups (i.e. p-values)
Cummings (2020), USA [51] Post-hoc analysis of RCT/Multicentre – outpatient clinics, ED 2011 to 2016 n = 2614; NR NR; suspected respiratory illness; NR; NR Specific AGMPs and AGMPs Combined: Respiratory/airway suctioning, intubation, nasopharyngeal aspiration, nebulizer treatment- Coronavirus strains HKU1, OC43, NL63, 229E/ RT-PCR Number of events, adjusted and unadjusted OR
Dimcheff (2020), USA [30] Cross-sectional/Single Centre – all units June 8 to July 8, 2020 n = 1476; advanced care practitioner (e.g., physician, dentist, NP, PA, nurse anesthetist), administrative, clinical support, nursing Veterans; NR; NR; NR Not specifically identified COVID-19/ Serology Number of events, unadjusted OR
Firew (2020), USA [31] Cross-sectional survey/Multicentre – Emergency medicine, ICU, inpatient hospital, pre-hospital, outpatient, long-term care facility/nursing home, other May 2020 n = 2040; physicians, nurses, EMTs, resident physicians or fellows, physician assistants and other HCW NR AGMPs Combined: Respiratory/airway suctioning, intubation, nasopharyngeal aspiration, nebulizer treatment- COVID-19/ PCR and antibody Number of events, unadjusted PR
Fowler (2004), Canada [64] Retrospective cohort/Single Centre—ICU April 1 to April 22, 2003 n = 122; physicians, registered nurses, respiratory therapist treating SARS patients NR; SARS-positive treated with ventilator support; NR; NR Specific AGMPs: Endotracheal intubation, high-airflow, noninvasive positive-pressure ventilation (NIPPV); high-frequency oscillatory (HFO) ventilation SARS/ PCR or serology Number of events, stratified and adjusted RR
Ha (2004), Vietnam [61] Prospective cohort/Single Centre – all units May 12 to 14 2003 n = 62; Physicians, nurses, nonclinical staff (housekeepers, clerks, elevator operators, laboratory technicians, and guards) NR; SARS-positive; NR; NR Specific AGMPs: Non-invasive positive pressure ventilation -, nebulizer medication SARS/ Serology Number of events only
*Haller (2021), Switzerland[49] Prospective observational cohort/Multicentre – all units June 22nd to August 15th, 2020, data were analysed up to March 9th 2021 n = 3259; primarily nurses and physicians NR AGMPs Combined: Bronchoscopies, intubation/extubation, gastroscopy, transesophageal echocardiography, reanimation, non-invasive ventilation, and suction of tracheal secretions COVID-19/ RT-PCR, seroconversion Number of events, unadjusted and adjusted OR, adjusted HR
Heinzerling (2020), USA[48] Cohort/Single Centre February 15 to February 19, 2020 n = 43; RN, RT, phlebotomist, certified nursing assistant, physician, environmental services worker, nutritionist, pharmacist, other One index patient, assumed adult; COVID-19-positive; NR; NR Specific AGMPs and AGMPs Combined: Airway suctioning, noninvasive positive pressure ventilation including BiPAP, manual ventilation, nebulizer treatments, breaking the ventilator circuit, sputum induction, intubation, bronchoscopy COVID-19/ RT-PCR Number of events and statistical comparison of groups (i.e. p-values)
*Lai (2020), China[50] Cross-sectional survey/Multicentre – all units February 11 to February 15, 2020 n = 325; nurses, doctors, technicians, security and cleaning staffs, and financial staffs NR; COVID-19 confirmed or suspected; NR; NR Not specifically identified COVID-19/ nucleic acid test or clinical diagnosis Number of events and statistical comparison of groups (i.e. p-values)
Langella (2021), USA[34] Ecological/Single Centre – emergency dental clinic March 30 to May 8, 2020 n = 267; dental care providers Adult and pediatric; NR; NR AGMPs Combined: High or low-speed dental handpieces, rotary instruments, ultrasonic scalers, air water syringes in a biologic environment (i.e. intraorally) including manipulation of gingival tissue, procedures likely to produce droplets at operative site, including extractions COVID-19/ NR Number of events
*Lentz (2020), USA[32] Case–control/Multicentre – international healthcare delivery settings April 20 to May 5, 2020 n = 1130; clinician, nurse, RT, other NR; laboratory confirmed or persons under investigation for COVID-19; NR; NR Specific AGMPs and AGMPs Combined: Intubation, extubation, open respiratory suctioning, bronchoscopy, nebulizer use, non-invasive positive pressure ventilation (NIPPV), tracheotomy, cardiopulmonary resuscitation COVID-19/ RT-PCR Unadjusted and adjusted OR
Liu (2009), China [62] Retrospective Case control; Single Centre – all units March 5 to May 17, 2003 n = 477; NR NR; SARS-positive; NR; NR Specific AGMPs: Chest compression, intubation, pulmonary lavage, respiratory secretion, sputum SARS/ Serology (ELISA) Number of events, unadjusted and adjusted OR
Loeb (2004), Canada [63] Retrospective cohort/Single Centre – critical care units March 8 to March 21, 2003 n = 32; nurses Three adult index patients; suspected SARS; NR; nR Specific AGMPs: Suctioning after intubation, suctioning before intubation, endotracheal aspirate, bronchoscopy, CPR, intubation, manual ventilation, nebulizer treatment, insertion of a nasogastric tube, manipulation of BiPAP mask, manipulation of oxygen mask, moth or dental care, nasopharyngeal swab obtained SARS/ Serology Number of events, unadjusted RR
Lormans (2021), Belgium [36] Cohort/Single Centre – COVID-19 and non-COVID-19 ICU April to May 2020 n = 142; nurses NR Specific AGMPs and AGMPs Combined: Broncho-alveolar lavage (more than 5 times), any assistance with either intubation or broncho-alveolar lavage, Intubation (more than once) COVID-19/ RT-PCR Unadjusted OR
*Lucar (2020), USA[41] Retrospective cohort/Single Centre – Operating room NR n = 11; anesthesiologist, certified registered nurse anesthetist, circulator, orthopedic surgeon, orthopedic resident, scrub technician One 17-year-old, asymptomatic index patient; COVID-19-positive AGMPs Combined: Extubation, intubation COVID-19/ RT-PCR Number of events
Macintyre (2014), China [56] Prospective cohort/Multicentre – emergency and respiratory wards December 1, 2008 to January 15, 2009 n = 481; doctors, nurses, other NR AGMPs Combined: Provision of nebulizer medications, suctioning, intubation, aerosol-generating procedures and chest physiotherapy adenoviruses, human meta pneumovirus, coronaviruses, parainfluenza, influenza, respiratory syncytial virus, rhinovirus A/B; Streptococcus pneumoniae, Mycoplasma pneumoniae, B. pertussis, Legionella spp, Chlamydophila and Haemophilus influenza type B./ based on presence of symptoms Number of events, unadjusted and adjusted RR
Nakagama (2021), Japan [45] Prospective cohort/Single Centre – all units June 30th to July 2nd 2020 n = 414; NR NR Specific AGMPs and AGMPs Combined: Airway suctioning, bronchoscopy, CPR, endotracheal intubation/extubation, bag mask ventilation, non-invasive ventilation, nebulizer administration, sputum induction, oxygen supplementation via tracheostomy, tracheotomy COVID-19/ RT-PCR or serology Number of events, unadjusted RR
Ogawa (2020), Japan [33] Cohort/Single Centre – ICU, general ward NR n = 15; doctors, nurses, speech-language-therapist, and physical therapists One 81-year-old female index patient, COVID-19 positive; 10 days from symptom onset AGMPs Combined: Ventilation, tracheotomy COVID-19/ IgG antibody blood test, RT-PCR test Number of events
Paris (2021), France [44] Cross-sectional survey/Single Centre – all units May, 29th and July, 10th 2020 n = 3234; nurses/midwives, students, residents, medical staff, administrative staff, cleaners NR Specific AGMPs and AGMPs Combined: Nasopharyngeal sampling, ear, nose and throat examinations, upper respiratory tract, nasogastric tube insertion, aerosol generating procedures (not specified but referred to as actions on upper respiratory tract) COVID-19/ Serology (ELISA) Number of events and statistical comparison of groups (i.e. p-values); adjusted OR
Pei (2006), China [60] Case–Control/Multicentre – all units 2002–2003 SARS outbreak; questionnaire carried out in April-June 2004 n = 443; doctors, nurses, nursing staff, workers, technicians, administrators, others NR Specific AGMPs: Tracheal intubation SARS/ Serology Number of events, unadjusted and adjusted OR
Pérez-García (2020), Spain[47] Cross-sectional/Single Centre – all units March 5, 2020 to May 30, 2020 n = 2963; medical staff, nurses, technical specialists, auxiliary nursing-care technician, hospital porter, resident physician, kitchen, administrative staff, others NR Not specifically described COVID-19/ RT-PCR and/or serology Unadjusted and adjusted OR
*Raboud (2010), Canada [55] Retrospective cohort/Multicentre 2003 n = 624; NR Adults; SARS-positive requiring intubation; days of illness reported Specific AGMPs; Suctioning after intubation, suctioning before intubation, bronchoscopy, CPR, defibrillation, intubation, manual ventilation after and before intubation, non-invasive ventilation, mechanical ventilation, nebulizer treatment, chest physiotherapy, insertion of NG tube, manipulation of oxygen mask, high flow oxygen (in room), collection of sputum sample, suction – sputum, bronchoscopy, tracheal intubation, tracheal tube removal, laryngoscope, tracheotomy SARS/ RT-PCR Number of events, unadjusted and adjusted OR
Ran (2020), China [42] Retrospective Cohort Study/Single Centre – high risk and low risk units The follow-up was ended on Jan 28 2020 n = 72; nurses and clinicians NR Specific AGMPs and AGMPs Combined: High exposure operation (medical or surgical procedures that generate respiratory aerosols including tracheal intubation, tracheotomy, tracheal tube removal, CPR, sputum suction, fiber bronchoscopy, laryngoscope) COVID-19/ RT-PCR Number of events, unadjusted RR
Rosano (2021), Italy [38] Cohort/Single Centre – ICU February 20 to May 5, 2020 n = 145; physicians and nurses NR; COVID-19-positive; NR; NR Specific AGMPs: Tracheotomy COVID-19/ RT-PCR or antibody test Number of events and statistical comparison of groups (i.e. p-values)
Rzepliński (2021), Poland [37] Cross-sectional/Single Centre – All units April 21 to July 20, 2020 n = 1572; NR NR Not specifically described COVID-19/ Serology and RT-PCR Number of events and statistical comparison of groups (i.e. p-values)
Scales (2003), Canada [59] Retrospective cohort/Single Centre—ICU 2003 n = 69; quarantined HCWs One 74-year-old, signs and symptoms of community-acquired pneumonia; SARS-positive Specific AGMPs: Intubation, non-invasive positive-pressure ventilation (present during procedure), contact with mucous membrane, contact with mucous membranes or respiratory secretions (performed procedure that involved contact with secretions) SARS/ WHO criteria of SARS Number of events
Shah (2021), USA[40] Retrospective cohort/Single Centre – emergency department, inpatient, outpatient May 13 to November 20, 2020 n = 345; RN, physician, RT, patient care assistant, housekeeping, other NR; confirmed of suspected COVID-19-positive; NR; NR AGMPs Combined: Tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation, bronchoscopy COVID-19/ RT-PCR Number of events and statistical comparisons of groups (i.e. p-values)
Teleman (2004), Singapore [58] Case–control/Single Centre – all units March 1 to March 31, 2003 n = 86; doctors, nurses, other NR; SARS-positive; NR; NR Specific AGMPs: Suction, intubation, oxygen administration, contact with respiratory secretions SARS/ Serology Number of events, unadjusted and adjusted OR
Vitrat (2021), France [39] Cross-sectional/Multicentre – all units June 27 to September 31, 2020 n = 3454; HCW, health-associated professionals, health management, support personals NR AGMPs Combined: Nasopharyngeal test, intubation, etc. (from survey), oral intubation, aerosolized therapy, high flow oxygen (in discussion) COVID-19/ Serology Unadjusted and adjusted OR
Wong (2004), Hong Kong [57] Retrospective cohort/Single Centre – general medical ward March 4 to March 10, 2003 n = 66; medical students One index patient presumed adult; SARS-positive; NR; 8 days from symptom onset Specific AGMPs: Nebulizer SARS/ Serology Number of events
Zhang (2013), China [52] 1:4 matched case–control study/Multicentre – high risk setting (intensive care, emergency, respiratory wards) August 30, 2009 and January 31, 2010 n = 255; nurse, doctor, or ward clerk NR; patient with confirmed pandemic influenza A ⁄ (H1N1); NR; NR AGMPs Combined: Suctioning, intubation, nebulizer medications, chest physiotherapy, other aerosol generating procedures Influenza A/H1N1/ RT-PCR Number of events and statistical comparison of groups (i.e. p-values)
  1. *Bolded authors also reported a stratified analysis of transmission of VRI to HCW during an AGMP when using a N95/respiratory versus other PPE. Specific AGMPs: Studies reporting transmission of VRIs by specific AGMPs; AGMPs Combined: Studies reporting transmission of VRIs by listed AGMPs combined; Not specifically described; Studies reporting transmission of VRIs by AGMPs, but AGMPs were not described in the study
  2. CPR cardiopulmonary resuscitation; COVID-19 SARS CoV-2; ELISA enzyme-linked immunoassay; EMT emergency medical technician; HCW healthcare worker; MERS Middle East Respiratory Syndrome; NP nurse practitioner; NR not reported; PA physicians assistant; RN registered nurse; RR relative risk; RT respiratory therapist; RT-PCR real-time polymerase chain reaction; SARS Severe Acute Respiratory Syndrome