Safety of the newborn and the protection of healthcare workers (HCWs) from aerosol exposure are extremely important during the current severe acute respiratory illness coronavirus 2 (SARS-CoV-2) pandemic. Use of personal protective equipment (PPE) has been shown to be associated with a reduced risk of infection [1]. As per WHO guidelines, it is mandatory to use personal protective equipment (PPE) while performing aerosol-generating procedures like suction, intubation, chest compression etc. [2,3]. However, despite the use of PPE, there remains a possibility that aerosols can contaminate nearby surfaces [4]. An aerosol box acts as a physical barrier against the aerosol spread [4,5]. PPE with a barrier enclosure like an aerosol box can be an effective measure to minimize aerosol spread and exposure during this pandemic [2,4].

Recent literature reports that when an aerosol box was used for airway management, the inner surface of the box and the laryngoscopist’s gloves and gowned forearms were observed to be contaminated [4], but no macroscopic contamination outside the box was observed [4]. Unlike adult resuscitation, the focus of newborn resuscitation is effective ventilation of baby’s lungs which includes aerosol-generating procedures like suction, PPV, using continuous positive airway pressure, intubation, chest compression, etc. [6,4]. To see the feasibility of using the standard aerosol box as a barrier enclosure while performing aerosol-generating procedures on neonates, a novel simulation session integrating a newborn delivery of a suspect or confirmed COVID-19 mother with a subsequent need for neonatal resuscitation was developed. The 15-minute simulation was run with two resident doctors, an embedded simulation nurse, and a low fidelity manikin in the delivery room setting. The ‘newborn’ was a low fidelity simulator (Laerdal Medical). During simulation sessions, accessing the neonate and performing resuscitation steps in the squared aerosol box was observed to be impossible. After completion of each session, the learners were debriefed using the PEARLS Healthcare Debriefing Tool with plus/delta and advocacy enquiry format by a trained simulation leader [8,9]. Difficulties were encountered at all steps of resuscitation like - attaching pulse oximeter, performing positive pressure ventilation, intubation, chest compression and umbilical catheterization, etc. These difficulties were addressed and the need for a modified aerosol box for neonates was informed to the biomedical department of our institute. The box underwent multiple modifications based on the feedbacks received. The final design specifications were given (Web Table I) and the NeoBox was developed (Fig.1).

Fig. 1 NeoBox with dimensions.

Fig.2 NeoBox in delivery room – resuscitator managing airway.

The NeoBox is made up of a transparent polycarbonate (3 mm thick). The material required was procured and necessary fabrications were done by the local acrylic / polycarbonate sheet fabricator. The average time required to make one NeoBox was approximately 4 hours. The cost was Rs 6500. An alcohol based disinfectant (Ethanol 70%) with a contact time of minimum 1 minute is used to clean the NeoBox [10].

The NeoBox was primarily designed as a physical barrier to prevent aerosol exposure and spread while performing aerosol-generating procedures during resuscitation in delivery room. While running simulation sessions, its wider application for neonatal care like transporting a suspected or confirmed COVID-19 neonate from one place to another (intra hospital transport) and caring for them in the neonatal intensive care unit (NICU) while performing aerosol-generating procedures was recognized. Use of NeoBox in addition to PPE helped boosting HCWs confidence for managing suspected or confirmed COVID-19 neonates. We found that the NeoBox would require training before use in the treatment of patients. Wearing PPE is must for HCWs while performing aerosol-generating procedures in a suspected or confirmed COVID-19 neonate. NeoBox works as a physical barrier to prevent aerosol spread. However, in case of difficulty it is advised to remove the NeoBox and perform intubation.

We propose the NeoBox as an additional protection, and suggest that it may be considered to be an adjunct to standard PPE for managing suspected COVID-19 newborns in delivery room (Fig. 2). It can also be used as a barrier enclosure during intrahospital transport and while performing aerosol-generating procedures in the NICU.

Acknowledgment: Dr Vaibhavi Upadhye, DrArti Rajhans and DrDhananjay Kelkar from Deenanath Mangeshkar Hospital for their support and guidance.

1. Chou R, Dana T, Buckley DI, Selph S, Fu R, Totten AM. Epidemiology of and risk factors for coronavirus infection in health care workers: A living rapid review.　Ann Intern Med. 2020;173:120-36.

2. World Health Organization. Infection Prevention and Control During Health Care When COVID-19 is Suspected: Interim Guidance. 19 March 2020. Available from: https://www.who.int/publications-detail/ infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125. Accessed May 23, 2020.

3. Harding H, Broom A, Broom J. Aerosol generating procedures and infective risk to healthcare workers: SARS-CoV-2 - the limits of the evidence. J Hosp Infect. 2020;105:717-25. Epub ahead of print.

4. Canelli R, Connor CW, Gonzalez M, Nozari A, Ortega R. Barrier enclosure during endotracheal intubation. N Engl J Med. 2020;382:1957 8.

5. Motara F, Laher AE, Du Plessis J, Moolla M. The "Intubox": Enhancing Frontline Healthcare Worker Safety During Coronavirus Disease 2019 (COVID-19). Cureus. 2020;12:e8530.

6. Chandrasekharan P, Vento M, Trevisanuto D, Partridge E, Underwood MA, Wiedeman J, et al. Neonatal resuscitation and postresuscitation care of infants born to mothers with suspected or confirmed SARS-CoV-2 infection. Am J Perinatol 2020;37:e3-e3.

7. Edelson DP, Sasson C, Chan PS, Atkins DL, Aziz K, Becker LB, et al. American Heart Association ECC Interim COVID Guidance Authors. Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association. Circulation. 2020;141:e933-43.

8. Bajaj K, Meguerdichian M, Thoma B, Huang S, Eppich W, Cheng A. The PEARLS healthcare debriefing tool. Acad Med. 2018;93:336.

9. Rudolph JW, Simon R, Rivard P, Dufresne RL, Raemer DB. Debriefing with good judgment: Combining rigorous feedback with genuine inquiry. Anesthesiol Clin. 2007;25:361 76.

10. World Health organization. Cleaning and Disinfection of Environmental Surfaces in the Context of COVID-19.https://www.who.int/publications-detail/cleaning-and-disinfection-of-environmental-surfaces-inthe-context-of-covid-19. Accessed May 23, 2020.