A special thank you to Dr. Jennifer Yourkavitch, Dr. Ellen Chetwynd, and Dr. Paige Hall Smith for continuing to update information regarding the cleaning and maintenance of the lactation rooms on UNCG campus during the COVID 19 pandemic. You can read the latest version here or select a printable copy.
Recommendations and Considerations for the Use and Cleaning of Lactation Rooms During the COVID-19 Pandemic (v.5; updated May 15, 2021)
Authors: Jennifer Yourkavitch, MPH, PhD, IBCLC; Ellen Chetwynd, PhD, MPH, BSN, IBCLC; Paige Hall Smith, PhD, MSPH
Department of Public Health Education
Introduction
As the COVID-19 pandemic continues to ravage communities around the world, and businesses, schools, government buildings, airports, and other spaces open for public use, it is important to consider how to maintain lactation rooms for public use. These spaces are unique in that, unlike restrooms, they serve a particular clientele with the purpose of feeding an infant or expressing a body fluid that has not been found to transmit the virus [1]. They are also not as heavily trafficked as restrooms. However, like restrooms, they have certain high-touch surfaces which may include doorknobs, light switches, sink handles, countertops, chairs, tables, and multi-user pumps, and may not be well ventilated. They may be designed to serve single or multiple users at a time and they may not be cleaned between use according to typical maintenance schedules. In preparing to support the re-opening and maintenance of lactation rooms at our institution, we recognized the need for evidence-based guidance to support human milk expression in public spaces during the pandemic. Although evidence is emerging quickly and is of varying quality, we offer these recommendations and considerations using available information and recognizing that they should be updated as more evidence emerges [2]. We have categorized considerations into these areas: air quality and flow, cleaning of the space, equipment in the room, and behavior in the room. We have provided evidence where available and noted where evidence is needed. The main feature of the May 15, 2021 update is consideration of vaccination status among people in lactation rooms. New guidance from the Centers for Disease Control and Prevention (CDC) states that fully vaccinated people do not need to wear masks or maintain physical distance, indoors or outdoors, except where required by law [3]. Because there is usually no way of monitoring vaccination status for people using lactation rooms, most of the previous recommendations still apply. However, vaccinated people would not need to wear a mask in the lactation room unless mandated by policy or law.
Air Quality and Flow
The dominant feature of coronavirus transmission currently is a higher risk in enclosed spaces with infected people [4]. The virus can linger in the air for up to three hours [5]. Evidence suggests that most transmission occurs in a space occupied by an infected person [6]; however, limited evidence suggests that aerosol transmission is possible in a space shortly after an infected person has left [7]. It is reasonable to take precautions if viruses are present in the room and WHO recommends “fresh, clean air in all workplaces” [8]. So how can facility managers address the issue of air flow?
Some options to consider include:
● Create private, protected outdoor spaces for lactation. These spaces could require only normal cleaning and not disinfection [9].
● Upgrade the air filtration system [10].
● Open windows [10].
● Space out usage so that there are breaks between users, which allows the virus to die over time in the empty space. Restrict usage to one person (plus nursing infant, if applicable) at a time [6]. ]
○ This can be accomplished with electronic booking systems that pre-specify usage and non-usage times.
○ If a reservation system is not feasible, there are other options:
■ Rooms with mediated access (user must check out key or interact with a moderator for every room use). The person providing room access records time of departure and ensures breaks between users.
■ Unmediated access (user enters the room without going through another person/process). The user could mark departure time on a whiteboard on the outside of the door.
● Ask unvaccinated users to wear a mask while in the room [3, 11].
Cleaning
Coronavirus can be transmitted if a person touches a contaminated surface and then touches their eyes, nose, or mouth [12]. However, the accumulation of evidence suggests that surfaces are not a major route of transmission [12, 13]. The virus can be killed by simple cleaning procedures with soap and water or other cleaning products [14]; in addition, the CDC provides disinfection guidance for high-touch surfaces [15]. In a lactation room, these surfaces include light switches, doorknobs, multi-user pumps, refrigerator handles, countertops, chair arms and the top of chair backs, tables, and sink handles. Facility managers can:
● Regularly inspect the unoccupied space to ensure that it is tidy and clean.
● Ensure typical cleaning of the space and disinfection of high-touch surfaces on a regular schedule.
● Provide supplies in the room: hand sanitizer (at least 60% alcohol) and disinfecting wipes (at least 60% alcohol or a hydrogen peroxide base [16]). If there is a sink, provide paper towels and soap. Check the expiration date on disinfecting wipes. Be careful using products with bleach due to fumes and toxicity produced when combined with other cleaning products [17]. We recommend not providing products with bleach for use by people using lactation rooms. However, bleach products may be used by professional custodial services.
○ Advise users to wipe down high-touch surfaces before use with a disinfecting wipe [12, 14, 15, 16], and to wash their hands before and after expressing milk [8].
● Provide tissues for personal use.
● Provide a trash receptacle for used tissues, paper towels, and wipes.
Equipment in the room
Keep the room as user-friendly as possible while eliminating anything extraneous. Provide places to set personal equipment e.g., shelves or tables.
There is no need to remove or switch out chairs, pumps (designed for multiple users), signs, or informational posters. Surface contamination is not a major route of infection transmission [12, 13].
Behavior in the room
To assist people using lactation rooms to minimize their risk of exposure in the room and to avoid contaminating the space themselves, consider advising the following, through posted signs and room use agreements:
● Wash hands before and after pumping [8].
● Wipe high-touch surfaces with a disinfecting wipe before use [15, 16].
● Avoid touching your face [12].
● Wear a mask while in the room if unvaccinated [3, 11].
● Restrict usage to one person at a time [6].
● Use the electronic booking system or other arrangement to reserve time in the room.
● Bring your own pillows (if needed), pen (for filling out user form, if needed), cleaning supplies for cleaning their personal pump parts (i.e., a brush, sponge, or other implements).
What to do if someone using a lactation room has suspected or confirmed illness
Following standard quarantine precautions, if someone who used the lactation room within the past two weeks reports suspected (showing symptoms) or confirmed infection, then that person should refrain from using the room for at least 10 days from when symptoms first appeared, 24 hours without fever and without use of fever-reducing medication, and other symptoms are improving [timing varies depending on conditions, see reference 17]. In addition, the CDC recommends that any unvaccinated person exposed to someone with COVID-19 should quarantine following the recommendations of their local public health department [3, 18].
Evidence gap
A major evidence gap for the use of indoor space is the amount of time needed for airborne virus to die or disappear under different conditions.
Endnotes
1. WHO. June 23, 2020. Available at W.H.O. news.
USAID. September, 2020. Transmission of Novel Coronavirus (SARS-COV-2) through breast milk and breastfeeding. Available at this article.
2. Given the novelty of the virus and the fast proliferation of research, most research would not be graded “high-quality” using conventional standards at this point (Alexander PE et al. 2020. Available at National Library of Medicine. As time passes, the quality of research will improve and this guidance will be updated.
3. Centers for Disease Control and Prevention. May 13, 2021. “When you’ve been fully vaccinated.” Available at the C.D.C. website.
4. WBUR reports that University of Maryland Environmental Health professor Donald Milton says that outbreaks are more likely to occur in indoor, poorly ventilated environments. Available at the W.B.U.R. website; More evidence accumulates: National Public Radio. December 26, 2020. “For scientists who study virus transmission, 2020 was a watershed year.” Available at this N.P.R. article.
5. “A person infected with coronavirus — even one with no symptoms — may emit aerosols when they talk or breathe. Aerosols are infectious viral particles that can float or drift around in the air for up to three hours. Another person can breathe in these aerosols and become infected with the coronavirus. This is why everyone should wear a mask that covers their nose and mouth when they go out in public.” Source: Harvard article, from March 9, 2021.
6. WHO. Q&A: How is COVID-19 transmitted? July 9, 2020. Available at the W.H.O. website.
7. Sun LH and Guarino B. CDC acknowledges airborne transmission can play a role in infections. The Washington Post, October 5, 2020. Available at Washington Post news.
8. WHO. June, 2020. Tips for health and safety at the workplace in the context of COVID-19. Available at the W.H.O. website.
9. Centers for Disease Control and Prevention. March 1, 2021. Available at the C.D.C. website.
10. Morawska L, and Milton DK. It’s time to address airborne transmission of COVID-19. Clinical Infectious Disease 2020. Available at the Oxford Academic website.
11. WHO. December 1, 2020. Advice on the use of masks in the context of COVID-19. Available at W.H.O. publications.
12. “Coronavirus can also spread from contact with infected surfaces or objects, though this is less common. For example, a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes.” Source: this Harvard article, from March 9, 2021.
13. National Public Radio. December 28, 2020. “Still Disinfecting Surfaces? It might not be worth it.” Available at this N.P.R. article.
14. CDC. December 21, 2020. Cleaning and disinfecting. Available at the C.D.C. website.
15. CDC. March 1, 2021. Guidance for Cleaning and Disinfecting Public Spaces, Workplaces, Businesses, Schools, and Homes. Available at the C.D.C. website.
16. University of California, San Francisco. 2021. Frequently Asked Questions About COVID-19. “What kinds of disinfectants and cleaners are effective against the novel coronavirus?” Available at the University of California (San Diego) Health F.A.Q..
17. CDC. March 12, 2021. When can you be around others after you had or likely had COVID-19? Available at the C.D.C. website.
18. CDC. March 12, 2021. When to quarantine. Available at the C.D.C. website.
