PUBLIC HEALTH EDUCATION

School of Health and Human Sciences

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Recommendations and Considerations for the Use and Cleaning of Lactation Rooms During the COVID-19 Pandemic (v.4; updated March 13, 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.

Air Quality and Flow
The dominant feature of coronavirus transmission currently is a higher risk in enclosed spaces with infected people [3]. The virus can linger in the air for up to three hours [4]. Evidence suggests that most transmission occurs in a space occupied by an infected person [5]; however, limited evidence suggests that aerosol transmission is possible in a space shortly after an infected person has left [6]. It is reasonable to take precautions if viruses are present in the room and WHO recommends “fresh, clean air in all workplaces” [7]. 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. [8]
  • Upgrade the air filtration system. [9]
  • Open windows. [9]
  • 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. [5]

    • 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 users to wear a mask while in the room. [10]

Cleaning
Coronavirus can be transmitted if a person touches a contaminated surface and then touches
their eyes, nose, or mouth [11]. However, the accumulation of evidence suggests that surfaces
are not a major route of transmission [11, 12]. The virus can be killed by simple cleaning
procedures with soap and water or other cleaning products [13]; in addition, the CDC provides
disinfection guidance for high-touch surfaces [14]. 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 [15]). 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 [15]. 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 [11, 13, 14, 15], and to wash their hands before and after expressing milk
      [7].
  • 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 [11,12].

Behavior in the room
To assist lactation room users 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. [7]
  • Wipe high-touch surfaces with a disinfecting wipe before use [14, 15].
  • Avoid touching your face. [11]
  • Wear a mask while in the room. [10]
  • Restrict usage to one person at a time. [5]
  • 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 a lactation room client 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 16]. In addition,
the CDC recommends that anyone exposed to someone with COVID-19 should quarantine following the recommendations of their local public health department. [17]

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, including an empty space.

Endnotes
1. WHO, June 23, 2020. Available at https://www.who.int/newsroom/commentaries/detail/breastfeeding-and-covid-19;
USAID, September, 2020. Transmission of Novel Coronavirus (SARS-COV-2) through breast milk
and breastfeeding. Available at https://www.advancingnutrition.org/resources/key-messagesrelated-evidence-transmission-covid-breastmilk
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 https://pubmed.ncbi.nlm.nih.gov/32330521/). As time passes, the quality of
research will improve and this guidance will be updated.
3. 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: https://www.wbur.org/hereandnow/2020/05/19/air-conditioning-coronavirus;
More evidence accumulates: National Public Radio, December 26, 2020. “For scientists who
study virus transmission, 2020 was a watershed year.” Available at
https://www.npr.org/sections/health-shots/2020/12/26/946901965/for-scientists-who-studyvirus-transmission-2020-was-a-watershed-year
4. “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
5
and mouth when they go out in public.” Source: https://www.health.harvard.edu/diseases-andconditions/covid-19-basics, March 9, 2021.
5. WHO. Q&A: How is COVID-19 transmitted? July 9, 2020. Available at
https://www.who.int/news-room/q-a-detail/q-a-how-is-covid-19-transmitted
6. Sun LH and Guarino B. CDC acknowledges airborne transmission can play a role in infections.
The Washington Post, October 5, 2020. Available at
https://www.washingtonpost.com/health/2020/10/05/cdc-coronavirus-airborne-transmission/
7. WHO. Tips for health and safety at the workplace in the context of COVID-19. June, 2020.
Available at https://www.who.int/emergencies/diseases/novel-coronavirus-2019/questionand-answers-hub/q-a-detail/q-a-tips-for-health-and-safety-at-the-workplace-in-the-context-ofcovid-19
8. Centers for Disease Control and Prevention. March 1, 2021. Available at:
https://www.cdc.gov/coronavirus/2019-ncov/community/reopen-guidance.html
9. Morawska L, and Milton DK. It’s time to address airborne transmission of COVID-19. Clinical
Infectious Disease 2020. Available at https://academic.oup.com/cid/advancearticle/doi/10.1093/cid/ciaa939/5867798
10. WHO. Advice on the use of masks in the context of COVID-19. December 1, 2020. Available
at https://www.who.int/publications/i/item/advice-on-the-use-of-masks-in-the-communityduring-home-care-and-in-healthcare-settings-in-the-context-of-the-novel-coronavirus-(2019-
ncov)-outbreak
11. “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:
https://www.health.harvard.edu/diseases-and-conditions/covid-19-basics, March 9, 2021.
12. National Public Radio, December 28, 2020. “Still Disinfecting Surfaces? It might not be
worth it.” Available at https://www.npr.org/sections/healthshots/2020/12/28/948936133/still-disinfecting-surfaces-it-might-not-be-worth-it
13. CDC. Cleaning and disinfecting. December 21, 2020. Available at
https://www.cdc.gov/coronavirus/2019-ncov/community/clean-disinfect/index.html
14. CDC. Guidance for Cleaning and Disinfecting Public Spaces, Workplaces, Businesses, Schools,
and Homes. March 1, 2021. Available at: https://www.cdc.gov/coronavirus/2019-
ncov/community/reopen-guidance.html
15. University of California, San Francisco. 2021. Frequently Asked Questions About COVID-19.
“What kinds of disinfectants and cleaners are effective against the novel coronavirus?”
6
Available at
https://health.ucsd.edu/coronavirus/Pages/FAQ.aspx#:~:text=You%20can%20remove%20the%
20virus,hydrogen%2Dperoxide%20based%20cleaners
16. CDC. When can you be around others after you had or likely had COVID-19? March 12,
2021. Available at https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/end-homeisolation.html
17. CDC. When to quarantine. March 12, 2021. Available at
https://www.cdc.gov/coronavirus/2019-ncov/if-you-aresick/quarantine.html#:~:text=You%20should%20stay%20home%20for,after%20exposure%20to
%20the%20virus.