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CDC Updates and Shortens Recommended Isolation and Quarantine Period for General Population
Given what we currently know about COVID-19 and the Omicron variant, CDC is shortening the recommended time for isolation for the public. People with COVID-19 should isolate for 5 days and if they are asymptomatic or their symptoms are resolving (without fever for 24 hours), follow that by 5 days of wearing a mask when around others to minimize the risk of infecting people they encounter. The change is motivated by science demonstrating that the majority of SARS-CoV-2 transmission occurs early in the course of illness, generally in the 1-2 days prior to onset of symptoms and the 2-3 days after.
Published 27 December 2021
Link to full article https://www.cdc.gov/media/releases/2021/s1227-isolation-quarantine-guidance.html
COVID-19 vaccination is strongly encouraged for non-pregnant women contemplating pregnancy. COVID-19 vaccines using the mRNA or viral vector technology should be offered to all pregnant women after 14 weeks gestation. Pregnant women with co-morbidities such as diabetes and hypertension in pregnancy should be prioritized for vaccination should vaccine supplies be limited. Health care workers are encouraged to discuss the risks and benefits of the COVID-19 vaccination with their patients. These discussions should include the lack of safety data for pregnancy and breastfeeding women, the strong immune response conferred to mothers following vaccination, the benefits of immune transfer to the neonate and that there are no known risks associated with other non-live vaccines given in pregnancy.
Published: 29 April 2021
Link to full article / Source: https://sasog.co.za/sahpra-guidance-on-use-of-jj-covid-vaccine-in-pregnant-and-lactating-mothers/
ESHRE STATEMENT ON COVID-19
vaccination and medically assisted reproduction
- Should men and women receive the COVID-19 vaccine before attempting conception?
- Should couples who received COVID-19 vaccination postpone conception, and if so, for how long?
- Should pregnant women be vaccinated?
Vitalab’s Official Update Regarding the Level 4 Regulations of Lockdown in South Africa –
Full Fertility Services Resumed from the 4th of May 2020.
Source: The Vitalab Doctors and Management Team
Date: 5th of May 2020
Vitalab’s main priority is to safeguard our patients’ ability to continue the evaluation and treatment for their infertility.
All health and safety measures are in place and will continue to be so.
We understand the uncertainty and anxiety that many are going through, especially in terms of treatment timelines with the hope of building their families.
Within level 4 regulations we are open to seeing new case appointments and all existing patients can continue their treatment protocols accordingly.
All previous communications, protocols and policies do apply – you can read them all below on this webpage.
For further information please call 011 911 4700 (JHB) or 031 880 1700 (KZN) for detailed and immediate assistance.
Guidance on Fertility Treatment during Level 4 Lockdown from SASREG (Southern African Society for Reproductive Medicine and Gynaecological Endoscopy)
Date: 4th of May 2020
The President of South Africa has announced a staged reopening of the economy during the COVID-19 pandemic. From the 1st of May South Africa moves from level 5 to level 4 lockdown. The regulations were gazetted on the 29th of April. All medical and veterinary services are allowed during level 4 lockdown. Therefore, a progressive stepwise resuming of all fertility services is acceptable.
It is the opinion of SASREG that all fertility services, including IVF and egg donation, are allowed to proceed during level 4 lockdown. All protective measures for staff and patients that have been published in the SASREG update #4 are still valid and need to be followed. It is, however, still the responsibility of the reproductive specialist to assess each case on its merits and to discuss the treatment options with the patient. All Fertility Units, freestanding or as part of a hospital, needs to abide by regulations as stipulated by the Department of Health and the NICD. Fertility Clinics part of a hospital group needs to adhere to regulations stipulated by hospital management.
All patients should be tested for COVID-19 before an ART procedure. The recommendation on the guideline to read that all patients should be screened every time they visit the Unit/Hospital and be tested with a PCR for SARS-CoV-2, 3 or 4 days before oocyte aspiration (approx. D10-D11 of the cycle).
For further information, please read the full and unedited article at the source mentioned above.
Vitalab’s update regarding Novel Coronavirus (COVID-19)
Official UPDATE regarding COVID-19 and the LOCK DOWN of South Africa
Source: The Vitalab Doctors and Management Team
Date: 26th of March 2020
In continuation from our previous communications and due to the Presidential address on the 23rd of March 2020 announcing the lock down period within South Africa, starting on midnight Thursday the 26th of March 2020, the Vitalab Doctors and Management would like to inform our patients of the following important information.
Vitalab JHB & KZN remain open as essential medical service
With our strict compliance and risk management controls already in place, we have been planning for this eventuality, so we are well-equipped to continue with all essential medical services for our current patients. Our core suppliers, such as the genetic testing and availability of medicines at our pharmacy, will continue to be available to all our patients.
Wellbeing of Staff & Patients
Our staff have been assigned different shifts and rotational weekly schedules within each of the critical departments, so that we can continue to provide our medical services during this lock down period, but do so responsibly with only the necessary staff being within the clinic. Our priority is always the health and safety of all our patients and staff; thus all possible precautions have been put into place accordingly.
Travel letters have been provided to all staff and our admin team is working hard to provide all existing patients with travel letters to cover them during the lock down period for all essential in-person appointments. This travel letter would include visits to a Pathology Laboratory for the necessary blood tests, if going to a laboratory closer to their home rather than travelling to Vitalab Clinic.
We urge our patients whom are on active treatment plans to please call or email the Clinic and get an update on your specific case and next steps.
Vitalab Sandton – 011 911 4700 and firstname.lastname@example.org
Vitalab KZN – 031 880 1700 and email@example.com
Existing Patients awaiting treatment plans / surgery
For our patients on medication in preparation for future treatment (such as contraceptive pills, down regulation medications, other hormones, etc.) please also contact the Clinic and they will provide you with further details on your specific plan and also email you the necessary scripts, blood forms and letters so that you can still continue your medication throughout the lock down period in preparation for future treatment.
Skype & Telephonic Consultations
We encourage all existing patients where possible to set up Skype or Telephonic consultations in place of their in-person consultations. Please contact the relevant reception to assist you with rescheduling, changing, re-booking all appointments.
You can check our website (www.vitalab.com) and social media pages (Facebook, Twitter) regularly for updates and other COVID-19 resources, as this is an unprecedented time therefore changes or additions may need to be made for the various policies and precautions in place, as this pandemic develops over the next few days and weeks.
Thank you again for your co-operation and understanding in this incredibly fluid and unprecedented situation facing our beautiful Country. Vitalab is confident that we as a country will overcome this together and while the 21-day lock down may seem daunting, it is certainly a necessary approach to curb the current trajectory in South Africa. So, we do urge all South Africans to please adhere to all the guidelines provided by our Government for this lock down.
Corona Virus & Continued Essential Testing with Next Biosciences
Date: 25th of March 2020
In light of COVID-19, we would like to reassure you that our business will continue with minimal disruption. Due to our strict compliance and risk management controls, we have been planning for this eventuality for a few weeks now, so are well-equipped to continue with essential testing services.
As an ISO accredited biotech business in the medical science sector, we have always operated with stringent risk management protocols and contingency plans. As a result, we have various measures in place to ensure the safety of our people and products during this declared national state of disaster and the lock down period, and that business continuity is assured.
Our Client Services Team are readily available to assist you should you have any queries:
WhatsApp: 082 386 5289
Corona Virus & Pregnancy
Source: Adapted from various sources by the South African Society of Obstetricians & Gynaecologists (SASOG)
Date: 25th of March 2020
How is the virus spread?
The virus is carried by droplets which are spread when an infected person coughs or sneezes. It can also be passed on if you touch a surface which has been contaminated by an infected person. The most effective way of protecting yourself against catching this virus is by washing your hands regularly and thoroughly with soap and water; not touching your face; avoiding large groups of people; and, keeping a distance of a meter or more between yourself and others. Building up your immune system by eating well and getting enough rest is important to prevent you from contracting the disease.
Am I more likely to get the virus because I’m pregnant?
In general, pregnant women are more susceptible to infections than women who are not pregnant. While there is still much to learn about this new virus, there is currently no evidence to suggest that pregnant women are at higher risk of becoming infected with coronavirus than the general population. If you do contract the disease, it is most likely that you will only experience mild to moderate flu like symptoms. These include: sore throat; fatigue; dry cough and a mild fever. However, if you suffer from an underlying condition such as asthma or diabetes, contracting coronavirus may make you feel more unwell. More severe symptoms, like pneumonia are more common in people who have weaker immune systems and older people.
What about my baby?
For pregnant women who are infected with coronavirus, it seems that there is no increased risk of miscarriage or having a baby with abnormalities. At the moment, there is also no evidence to suggest that a pregnant woman can pass on the virus to her unborn baby. While there MAY be a higher risk of your baby being born prematurely, the research on this is not yet conclusive.
Can I breastfeed?
Yes. There is currently no evidence that the virus can be passed on through breastmilk. However, since the virus is passed on through respiratory droplets, it is important that you wash your hands before breastfeeding and that you consider wearing a mask, if you have one. Avoid coughing or sneezing while you are breastfeeding your baby. If you are using a breast pump to express breast milk, make sure that you wash your hands before touching the pump or the bottles and that you sterilise the bottles and pump after use. Where possible, use a dedicated breast pump if you are expressing breast milk in hospital. If you are using formula to feed your baby, ensure that bottles are sterilised.
How can I protect myself against becoming infected with coronavirus?
Personal hygiene, especially handwashing is the most effective way of preventing infection. Wash your hands regularly with soap and water or alcohol gel where there is no soap and water. Try to ensure that there is always 1.5m of physical distance between you and the next person to avoid breathing in any respiratory droplets. Try to avoid closed or crowded spaces where there is limited airflow. Drinking enough fluids, eating a healthy diet and getting enough rest will you’re your immunity against infection.
Should I attend my antenatal and postnatal appointments?
Antenatal and postnatal visits are important for you and your baby. If you have no symptoms and have had no known contact with an infected person, then you should attend your antenatal or postnatal appointments as usual. If you think you may have become infected with the virus or have symptoms, then you should postpone you visits until after your period of isolation. Contact your doctor or your health facility if you have a scan booked and you think you may be infected with the virus.
What should I do if I think I have been exposed to the virus or may have it?
If you think you have been in contact with the virus or suspect that you may have it, it is important that you do not simply visit your doctor’s rooms as this may spread the infection. you should call your doctor or the COVID-19 helpline on 0800 029 999 and tell them of your symptoms, your travel history and your contact with someone who has been infected with the virus. If you develop a continuous cough or a high temperature you should call your doctor or the COVID-19 hotline to tell them that you think you may have become infected with the virus. They will provide advice on whether you should be tested or whether you should be evaluated. You should also self-isolate for seven days.
Can I still go to work?
Since coronavirus is extremely contagious, it is advisable to work from home if possible. If your job or other factors prevent you from working from home, you should discuss with your employer ways in which exposure to the virus can be limited.
Can I travel?
Unless it is essential, travel should be avoided. If you must travel, then ensure that you have adequate insurance to cover you should you give birth to your baby while you’re away.
How are the tests for coronavirus conducted?
Tests for pregnant women are the same as for any other person. Currently, the test for coronavirus involves a swab being taken from your mouth and nose. You may also be required to cough up sputum, which will be tested.
What if I test positive?
If you have tested positive, you should inform your doctor or health facility. If your symptoms are mild or if you have no symptoms, you will be advised to stay at home to recover. If your symptoms are severe, you may have to be treated in hospital.
When should I self-isolate?
If you develop symptoms such as a high temperature or a new continuous cough or if you have been advised to recover at home after testing positive for coronavirus.
What does self-isolation mean?
If you have been advised to self-isolate, you should avoid contact with others for seven days.
Not going to work or public places
Not using public transport
Ensuring that there is good airflow in your room
Separating yourself from other members of your household and using separate crockery, cutlery, towels etc.
Eating at different times from others in the household
Trying to avoid the need for others to be in your room
Trying to keep active by exercising
Should I attend my antenatal visits if I am self-isolating?
If you are in self-isolation, it is most likely that your routine visits will be delayed until the self-isolation period is over. You should contact your doctor or health facility to let them know that you are in self-isolation and get their advice on how and when to proceed with antenatal visits.
What should I do if I am worried about my baby during self-isolation?
To avoid the risk of infecting others, it is not advisable to visit your doctor or health facility. Unless the matter is urgent, you should call your doctor or health facility for advice. If you are advised to go to hospital, then you should inform the hospital prior to admission that you have tested positive for the virus or suspect that you may be infected with the virus.
How will my confirmed or suspected coronavirus infection affect where I give birth?
Once you have informed your doctor or health facility of your suspected or confirmed infection, you may be advised to give birth in an obstetric unit where your baby can be monitored regularly. Since these monitors are only available in an obstetric unit in a hospital, homebirths or births where only a midwife is present, are not advised.
How will my confirmed or suspected coronavirus infection affect how I give birth?
Your coronavirus status should not affect how you give birth, so you should stick to your birth plan as far as possible. A caesarean section may be necessary if respiratory complication occur. Options for pain relief will be discussed with you early on during labour. Currently, there is no evidence against using methods such as epidurals or spinal blocks to relieve pain. However, the use of Etonox (gas and air) may cause the virus to spread.
What if I go into labour during self-isolation?
You should call your doctor, health facility or the COVID-19 hotline to inform them that you have a suspected or confirmed case of coronavirus and have gone into labour. They will provide advice on how to proceed. If you have mild symptoms, you will no doubt be encouraged to remain at home (self-isolating) in early labour, as per standard practice.
What care will I receive once I have recovered?
To ensure that your baby is well, you will most probably have an ultrasound scan two weeks after your recovery. Once you have recovered from the coronavirus infection, when and how you give birth will not be affected by your previous illness.
Will my baby be tested for coronavirus?
Yes, if you have suspected or confirmed coronavirus at the time of your baby’s birth.
Will I be able to touch my baby if I have suspected or confirmed coronavirus?
If your baby is well and doesn’t require neonatal care, then it is likely that your baby will be handed to you after giving birth and will be able to stay with you while you’re in hospital. Your doctor or health care worker may discuss with you the risks and benefits associated with this.
What if I am a health care worker and I am pregnant?
Currently, there is no evidence to show that pregnant women are more susceptible to the virus. However, if you become unwell, it is possible that there are some risks which include foetal growth restriction and premature birth. You are advised to discuss this with your superior.
Patient education: Coronavirus disease 2019 (COVID-19) (The Basics)
Source – Written by the doctors and editors at UpToDate, last updated Mar 20,2020.
What is COVID-19?
Coronavirus disease 2019, or “COVID-19,” is an infection caused by a specific virus called SARS-CoV-2. The virus first appeared in late 2019 in the city of Wuhan, China. But it has spread quickly since then, and there are now cases in many other places, including Europe and the United States.People with COVID-19 can have fever, cough, and trouble breathing. Problems with breathing happen when the infection affects the lungs and causes pneumonia.
Experts are studying this virus and will continue to learn more about it over time.
How is COVID-19 spread?
COVID-19 mainly spreads from person to person, similar to the flu. This usually happens when a sick person coughs or sneezes near other people. Doctors also think it is possible to get sick if you touch a surface that has the virus on it and then touch your mouth, nose, or eyes.
From what experts know so far, COVID-19 seems to spread most easily when people are showing symptoms. It is possible to spread it without having symptoms, too, but experts don’t know how often this happens.
What are the symptoms of COVID-19?
Symptoms usually start a few days after a person is infected with the virus. But in some people it can take even longer for symptoms to appear.
Symptoms can include:
- Feeling tired
- Trouble breathing
- Muscle aches
Most people have mild symptoms. Some people have no symptoms at all. But in other people, COVID-19 can lead to serious problems like pneumonia, not getting enough oxygen, or even death. This is more common in people who are older or have other health problems. While children can get COVID-19, they seem less likely to have severe symptoms.
Should I see a doctor or nurse?
If you have a fever, cough, or trouble breathing and might have been exposed to COVID-19, call your doctor or nurse. You might have been exposed if any of the following happened within the last 14 days:
- You had close contact with a person who has the virus – This generally means being within about 6 feet of the person.
- You lived in, or travelled to, an area where lots of people have the virus
- You went to an event or location where there were known cases of COVID-19 – For example, if multiple people got sick after a specific gathering or in your workplace, you might have been exposed.
If your symptoms are not severe, it is best to call your doctor, nurse, or clinic before you go in. They can tell you what to do and whether you need to be seen in person. If you do need to go to the clinic or hospital, you will need to put on a face mask. The staff might also have you wait someplace away from other people.
If you are severely ill and need to go to the clinic or hospital right away, you should still call ahead. This way the staff can care for you while taking steps to protect others.
Your doctor or nurse will do an exam and ask about your symptoms. They will also ask questions about any recent travel and whether you have been around anyone who might be sick.
Will I need tests?
If your doctor or nurse suspects you have COVID-19, they might take a sample of fluid from inside your nose, and possibly your mouth, and send it to a lab for testing. If you are coughing up mucus, they might also test a sample of the mucus. These tests can show if you have COVID-19 or another infection. Your doctor might also order a chest X-ray or computed tomography (CT) scan to check your lungs.
How is COVID-19 treated?
There is no specific treatment for COVID-19. Many people will be able to stay home while they get better, but people with serious symptoms or other health problems might need to go to the hospital:
- Mild illness – Most people with COVID-19 have only mild illness and can rest at home until they get better. People with mild symptoms seem to get better after about 2 weeks, but it’s not the same for everyone.
If you are recovering from COVID-19, it’s important to stay home, and away from other people, until your doctor or nurse tells you it’s safe to go back to your normal activities. This decision will depend on how long it has been since you had symptoms, and in some cases, whether you have had a negative test (showing that the virus is no longer in your body).
- Severe illness – If you have more severe illness, you might need to stay in the hospital, possibly in the intensive care unit (also called the “ICU”). While you are there, you will most likely be in a special “isolation” room. Only medical staff will be allowed in the room, and they will have to wear special gowns, gloves, masks, and eye protection.
The doctors and nurses can monitor and support your breathing and other body functions and make you as comfortable as possible. You might need extra oxygen to help you breathe easily. If you are having a very hard time breathing, you might need to be put on a ventilator. This is a machine to help you breathe. Doctors are studying several different medicines to learn whether they might work to treat COVID-19. In certain cases, doctors might recommend these medicines.
Can COVID-19 be prevented?
There are things you can do to reduce your chances of getting COVID-19. These steps are a good idea for everyone, especially as the infection is spreading very quickly. But they are extra important for people age 65 years or older or who have other health problems. To help slow the spread of infection:
- Wash your hands with soap and water often. This is especially important after being in public and touching other people or surfaces. Make sure to rub your hands with soap for at least 20 seconds, cleaning your wrists, fingernails, and in between your fingers. Then rinse your hands and dry them with a paper towel you can throw away. If you are not near a sink, you can use a hand gel to clean your hands. The gels with at least 60 percent alcohol work the best. But it is better to wash with soap and water if you can.
- Avoid touching your face with your hands, especially your mouth, nose, or eyes.
- Try to stay away from people who have any symptoms of the infection.
- Avoid crowds. If you live in an area where there have been cases of COVID-19, try to stay home as much as you can. Even if you are healthy, limiting contact with other people can help slow the spread of disease. Experts call this “social distancing.” In general, the recommendation is to cancel or postpone large gatherings such as sports events, concerts, festivals, parades, and weddings. But even smaller gatherings can be risky. If you do need to be around other people, be sure to wash your hands often and avoid contact when you can. For example, you can avoid handshakes and high fives, and encourage others to do the same.
- Some experts recommend avoiding travel to certain countries where there are a lot of cases of COVID-19. Travel recommendations are changing often. Experts do not recommend wearing a face mask if you are not sick, unless you are caring for someone who has (or might have) COVID-19.
If someone in your home has COVID-19, there are additional things you can do to protect yourself and others:
- Keep the sick person away from others – The sick person should stay in a separate room and use a separate bathroom if possible. They should also eat in their own room.
- Use face masks – The sick person should wear a face mask when they are in the same room as other people. If you are caring for the sick person, you can also protect yourself by wearing a face mask when you are in the room. This is especially important if the sick person cannot wear a mask.
- Wash hands – Wash your hands with soap and water often (see above).
- Clean often – Here are some specific things that can help:
- Wear disposable gloves when you clean. It’s also a good idea to wear gloves when you have to touch the sick person’s laundry, dishes, utensils, or trash.
- Regularly clean things that are touched a lot. This includes counters, bedside tables, doorknobs, computers, phones, and bathroom surfaces.
- Clean things in your home with soap and water, but also use disinfectants on appropriate surfaces. Some cleaning products work well to kill bacteria, but not viruses, so it’s important to check labels. The United States Environmental Protection Agency (EPA) has a list of products here: www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2.
There is not yet a vaccine to prevent COVID-19.
What should I do if there is a COVID-19 outbreak in my area?
The best thing you can do to stay healthy is to wash your hands regularly, avoid close contact with people who are sick, and stay home if you are sick. In addition, to help slow the spread of disease, it’s important to follow any official instructions in your area about limiting contact with other people. Even if there are no cases of COVID-19 where you live, that could change in the future.
If there is an outbreak in your area, schools or businesses will likely close temporarily, and many events will be cancelled. If this happens, or if someone in your family gets sick with COVID-19, you will probably need to stay at home for some time. There are things you can do to prepare for this. For example, you might be able to ask your employer if you can work from home, or take time off, if it becomes necessary. You can also make sure you have a way to get in touch with relatives, neighbours, and others in your area. This way you will be able to receive and share information easily.
Rules and guidelines might be different in different areas. If officials do tell people in your area to stay home or avoid gathering with other people, it’s important to take this seriously and follow instructions as best you can. Even if you are not at high risk of getting very sick from COVID-19, you could still pass it along to others. Keeping people away from each other is one of the best ways to control the spread of the virus.
What can I do to cope with stress and anxiety?
It is normal to feel anxious or worried about COVID-19. You can take care of yourself, and your family, by trying to:
- Take breaks from the news
- Get regular exercise and eat healthy foods
- Try to find activities that you enjoy and can do in your home
- Stay in touch with your friends and family members
Keep in mind that most people do not get severely ill or die from COVID-19. While it helps to be prepared, and it’s important to do what you can to lower your risk and help slow the spread of the virus, try not to panic.
Where can I go to learn more?
As we learn more about this virus, expert recommendations will continue to change. Check with your doctor or public health official to get the most updated information about how to protect yourself.
You can also find more information about COVID-19 at the following websites:
- South African Resource Portal: https://sacoronavirus.co.za/
- United States Centers for Disease Control and Prevention (CDC): www.cdc.gov/COVID19
- World Health Organization (WHO): www.who.int/emergencies/diseases/novel-coronavirus-2019
SASREG – Southern African Society for Reproductive Medicine and Gynaecological Endoscopy – which is the society for professionals within reproductive medicine, has released the following guidance and recommendations for Fertility Care and Surgery in South Africa during the COVID-19 pandemic.
Link to FULL article is here:
In summary for our patients: Anyone who is asymptomatic can continue treatment and surgery. A patient with a positive contact or positive test or has symptoms must obviously have their treatment deferred. Should a patient have to cancel their cycle we will obviously credit the account and the only loss they will incur will be for the cost of the medication.
Vitalab has been closely monitoring the official advice regarding COVID-19 and adopting best practice guidelines at both of our clinics.
In addition to the advice from World Health Organisation (WHO), American Society of Reproductive Medicine (ASRM) and South Africa’s Department of Health and other local relevant authorities, we would like to share further information about enhanced precautionary measures we have put in place at both our clinics.
The wellbeing of our patients and staff is always our priority and we ask for your assistance for us to continue to provide the best possible care at this time.
You may notice some changes in our reception areas, such as signage referring to our interactions with you, as well as hand sanitiser that we request you use upon entry. We’ve also temporarily removed magazines and some of our complimentary drinks and snacks.
Behind the scenes, we’re also increasing the frequency and level of cleaning in all patient areas including bathrooms, waiting areas and clinical areas. And as you know in our laboratories, your embryos develop in individual chambers in incubators.
What we need you to do:
1. Let us know if you or your support person:
are experiencing any symptoms such as fever, headache, runny nose, cough, sore throat or shortness of breath, ahead of attending one of our clinics.
have travelled internationally within the last 14 days.
have had close contact with someone diagnosed with or suspected of having COVID-19 within the last 14 days.
2. Apply hand sanitiser gel on arrival to our clinic.
3. For the protection of patients and their families, please consider who needs to be with you at your appointments and procedures. In addition, we respectfully request that you do not bring children or persons over 65yrs to the clinic at this time.
4. If you prefer not to attend the clinic, we can offer some appointments via phone/Skype. Please let us know so this can be arranged in advance.
We appreciate your cooperation during this time, and we will continue to update you as more information becomes available.
Please contact your Nursing Team or Reception, if you have any questions or concerns at this time.