#ProtectYourPastor

Dear fellow Christians,

I would like to provide specific advice to pastors and other church-members for providing spiritual and physical care to suffering persons with COVID-19.  None of this advice supersedes direction by your Church leaders or by the CDC or your local public health department.  It is important to be aware of city-wide planning and contingency plans to not reinvent the wheel.  Use your discretion when applying this personal advice.  Recognize this advice will not guarantee your protection.  Also, this is not intended to be used as medical advice; call 911 or your doctor’s office if any medical questions.

CDC guidelines for faith-based institutions and cleaning.

While we hope that hospitals will be able to cope with number of COVID-19 cases and other types of serious health conditions, it is possible that there will be people who will not be admitted to a hospital because of capacity limitations, due to lack of healthcare staff, rooms or supplies. Hopefully cities are preparing for this possibility by planning on areas (such as hotels, stadiums or gyms) for mild cases to isolate people (providing them with food and basic necessities while they recover) and other places for severe cases to have some sort of support at the end of life, especially so people don’t die alone.  If such planning is underway, I encourage church-members to consider helping with planning and volunteering.  In the event that these places are not set up and/or become overwhelmed, I believe churches may want to have some training in safety measures (such as Personal Protective Equipment) and other practical ways to help.  It is possible that you will need to accompany someone in their dying process or as they recover, either family members, fellow church-members or other clergy.  Most people do not have training in hospice care, nor in how to keep themselves safe while caring for someone who is contagious. I hope to provide this below.

Quarantine is the term for well people who were exposed to the disease.  Isolation is the term for sick people who are recovering at home.  In the same home, you can have people on quarantine (family members) and isolation (sick person).

Most people with COVID-19 will have mild symptoms, with symptoms similar to the flu (fever, cough, body aches, fatigue, shortness of breath), but they will not require hospital care.  They will not be so significantly short of breath that they need to be admitted or need oxygen.  These people will need to be isolated at home, but they still need physical, emotional and spiritual support.  Support will be especially needed for those who live alone, and especially older persons who are more likely to worsen, elder couples with no close family or friends to provide necessities or check in on them, those with physical or mental health issues, single parents with dependents, and the poor or vulnerable.  Sometimes people will initially be mild at home, but may need to go to the hospital if they worsen. Having someone calling them to check in several times a day and pray for them would be helpful.

The spouse or other household members (as well as anyone who has or had close contact with the sick person, including pastors) will need to be on quarantine.  Quarantine means that even people who feel well should not leave their house or be exposed to other persons for 2 weeks, in case they begin showing symptoms (you can go for walks, but do not have contact with other people, including the store, gas station, etc).  While most new cases occur from people who know they are sick, some people have mild symptoms and may not think they have COVID-19. It is also possible to transmit the infection to others even if you feel well!  This is because in the several days before symptoms start, you can shed the virus without knowing it.  As many as 25% of new cases may be caused by people who think they are well (pre-symptomatic).  Therefore, a quarantine for 2 weeks would include YOU if you decide to care for someone who is sick.  This means that YOU should stay at home and not have contact with other people while you monitor for any symptoms. This also means you could spread it to YOUR family members and/or, if you are a pastor, to other church-members or other clergy.  If you are a married clergy, your family needs to understand that if you are closely ministering to the sick in their home,s you will be quarantined, but they will not automatically be on quarantine.  However, they should avoid being close to you and be mindful of any symptoms and try to limit their exposure to others.  This may be especially hard for children to stay away from parents.  Then, if you develop symptoms, your family will have to start their 2 week quarantine while YOU are now placed in isolation (or admitted to the hospital).

If you are living in the same house as a sick person or decide to move in to care for them, you should stay in another room, preferably use a separate bathroom, and especially try not to be within 6 ft of the sick person.  The sick person should always wear a mask, especially if others are around.  You also need to wear a mask if you have close contact with a sick person.  You should wash your hands immediately after this close contact, or after touching anything the person might have touched, such as chairs, counters, tables, dishes, electronic devices, televisions, etc.  Shared bathrooms are a frequent place of exposure for family members and need frequent cleaning of handles, faucets, light switches, towels, etc.  Hands should be washed after cleaning bathrooms with soap for 20 seconds.  Special guidelines for pets are also given.  See the excellent CDC guidelines for home isolation guidance for family members and for patients.

These are the current CDC definitions for being a person who is at risk because of close contact and therefore needing to be quarantined. The CDC does not say what a “prolonged period of time” is but even sharing waiting rooms and buses has resulted in transmission.

“Close contact is defined as—a) being within approximately 6 feet (2 meters) of a COVID-19 case for a prolonged period of time; close contact can occur while caring for, living with, visiting, or sharing a health care waiting area or room with a COVID-19 case– or –b) having direct contact with infectious secretions of a COVID-19 case (e.g., being coughed on).” 

Again, if you are a pastor and have close contact with sick people to minister to them, even if you are not living with them, you need to be aware that this close contact would classify YOU as being at risk of being infected AND could mean that YOU could become contagious, passing it to other church members inadvertently.  If you have close contact with sick people, you must start your quarantine.  Whenever you leave a sick person’s home, you restart your 14 day quarantine, including not going out to other places (unless perhaps to another sick person’s house).  This is true even if you and/or the sick person are wearing a mask the whole time you visit them (a mask is helpful but no guarantee).

One way to avoid having “close contact” is to ask a sick person or their family member to drive to you and have the sick person stay in the car, and you stay at least 6 feet away.  You can pray for them this way and give them a blessing.  If you offer communion, you could wear a mask and/or breathe out while you approach and immediately back away to 6 feet.  Wash or sterilize your hands as soon as you can and never touch your face.  In my opinion and I believe in that of the CDC, this would not put you at risk or need to be on quarantine (this is not “prolonged exposure” with a sick person).  (This could potentially put the family member in the car at more risk (since this is less than 6 ft), so it is recommended that the sick person should wear a mask in the car, sit in the backseat away from the driver, maybe roll down windows. The family member driving could also wear a mask.)

If you are ministering to those with COVID-19 in homes, remember you are entering homes that are on quarantine.  As much as possible, you need to limit interactions with anything and anyone in the household.  Just because people look well does not mean they are not contagious (germs could be either on their clothes/hands, or they could shed the virus when coughing, sneezing or blowing their nose).  AND just because YOU feel well does not necessarily mean YOU are not contagious (it’s unlikely but still possible).  In other words, if you are entering homes where people are sick, you should try to refrain from hugging family members, touching them to pray for them, using their cups/utensils/bathrooms, etc because this increases exposure.  If any of this occurs, recognize that germs may be on your clothes and hands. Wash your hands afterwards, don’t wipe them on your clothes, use a paper towel to dry or air-dry, and don’t ever touch your face.  Ask them to tie up pets before you come over because pets could jump up on you and it might be on their fur.  If you touch the sick person to pray with them or anoint them, also recognize that germs are even more likely to be on the sick person’s body, clothes, bedding and other surfaces around them from their coughing.

That’s where this advice comes in – how to prevent yourself getting sick.

Personal Protective Equipment:
With regard to masks, the CDC guidelines recommend that at least the sick person at home should wear a mask.  However, if you are a pastor ministering in someone’s home, there may not be sufficient masks for sick people.  Also people who are very sick with shortness of breath will not be able to tolerate a mask; it can make it feel much harder to breathe. The family also may not have an extra mask for you and you should NOT wear one that they have already worn.  You should prepare to protect yourself, not only for your sake, but so that you don’t infect others inadvertently and also so that you don’t become a burden on the healthcare system that is already taxed.

Ideally, according to the CDC, you should wear a “surgical mask” (the normal kind of mask you see physicians wearing) to protect yourself from droplets from the coughing person.  We hope these provide enough protection, since there are not enough n95 masks to go around.  Surgical masks are likely difficult to find, but may still be available online. Three layers (three ply) are probably better than two layers (two ply) to stop droplets.  You have to try very hard not to adjust the mask while wearing it because every time you touch it, you can get germs from the mask onto your fingers.  It does need to cover both your mouth and nose.  Don’t pull it down under your chin between visits because you will increase the chance of getting germs on your fingers and chin.  We think the virus lives no more than 3 days on solid surfaces and only 24 hours on cardboard.  Newest CDC guidelines say these masks can be reused if folded carefully between uses and not visibly dirty, but the outside (the side facing the sick person) could have their germs on it.  *Please know that reusing these masks does increase the risk of getting germs from the outside of the mask onto yourself when you reuse it.*  I don’t know if Lysol would kill the germs but if you reuse it, you could consider spraying it down very carefully when you remove it and then letting it dry.

Please be aware that if the sick person has used a nebulizer (a machine with medicine for wheezing) in the last 3 hours or is on high-flow oxygen, you likely need something more than a surgical mask because of aersolization (germs becoming airborne).  It is unlikely that you will find disposable N95 respirators at this point, but this would be preferred for you to wear if patients have recently used a nebulizer or high flow oxygen.  If you do use either a surgical mask or an N95 respirator, the most dangerous part is removing the mask (called ‘doffing’).  This is where people accidentally get infected.  Again, you need to understand the outside is contaminated because it is a filter. If you adjust it throughout the day by touching the outside, you may spread germs on your fingers.  This is sometimes how healthcare workers get exposed to the virus – they touch their masks during the day or rub their nose under the mask after touching the mask, or they taking them off and reusing them without being careful about keeping the “dirty” side away from their face.  Meanwhile they contaminate their hands and/face or touching the inside of the mask which touches the mouth/nose.

You might consider using a full or half-mask respirator like this if you expect to do a lot of care for the sick and dying.  It might be “overkill” for most situations, but it would be safe, reusable and would certainly protect your eyes, nose and mouth.  https://www.amazon.com/3M-Facepiece-Respirator-Packout-Organic/dp/B000P18N4Y or https://www.grainger.com/category/safety/respiratory-protection/full-face-respirators

You buy the mask and the filters separately (but make sure they are the same brand to fit). Filters that are N95/P95 or above (99 or 100) would be more than sufficient (I think this is all of them).  You don’t need the more expensive organic chemical poisoning filter, just enough for germs. If you use something like this, the outside of the respirator could become contaminated if the patient coughs on it or if you touch the outside with dirty hands.  You need strong clorox wipes or Lysol spray with wipes to carefully clean the outside but even then, you probably won’t be able to clean every part of it, so it’s best to try to not touch the side that faces the outside world.  You cannot get the filters wet and should NOT spray them with Lysol. You should wash your hands before and after cleaning the respirator and before and after putting it on.

People might be surprised or scared to see you in this device, but it might also reassure them that you want to stay healthy in order to minister to more people.  You might ask your parish to buy one for you, since it would protect you from sick persons and would also protect well persons (family members in quarantine) from YOU, if you were sick without knowing it.  If these are sold out or not an option, stay tuned on this page because I am hoping we can design simple instructions for making surgical masks and perhaps people in the parish could make them for you, ones that you could throw away or potentially sterilize with bleach or wash and reuse.  A final option might be purchasing a solid pollution mask from Cambridge.  These are also N95 or above.  This is similar to what I have for daily use now in the office.  These are sold out for some time but you can get on the waiting list. See my last blog for healthcare worker tips on how to clean this type of mask.

See this link for information on homemade masks vs surgical masks vs n95.

You also need to protect your eyes from droplets containing germs. If you don’t have a full face respirator like the one linked above, you can use woodworking type goggles or a full face shield.  Even glasses may provide some protection.

You won’t have gowns and don’t likely need them if you don’t sit down and are able to wash your clothes as soon as you get home.  However, you can consider wearing a long-sleeved apron (like a painter’s shirt) or long-sleeve button-down shirt (with buttons on the back that you don’t button closed) that you can carefully remove (inside out, so the dirty part never touches your clothes).  I recommend you watch how healthcare workers remove their gowns and try to imitate this according to your situation.  You could carefully place it into a plastic bag and wash it immediately.  I would NOT recommend a T-shirt that you pull over your head because you might drag germs over your face when you remove it.

Gloves often give a false sense of reassurance, and if used, have to be carefully removed to prevent getting germs on yourself.  I think good hand-washing for 20 seconds with soap and warm water is much better than gloves.

Process of entering:
Before you enter the house, you should “don” your shirt/gown if you have one, your eye protection and face mask or respirator.  Again, a face mask must cover mouth and nose to be effective. Don’t touch your face after you enter the house, no matter how bad your nose itches. If you MUST touch your face, wash or sterilize your hands before you do.

Process of leaving:
When you get ready to leave the house of the sick, the last thing you should do is wash your hands before leaving their house. Ask the family to open to the door so you don’t touch the door handle.  Alternatively, use hand sanitizer immediately upon leaving.  Once outside the house, untie or remove the mask/respirator from behind your head and try not touch the front.  If it is disposable, let it fall away from your face and throw it away carefully outside (maybe leave it on their porch for them to collect later or pick it up with a bag like its dog-poo).  If a reusable respirator mask, remove it before getting in your car and sterilize it very carefully with wipes.  Place it in a clean plastic grocery bag (use a new grocery bag each time; it’s okay if it had groceries in it some time ago).  Remove the googles or face shield carefully and sterilize them as well with wipes or lysol and place them a clean grocery bag.  Leave these in the car.  (When you use them next time, throw away the dirty grocery bag and always have clean ones for the next time after you sterilize it).  After you remove your mask/respirator and goggles or face shield, sterilize your hands again.  Go home immediately after ministering to people.  Close your eyes and mouth and carefully remove your clothes.  Place them directly in the washing machine without having them touch any clean clothes or items. Carefully sterilize any pens, car-keys, wallet or iphone that you had touched.  Then shower, trying to let the initial water on your face drain away from your eyes, nose and mouth (in case any germs landed on your neck or forehead, you don’t want them to end up in your eyes/nose/mouth).  Then, if you have Lysol, go back outside, spray down your steering wheel, door handle, gear-shift, seat belt and seat (anything where germs from your hands or on your clothes might have landed in your car).

If you are visiting multiple people with COVID-19 during the day, it may be best to stay in the gear (without touching/adjusting your mask – this is really hard!) or removing the eye protection.  Then do everything above when you leave the last house and when get home.  If you visit multiple homes, you would potentially be carrying more germs, so it would be even more important that well family members on quarantine not touch you if you had been to several other homes already.  You should certainly not go the homes of people who are NOT under isolation or quarantine.

Consider prioritizing younger and healthy clergy and those without families to minister to those sick or dying, rather than parish-by-parish/church-by-church.  This way not all clergy are on quarantine at the same time.  Younger and healthier people have less risk of hospitalization or dying if they contract the disease.  Also, church-members who are ill with other conditions may still need a priest to visit them and funerals will need to happen too.  If you have all priests/pastors on quarantine, no one will be able to minister to other people.  Again, I can’t stress this enough – clergy shouldn’t interact with healthy people if they are on quarantine, because they might accidentally infect healthy people!  Phone or video ministry by clergy will likely become even more important.  Clergy who are more at risk if they got COVID-19 could also consider phone and video ministry.  That said, even with your best efforts to keep high-risk clergy away from sick people, some clergy will get infected accidentally even if they are only ministering to people they think are healthy, and even if they are being careful. You need to be prepared for this and how to support them.

If clergy get infected and are able to be isolated at home, they can still minister to other infected people if well enough, but technically are not supposed to leave their own homes (because they are on isolation).  Once someone is infected and recovered, they are immune and we don’t think they will get reinfected.  This needs more research.

I would not recommend that you consecrate hosts for ministry if you yourself are on quarantine.  I would recommend having a priest who is NOT on quarantine (not sick or at risk of being sick) to enough consecrate hosts for ministry and you use these to offer to the family members.

Churches might consider a hot-line for people to call if they become isolated at home with COVID-19 or if they are quarantined at home, and need food, toiletries or money for bills.  Some people may need someone to take care of children or pets if hospitalized.  Some people might need someone to collect over-the-counter or prescription medication for them or their family members.  Most churches already have someone in charge of support for other needs and perhaps there can be a 24 hr hot-line resource with multiple people “on call” to help.

You may need to designate pastors for funerals and may need to have multiple funerals at the same time, which would be difficult if family members for each deceased person want to attend.  Remember the mourning family members after funerals.  Try to offer support to them.  Have church-members sign up to call and touch base with mourners, bring them food, etc.  Also let us not forget the homeless, the poor, those who are not “churched,” etc. Many will suffer economically and emotionally.

Hospice measures:
Again, we hope that people will not be turned away from the hospital and that there will be hospice for those expected to die.  However, this may not be the case. For people who are expected to die, a fan can help with breathlessness (although this perhaps makes things more risky for family members by potentially “blowing” germs around).  Hospice medications that help with breathlessness include anxiety medications called “benzos” (benzodiazepines) and pain medication called narcotics.  These help relieve symptoms and you could ask a telemedicine doctor to call these prescriptions in for your loved one (most doctors are starting telemedicine this week and these medications no longer require a paper prescription, at least in Kansas).

Those who care for dying persons would be at very high risk of getting sick, especially if they are physically lifting them, cleaning them, helping them to use the bathroom, etc.  Often this responsibility will fall on family members (for example an elderly spouse) who may not be the best equipped for this kind of physical or emotional work.  This work would be an act of charity ideally by church volunteers who have already recovered from the virus, and if not available, by young healthy persons, preferably without dependents, who are aware of the high personal risk they are taking.  They should try to wear Personal Protective Equipment, such as gown, mask, goggles, etc.  These volunteers should be spiritually and emotionally supported by others because accompanying people as they die, especially if you are not trained in hospice, can be very hard. If they get sick (which is likely), they too should be supported.

I will continue to update this.  Please comment with any questions. Please also link on social media with any other ideas with #ProtectYourPastor

In Christ,

Dr. Lisa Gilbert

She is a fellow CMA (USA) member, Global Missions Committee Chair, and Chair of the Family Medicine Section of American Academy of Prolife Obstetricians and Gynecologists.