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Abstract
Doctors, nurses, house cleaning staff and hospital ward attendants are at increased
risk of acquiring coronavirus disease 2019 (COVID-19) if there is a breach in the
personal protection equipment. A new simple, easy to implement scoring system has
been developed by our Suraksha Chakra team which can be used by the policy makers
and hospital administrators. The scoring system is not to discourage anyone but constantly
reinforce the healthcare workers for safe practices during patient care.
Background & objectives: Healthcare workers (HCWs) are at an elevated risk of contracting COVID-19. While intense occupational exposure associated with aerosol-generating procedures underlines the necessity of using personal protective equipment (PPE) by HCWs, high-transmission efficiency of the causative agent [severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)] could also lead to infections beyond such settings. Hydroxychloroquine (HCQ), a repurposed antimalarial drug, was empirically recommended as prophylaxis by the National COVID-19 Task Force in India to cover such added risk. Against this background, the current investigation was carried out to identify the factors associated with SARS-CoV-2 infection among HCWs in the country. Methods: A case-control design was adopted and participants were randomly drawn from the countrywide COVID-19 testing data portal maintained by the ICMR. The test results and contact details of HCWs, diagnosed as positive (cases) or negative (controls) for SARS-CoV-2 using real-time reverse transcription-polymerase chain reaction (qRT-PCR), were available from this database. A 20-item brief-questionnaire elicited information on place of work, procedures conducted and use of PPE. Results: Compared to controls, cases were slightly older (34.7 vs. 33.5 yr) and had more males (58 vs. 50%). In multivariate analyses, HCWs performing endotracheal intubation had higher odds of being SARS-CoV-2 infected [adjusted odds ratio (AOR): 4.33, 95% confidence interval (CI): 1.16-16.07]. Consumption of four or more maintenance doses of HCQ was associated with a significant decline in the odds of getting infected (AOR: 0.44; 95% CI: 0.22-0.88); a dose-response relationship existed between frequency of exposure to HCQ and such reductions (χ2 for trend=48.88; P<0.001). In addition, the use of PPE was independently associated with the reduction in odds of getting infected with SARS-CoV-2. Interpretations & conclusions: Until results of clinical trials for HCQ prophylaxis become available, this study provides actionable information for policymakers to protect HCWs at the forefront of COVID-19 response. The public health message of sustained intake of HCQ prophylaxis as well as appropriate PPE use need to be considered in conjunction with risk homoeostasis operating at individual levels.
The severity of the COVID-19 outbreak is the greatest public health threat caused by a respiratory virus since 1918. According to the Imperial College, 2.2 million Americans could die if we do not mitigate the spread of infection [1]. With the incidence of COVID-19 increasing, it may only be time before the healthcare system becomes overwhelmed and forces physicians to triage treatment among critically ill patients. Without an intervention, it is likely that there will be more seriously ill people than we have the resources to care for [1]. The rate of COVID-19 infection is largely determined by its reproductive number (R0)-the number of secondary infections produced by an infected person. If the R0 is >1, infections will continue to spread. If R0 is ≤1 the infection will eventually diminish. The R0 of COVID-19 is estimated at 1.3–6.5, with an average of 3.3 [2]. R0 is affected by a number of factors including the innate properties of the virus, and the amount/duration of contact people have with each other [3]. Although we cannot influence biological properties of the virus, we can change the amount of contact we have with each other via a phenomenon known as social distancing. Social distancing is the practice of increasing the space between people in order to decrease the chance of spreading illness. According to the CDC, spacing of 6 ft away decreases the spread of COVID-19 [4]. Individual actions include working remotely, avoiding public transportation, and staying home if you suspect you have been exposed and/or are symptomatic [5]. Community-wide measures include transition to online teaching, businesses temporarily closing, and the widespread engagement of telecommunication [6]. Multiple states including Washington state, California, and New York are resorting to statewide home orders being issued to minimize contact [[7], [8], [9]]. Nationwide measures taken to minimize contact with potentially infected individuals include cancelling travel from China and Europe [10]. It is likely that additional action will be taken with suspension of domestic air travel on the list. According to a large study performed in China, younger individuals are more likely to be asymptomatic when infected and could be unaware they are putting others at risk [11]. Of noteworthy importance is the risk of transmitting infection to the elderly, particularly those over the age of 60 [12]. The severity of illness is much more dire in this population with a strong association between in-hospital death and older age [13]. For this reason, it is essential that contact is limited not only to ensure personal safety, but also to prevent the spread of disease to others who are at high risk for developing severe complications. Social distancing also plays a role in lessening the burden imposed on the healthcare system. In the absence of any intervention, there would be a rapid rise in the number of cases that could overwhelm the healthcare system's capacity, and force physicians to treat some patients over others. If 200,000 people became critically ill in the same week, it would overwhelm the <100,000 ICU beds [14]. Moreover, it is likely that many of these patients would require a full-feature ventilator, exceeding the 62,000 available [15]. On the other hand, if this same situation occurred over the course of several weeks, it would be more manageable. Social distancing has the potential to slow the rate of infection and reduce the peak of incidence, and then fewer critically ill patients would need care on any one day. The peak incidence could be reduced to a level the healthcare system is equipped to adequately respond to and save thousands of lives that would otherwise be left without treatment. Delaying the peak to a later time-period could be beneficial. Delaying the peak incidence to the summer holds potential for healthcare facilities to dedicate more resources to those ill with COVID-19. Many of the resources used for serious cases of influenza are also required for severe cases of COVID-19 and stalling the peak incidence of cases to the summer when the majority of influenza cases have resolved may lend more resources to these patients. In the end, this improves the healthcare system's ability to treat those in critical condition without the need to ration. It is too late to stop COVID-19; the importance of slowing the infection cannot be understated. With the vast amount of cases identified in the US, resources are becoming scarce. Concern in public health has often been about the shortage of physicians- rarely do we consider if a ventilator will be available if you become critically ill. Social distancing is a realistic solution that all individuals can take part in to reduce the risk of infection while increasing available resources to critically ill patients, during this pandemic. We can still practice physical distancing while remaining connected socially, emotionally, and spiritually. We can do this together to defeat the COVID19 pandemic and continue moving forward towards a brighter future for our current and future generations.
Currently, there are 1.2 million physician Healthcare Workers (HCWs) in the United States (US), 20% over the age of 55 [2]. Similarly, in the hospital setting, there are 2 million registered nurses, with 22% are over the age of 55 and of the 1.2 million registered nurses employed outside of the hospital, 29% are over the age of 55 [1]. According to the CDC, older adults are at higher risk of infection and complications related to COVID-19, particularly those over the age of 65, the age group that currently comprises 8 out of 10 US deaths from COVID 19 [2]. All ages are susceptible to COVID-19, with close contact with an infected individual [3]. Given this assessment, physicians, nurses and other staff risk their personal health each time they tend to COVID-19 patients and this is made worse by the shortage of PPE (Personal Protective Equipment). Lack of PPE and inadequate social distancing are the two modifiable risk factors that if addressed through the implementation of enforced physical distancing, increasing the availability of PPEs, and proper guidelines would significantly reduce transmission rates and help save lives [4,5]. In March 2020, Italy reported over 2600 HCWs were infected, devastating their already worn-down workforce [6]. Observing the wreckage ensuing across the globe, it is imperative to better prepare and care for our HCWs. Many hospitals and states have not yet released their number of HCWs testing positive for COVID 19. Those who have released their numbers include hospitals from Washington State, Massachusetts and Alabama. The number of US HCWs confirmed infected with COVID 19 is over 800 [[7], [8], [9], [10], [11]]. As more states release their numbers, the amount is expected to rise, possibly dramatically, as more states are issuing tests to their HCWs in high risk exposure situations [12]. Additionally, there is an ever-growing list of HCWs from across the globe who have lost their lives due to COVID-19 [[13], [14], [15]]. As the number of HCWs infected and dying continue to rise, so our providers continue to diminish. The physical and psychological well-being of our HCWs are being tested as patient loads continue to increase and fellow co-workers become infected with COVID-19, contributing significantly to burnout among healthcare workers [[16], [17], [18]]. The effects of this increase in workload in the dangerous atmosphere of this pandemic are the decline in the mental health of our HCW [16,17]. Throughout this pandemic HCWs have had to self-isolate from their own families for fear of transmitting the virus to their loved ones [17]. There will be guilt when a family member becomes infected. Our HCWs are bravely living in a constant state of psychological stress founded in fear; fear of transmitting the virus and stress of the unknown aspects of this virus. The long-term effects of stress can result in post-traumatic stress disorder, anxiety and depression [19]. Thus, it is imperative to employ productive strategies to care for the mental health of our HCW. The mental health needs of our providers must be addressed with the same priority of their physical health. Keeping our HCWs updated on the latest information diminishes the fear of uncertainty and negative emotions associated with the virus [20]. This entails frequent information sessions on the specific details of the virus, practicing ethical decision making, and how to effectively use hospital resources [19]. By ensuring that the entire team maintains the same understanding of information and protocols, a certain amount of order can be maintain to curtail the negative impacts of this crisis. Additionally, establishing break time will allow for HCWs time to take care of themselves. Another recommendation centers on creating healthcare staff reserves to relieve those on duty before exhaustion and strain sets in resulting in anxiety and depression, affecting the quality of healthcare delivery. This can be done in several ways, including incorporating outside registered nurses into the hospital system, re-employing HCWs who recently retired, and adding in the newly matched fourth year medical students. As this crisis progresses it is imperative to continue to evaluate the well-being of our HCW and implement effect measures to care for their mental health. This global crisis has fostered fear among healthcare workers. Healthcare workers are scared for their co-workers, their families, their friends, our communities and our country. Despite this fear, they continue to fight on the frontlines to execute their job while in a persistent state of survival mode in order to protect everyone around them. In order to win this war against COVID 19, we must come together on a united front to support those on the frontlines. While our healthcare workers continue to fight, we must help them fight off any potential short or long-term effects during and after the COVID19 pandemic. This requires the implementation of accessible counseling services and effective measures to care for their mental well-being in order to preserve their health.
Title:
Journal of Family Medicine and Primary Care
Publisher:
Wolters Kluwer - Medknow
(India
)
ISSN
(Print):
2249-4863
ISSN
(Electronic):
2278-7135
Publication date
(Print):
April
2021
Publication date
(Electronic):
29
April
2021
Volume: 10
Issue: 4
Pages: 1512-1514
Affiliations
[1
]Department of Diagnostic and Interventional Radiology, All India Institute of Medical
Sciences (AIIMS), Basni, Jodhpur, Rajasthan, India
[2
]Department of Microbiology, All India Institute of Medical Sciences (AIIMS), Basni,
Jodhpur, Rajasthan, India
[3
]Department of Nursing College, All India Institute of Medical Sciences (AIIMS), Basni,
Jodhpur, Rajasthan, India
[4
]Department of General Medicine, All India Institute of Medical Sciences (AIIMS), Basni,
Jodhpur, Rajasthan, India
[5
]Director and CEO, All India Institute of Medical Sciences (AIIMS), Basni, Jodhpur,
Rajasthan, India
Author notes
Address for correspondence: Dr. Binit Sureka, Associate Professor and Deputy Medical Superintendent, All India
Institute of Medical Sciences (AIIMS) Jodhpur - 342 005, Rajasthan, India. E-mail:
binitsurekapgi@
123456gmail.com
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