|Year : 2021 | Volume
| Issue : 3 | Page : 151-156
Clinical spectrum, transmission dynamics, outcome and hydroxychloroquine prophylaxis in COVID-19 positive health care workers at a tertiary care hospital
Shiwangi Sharma1, Arvind Achra2, Abhinaya Venugopal2, Desh Deepak3, Kirti Nirmal4, Stuti Kansra2, Anuradha Shulania2, Mala Chhabra2, Nandini Duggal2
1 Integrated Disease Surveillance Programme, National Centre for Disease Control, New Delhi, India
2 Atal Bihari Vajpayee Institute of Medical Sciences, New Delhi, India
3 Department of Respiratory Medicine, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, India
4 University College of Medical Sciences, Guru Teg Bahadur Hospital, New Delhi, India
|Date of Submission||06-Mar-2021|
|Date of Decision||12-Apr-2021|
|Date of Acceptance||15-Apr-2021|
|Date of Web Publication||13-Sep-2021|
Assistant Professor, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
Introduction: Being at the forefront, health-care workers (HCWs) have been at an increased risk of developing COVID-19.
Objectives: To understand the pattern of the clinical symptoms, transmission dynamics, intake of hydroxychloroquine (HCQ) prophylaxis and outcome in COVID-19 positive HCWs.
Methods: One hundred and fifty-one COVID-19 infected HCWs were telephonically followed up to study the exposure details, clinical presentation, comorbidities, HCQ prophylaxis, outcome and further transmission to their families.
Results: The most commonly infected were doctors 60 (39.74%), followed by nursing staff (22.52%) and office staff (13.25%). Only 40 (26.49%) of infected staff was posted in COVID area. The most common source of exposure were patients (33.11%), followed by fellow staff members (28.48%) and 13 (8.61%) had contracted the disease from their family. Fever (74.17%) was the most common symptom followed by myalgia (43.71%), anosmia (37.75), sore throat (33.77%), ageusia (31.13%) and dry cough (28.48%). Three (1.99%) HCWs expired due to COVID-19 and 23 (16.31%) transmitted infection to their family members.
Conclusions: This study concludes that HCWs are at greater risk of acquiring infection, particularly while working in non COVID areas, contracting the virus mainly from patients and co-workers. They are also a potential source of onward transmission to their colleagues and family.
Keywords: Burden of COVID-19, COVID-19 in health-care workers, hydroxychloroquine prophylaxis
|How to cite this article:|
Sharma S, Achra A, Venugopal A, Deepak D, Nirmal K, Kansra S, Shulania A, Chhabra M, Duggal N. Clinical spectrum, transmission dynamics, outcome and hydroxychloroquine prophylaxis in COVID-19 positive health care workers at a tertiary care hospital. J Clin Sci Res 2021;10:151-6
|How to cite this URL:|
Sharma S, Achra A, Venugopal A, Deepak D, Nirmal K, Kansra S, Shulania A, Chhabra M, Duggal N. Clinical spectrum, transmission dynamics, outcome and hydroxychloroquine prophylaxis in COVID-19 positive health care workers at a tertiary care hospital. J Clin Sci Res [serial online] 2021 [cited 2021 Nov 29];10:151-6. Available from: https://www.jcsr.co.in/text.asp?2021/10/3/151/325817
| Introduction|| |
COVID-19 came into the world unannounced and soon became a part of our existence. It started rapidly spreading in an immune naive population as an illness of concern. The outbreak of COVID-19; the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) has a detrimental effect on every aspect of human life and in particular on the global healthcare systems. Globally as millions of people stayed at home to minimise the transmission of SARS-CoV-2, health-care workers (HCWs) prepared to do the exact opposite. This increased their exposure and hence the risk of acquiring COVID-19. In addition, they became a potential source infection in terms of local hospital transmission and further transmission to their families. Ours was the first hospital in Delhi to be designated as a nodal centre. Soon as the cases were rising, many HCWs contracted the disease. The aim of this study was to understand the pattern of the clinical symptoms, transmission dynamics, intake of hydroxychloroquine (HCQ) prophylaxis and outcome in COVID-19 positive HCWs in a tertiary care hospital.
| Material and Methods|| |
Our hospital was physically demarked into COVID and non-COVID area from the start of March 2020. The patients were admitted accordingly and so were the duties assigned to the hospital staff. Staff was tested for COVID-19 whenever they developed symptoms suggestive of the said disease or after an exposure, lacking appropriate PPE from a COVID-19 patient. Moreover, all the staff was also tested after the 15 days of rotational COVID duty irrespective of their symptoms. Whenever a sample was collected for COVID-19 testing, a mandatory Indian Council of Medical Research (ICMR) formulated specimen referral form (SRF) was filled. Categories 3 and 5b of the form are designated for HCWs. The polymerase chain reaction (PCR) test was used to detect the positivity to genes of SARS-COV-2, using various commercially available reverse transcription PCR (RT-PCR) kits. From the very beginning of COVID testing, all the microbiologically tested COVID-positive HCWs were personally informed about their results by residents of the Department of Microbiology. During this conversation, information provided in SRF form was verified and missing information was collected. This study was conducted over a duration of 3 months from May to July 2020. All the COVID-19 infected HCWs were telephonically followed up to study the exposure details, clinical presentation, comorbidities, HCQ prophylaxis, outcome and further transmission to their families. During telephonic conversation, participants consented to use of information for research and the study was approved by the Institutional Ethics Committee.
The data entry was done in the Microsoft Excel (Microsoft Corp, Redmond, WA), spread sheet. Categorical variables are presented as numbers and percentages. Continuous variables are presented as mean ± standard deviation (SD). The association of the variables which were qualitative in nature were analysed using Fisher's exact test. A P value <0.05 was considered as statistically significant. Statistical Package for Social Sciences (SPSS) software version 21.0 (IBM Corp Somers NY, USA) was used for statistical analysis.
| Results|| |
In a span of 3 months (May-July, 2020) 189 HCWs tested positive for COVID-19. Of these 151 could be followed up for the study. Their mean age was 34.9 ± 10.2; 58.3% were males. The most commonly infected were doctors 60 (39.7%), followed by nursing staff (22.5%) and office staff (13.3%) [Table 1].
|Table 1: Distribution of sociodemographic characteristics of study subjects|
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Only 40 (26.5%) of infected staff was posted in COVID area. Whereas, 111 (73.5%) were posted in non-COVID areas. Out of the infected 151 HCWs, 106 (70.2%) had a clear exposure history while 45 (29.8%) did not have any known exposure history. The most common source of exposure were patients (n=50, 33.1%), followed by fellow staff members (n=43, 28.5%) and (13, 8.61%) had contracted the disease from their family [Table 2].
One hundred and thirty (86.1%) HCWs were symptomatic while 21 (13.9%) remained asymptomatic. The total duration of symptoms ranged between 0 and 30 days, mean being 8.2 ± 6.6 days. The most common symptoms observed were fever (74.2%), myalgia (43.7%), anosmia (37.8), sore throat (33.8%), ageusia (31.1%) and dry cough (28.5%). The less common symptoms were headache, diarrhoea, breathlessness and productive cough. The least common symptoms were runny nose, chest pain, vomiting and abdominal pain. Fever, myalgia, anosmia persisted for maximum number of days in many HCWs, range being 1–18, 1–20 and 2–20 days, respectively. Furthermore, 5 (3.3%) cases reported a petechial rash while 2 (1.3%) complained of hypersomnia [Table 3].
Of all the infected HCWs, 101 were isolated at home, due to mild symptoms while 12 were isolated at COVID-care centre arranged by the hospital. However, 38 (25.2%) were admitted in hospital due to reasons such as breathlessness, persistent high grade fever and co-morbidities [Table 4].
Eighty-three (55%) of the HCWs did not take any HCQ prophylaxis. Out of 67 (44.4%) who took the drug, 22 were on HCQ prophylaxis and they contracted the virus before the completion of regimen. One HCW was already on therapeutic HCQ due to preexisting Rheumatoid arthritis for the past 1 year. The duration of taking HCQ ranged between 1 and 63 days, depending on the compliance of the HCW and appearance of side-effects of the drug, if any. The mean ± SD duration of HCQ prophylaxis was 26.2 ± 15.4 days [Table 5].
The most common co-morbidity in the study group was diabetes (6%) followed by hypertension (4%) and asthma (3.3%) [Table 6].
During the study, 3 (1.99%) HCWs expired due to COVID-19. We did not find any association of HCQ with the mortality (P > 0.99) [Table 7]. Onward transmission of infection by HCWs to their family members was observed in 23 (16.3%) cases.
| Discussion|| |
Given the transmission dynamics of SARS-CoV-2, HCWs are at increased risk of being exposed to the virus within hospitals and can also be a source of transmission by introducing the virus into their hospital and to their families. Compared with the general community, front-line HCWs were at increased risk of reporting a positive COVID-19 test (adjusted hazard ratio 11.61, 95% confidence interval [CI] 10.93–12.33) in the UK and USA. Out of the total staff of 6300 working in our hospital, 189 (3%) were tested positive for COVID-19 in a span of 3 months. Although the actual numbers may be higher, as only those who were tested by RT-PCR in our department were included in the study and we believe that some asymptomatic staff might have never been tested. A study from Qatar showed that 10.6% of their HCWs tested positive for COVID-19 from 10 March, 2020 to 24 June, 2020. However, a meta-analysis conducted for studies till September end estimated an overall seroprevalence of SARS-CoV-2 antibodies among HCWs to be 8.7% (95% CI 6.7%–10.9%).
Of the followed up 151 HCWs, 63 (41.72%) were female and 88 (58.28%) were male. Although there is no preponderance of COVID-19 for any sex, slightly higher proportion of males can be explained by the fact that higher number of male staff is working in hospital as compared to females.
The most commonly infected were doctors 60 (39.7%), followed by nursing staff (22.5%). This highlights the fact that the maximum infection rate was seen in staff which had the most direct contact with the patients. The mean age of the infected staff was 34.9 ± 10.2 (SD) years. This can be explained by the fact that majority of overall staff of the hospital comprises of younger age group, such as resident doctors and nursing staff.
Only 26.49% of the staff was posted in COVID area when they got the infection, while the majority 73.5% were posted in non-COVID area when they contracted the virus. To the best of our understanding, this could be because in the non-COVID area, the HCWs must have been complacent about the precautions, such as PPE and hand hygiene. Also, in the course of the pandemic, we observed that many patients who initially presented with non-COVID symptoms and were admitted in non-COVID care, were later found to be COVID positive during the course of their hospital stay, exposing many HCWs. A similar study stated that, only 5% of the infected HCWs acquired infection while working at a COVID-19 facility and full personal protection equipment (PPE) adherence was observed to be 82% at COVID-19 facilities but only 68% at non-COVID-19 facilities.
History of exposure was available in 106 infected; patients (33.1%) being the most common source followed by co-workers/staff (28.5%). This states that majority of the staff who became infected, got the disease in hospital premises. Accidental exposure to co-workers has been noted to be responsible for up to 45% of the infections. This can be due to reasons such as casual conversation during asymptomatic phase, eating meals together, sharing common areas such as hospital mess, canteen and lavatories. A recent analysis has demonstrated that transmission from asymptomatic individuals can account for more than half of the total transmissions. However, 13 (8.6%) HCWs had an exposure from known positive family member. Households have been noted as important venues for transmission. In 45 (29.8%) cases no source could be identified. This could be plausibly explained by the widespread community transmission of the virus around that time.
Symptoms and temperature monitoring have been used as essential screening tools for predicting SARS-CoV-2 infection in HCWs. Anosmia/ageusia, fever and myalgia are the strongest independent predictors of positive results. The mean duration of symptoms was 8.21 ± 6.6days (range 0–30 days). Fever was the most common symptom and was present in 112 (74.2%) cases. It was high grade and was associated with chills in maximum number of cases. Myalgia (43.7%) was second most consistent symptom and was the most debilitating. Many complained that they never experienced such severe body ache before COVID. Anosmia (37.8%), sore throat (33.8%), ageusia (31.1%) and dry cough (28.5%) were other common symptoms. The least common symptoms were mainly abdominal such as diarrhoea (10.6%), vomiting (2.7%) and pain abdomen (1.3%). However, 21 (13.9%) HCWs remained asymptomatic throughout the span of positive RT-PCR. The symptoms were consistent as per the WHO list of most common symptoms., However, we did encounter some unusual symptoms such as a petechial rash in 5 (3.3%) patients. These rashes were centripetal in nature and were itchy. These appeared either in the very beginning or in the convalescence phase of the disease and subsided in 3–4 days. Similar findings have been reported by other studies. It is discussed in literature that this may be a COVID related symptom or side effects of drugs which were rampantly used in COVID positive patients. Two (1.32%) patients also complained of hypersomnia post recovery from primary symptoms (fever, myalgia) which continued for around 20 days. Persistent altered olfactory symptoms have been stated by other studies as well.
Of all infected, 101 (66.9%) had mild symptoms and were isolated at home, others with similar symptoms were isolated at hospital arranged facility 12 (7.9%) due to unfavourable isolation circumstances at their respective homes. While 38 (25.17%) patients were admitted to hospital due to severe symptoms such as breathlessness, chest pain and persistent high grade fever. However some centres have reported that only 15.4% HCWs were hospitalised.
HCQ was used as a prophylactic drug against COVID-19 from March onwards. ICMR task force in March 2020 advised on the use of HCQ for chemoprophylaxis for asymptomatic HCWs involved in care of suspected or confirmed case of COVID-19. Revised advisory on 22.05.2020 extended the chemoprophylaxis for all asymptomatic HCWs involved in care of COVID-19 and asymptomatic HCWs working in non-COVID hospitals/non-COVID areas of COVID hospitals/blocks., We observed that 67 (44.4%) of the total infected staff members did not take the HCQ prophylaxis, stating reasons such as lack of avid literature highlighting the positive effects of the drug, fear of side effects, experiencing side effects. Overall 83 (55%) COVID infected HCWs took HCQ prophylaxis, however 22 patients were on HCQ prophylaxis, when they contracted the virus. The remaining 61 had completed the HCQ prophylaxis when they got infected. We did not find any importance of HCQ prophylaxis in preventing the disease. In addition, no significant association of HCQ was found with mortality. The role of HCQ in preventing COVID has been debated since the very beginning of COVID. Literature stating pro and against the motion exists in abundance.,
Twenty-three (15.2%) HCWs had co-morbidities, diabetes 9 (6%) being the most common followed by hypertension 6 (4%) and asthma 5 (3.3%). At least one comorbidity was noted in 22.2% HCWs in a study, diabetes and hypertension being the most common.
We lost 3 infected staff members to COVID-19. One of the demised patients had diabetes as a comorbidity, one was HIV positive and the other did not have any pre-existing conditions. All 3 were males and in the age group between 45 and 55 years.
Onward transmission of coronavirus to the HCWs family from the infected HCW was observed in 23 (16.3%). We realised while calling the HCWs to inform them about their positive report that they were very scared and apprehensive about passing on the infection to their family members. Some of them stayed with elderly parents/grandparents who had co-morbidities. One of the infected HCWs further passed on the infection to both the parents and lost her father to COVID-19. A recent study suggests that even though individuals with suspected or confirmed infections are being referred to isolate at home, households will continue to be a significant venue for the transmission of COVID-19.
Although COVID cases are declining in community, HCWs are still at higher risk of acquiring infection if proper infection control measures are not followed. They are at greatest risk while working in non-COVID areas and can become a potential source of infection for fellow colleagues and their families. Temperature and symptom monitoring should be continued as majority of the cases have at least one of the identified symptoms. Strict social distancing needs to be followed to avoid transmission from unidentified asymptomatic cases.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]