Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) can attack lung cells through receptor entries mainly by binding of its spike (S) protein with angiotensin converting enzyme-2 (ACE2). [3] Human to human mode of transmission is by droplets, respiratory secretions, and direct contact with cases or fomites. [5] Presence of this virus in host cells may initiate various protective responses leading to pneumonia and Acute Respiratory Distress Syndrome. [5] As of June 13, 2020, we have approximately 7,553,182 confirmed cases worldwide with deaths numbering up to 4,23,349. The situation in India is no exception with 3,08,993 confirmed cases and around 8,884 total deaths. [9] The incubation period of this disease ranges from 1 to 12.5 days (with median estimates of 5 to 6 days), but can be as long as 14 days. [6] The affirmed mortality rate is around 3.4% as of March 2020. There is no room for complacency if one considers the colossal loss to human life caused by 1918 influenza pandemic with a case-fatality ratio of less than 5%. [10] No sooner than the knowledge of the disease was acquired the WHO and national health bodies everywhere promulgated the concept of social distancing and the practice of hygiene and physical protection, with use of alcohol-based sanitizers, handwash, use of mask, gloves and personal protective equipment (PPE).
Clinical spectrum of COVID has been observed to range from asymptomatic to symptomatic with febrile myalgia to ARDS at far end of spectrum. Most commonly encountered symptoms include fever, fatigue and dry cough. Other clinical manifestations include anorexia, dyspnoea, cough, myalgias, sore throat, rhinorrhoea, headaches and less frequently nausea and diarrhoea, seen in mild to moderate forms of the disease. Patients with dysgeusia, hyposmia or even isolated anosmia with complete absence of other symptoms have also been reported. [11,12] As these are fairly common presentations to otolaryngologists, they are at high risk of contracting infection while examining patients.
In this study, the first HCP who tested positive was an otolaryngology resident. Hospital infection control team’s response was fast and all otolaryngology faculty and residents who were in contact, including her room partner were asked to self-isolate and underwent testing. ENT OPD services were closed for 5 days and contact tracing was done meticulously. It was not clear whether she acquired infection at work-place or out of it. Her room partner and co-resident had assisted in tracheostomy in a cardiac patient who later on tested Covid19 positive. But the room partner herself had tested negative.
Otolaryngologists may get infected in outdoor clinic or in ICU, attending to emergencies or in OR while doing surgeries. The virus has been shown to be viable in aerosols for 3 hours and to be more stable on steel and plastics then on copper and cardboard remaining viable up to 72 hours on steel surfaces. [13] If asymptomatic, otolaryngologists can infect several others at work. Viral transmission via the use of instruments, even the ones commonly used in OPDs such as tongue depressors, stethoscopes and sphygmomanometers is a high possibility. As such, otolaryngologists are advised to exercise utmost care and refrain from examining nose, throat and avoid aerosol generating procedures (AGPs), where possible. Even potentially vital procedures like tracheostomies have been asked to be deferred or avoided where deemed unnecessary by most national guidelines of otolaryngologist’s association. The importance of proper training regarding protective and operative equipment, fitting of masks, donning and doffing of PPEs cannot be understated. Other recommendations include meticulously planned surgery wherever possible in negative pressure ICUs, negative pressure ORs or OT complexes with dedicated patient transport routes, reduced time of exposure to intra or post-operative aerosolization, a dedicated and well experienced team and appropriate measures of postoperative waste disposal and decontamination. [14]
The risks of acquiring COVID19, for anaesthetists and those involved in emergency management is high as they have to undertake AGPs like intubation and administration of oxygen by masks. Despite following all precautions an anaesthetist and emergency medicine team physician were infected. Yet, exposure through aerosolization of virus in OR and emergency settings can occur. If asymptomatic or in pre-symptomatic phase, infected HCPs in emergency can potentially spread infection to several critical patients. Also if they have to be quarantined along with their contacts it may cause severe strain on emergency team.
Since anesthetists and intensivists are playing a pivotal role in helping fight this war, reduction in the time of exposure should be practiced at every cost without compromising the protective measures. Avoidance of general anaesthesia wherever possible by avoiding electives, can greatly help. Decreased intubation time, reducing the delay in intubation and curtailing the number of multiple attempts can be achieved if these procedures are handled by experts with adequate use of neuromuscular relaxants and observance of rapid sequence anesthesia.
The danger of residents in general medicine or paediatrics, passing on infection to patients once positive is real and hence utmost precaution is needed in sanitising hands and all appliances needed to examine patients.
In the study 23 members of nursing staff and 10 radiology technicians were detected positive for COVID19. Most of them felt that they had acquired infection at work-place while some were unsure. Importance of nursing and paramedical staff working as ‘super-spreader’ cannot be understated. Nurses and attendants not only look after patients but also handle equipment, instruments, drugs and other material including waste, in OPDs, wards and ICUs alike. This only leads to exponential rise in number of people infected through even a single HCP. A news-report of 49-year-old doctor testing positive after exposure to a COVID positive female and eventually leading to isolation of around 1100 people, including HCPs, for 14 days in national capital, Delhi had recently emerged. [15] This further emphasizes importance of containment and isolation of infected HCP.
The situation has been accelerating globally with a possible doubling rate of every 3 to 4 days. The numbers of HCP exposed to the disease has also risen, with a consequent surge in numbers of HCP quarantined and a resultant decrease in strength of the doctors and the team handling the patients on the frontline. As reported by CDC, by April 16, 2020, 9,282 U.S. doctors, nurses and other health care professionals had contracted the coronavirus, and 27 had died of it. After analysing data on their exposure to Covid19 cases, 780 (55%) were found to have been exposed only in health care settings. [16] In Italy, 20% of responding HCP were infected with some succumbing to the disease. According to a WHO situation report on April 8 2020, 22,073 HCPs across 52 countries have been infected by COVID. [17] In a world of established scarcity of medical professionals, decrement in number of doctors and nurses, puts immense moral stress on healthier counterparts.
Discussion with medical staff have highlighted physical and mental exhaustion, torture of difficult triage decisions accompanied with not only pain of losing patients but also colleagues with constant fear of acquiring the infection. [18] Although most HCPs evidently acquired infection through work-place exposures, household and community transmission cannot be denied with increase in numbers everywhere.
In this study 57.5% HCPs revealed psychological stress subsequent to testing positive and being isolated. Mental health issues have always been sequelae to large scale disasters such as pandemics. SARS patients had disturbed psychological health immediately post being infected or shortly after hospital discharge. [19] Increase in period of confinement is associated with worse psychological health outcomes. [20] Escalation in lockdown periods causes increase in depression, posttraumatic stress disorder (PTSD), substance use disorder, a broad range of other mental and behavioral disorders, domestic violence or even child abuse. [21,22]
Association of social stigma results in resistance from patients and their family in sharing their illness status and seeking health care early. In this study too HCPs admitted to perception of stigma from friends and relatives. There have been instances of HCPs working in COVID facilities, being denied entry to their residential premises in Indian cities. This can further aggravate stress encountered by healthcare workers. The role of social media in both uplifting and distressing people in complete isolation and those in-home quarantine cannot be over emphasized. Uplifting posts showing HCPs dancing or enjoying their work will definitely motivate other HCPs, Distressing forwards of HCPs suffering should be avoided at all costs. Ensuring availability of PPEs and creating safe atmosphere for HCPs is the responsibility of every institution and nation.
The role of prevention cannot be over emphasized especially nosocomial spread through HCPs. The WHO and governments world over are constantly working for development of vaccines.. The utility of drugs like hydroxychloroquine and anti-virals is still questionable. As such, strict adherence to barrier precautions and social distancing remains our best bet.