The conundrum of rising Covid19 infection among health care workers: An emerging paradigm

To, The Editor,

Most of the countries over the world are still struggling with the ongoing battle against covid19 pandemic. Months have passed since the first appearance of covid19 but many of its nature and behaviors still remain a mystery to the world. In spite of taking all the precautions and protection measures, distressing number of health care workers (HCWs) are getting infected with covid19 which is indeed worrisome. This is the reason why the articles by Sahu et al. [1] and Smereka et al. [2] in your esteemed journal have drawn our attention and we read it very keenly. Many other reports along with our own experience which we are sharing here, strongly suggests that we need to think outside the box to protect our HCWs in the current challenging situation.

First of all, we would like to illustrate few of the case events which we witnessed in our own tertiary care hospital. One unsuspected case of a young male with acute abdomen was being conservatively managed for a week then suddenly he developed respiratory distress. His review chest X-ray showed sign of infiltrations in both sides of lung. We got the RT-PCR for covid19 done and it came out positive. After contact tracing we tested all of his primary and close contacts (six doctors and eight staff chosen as per defined protocols for exposure). Report of RT- PCR for covid19 of all the contacts came negative.

In another event, nursing officer and administrative in charge of our surgical ward found positive for RT PCR of covid19. Surprisingly, all her close contacts including her own family members and many other nursing staff tested negative for covid19 RT-PCR.

Recently, a case of perforation peritonitis with strong suspicion of covid19 (of which later on report came indeterminate for covid19 RT-PCR test) has been operated in emergency. Surgery was done by a team of senior and experienced doctors who took all the precautions and due tertiary protection measures recommended for covid19. All the doctors and other support staff who were involved in surgery and post-operative care of the patient later tested for covid19 RT-PCR and only one anesthetist was found positive for covid19.

Numerous such instances are being reported from other parts of the world too [3]. These sorts of events always create doubt and feeling of uncertainty among HCWs. So far, whatever evidences for implication of covid19 on the HCWs are available is not assertive and rather it is confusing. In China, out of 23 HCWs who died during current covid19 pandemic, no one was working in the hospital of infectious disease and interestingly, only 2 out of 23 were physician in respiratory disease [4]. Further, it's also reported that none of the 42,600 HCWs, who went to Hubei province specially to fight Covid19 got infected [4]. Another report from china cited that most of the covid19 infection among HCWs occurs during early stage of pandemic and to the HCWs who were not a front-line fighter [5].

So far, no official data related to covid19 infection among HCWs are available. Whatever reports in the form of case report or series are available, have a huge variation. We must congratulate Sahu et al. [1] for their successful attempt in estimation of proportion of HCWs infected with covid19. According to them also, there is huge variation of estimated percentage of HCWs infected with Covid19 among total infected population among different countries. It is found to be 4.2% in China, 9.0% in Italy and 17.8% in United State while overall it is 10.1% [1]. There is also a huge variation in the proportion of HCWs infected with SARS CoV-2 among total HCWs around the globe. It was reported 1.1% from China [5], 5% from India [6] and highest 20% from Italy [7].

In the beginning of the pandemic, lack of knowledge about covid19 was blamed for infection among HCWs [4,5]. Maybe it is true but with time, situation is not improving either. In fact, in some cases it has become worse [6,7]. So far, most of the reports cited reason for this large number of infections among HCWs are lack of resources like PPE kits, lack of infection control training, long working hours & stressful environment and particular procedure with potential of high aerosol generation [[4], [5], [6]]. Not only an article by Smereka et al. [2] but almost every relevant article on the safety issues of HCWs has paid lot of attention to personal protection kit (PPE) for protection of HCWs while available evidence is not strong enough that makes it 100% effective [8].

With the time, issue of asymptomatic HCWs infected with covid19 has also become a big concern. Such asymptomatic infected HCWs can transmit infection unknowingly to the patients and other HCWs. At one of the London hospital, sample for RT-PCR testing for covid19 taken from asymptomatic and healthy HCWs at multiple point of time. In a total number of 1479 health care worker's sample, 1.1% to 7.1% (at different point of time) were found positive for Covid19 [9]. That's why, now epidemic surveillance and routine testing at multiple point of time for every HCWs including asymptomatic one is strongly recommended [10].

Worse of all, no country around the world is tracking or reporting any data related to covid19 infection among HCWs. W.H.O. and International Council of Nurses (ICN) raised serious concern regarding lack of data of Covid19 related infection and deaths among HCWs. In spite of this, no steps have so far been taken by any concerned authorities across the world. Unless we maintain transparency in record keeping related to covid19 infection among HCWs, we can't analyse and prevent it further.

Sources of financial support

Nil.

Declaration of competing interest

Nil.