High-risk warriors

Vulnerability of health care workers during the crisis and the lessons to be learnt on their care according to Dr Zarir Udwadia.

Doctors representing the Mahim Dharavi Medical Practitioners Association with help from the BMC Health Department check patients in slum pockets of Kalyanwadi, Dharavi, Mumbai on April 12.

AN editorial in The Lancet on March 21 gave voice to a neglected crisis that has been growing alongside the spread of COVID-19. It said: “Worldwide, as millions of people stay at home to minimise transmission of severe acute respiratory syndrome coronavirus 2, health care workers prepare to do the exact opposite. They will go to clinics and hospitals, putting themselves at high risk from COVID-2019…. Reports from medical staff describe physical and mental exhaustion, the torment of difficult triage decisions, and the pain of losing patients and colleagues, all in addition to the infection risk.”

The risk of infection for health care workers following exposure in hospitals is now a hard reality. The number of health care workers infected in Mumbai as on April 11 is 100. The multi-specialty Saifee Hospital in south Mumbai was among the first to report cases of doctors and nurses showing symptoms of coronavirus infection. A senior doctor of the hospital contracted the virus and died in another hospital subsequently in late March. The 250-bed hospital suspended its outpatient department services, and became a dedicated COVID-19 facility. Bhatia Hospital, whichwas under containment after a few nurses and doctors tested positive, has been sealed. Other private hospitals such as Shusrusha, Jaslok, Wockhardt and Breach Ccandy stopped new admissions after health care workers showed symptoms of infection. Breach Candy is operating minimal emergency services. With smaller hospitals and nursing homes also shutting down, the city is left with fewer beds.

A pandemic is a huge burden on a health system. The burden increases when the ratio of doctors to patients is low, as is the case in India. According to government’s 2019 figures, there is one doctor for every 1,445 Indians, far below the World Health Organisation (WHO) norm of 1:1,000. The problem is compounded when health care workers themselves take ill.

Dr Zarir F. Udwadia, a leading pulmonologist in Mumbai, in a paper co-authored with Dr Reyma Sara Raju, clinical assistant in Mumbai’s Hinduja Hospital, says: “From the very start of the epidemic it has been recognised that health care workers (HCWs) managing this potentially lethal airborne disease are a uniquely high-risk group.”

The research paper titled “How to protect the protectors: 10 lessons to learn for doctors fighting the COVID-19 Coronavirus”, was published by Elsevier on March 31. Dr Udwadia has shared it with Frontline .

He writes: “There are numerous reports of front line HCWs, both physicians and nurses, contracting the disease from their patients and several have succumbed to it. In the index outbreak in Wuhan, thirteen hundred health-care workers became infected; their likelihood of infection was more than three times as high as the general population. Figures from China's National Health Commission show that across China more than 3,300 health-care workers (HCW’s) have been infected as of early March and, according to local media, by the end of February at least 22 had died. In Italy, the virus has infected more than 5,000 doctors, nurses, technicians, ambulance staff and other health employees and resulted in the deaths of 41 HCWs. The majority were on the frontline in the badly affected northern regions around Lombardy and contracted the illness at the start of the outbreak when protective equipment was lacking.”

Udwadia says four questions rankle health care workers: what is the route of transmission of COVID-19? How infectious is it compared to influenza? Do asymptomatic patients exist and are they a source of infection? And finally, how do we ensure physicians do not end up becoming patients themselves?

While it is established that the virus spreads through “aerosolised droplets that are expelled during coughing, sneezing, or breathing, there are also concerns about possible airborne transmission. Faeco-oral transmission has also been reported in a few cases, with viral isolation from the faeces of some patients.”

As far as the comparison with influenza goes, Udwadia says: “The transmission dynamics of COVID-19 have been studied and reveal the estimated basic reproduction number (R0) to be 2.2 (versus 1.3 for common influenza), demonstrating the potential for the virus to spread to two additional persons from a single infected person. It is to be noted that unless the R0 falls less than one, the outbreak cannot be halted.”

The spread of infection via asymptomatic patients, he says is “a new and worrying dimension to the spread of the pandemic”. Udwadia explains this: “What is more worrying is that significant numbers of these totally asymptomatic patients are contagious for up to two days before they develop symptoms. Thus, it is ominously clear that people who are asymptomatic or mildly symptomatic may be responsible for more transmission than previously thought, making efforts at control even more difficult.”

Udwadia says there is no need for casually exposed health care workers to go in to self-quarantine. Citing a paper from Singapore, he writes: “41 HCWs were exposed for four days to a critically ill patient before he was eventually diagnosed with COVID-19 infection.

Despite the high-risk nature of the exposures, including intubation, ventilation and regular intensive care, none of the workers became infected. 85 per cent of these exposed workers had used only surgical masks (not N-95). All had, however, adhered to proper hand hygiene. The important message that emerges is that universal precautions of strict hygiene must be adhered to, with N-95 masks and full PPEs then being conserved for procedures where respiratory secretions can be aerosolised and for known or suspected cases of COVID-19. For medical staff who are inadvertently exposed to a patient who unexpectedly tests positive, the quarantine recommendation should be based on the duration of exposure… People who have had brief, incidental contact are just asked to monitor themselves for symptoms. Contrast this with the recent panic in Mumbai when a large hospital was shut down after it was detected that an asymptomatic doctor and another outpatient who had a CT scan in the radiology department of the hospital had both tested positive. If health care workers are quarantined after even casual exposure and hospitals shut down, there will be no one left to treat patients!”

Udwadia says “The emotional needs of HCWs must not be ignored.” He writes: “A study conducted by Chinese doctors and published in The Lancet showed that 70 per cent of health workers on the frontline in Hubei suffered from extreme levels of stress, 50 per cent had depressive orders, 44 per cent had anxiety and 34 per cent insomnia.” .

It is pertinent here to recall the remarks made in The Lancet editorial: “Health care systems globally could be operating at more than maximum capacity for many months. But health care workers, unlike ventilators or wards, cannot be urgently manufactured or run at 100 per cent occupancy for long periods. It is vital that governments see workers not simply as pawns to be deployed, but as human individuals.”