Health workers may be at risk early in the COVID-19 outbreak

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Shortly after the first case of COVID-19 was identified in the Netherlands, a substantial number of health workers (PS) in two hospitals there, about 1%, tested positive for the new coronavirus, according to a published study. online May 21 at JAMA Network Open.

"This unexpectedly high prevalence supported the SARS-CoV-2 community hidden propagation hypothesis," the researchers write.
Exposure to patients may also be a key factor, said Aaron E. Glatt, MD, spokesman for the Infectious Diseases Society of America and professor and president of medicine at Mount Sinai South Nassau in Oceanside, New York.

In the early stages of a COVID-19 outbreak, healthcare workers may not recognize that patients have the disease. As a result, they are at increased risk when entering patients' rooms without personal protective equipment (PPE), said Glatt, who was not involved in the Dutch study.

However, once PPE is used correctly, it is quite effective, Glatt said. Unpublished data from New York suggests that, with proper precautions, infection rates in health workers are lower than in the general community, he said.
That view is supported by data from a second study, also published in the JAMA Network Open by Xiaoquan Lai, MD, of Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China, and colleagues.
Lai and colleagues found that most HCW infections occurred early in the disease outbreak, before doctors may have been fully aware of the risk and therefore may not have used proper PPE.

"At a minimum, each healthcare worker should receive the appropriate PPE and be taught to use it properly," he said. Furthermore, healthcare workers must have a "very, very high suspicion" of COVID-19. Infected people are often asymptomatic, requiring wearing masks and practicing social distancing at all times, Glatt noted.
Common but not ubiquitous fever
Following the detection of the first case of COVID-19 in the Netherlands on February 27, nine healthcare workers at the two teaching hospitals were diagnosed with COVID-19. To better understand the overall number of cases, Marjolein CF Kluytmans-van den Bergh, PhD, from the department of infection control, Amphia Hospital, Breda, The Netherlands, and her colleagues conducted a cross-sectional study among TSs with fever or respiratory symptoms .
Until March 12 at both hospitals, health workers with fever or respiratory symptoms were asked to voluntarily participate in screening. The researchers tested SARS-CoV-2 using a real-time semi-quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) on oropharyngeal samples and symptoms documented through structured interviews.

Of 9,705 health workers employed in hospitals, 1,353 (14%) reported fever or respiratory symptoms and were tested. Of these, 86 (6%) were infected with SARS-CoV-2. Patients with the virus had a median age of 49 years.

Most of the infected PS had a mild illness. Just over half (53%) of those who tested positive had a fever. Two healthcare workers with COVID-19 required hospital care but were not critically ill at the time of the report.

Among those who tested positive, three had traveled to China or northern Italy, and three had been exposed to a hospitalized patient diagnosed with COVID-19 before the onset of symptoms.

In particular, seven of those who tested positive reported being symptomatic before the first COVID-19 diagnosis reported in the country. About 24% of infected healthcare workers had no contact with the patient during their work, and 63% had worked symptomatic.

"During the containment phase and within 2 weeks of detection of the first Dutch case, a substantial proportion of healthcare workers with fever or self-reported respiratory symptoms became infected with SARS-CoV-2, likely as a result of virus acquisition in the community during the first phase of local spread, "concluded Kluytmans-van den Bergh and his colleagues. "This observation confirms the insidious nature of the spread of SARS-CoV-2, given the high prevalence of mild clinical presentations that may go unnoticed."

Furthermore, the data indicates that the case definition of suspected COVID-19 should include fever as a possible but not required symptom, the researchers say. Adding severe myalgia and general malaise to the definition can further improve the sensitivity of COVID-19 detection, they say.

"Overall, the healthcare workers in the Netherlands who became infected were employed in 52 different hospital departments," writes Vincent Chi-Chung Cheng, MD, of Queen Mary Hospital, Hong Kong, and colleagues in an accompanying editorial. "The diversity of workplaces among them suggests that the hospital outbreak was unlikely … This underscores the importance of health workers, like anyone else, remaining vigilant of community risk while maintaining social distancing and avoiding social gatherings afterward. working hours. "

Relative to patients in the general public, HCPs "appear to experience less severe illness and mortality … possibly related to younger age and fewer concomitant illnesses," according to a recent review in the Annals of Internal Medicine that examined studies of coronavirus in this population. The review incorporated data from a preprint of the Dutch study, as well as reports from China and previous coronavirus outbreaks.

"The evidence for SARS-CoV-2 infections in healthcare workers is sparse and has methodological limitations," wrote Roger Chou, MD, of Oregon Health & Science University in Portland, and colleagues. More research is needed to understand how the infection affects this group, including their ability to work and the potential for transmission to family members and close contacts. Studies that identify optimal methods to reduce your risk are urgently needed, Chou and colleagues say.

A co-author of the study served as a scientific consultant to the Luminex advisory board. Cheng and his colleagues have disclosed no relevant financial relationships.

JAMA network open. Published online May 21, 2020. Full text, Editorial

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