key: cord-0769664-wf5yltmu
authors: Öztürk, Berkant; Öztürk, Sema; Çağlar, Ahmet; Kaçer, İlker; Hacimustafaoğlu, Muhammet; Öztürk, Kemal
title: An Analysis of the impact of the COVID-19 pandemic on healthcare workers in a tertiary hospital in Turkey
date: 2021-03-29
journal: J Emerg Nurs
DOI: 10.1016/j.jen.2021.03.013
sha: c47262002236c0b3ffbd6d91789a89b3157da78e
doc_id: 769664
cord_uid: wf5yltmu

Background Several vaccines have been developed and approved for use against SARS-CoV-2; however, the use of personal protective equipment (PPE) and precautions against transmission remain important due to the lack of effective specific treatment and whole community immunity. Hydroxychloroquine sulfate (HCQ) was used as a treatment option in the early days of the pandemic; however, it was subsequently removed due to a lack of evidence as an effective treatment for COVID-19. Aim To evaluate the testing and infection characteristics of COVID-19 among health care professionals (HCPs) and determine the efficacy of prophylactic HCQ use to prevent transmission. Methods This retrospective cross-sectional study was carried out between 1 May and 30 September 2020. The HCPs included in the study were doctors, nurses, and paramedical personnel, such as secretaries or technical staff. The medical records of HCPs who had been tested for SARS-CoV-2 using polymerase chain reaction (PCR) were retrospectively analyzed. Student's t-test and Pearson's Chi-square test were used for inter-group comparisons. Results 508 HCPs were included in the study. A total of 152 (29.9%) HCPs were diagnosed with COVID-19. The positive PCR rate was 80.3% (n = 122). A comparison of infected and uninfected HCPs showed a significant difference in terms of age and occupation, and no significant difference in terms of gender, working area, and prophylactic HCQ use. Conclusion Protective measures in low-risk areas of our hospital require improvements. All HCPs should be trained on PPE usage. Furthermore, there was no evidence to support the efficacy of prophylactic HCQ against SARS-CoV-2 transmission.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to show worldwide impact; to date, approximately eighty-six million people have been infected and over one and a half million have died (1, 2) . In Turkey, 2.3 million people have been infected and the total number of deaths has reached 22,450 (3) . The rapidly increasing number of critical and mortal patients caused a significant challenge to public health. Mortality rates are correlated with countries' health care resources. In addition, the invasive ventilator and intensive care unit resources are inadequate (4) .

It is important to protect healthcare professionals (HCPs) from the risk of infection to ensure continuity of effective healthcare. The World Health Organization recommends the use of personal protective equipment (PPE) for HCPs at high risk due to their interaction with COVID-19 patients (5) .

Several vaccines have been recently developed for use against SARS-CoV-2; however, the use of PPE and precautions against transmission remain important due to the lack of effective specific treatments and whole community immunity (6) (7) (8) (9) .

The efficacy of hydroxychloroquine sulfate (HCQ) against SARS-CoV was demonstrated in vitro after the first SARS epidemic in 2005 (10) . It was included in treatment algorithm in the early days of the 2020 pandemic; however, there was no evidence for its efficacy in the treatment of COVID-19 and it was subsequently removed from use (11) (12) (13) (14) (15) . Additional studies have investigated the efficacy of HCQ use before exposure to SARS-CoV-2, and during the pandemic, we became aware that some HCPs working in our hospital had used HCQ as prophylaxis (16) (17) (18) .

This study's primary focus was to evaluate the testing and infection characteristics of COVID-19 among HCPs. In addition, we sought to determine the efficacy of prophylactic HCQ use in the prevention of transmission.

This retrospective cross-sectional study was performed between 1 May and 30 September 2020 in a tertiary academic hospital. This is the only hospital in our city within which COVID-19 patients are hospitalized. During the study process, the mean daily admission to the emergency department with COVID-19 symptoms was 352. In total, 1,957 patients with COVID-19 pneumonia were hospitalized in five months. Our hospital has continued to provide routine healthcare, in addition to COVID-19, during the pandemic. The working areas in the hospital were divided into two groups according to high and low COVID-19 transmission risk. High-risk areas were defined as the emergency department, COVID-19 suspected emergency department, COVID-19 isolation wards, and COVID-19 intensive care units. The low-risk areas were defined as the outpatient clinics, administrative divisions, information technology clerical, technical clerical, and other areas where routine hospital operations continued. Healthcare professionals with no chronic disease worked in the high-risk areas of the hospital; working shifts were limited to 4 hours in these areas. A disposable mask (1200 N95/FFP2 NR, ERA, İstanbul, Turkey), goggles (Pulsafe LG20 Goggle, Bacou-Dalloz Company, Paris, France), isolation gowns (Safetouch TP63 5/6 classic disposable protective coverall, Safetouch Ltd, Istanbul, Turkey), and non-sterile gloves were used routinely during the care of COVID-19 suspected and confirmed patients in high-risk areas. Furthermore, all PPE were used for one shift in high risk areas. After each shift, the goggles were routinely sterilized, and all other PPE was disposed of. Surgical masks and non-sterile gloves were used in low-risk areas.

Of the 1,830 HCPs working in our hospital, 523 were tested for SARS-CoV-2 via oropharyngeal/nasal swabs and polymerase chain reaction (PCR) between 1 May and 30 September 2020. Fifteen HCPs were excluded due to missing data; therefore, 508 HCPs were included in the final analysis. Informed consent was obtained from each HCP. The study was conducted in compliance with the Declaration of Helsinki and approved by the regional ethics committee (2020/03-47).

Age, gender, occupation (doctors, nurses, and paramedical personnel), working area (high/low risk), the reason for PCR testing (suspected contact, screening, presence of COVID-19 symptoms), COVID-19-related symptoms (fever, sore throat, anosmia, shortness of breath, cough, joint pain, fatigue), use of prophylactic HCQ, side effects if HCQ was used, PCR result, chest computed tomography (CT) result, hospitalization, and treatment regime for COVID-19 were retrospectively analyzed. Healthcare professionals with a positive PCR test were classified as being infected with COVID-19. In addition, HCPs with a positive chest CT for COVID-19, or had COVID-19 related symptoms, even with a negative PCR test, were classified as being infected with COVID-19.

The data were analyzed using SPSS version 22.0 (SPSS Inc, Chicago, IL, USA). Visual (histogram and probability graphs) and analytical methods (Kolmogorov-Smirnov test) were used to determine the distribution normality. The descriptive statistics were expressed as mean ± standard deviation (SD) for normally distributed variables. The categorical data were expressed as n (%). For the inter-group comparisons, Student's t-test was used to compare the normally distributed data (age), and Pearson's Chi-square or Fisher's exact test was used to compare the categorical variables. All analyses were 2-tailed. A p value of <0.05 was considered statistically significant.

Five hundred and eight HCPs were included in the study. The mean age was 35.89 ± 8.2 years and the majority of the HCPs (n = 328, 64.6%) were female. Nurses were the largest proportion of HCPs (n = 310, 61%), followed by paramedical personnel (n = 102, 20.1%), and doctors (n = 96, 18.9%). In total, 307 (60.4%) HCPs were working in high-risk areas, and 152 (29.9%) were diagnosed with COVID-19. The positive PCR rate was 80.3% (n = 122). The number of HCPs using HCQ before any suspected contact was 40 (7.9%), and one participant reported HCQ-related side effects (arrhythmia). All demographic data are shown in Table 1 .

HCPs who had been diagnosed with COVID-19 were significantly younger than HCPs who had not been diagnosed with COVID-19 (33.97 ± 8.45, P = 0.001). Eighty-four (55.3%) nurses, 43 (28.3) paramedical personnel, and 25 (16.4%) doctors had been diagnosed with COVID-19. The paramedical personnel were diagnosed significantly more than nurses and doctors (P = 0.01). The majority of HCPs diagnosed with COVID-19 (n = 84, 55.3%) were working in high-risk areas. Among the HCPs who had been used prophylactic HCQ, 15 (40%) had been diagnosed with COVID-19 and 25 (60%) had not. There was no significant difference in terms of gender, working area, and prophylactic HCQ medication between diagnosed and undiagnosed HCPs. The inter-group comparisons are summarized in Table 2 .

Sixty-two (40.8%) of the HCPs who had been diagnosed with COVID-19 were asymptomatic.

The most common symptom was joint pain (n = 48, 31.6%), followed by weakness (n = 33, 21.7%) and anosmia (n = 32, 21.1%). The PCR was false negative in 30 (19.7%) HCPs. COVID-19 was confirmed in these participants via symptoms related to COVID-19; 2 of these showed positive COVID-19 on chest CT. A total of 5 (3.3%) HCPs had a positive chest CT for COVID-19. Three out of these were hospitalized. Acetylsalicylic acid and enoxaparin were administered to the 2 discharged HCPs, in addition to HCQ, favipiravir, and paracetamol. Plasma and prednisone were added to this treatment for the 3 hospitalized HCPs. Two of the 3 hospitalized HCPs required non-invasive mechanical ventilation and were placed in the prone position. Hypoxia worsened and 1 HCP who had been used HCQ as prophylaxis required intubation. This HCP was extubated on the fourth day of hospitalization, fully recovered on the 13th day, and discharged on the 14th day. The characteristics of the HCPs diagnosed with COVID-19 are summarized in Table 3 .

We evaluated the testing and infection characteristics of 508 HCPs who had been tested for SARS-CoV-2 using PCR. Over the five month study period, 152 HCPs were diagnosed with COVID-19. A false negative PCR was found in 30 HCPs. The majority of those infected with COVID-19 were asymptomatic and recovered with outpatient treatment. One HCP developed respiratory failure and required intubation. There was no evidence to support that prophylactic HCQ medication was effective against SARS-CoV-2 transmission.

SARS-CoV-2 spreads person-to-person through direct contact or indirectly through contact with contaminated surfaces (19) . Healthcare professionals working in the emergency department, isolation services, and intensive care units where aerosol-generating procedures, such as non-invasive ventilation and tracheal intubations are frequently used, are at high risk for transmission (20) .

Enhanced PPE use is recommended for HCPs to prevent the risk of infection (21) . Simpler PPE, such as surgical masks alone or in combination with a face shield, is used in areas such as outpatient clinics where the risk is relatively lower and routine hospital operation continues (4). The risk of transmission to HCPs has increased as the number and required healthcare of cases has increased; however, the rate of infected HCPs decreases with appropriate PPE use, pandemic design within hospitals, and community protective measures. At the beginning of the pandemic, in January 2020, the rate of infected HCPs was reported as 29% among hospitalized patients in Wuhan (22) . In Italy, there were 15,314 cases of COVID-19 infections among HCPs by April 2020, which accounted for 11% of all confirmed cases (23). Chou et al. have reported that the COVID-19 infection rate among HCPs from various countries ranged from 1.9-12.6% in the third update of their review in August 2020 (24) . In the absence of official data, medical society research has shown that 29,865 HCPs have been infected, which corresponds to 11.5% of all confirmed cases by 17 September 2020 in Turkey (25). The total number of confirmed cases and infected HCP rate in our city is unknown due to a lack of official data.

However, during the study period, 1,957 patients have been hospitalized and only 3 (0.15%) were

HCPs. This rate seems very low when compared with the literature, which may be related to the consistent use of PPE and working conditions in the hospital. For example, shorter working hours reduces viral load exposure, which means better prognosis in COVID-19 (26) . (20) . In this study, we found no significant difference in the number of COVID-19 diagnoses between high-and low-risk areas, in line with the literature. This result provides important information regarding SARS-CoV-2 transmission measures in hospital. Low infection rates in high-risk working areas are associated with transmission prevention protocols and PPE usage that is sufficient to prevent transmission. In contrast, the high infection rates in low-risk working areas may be due to low personnel compliance with PPE usage. PPE use is included in the standard training curriculum of doctors and nurses in medical faculties; however, paramedical personnel, such as secretaries or technical staff, were not trained on how to use PPE at this facility. The results of our study confirmed this lack of training; paramedical personnel had a greater likelihood of being infected with COVID-19. We concluded that training on correct PPE use should be conducted repeatedly for all HCPs working in the field, as recommended by the World Health Organization. This is particularly important for paramedical personnel because the benefits of such training are lost within 6 months (5, 29) . In addition, screening testing is not being performed on the people who have not COVID-19

symptoms and suspicious contact in many countries. Therefore, many SARS-CoV-2 carriers remain undetected, and HCPs working in low-risk areas who use a simpler PPE face a higher risk of contracting the disease.

COVID-19 infections are commonly asymptomatic or show mild symptoms (30) . However, this infection can be life-threatening by causing severe respiratory failure, acute ischemic stroke, or myocardial involvement (31, 32) . It is often more severe in the elderly and individuals with comorbidities (33, 34) . In line with previous studies, most HCPs were asymptomatic in this study. No life-threatening complications were observed, except in one case requiring respiratory support. At the beginning of the pandemic, fever and dyspnea were the main symptoms of COVID-19 in Wuhan, China (20, 35) . However, after spread of SARS-CoV-2 worldwide, joint pain and weakness are observed as the main viral symptoms (35, 36) . In addition, gastrointestinal symptoms, such as diarrhea, nausea, and vomiting are common in COVID-19 patients (38) . In this study, the most common symptoms noted were joint pain, weakness, and anosmia, which is similar to recent literature. Only 12 out of 152 HCPs reported having a fever. Interestingly, gastrointestinal symptoms were not observed among any of our HCPs diagnosed with COVID-19.

Multiple vaccines have been developed for SARS-CoV-2; however, specific treatment has not been developed, which increases the anxiety of HCPs regarding transmission and leads to them seeking alternative chemoprophylaxis options (6, 7, 39) . Yao et al. have demonstrated that HCQ could reduce the spread of SARS-CoV-2 in vitro (40) . In a retrospective study conducted in India, Chatterjee et al. have reported that the SARS-CoV-2 incidence is significantly lower in HCPs who used prophylactic HCQ (41) . However, Abella et al. have reported no significant difference in the incidence of SARS-CoV-2 between HCPs administered with HCQ or a placebo (16) . The World Health Organization reported no significant difference in patient improvement following the use of HCQ and subsequently removed HCQ from routine treatment recommendations (17) . The results of this study support that HCQ is not effective in preventing SARS-CoV-2 transmission. In addition, the HCP that needed respiratory support and intensive care had been using prophylactic HCQ.

This study has some limitations due to its retrospective nature. First, the number of HCPs using HCQ was very low compared with the total number of participants. In addition, HCPs may have used other drugs/medications, such as vitamin supplements, that were not reported during the study. This situation may have affected the efficacy of prophylactic HCQ use. PPE use, rule compliance, and HCP behavior against possible transmission in normal daily life were unknown. These limitations prevented any comparisons of transmission occurrence in HCPs. To address these factors, multicenter, prospective studies are needed.

In summary, protective measures in the low-risk areas of hospitals must be improved. All

HCPs should be trained on proper PPE use at regular intervals, particularly paramedical personnel, such as secretaries or technical staff. Furthermore, according to the results of this study, there was no evidence to support the use of prophylactic HCQ against SARS-CoV-2 transmission. 

Data were presented as n (%). HCQ: Hydroxychloroquine sulfate

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