key: cord-0778548-py08j97x authors: Gianola, Silvia; Bargeri, Silvia; Campanini, Isabella; Corbetta, Davide; Gambazza, Simone; Innocenti, Tiziano; Meroni, Roberto; Castellini, Greta; Turolla, Andrea title: The Spread of COVID-19 Among 15,000 Physical Therapists in Italy: A Cross-Sectional Study date: 2021-05-08 journal: Phys Ther DOI: 10.1093/ptj/pzab123 sha: f8f49095181c2cd6513db01b1fe7b6fcc3239716 doc_id: 778548 cord_uid: py08j97x OBJECTIVES: The purpose of this study was to explore the prevalence, personal- and work-related exposures, and signs and symptoms among physical therapists during the first wave of coronavirus disease 2019 (COVID-19) in Italy. METHODS: This cross-sectional, survey-based study collected demographic and exposure data from physical therapists from April to May 2020. All physical therapists working in an inpatient and outpatient care in Italy were eligible. A self-administered questionnaire was distributed among all eligible physical therapists to collect (1) demographic characteristics, (2–3) personal- and work-related exposures, and (4) signs and symptoms of COVID-19. Factors associated with a COVID-19 positive nasopharyngeal swab (NPS) were explored through logistic regression models and multivariate methods. RESULTS: A total of 15,566 respondents completed the survey, with a response rate of 43.3%, achieving high statistical precision (99% CI, 1% type I error). Among physical therapists who received NPS testing, 13.1% (95% CI = 12.1–14.1%) had a positive result, with a peak reached in March 2020 (36%). The top five symptoms were fatigue and tiredness (69.1%), loss of smell (64.5%), aches and pains (60.8%), loss of taste (58.3%), and headache (51.1%). No symptoms were reported by 8.9%. Working in a health care institution [odds ratio (OR) = 7.2; 95% CI = 5.4–9.7], being reallocated to a different unit (OR = 1.7; 95% CI = 1.3–2.2) and changing job tasks (OR = 1.6; 95% CI = 1.2–2.2) increased the risk of being COVID-19 positive. In therapists with a confirmed diagnosis of COVID-19, comorbidities were associated with male sex and age older than 51 years. CONCLUSIONS: During the first wave in Italy, almost 1 out of 7 physical therapists tested positive on the COVID-19 NPS test. Considering personal- and work-related exposures, health care organizations should adopt prevention measures and adequate preparedness to prevent high rate of infections during future pandemics. IMPACT: This is the largest investigation about the spread of and the main risk factors for COVID-19 in the physical therapy field. Impact. This is the largest investigation about the spread of and the main risk factors for COVID-19 in the physical therapy field. Severe acute respiratory syndrome coronavirus 2 (SARS- We developed a web-based questionnaire using the Survey Monkey platform 15 to collect answer data. We launched the survey on April 28, 2020, with a reminder sent on May 15, 2020 (Fig. 1) . We closed the data collection period 4 weeks later. Informed consent and data protection were explicitly given by the respondents before they [H2]Survey questionnaire We conducted a pilot test of our survey involving all the members of the Scientific Committee of AIFI to assess its clarity and accuracy. After revision, the final version of the questionnaire consisted of "consent to participate and privacy" (item 1) and 4 sections: (I) "demographic characteristics" (items 2 to 3), (II) "personal risk of exposure" (items 4 to 12), (III) "work-related risk of exposure" (items 13 to 18), and (IV) "prevalence of COVID-19" (items 19 to 27). All items were mandatory. To ensure that the questionnaire was well suited for collecting data from the target population, the questionnaire was developed in Italian. A translated version in English is available in Supplement 2. [H2]Statistical analyses Descriptive statistics are presented as medians and interquartile ranges (IQRs) or absolute values, percentages, and frequencies, as appropriate. We report the data in either a narrative description or a quantitative summary in tables and plots. We primarily look at the overall cohort investigating the response rate, the prevalence of collection were managed by the National Directive Committee of AIFI and anonymously entrusted to an independent unit for data analysis. The data subject cannot be reidentified and therefore was outside the scope-of-data protection law. [23] [24] [25] The study complies with the Declaration of Helsinki. [H2]Role of the Funding Source The Italian Association of Physiotherapy (AIFI) only supported the acquisition of the Survey Monkey license. The Scientific Committee of AIFI did not receive any fee in conducting the study design and in preparation, review, and approval of the manuscript. [H1]Results The delivery rate was 99.7%. Overall, we had 15,566 respondents out of 35,938 active members, yielding a response rate of 43.3%. Among those who responded, 589 did not give consent (3.7%), and 370 failed to complete the questionnaire after the first question (2.4%). The sample obtained for every section is reported in the flow diagram ( Fig. 1) . [H2]Respondents' characteristics In the overall cohort, we assessed the prevalence of symptoms reported by respondents with a positive NPS test of COVID-19 (n = 530). The top 5 symptoms were fatigue and tiredness (69.1%), loss of smell (64.5%), aches and pains (60.8%), loss of taste (58.3%) and headache (51.1%). No symptoms were reported by 8.9% (Fig. 2) . In Supplement 4, Figure S1 we reported the symptoms stratified by any confirmed and suspected diagnosis of COVID-19. For work-related risk of exposure, we refer to questions 13 to 18 (Sec. 3 of Suppl. 2). In The relationship between personal characteristics (questions 4 to 12, Section 2 in Supplement 2) in physical therapists with COVID-19 is summarized in Supplement 5, Figure S1 . The MCA biplot showed a global pattern along the first axis for physical therapists with and without comorbidities. In physical therapists with a diagnosis of COVID-19, all the evaluated comorbidities were associated with male sex and with an age older than 51 years. In contrast, younger age (ie, the fourth decade of life) was associated with the absence of all evaluated comorbidities and the investigated risk factors, such as smoking or excessive weight. Moreover, having received the seasonal influenza vaccination was strongly associated with smoking and with the presence of immune system disorders and other chronic conditions. During the first 5 months of 2020, we found 13.1% (95% CI = 12. Regarding the symptoms described, we found that loss of smell and loss of taste were in the top 5 symptoms in all groups analyzed, whereas fever was not. 26 Our findings agree with those of a multicenter European study (n = 417) 27 in which the prevalence of olfactory and gustatory dysfunction were relatively higher in European patients with COVID-19, often as the only significant complaint. Moreover, these symptoms seem to be potential predictors of COVID-19, and they could be included as part of routine triage screening for COVID-19. 28, 29 Our data should be contextualized in the first-wave pandemic era during which Finally, considering personal variables, we found that some physical therapists who contracted COVID-19 had various chronic conditions. The presence of risk factors such 18 as obesity and smoking tobacco, coupled with preexisting health conditions, is known to increase the likelihood of poor outcomes (eg, multiple organ failure). 34 35, 36 Consistent with physical therapy being a female-dominated profession, 37 our sample was predominately female; however, the men in the sample were likely to be more vulnerable, especially when they have more underlying diseases 38 , which would increase the likelihood of poor outcomes in the sample. To our knowledge, this is the largest cross-sectional survey exploring the spread of COVID-19 among physical therapists in Italy and worldwide. We enrolled 15,566 respondents, of whom 14,607 (94%) completed at least 1 question after giving consent and 13,433 (86%) completed the entire survey. We were able to reach the sample size required to achieve high statistical precision at a 99% confidence level with a type I error of 1%; however, this does not guarantee the absence of selection bias because we did not perform an analysis of nonrespondents. Some other limitations must be acknowledged. Factors such as questionnaire length, the term "survey" in the text of the e-mail, and the lack of incentives might have influenced the response rate: a Cochrane review showed a lower odds of response in such situations. 39 However, the final percentage of respondents did not seem to bias our results, as we reached the planned target sample size even for the completion of the entire questionnaire. We kept the survey open for a month, and some of the questions necessitated retrospection on the part of the participants; thus, there may have been recall bias. Moreover, we cannot ignore the fact that our findings may have been affected by Neyman bias, because our investigation collected data pertaining to a span of time 40 ; therefore, we could not completely elucidate the relationship between exposure and disease development (eg, symptoms suggesting a diagnosis of COVID-19 that occurred in February might not be accurately reflected in the negative results of a NPS test performed in April). Finally, the accuracy of the data regarding perceived knowledge is uncertain, as the data were collected via a self-reported survey. [H1]Implications for the Future The authors thank all the participants who contributed to our work. [H1]Ethics Approval Ethics approval was exempted according to the "ethics and data protection" regulations of the European advisory body and European Commission. The recruitment of physical therapists was based on the TSRM-PSTRT Registry. The study project and data collection were managed by the National Directive Committee of AIFI and anonymously entrusted to an independent unit for data analysis. The data subject cannot be reidentified and therefore outside the scope of the data protection law. [23] [24] [25] The study complies with the Declaration of Helsinki. This study was funded by the Italian Association of Physiotherapy (Associazione Italiana Fisioterapia-AIFI). This study was registered in the COVIDPhysio Registry of the World Confederation for Physical Therapy, which represents more than 625,000 physical therapists worldwide, at the following link: https://www.wcpt.org/COVIDPhysio#project-6. All data generated or analyzed during this study are included in this published article OR calculated as the ratio between the odds in the presence of characteristic variable against the odds in the absence of the variable (ie, reallocation to different unit. The OR is the ratio between the odds of reallocation to different unit against the odds of no reallocation to different unit). See item 17, Section 3-Supplement 2. d OR calculated as the ratio between the odds in the presence of characteristic variable against the odds in the absence of the variable (ie, changing job tasks. The OR is the ratio between the odds of changing JOB tasks against the odds of no changing JOB tasks). See item 18, Section 3-Supplement 2. Reporting guidelines for survey research: an analysis of published guidance and reporting practices. 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