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Protecting healthcare workers from SARS-CoV-2 and other infections

Published online by Cambridge University Press:  21 September 2020

Mengding Chen ,
Xin Wei  and
Zhengguang Wang Open the ORCID record for Zhengguang Wang [Opens in a new window]
Mengding Chen
Affiliation:
First Affiliated Hospital of Anhui Medical University, Hefei230000, China
Xin Wei
Affiliation:
First Affiliated Hospital of Anhui Medical University, Hefei230000, China
Zhengguang Wang*
Affiliation:
Department of General Surgery for Cadres, First Affiliated Hospital of Anhui Medical University, Hefei230000, China
*
Author for correspondence: Zhengguang Wang, E-mail: wangzhengguang@ahmu.edu.cn, cmd18805604716@163.com
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Abstract

Coronavirus disease 2019 (COVID-19) has had a tremendous impact in China and abroad since its onset in December 2019 and poses a major threat to human health. Healthcare workers (HCWs) are at the forefront of the response to outbreaks. This study reviewed literature data and found that HCWs were at high risk of infection during the COVID-19 pandemic, especially at the early stage of the epidemic, and many factors greatly affected their occupational safety. Although SARS-CoV-2 transmission was controlled in China, the Chinese experience can help protect HCWs from COVID-19 and other respiratory diseases.

Keywords

COVID-19healthcare workersSARS-CoV-2

Information

Type
Review
Information
Epidemiology & Infection , Volume 148 , 2020 , e217
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Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
Copyright © The Author(s), 2020. Published by Cambridge University Press

Introduction

The first cases of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), were reported in Wuhan, Hubei province, China, in December 2019 [Reference Wu1, Reference Zhou2], and this disease has had a significant impact on the social and economic development of China and other countries. As of 17 May 2020, approximately 4 525 497 cases were confirmed worldwide, including 84 484 cases in China, 1 870 545 in Europe, 1 966 932 in the Americas and 603 536 in other regions [3, 4]. The estimated case fatality rate of COVID-19 (this rate was used because limited testing capacity prevented determining the actual mortality rate) is 6.8% but varies between countries [4] and is lower than that of severe acute respiratory syndrome (SARS) (9.5%) and Middle East respiratory syndrome (MERS) (34.4%) [Reference Munster5] (Table 1). The National Health Commission of the People's Republic of China reported that, as of 24 February, 3387 healthcare workers (HCWs) had been infected with SARS-CoV-2 in China, and 22 (0.6%) died [6].

Table 1.

Pathogenicity and transmission characteristics of SARS, MERS and COVID-19

a As of 1 April 2020.

Table 2.

Proportion of healthcare workers diagnosed with SARS-CoV-2 relative to total confirmed cases during the COVID-19 outbreak

a From 1 January to 28 January 2020, in Zhongnan Hospital of Wuhan University, Wuhan, China.

b As of 24 February 2020.

c As of 12 March 2020.

d As of 5 April 2020.

The basic reproduction number (R0) is a common measure of transmissibility and is defined as the average number of people infected by one individual over the course of illness. R0 values lower than 1 indicate that transmission is interrupted, R0 values higher than 1 indicate that transmission is sustained [Reference Swerdlow and Finelli7, Reference Zhao8]. R0 was >2 and <1 at the early and late stage of the 2003 SARS outbreak, respectively [Reference Chowell9]. R0 ranged from 2.2 to 3.9 during the COVID-19 epidemic in China, depending on the disease transmission model used and testing capacity [Reference Zhao8, Reference Zhou10, Reference Li11], and tended to decrease as the epidemic was controlled and effective policies were implemented.

COVID-19 is a major threat to human health, and HCWs in affected countries can benefit from the Chinese experience in managing this pandemic. The purpose of this study is to discuss the Chinese experience to help protect HCWs from viral outbreaks.

Occupational exposure of HCWs to coronaviruses

SARS-CoV-2 is the seventh coronavirus strain known to infect humans since the first human coronavirus was identified in the 1960s [Reference Cui, Li and Shi12]. Four strains – NL-63, 229E, HKU1 and OC43 – cause mild illness, whereas three strains – MERS-CoV, SARS-CoV and SARS-CoV-2 – may cause severe disease [Reference Zhu13]. MERS-CoV and SARS-CoV were a public health threat in some countries, whereas SARS-CoV-2 has had a significant health and economic impact worldwide. The number of nosocomial cases during the 2003 SARS and 2012 MERS outbreaks corresponded to 58% and 70% of all confirmed cases, respectively [Reference Munster5] (Table 1).

The COVID-19 pandemic put global public health authorities (PHAs) on high alert. HCWs are at the forefront of the response to communicable diseases and, therefore, have a higher risk of viral exposure. Among all detected MERS-CoV and SARS-CoV infection cases, 18.6% and 21% occurred in HCWs, respectively [Reference Malave and Elamin14, Reference Park15]. In addition, the prevalence of COVID-19 was higher among HCWs than in the general population in several countries [Reference Huff and Singh16].

SARS-CoV-2 infections in HCWs accounted for 29% (40/138) of all cases treated in Zhongnan Hospital of Wuhan University in Wuhan, China, from 1 January to 28 January 2020Footnote 1 [Reference Wang17] and 4.4% (3387/77 262) of all cases reported in China until 24 February 2020 [6, 18]. Similarly, in Italy, SARS-CoV-2 infections in HCWs accounted for approximately 20% (350/1350) of cases notified until 12 March 2020 [Reference Remuzzi and Remuzzi19] and 10% of cases (1225/12 252) reported until 5 April 2020 [20] (Table 2), suggesting that transmission to HCWs decreased as the outbreak progressed. The use of personal protective equipment (PPE) may have reduced viral transmission to HCWs in China [Reference Chen21], and improvements in testing capacity have been shown to reduce hospital transmission [Reference Black22–Reference Treibel24].

Challenges in the early response to COVID-19 in China

HCWs actively participated in controlling the outbreak during the period from the diagnosis of the first case in Wuhan to public acknowledgement of the situation. The timeline of the COVID-19 outbreak in China is shown in Figure 1a (adapted from Wu et al. [Reference Wu1]) [Reference Li11, Reference Wu and McGoogan25, 26]. Despite the clinical similarities between SARS and COVID-19, the response of Chinese PHAs to the latter was better regarding the number of confirmed cases before the day the WHO was notified (300 and 27, respectively), number of deaths (five and zero, respectively) [Reference Wu and McGoogan25] and the period from WHO notification to the identification of the etiological agent (2 months and 1 week, respectively) [Reference Wu and McGoogan25]. The period between the notification of the first cases to the Chinese CDC and the identification of the causative pathogen was 12 days, and the period from pathogen identification to the declaration of public health emergency was 22 days. Although great progress has been made, there is room for improving the prevention and control of SARS-CoV-2 transmission among HCWs.

Fig. 1.

(a) Number of cases of COVID-19 diagnosed between 8 December 2019, and 31 January 2020, in China (adapted from Wu et al. [Reference Wu1]). (b) Response of healthcare workers in the early stage of the COVID-19 outbreak in China.

The emergency response period can be divided into three stages (Fig. 1b): (1) from clinical detection to the reporting of the first case to PHAs by HCWs; (2) from the notification of PHAs to decision-making; (3) from decision-making to the provision of new guidelines to HCWs. Four challenges negatively impacted the emergency response:

  1. (A) Disease aetiology was unknown at the beginning of the epidemic, and new cases were reported to PHAs by HCWs

  2. (B) The lack of clinical and epidemiological data delayed decision-making

  3. (C) The lack of PPE and low testing capacity limited the prevention and control of COVID-19 by HCWs

  4. (D) Delays in communication hindered the ability of HCWs to adopt adequate self-protection measures

Suggestions and expectations

These challenges can be overcome using the following approaches.

Improvement of the emergency response

Shortening the period between the diagnosis of the first case and reporting the situation to the local CDC is paramount. However, in the face of unknown diseases, relying on the experience of HCWs to treat patients and report unusual cases is not enough, and adequate surveillance and early warning systems are necessary to interrupt the spread of respiratory viruses. Other factors that reduce the effectiveness of the emergency response are the limited focus on disease prevention and control, insufficient understanding of the epidemic situation by decision-makers and lack of public awareness of the situation [Reference Tan, Wu and Han27]. Addressing these problems is crucial to prevent and control new cases and protect HCWs in a timely manner. These goals can be achieved in China by improving disease surveillance systems and public health, increasing the number of public health workers in hospitals and government agencies, and increasing public health knowledge through the media and other communication channels.

Collection, analysis and reporting of clinical and epidemiological data

Epidemiological data are essential for accurate diagnosis but are not collected in many hospitals in China. The emergency response can be further strengthened by (1) rigorously collecting epidemiological data through testing, including contact history, especially in emergency and respiratory departments; (2) hiring specialised personnel to analyse epidemiological data, including incidence rates, mortality and the distribution of disease cases, and inform the appropriate authorities about changes in epidemiological patterns. Since SARS, hospitals in China have realised the importance of epidemiological data.

Use of PPE by HCWs and nucleic acid testing

Many infectious diseases are transmitted by droplets and cause respiratory symptoms and fever. However, many physicians in China did not wear face masks in the hospital setting before the COVID-19 pandemic. In some hospitals, outpatient infrastructure is limited, and ventilation and disinfection are inadequate, which may increase the rate of nosocomial infections, underscoring the need to improve outpatient services to control infections. Furthermore, fever clinics help reduce nosocomial transmission during outbreaks [Reference Pang28] and can be introduced in respiratory and emergency departments for fever screening. The risk of nosocomial infections among HCWs was higher at the initial stage of the COVID-19 epidemic because the availability of PPE was limited at this stage [29–Reference Zheng31]. Therefore, the adequate supply of PPE to HCWs and guidelines on its correct use are fundamental to prevent and control the spread of respiratory infectious diseases [Reference Alhazzani32–Reference Mahmood34].

Studies showed that PCR screening might reduce viral transmission among HCWs [Reference Black22–Reference Treibel24]. In this context, hospitals should test all HCWs and patients routinely whenever possible. China improved the research, development and production of diagnostic reagents during the COVID-19 pandemic and reduced disease transmission despite the limited availability of PPE and low testing capacity at the early stage of the outbreak.

Improve the communication between PHAs and hospitals

During the COVID-19 epidemic, the communication between PHAs and hospitals was inadequate in China, and the activities of these entities were not coordinated, resulting in underreporting and failure of HCWs to promptly obtain disease information after identifying the first cases, consequently increasing the risk of hospital-acquired infections. However, the National Health Committee stressed the need to establish communication and cooperation between these institutions during outbreaks. In this respect, the following actions can be carried out to overcome these limitations: (1) establishment of new mechanisms of communication, information exchange, and cooperation between PHAs and HCWs at the national level (via the National Health Committee) and local level, including joint training on outbreak management; (2) prompt reporting of new cases to PHAs; (3) establishment of guidelines by PHAs for diagnosis, case reporting, treatment and self-protection. These approaches stimulate medical staff to adopt protective measures and facilitate the timely collection of epidemiological data to accurately assess the epidemic situation and make appropriate decisions.

Financial support

This research was not funded by any agency or organisation.

Conflict of interest

None.

Data availability statements

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Footnotes

1 This rate was estimated using hospital data because of the limited access to public data in China.

References

Wu, F et al. (2020) A new coronavirus associated with human respiratory disease in China. Nature 579, 265–269. doi: 10.1038/s41586-020-2008-3.Google ScholarPubMed
Zhou, P et al. (2020) A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature 579, 270–273. doi: 10.1038/s41586-020-2012-7.CrossRefGoogle ScholarPubMed
World Health Organization. WHO coronavirus disease (COVID-19) dashboard. https://covid19.who.int/.Google Scholar
World Health Organization. Coronavirus disease 2019 (COVID-19) Situation Report – 72. https://wwwwhoint/emergencies/diseases/novel-coronavirus-2019/situation-reports/.Google Scholar
Munster, VJ et al. (2020) A novel coronavirus emerging in China – key questions for impact assessment. The New England Journal of Medicine 382, 692–694. doi: 10.1056/NEJMp2000929.Google ScholarPubMed
Web. NI. 3387 cases of healthcare workers infected with novel coronavirus disease. https://news.ifeng.com/c/7uKe45oGSZM%20[Accessed%20on%2028%20February%202020.Google Scholar
Swerdlow, DL and Finelli, L (2020) Preparation for possible sustained transmission of 2019 novel coronavirus: lessons from previous epidemics. JAMA 323, 1129–1130. doi: 10.1001/jama.2020.1960.CrossRefGoogle ScholarPubMed
Zhao, S et al. (2020) Preliminary estimation of the basic reproduction number of novel coronavirus (2019-nCoV) in China, from 2019 to 2020: a data-driven analysis in the early phase of the outbreak. International Journal of Infectious Diseases: IJID 92, 214–217. doi: 10.1016/j.ijid.2020.01.050.CrossRefGoogle ScholarPubMed
Chowell, G et al. (2004) Model parameters and outbreak control for SARS. Emerging Infectious Diseases 10, 1258–1263. doi: 10.3201/eid1007.030647.Google ScholarPubMed
Zhou, T et al. (2020) Preliminary prediction of the basic reproduction number of the Wuhan novel coronavirus 2019-nCoV. Journal of Evidence-Based Medicine 13, 3–7. doi: 10.1111/jebm.12376.CrossRefGoogle ScholarPubMed
Li, Q et al. (2020) Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. The New England Journal of Medicine 382, 1199–1207. doi: 10.1056/NEJMoa2001316.Google ScholarPubMed
Cui, J, Li, F and Shi, ZL (2019) Origin and evolution of pathogenic coronaviruses. Nature Reviews Microbiology 17, 181–192. doi: 10.1038/s41579-018-0118-9.Google ScholarPubMed
Zhu, N et al. 2020 A novel coronavirus from patients with pneumonia in China, 2019. The New England Journal of Medicine 382, 727–733. doi: 10.1056/NEJMoa2001017.CrossRefGoogle Scholar
Malave, A and Elamin, EM (2010) Severe acute respiratory syndrome (SARS)-lessons for future pandemics. The Virtual Mentor: VM 12, 719–725. doi: 10.1001/virtualmentor.2010.12.9.cprl1-1009.Google ScholarPubMed
Park, JE et al. (2018) MERS transmission and risk factors: a systematic review. BMC Public Health 18, 574. doi: 10.1186/s12889-018-5484-8.Google ScholarPubMed
Huff, HV and Singh, A (2020) Asymptomatic transmission during the COVID-19 pandemic and implications for public health strategies. Clinical Infectious Diseases. doi: 10.1093/cid/ciaa654.Google ScholarPubMed
Wang, D et al. . (2020) Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA 323, 1061. doi: 10.1001/jama.2020.1585.Google ScholarPubMed
World Health Organization. Explore the Data. https://covid19whoint/explorer.Google Scholar
Remuzzi, A and Remuzzi, G (2020) COVID-19 and Italy: what next? The Lancet 395, 1225–1228. doi: 10.1016/s0140-6736(20)30627-9.CrossRefGoogle ScholarPubMed
Epicentro. ISdS. Sorveglianza integrata COVID 19 in Italia. https://wwwepicentroissit/coronavirus/sars-cov-2-sorveglianza-dati.Google Scholar
Chen, W et al. (2020) Early containment strategies and core measures for prevention and control of novel coronavirus pneumonia in China. Chinese Journal of Preventive Medicine (3), 1–6. doi: 10.3760/cma.j.issn.0253-9624.2020.03.003.Google ScholarPubMed
Black, JRM et al. (2020) COVID-19: the case for health-care worker screening to prevent hospital transmission. The Lancet 395, 1418–1420. doi: 10.1016/s0140-6736(20)30917-x.CrossRefGoogle ScholarPubMed
Imperial-College-COVID-19-Response-Team. Report 16: Role of testing in COIVD-19 control. https://wwwimperialacuk/media/imperial-college/medicine/mrc-gida/2020-04-23-COVID19-Report-16pdf. doi:10.25561/78439.CrossRefGoogle Scholar
Treibel, TA et al. (2020) COVID-19: PCR screening of asymptomatic health-care workers at London hospital. The Lancet 395, 1608–1610. doi: 10.1016/s0140-6736(20)31100-4.Google ScholarPubMed
Wu, Z and McGoogan, JM (2020) Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention. JAMA 323(13), 1239–1242. doi: 10.1001/jama.2020.2648.Google ScholarPubMed
The-Novel-Coronavirus-Pneumonia-Emergency-Response-Epidemiology-Team-in-China (2020) The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China. Zhonghua liu xing bing xue za zhi = Zhonghua liuxingbingxue zazhi 41, 145–151. doi: 10.3760/cma.j.issn.0254-6450.2020.02.003.Google Scholar
Tan, ZX, Wu, ST and Han, XP (2020) The reference and enlightenment of the emergency response system of public health emergencies in the United States and Japan – discussion on the response to the novel coronavirus pneumonia epidemic in China. Health Economics Research (3), 11–16. doi: 10.14055/j.cnki.33-1056/f.20200210.001.Google Scholar
Pang, X et al. (2003) Evaluation of control measures implemented in the severe acute respiratory syndrome outbreak in Beijing, 2003. JAMA 290, 3215–3221. doi: 10.1001/jama.290.24.3215.CrossRefGoogle Scholar
CDC. Resources for clinics and healthcare facilities|CDC. Resources for clinics and healthcare facilities|CDC. https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/index.html (Accessed 28 March 2020).Google Scholar
Kicska, G et al. (2020) Statement from the North American Society for cardiovascular imaging on imaging strategies to reduce the scarcity of healthcare resources during the COVID-19 outbreak. International Journal of Cardiovascular Imaging 36, 1387–1393. doi: 10.1007/s10554-020-01861-1.CrossRefGoogle ScholarPubMed
Zheng, C et al. (2020) Characteristics and transmission dynamics of COVID-19 in healthcare workers at a London teaching hospital. Journal of Hospital Infection 106(2), 325–329. doi: 10.1016/j.jhin.2020.07.025.CrossRefGoogle Scholar
Alhazzani, W et al. (2020) Surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Intensive Care Medicine 46, 854–887. doi: 10.1007/s00134-020-06022-5.CrossRefGoogle Scholar
Cook, TM (2020) Personal protective equipment during the coronavirus disease (COVID) 2019 pandemic – a narrative review. Anaesthesia 75, 920–927. doi: 10.1111/anae.15071.CrossRefGoogle ScholarPubMed
Mahmood, SU et al. (2020) Strategies for rational use of personal protective equipment (PPE) among healthcare providers during the COVID-19 crisis. Cureus 12, e8248. doi: 10.7759/cureus.8248.Google ScholarPubMed
Figure 0

Table 1. Pathogenicity and transmission characteristics of SARS, MERS and COVID-19

Figure 1

Table 2. Proportion of healthcare workers diagnosed with SARS-CoV-2 relative to total confirmed cases during the COVID-19 outbreak

Figure 2

Fig. 1. (a) Number of cases of COVID-19 diagnosed between 8 December 2019, and 31 January 2020, in China (adapted from Wu et al. [1]). (b) Response of healthcare workers in the early stage of the COVID-19 outbreak in China.