Healthcare workers & SARS-CoV-2 infection in India: A case-control investigation in the time of COVID-19

Abstract

Background & objectives: Healthcare workers (HCWs) are at an elevated risk of contracting COVID-19. While intense occupational exposure associated with aerosol-generating procedures underlines the necessity of using personal protective equipment (PPE) by HCWs, high-transmission efficiency of the causative agent [severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)] could also lead to infections beyond such settings. Hydroxychloroquine (HCQ), a repurposed antimalarial drug, was empirically recommended as prophylaxis by the National COVID-19 Task Force in India to cover such added risk. Against this background, the current investigation was carried out to identify the factors associated with SARS-CoV-2 infection among HCWs in the country. Methods: A case-control design was adopted and participants were randomly drawn from the countrywide COVID-19 testing data portal maintained by the ICMR. The test results and contact details of HCWs, diagnosed as positive (cases) or negative (controls) for SARS-CoV-2 using real-time reverse transcription-polymerase chain reaction (qRT-PCR), were available from this database. A 20-item brief-questionnaire elicited information on place of work, procedures conducted and use of PPE. Results: Compared to controls, cases were slightly older (34.7 vs. 33.5 yr) and had more males (58 vs. 50%). In multivariate analyses, HCWs performing endotracheal intubation had higher odds of being SARS-CoV-2 infected [adjusted odds ratio (AOR): 4.33, 95% confidence interval (CI): 1.16-16.07]. Consumption of four or more maintenance doses of HCQ was associated with a significant decline in the odds of getting infected (AOR: 0.44; 95% CI: 0.22-0.88); a dose-response relationship existed between frequency of exposure to HCQ and such reductions (χ[2]for trend=48.88; P <0.001). In addition, the use of PPE was independently associated with the reduction in odds of getting infected with SARS-CoV-2. Interpretations & conclusions: Until results of clinical trials for HCQ prophylaxis become available, this study provides actionable information for policymakers to protect HCWs at the forefront of COVID-19 response. The public health message of sustained intake of HCQ prophylaxis as well as appropriate PPE use need to be considered in conjunction with risk homoeostasis operating at individual levels. Chatterjee Pranab 1 Translational Global Health Policy Research Cell, New Delhi Anand Tanu 2 Multidisciplinary Research Unit/Model Rural Health Research Unit, New Delhi Singh Kh 3 ICMR-National Institute of Medical Statistics, New Delhi Rasaily Reeta 4 Division of Reproductive Biology, Maternal Health & Child Health, New Delhi Singh Ravinder 5 Division of Non-Communicable Diseases, Indian Council of Medical Research, New Delhi Das Santasabuj 6 Division of Clinical Medicine, ICMR-National Institute of Cholera & Enteric Diseases, Kolkata, West Bengal Singh Harpreet 7 Informatics, Systems & Research Management Cell, Indian Council of Medical Research, New Delhi Praharaj Ira 8 Division of Epidemiology & Communicable Diseases, Indian Council of Medical Research, New Delhi Gangakhedkar Raman 9 Division of Epidemiology & Communicable Diseases, Indian Council of Medical Research, New Delhi Bhargava Balram 10 Department of Health Research, Ministry of Health & Family Welfare; Indian Council of Medical Research, New Delhi Panda Samiran 11 ICMR-National AIDS Research Institute, Pune, Maharashtra Liu J, Liao X, Qian S, Yuan J, Wang F, Liu Y, et al. Community transmission of severe acute respiratory syndrome coronavirus 2, Shenzhen, China, 2020. Emerg Infect Dis 2020; 26 : 1320-3. Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: A study of a family cluster. Lancet 2020; 395 : 514-23. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020; 382 : 1199-207. Chatterjee P, Nagi N, Agarwal A, Das B, Banerjee S, Sarkar S, et al. The 2019 novel coronavirus disease (COVID-19) pandemic: A review of the current evidence. Indian J Med Res 2020; 151 : 147-59. Huang L, Zhang X, Zhang X, Wei Z, Zhang L, Xu J, et al. Rapid asymptomatic transmission of COVID-19 during the incubation period demonstrating strong infectivity in a cluster of youngsters aged 16-23 years outside Wuhan and characteristics of young patients with COVID-19: A prospective contact-tracing study. J Infect 2020; 80 : e1-13. Nguyen LH, Drew DA, Joshi AD, Guo C-G, Ma W, Mehta RS, et al. Risk of COVID-19 among frontline healthcare workers and the general community: A prospective cohort study. medRxiv 2020. doi: https://doi.org/10.1101/2020.04.29.2008411. Lewnard JA, Lo NC. Scientific and ethical basis for social-distancing interventions against COVID-19. Lancet Infect Dis 2020. doi: 10.1016/S1473-3099(20)30190-0. Prather KA, Wang CC, Schooley RT. Reducing transmission of SARS-CoV-2. Science 2020. pii: eabc6197. World Health Organization. Coronavirus disease (COVID-19) advice for the public. Geneva: WHO; 2020. The Lancet. COVID-19: Protecting health-care workers. Lancet 2020; 395 : 922. Verbeek JH, Rajamaki B, Ijaz S, Mischke C, Ruotsalainen JH, Mäkelä E, et al. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. Cochrane Database Syst Rev 2016; 4 : CD011621. Bai Y, Yao L, Wei T, Tian F, Jin DY, Chen L,et al. Presumed asymptomatic carrier transmission of COVID-19. JAMA 2020; 323 : 1406-7. World Health Organization. Novel coronavirus (2019-nCoV)-Situation Report-2; January 22, 2020. Geneva: WHO; 2020. Zhong NS, Zheng BJ, Li YM, Xie ZH, Chan KH, Li PH, et al. Epidemiology and cause of severe acute respiratory syndrome (SARS) in Guangdong, People's Republic of China, in February, 2003. Lancet 2003; 362 : 1353-8. Ramadan N, Shaib H. Middle East respiratory syndrome coronavirus (MERS-CoV): A review. Germs 2019; 9 : 35-42. Hashem AM, Alghamdi BS, Algaissi AA, Alshehri FS, Bukhari A, Alfaleh MA, et al. Therapeutic use of chloroquine and hydroxychloroquine in COVID-19 and other viral infections: A narrative review. Travel Med Infect Dis 2020: 101735. doi:10.1016/j.tmaid.2020.101735. Liu J, Cao R, Xu M, Wang X, Zhang H, Hu H, et al. Hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting SARS-CoV-2 infection in vitro. Cell Discov 2020; 6 : 16. Al-Bari MAA. Targeting endosomal acidification by chloroquine analogs as a promising strategy for the treatment of emerging viral diseases. Pharmacol Res Perspect 2017; 5 : e00293. Vincent MJ, Bergeron E, Benjannet S, Erickson BR, Rollin PE, Ksiazek TG, et al. Chloroquine is a potent inhibitor of SARS coronavirus infection and spread. Virol J 2005; 2 : 69. National Task Force for COVID-19 in India. Recommendation for empiric use of hydroxychloroquine for prophylaxis of SARS-CoV-2 infection; 2020. Available from: https://www.mohfw.gov.in/pdf/AdvisoryontheuseofHydroxychloroqui nasprophylaxisforSARSCoV2infection.pdf, accessed on May 25, 2020. Lee SH, Son H, Peck KR. Can post-exposure prophylaxis for COVID-19 be considered as an outbreak response strategy in long-term care hospitals? Int J Antimicrob Agents 2020. doi: 10.1016/j.ijantimicag.2020.105988. Principi N, Esposito S. Chloroquine or hydroxychloroquine for prophylaxis of COVID-19. Lancet Infect Dis 2020. pii: S1473-3099: 30296-6. Dupont WD. Power calculations for matched case-control studies. Biometrics 1988; 44 : 1157-68. Hintze J. PASS 11. NCSS, LLC. Kaysville, Utah, USA: NCSS; 2011. Available from: http://www.ncss.com">http://www.ncss.com, accessed on May 25, 2020. Pearce N. Analysis of matched case-control studies. BMJ 2016; 352 : i969. Jacobsen KH, Aguirre AA, Bailey CL, Baranova AV, Crooks AT, Croitoru A, et al. Lessons from the Ebola outbreak: Action items for emerging infectious disease preparedness and response. Ecohealth 2016; 13 : 200-12. Arunkumar G, Chandni R, Mourya DT, Singh SK, Sadanandan R, Sudan P, et al. Outbreak investigation of Nipah virus disease in Kerala, India, 2018. J Infect Dis 2019; 219 : 1867-78. Zhou D, Dai SM, Tong Q. COVID-19: A recommendation to examine the effect of hydroxychloroquine in preventing infection and progression. J Antimicrob Chemother 2020. doi:10.1093/jac/dkaa114. Tett SE, Cutler DJ, Day RO, Brown KF. Bioavailability of hydroxychloroquine tablets in healthy volunteers. Br J Clin Pharmacol 1989; 27 : 771-9. Mehra MR, Desai SS, Ruschitzka F, Patel AN. Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: A multinational registry analysis. Lancet 2020; S0140-6736(20)31180-6. Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ, et al. COVID-19: Consider cytokine storm syndromes and immunosuppression. Lancet 2020; 395 : 1033-4. Mitjà O, Clotet B. Use of antiviral drugs to reduce COVID-19 transmission. Lancet Glob Health 2020; 8 : e639-40. Bellizzi S, Fiamma M, Arru L, Farina G, Manca A. COVID-19: The daunting experience of healthcare workers in Sardinia, Italy. Infect Control Hosp Epidemiol 2020. doi:10.1017/ice.2020.149. Barrett ES, Horton DB, Roy J, Gennaro ML, Brooks A, Tischfield J, et al. Prevalence of SARS-CoV-2 infection in previously undiagnosed health care workers at the onset of the U.S. COVID-19 epidemic. medRxiv:2020.04.20.20072470; 2020. doi:10.1101/2020.04.20.20072470. Legido-Quigley H, Mateos-García JT, Campos VR, Gea-Sánchez M, Muntaner C, McKee M. The resilience of the Spanish health system against the COVID-19 pandemic. Lancet Public Health 2020; 5 : e251-2. Richens J, Imrie J, Copas A. Condoms and seat belts: The parallels and the lessons. Lancet 2000; 355 : 400-3. Adams J. Risk, 1st ed. London: Routledge, Taylor & Fransis Group; 1995. Available from: http://www.john-adams.co.uk/wp-content/uploads/2017/01/RISK-BOOK.pdf">http://www.john-adams.co.uk/wp-content/uploads/2017/01/RISK-BOOK.pdf, accessed on May 28, 2020. Wilde GJS. Target risk: Dealing with the danger of death, disease and damage in everyday decisions. Toronto, ON, Canada: Castor & Columba; 1994.