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The coronavirus outbreak has exposed a lot of flaws in otherwise robust healthcare systems. A major issue is the peak of the case-load increase – the point at which our hospitals are most overwhelmed. A corresponding issue then is to have fewer healthcare workers (HCWs) at our hospitals thanks to they themselves getting infected. Add to this number the issue of many HCWs being quarantined for 14 days due to exposure to a COVID-19 patient, and it quickly becomes clear that we’re at risk of a double whammy.
Mumbai, for example, initially locked down entire hospitals due to an HCW developing COVID-19. As reported on April 11, at least 800-900 beds were out of circulation in South Mumbai as a result.
India is still not near its peak thanks to the effects of the lockdown. The time we have thus gained needs to be used to formulate practical policies to minimise exposure of HCWs, and to manage its downstream effects. These policies could hold us in good stead once the lockdown is lifted and the case-load curve begins to unflatten again. HCW infection can be minimised only with adequate personal protective equipment; this is not rocket science. However, quarantining HCWs is something we need to deliberate carefully based on the available evidence.
It is a potential double-edged sword. Quarantine overzealously and you are left with an extremely depleted workforce with exponential downstream effects. Quarantine too little and many more HCWs and patients could get infected. India has to strive hard to strike this delicate balance.
The guidelines of and success stories in other countries could be instructive. For example, in Singapore, HCWs are quarantined only if they have been exposed for more than 30 minutes (or 15 minutes in Hong Kong) to a patient who has tested positive for COVID-19, at a distance of less than six feet if a surgical mask wasn’t worn. Otherwise, the worker can continue while monitoring themselves for symptoms.
The US Centers for Diseases Control and Prevention (CDC) guidelines are more detailed, with different rules based on the duration of exposure (brief v. prolonged), whether the patient was wearing a mask (including cloth masks), and the extent to which the worker wore personal protective equipment (complete PPE v. mask plus eye protection v. only surgical mask/N95 v. none). An exposure is accordingly rated high-risk, medium-risk and low-risk. Again, in the case of a prolonged exposure, HCWs need not be quarantined unless they lacked even a surgical mask. If the patient was not wearing a mask, the HCW needs to be quarantined if she was not wearing both surgical mask and eye protection. No quarantine is necessary for brief, casual exposures.
Unfortunately, the situation is very confusing in India. There is no clear, official guideline on this important matter. The Ministry of Health and Family Welfare has published guidelines on the rational use of PPE, according to which pretty much everyone in a hospital (including all those in patient-screening and patient-waiting areas, doctors chambers, OPDs and sanitary facilities) must wear at least N95 masks and gloves.
But the unfortunate truth is that this is not happening thanks to the limited availability of PPE. According to the Indian Council of Medical Research, “asymptomatic direct and high-risk contacts of a confirmed case should be tested once between day 5-14 days”, but the corresponding document doesn’t discuss quarantining measures. Guidelines from the Municipal Corporation of Greater Mumbai (dated April 15) also state that HCWs exposed to COVID-19 should be tested and that asymptomatic high-risk contacts need to be quarantined for 14 days. Put all these different guidelines together and you get HCWs without N95 masks falling in the ‘high-risk’ category, and will need to be quarantined for 14 days per the existing recommendations.
Let’s consider practical issues. Most hospitals now handle patients with fever or cough very efficiently, minimising exposure to HCWs. However, patients often come in with symptoms like breathlessness as well, which can be mistaken for a cardiac issue or an asthma attack. Such patients breach the hospital’s initial ‘defences’ with ease. Further, some hospitals now mandate COVID-19 tests for every admission, so some asymptomatic patients also get through, only to be detected later on. Given that a hospital’s staff members work in shifts, they will have encountered at least a few doctors, some nurses and wardboys, and perhaps paid a few visits to X-ray or ultrasound diagnostic facilities by the time the test report is in (at least 1-2 days). What happens to these HCWs? Will all of them need to be quarantined for 14 days even if they wore surgical masks?
On average, about 15-30 HCWs end up falling in this category, depending on how quickly the test results are available.
Next, what do we do with the people they interacted with in the interim? Do they need to be quarantined as well?
Most hospitals in the country are currently grappling with these questions, with no fixed answers.
Some hospitals have proactively created and are following their own guidelines based on the available evidence. However, many institutes don’t have such guidelines in place, so the first time they face this scenario, they simply take the safest route and isolate everyone who crossed paths with a patient. The resulting sting is likely to be felt more sharply in government hospitals, where there is a smaller incentive to work and where workers’ unions may demand the perceived safest option of 14-day quarantining.
Hospitals’ workload at the moment is currently relatively lower thanks to the lockdown, so it might be possible to continue steering the ship with the number of hands that are still available on deck. But in the near future – after May 3, after the second lockdown is lifted – our healthcare system may not be able to afford so many HCWs being absent from their stations. This is why it’s for health authorities to quickly install a rational and evidence-based pan-India guideline to quarantine HCWs, or at least provide some granular way to rationally manage the situation. Such guidelines will help hospitals function smoothly, help HCWs feel safe and conserve our health workforce for doing what it does best – save lives.
Dr Akshay Baheti is an assistant professor at a hospital in Mumbai. The views expressed here are the author’s own.