The Covid-19 pandemic has posed unprecedented challenges to healthcare systems globally.
Healthcare staff are at the forefront of governments’ efforts to control the spread of the SARS-CoV-2 virus, which causes Covid-19. Malaysia is no exception.
The China National Health Commission reported that as of Feb 24 (2020), 3,387 of 77,262 Chinese patients with Covid-19 (4.4%) were healthcare staff or others who worked in healthcare facilities.
As of April 3,23 of those healthcare staff had died after being infected during their work.
There have been similar reports elsewhere and healthcare website Medscape has set up a webpage in memory of healthcare staff who have died of Covid-19.
The Health Ministry reported that the numbers of healthcare staff who tested positive for Covid-19 were 24 on March 21,80 on March 26,138 on April 3 and 224 on April 11 respectively.
That is an increase of nine times in 22 days!
Many experts believe that the asymptomatics (those with no symptoms), pre-symptomatics (those diagnosed before having symptoms) and those with mild symptoms who are unnoticed by anyone, could be an important source of the spread of the infection.
Many without symptoms
The first report of infectious spread by an asymptomatic person was that of a 20-year-old Chinese woman in Wuhan, who spread the virus to five family members, but never had any symptoms herself.
An analysis of 262 confirmed Covid-19 cases hospitalised in Beijing, China, as of Feb 10, to determine the clinical and epidemiological characteristics of the disease in the city, reported that 5% were asymptomatic.
The Diamond Princess cruise ship quarantined off Yokohama, Japan, from Feb 5-21, had 634 positives among the 3,063 passengers and crew tested, with 328 (50%) of the positives asymptomatic at the time of testing.
A study done in a long-term care skilled nursing facility in King County, Washington state, United States, tested 76 out of 82 residents (93%) to evaluate the usefulness of screening based on the presence of symptoms for accurate diagnosis.
The results stated that of the 23 positives at the time of testing, 10 (43%) had symptoms and 13 (57%) did not.
Ten of the 13 people without symptoms developed them a week after the test.
This led to the conclusion that symptom-based screening would fail to identify about half of the residents with Covid-19.
The China Health Commission started to publish daily data of asymptomatic cases from April 1.
The asymptomatic accounted for 133 of 166 new infections, i.e. 78% of the first day’s figures, according to a BMJ report.
The UK Centre for Evidence-Based Medicine in Oxford, which reviewed 21 reports from a search of LitCovid (a subset of the PubMed library system that tracks scientific information about the virus), medRxiv, Trip, Scholar and Google reported on April 6 (2020) that:
- Between 5% and 80% of people testing positive for SARS-CoV-2 may be asymptomatic.
- Symptom-based screening will miss cases, perhaps a lot of them.
- Some asymptomatic cases will become symptomatic over the next week (sometimes known as “pre-symptomatics”).
- Children and young adults can be asymptomatic.
The centre also said “that there is not a single reliable study to determine the number of asymptomatics.
“It is likely we will only learn the true extent once population-based antibody testing is undertaken.”
Of 215 women admitted in labour to the New York–Presbyterian Allen Hospital and Columbia University Irving Medical Centre in the US between March 22 and April 4 (2020), 29 of the 33 patients (87.9%) who were positive at admission were asymptomatic at presentation.
Fever developed in three women (10%) before discharge after delivering their baby (median length of stay was two days).
The findings of population screening in Iceland revealed that 43% of the participants who tested positive were asymptomatic, although symptoms almost certainly developed later in some of them.
In short, there is increasing evidence that a certain percentage of those positive for SARS-CoV-2 are asymptomatic or pre-symptomatic.
They are currently largely unassessed as testing is performed predominantly on those with symptoms or who are at high risk of developing symptoms.
Malaysian data lacked details.
The Health Ministry stated that the test positivity rate was 0.5% when all residents living in enhanced movement control order (EMCO) areas were tested.
The Selangor Menteri Besar reported a test positivity rate of 0.77% (five cases) in 649 samples taken in Hulu Langat on April 11-12.
Four out of these five cases were asymptomatic.
While it is not scientific to assume that the positivity rates in EMCO areas or Hulu Langat, are representative of the rest of the country, 0.5% and 0.77% of our population of 32 million would translate into about 160,000 and 250,000 persons respectively.
Compare that with the number of positive cases reported daily.
The World Health Organization (WHO) defines healthcare-associated (also termed nosocomial) infection as “an infection occurring in a patient during the process of care in a hospital or other healthcare facilities, which was not present or incubating at the time of admission”.
According to WHO, healthcare-associated infections are the most frequent adverse event in healthcare delivery worldwide.
The organisation says, “Of every 100 hospitalised patients at any given time, seven in developed and 10 in developing countries will acquire at least one healthcare-associated infection.”
The potential for asymptomatic and presymptomatic Covid-19 cases among healthcare staff to spread the infection to patients without Covid-19, other healthcare staff or the public, has yet to be worked out.
The public are aware of Malaysian general practitioners’ (GPs’) concerns about the lack of access to basic personal protective equipment (PPE) like face masks and face shields, since early this year (2020).
Does the finding that half of Malaysian GPs reported getting only a quarter of their usual patient numbers, with 21.7% not getting any patients at all, on most days, reflect public concern about healthcare-associated infections?
This will impact negatively on the management of non-communicable diseases like diabetes, hypertension and so on, which require regular monitoring.
Testing asymptomatic healthcare staff will reduce the risk of them unintentionally spreading the virus to their colleagues or patients.
It would also allay anxiety among healthcare staff and reduce the numbers of self-imposed quarantines following contact with a potential Covid-19 patient.
On March 29 (2020), I discussed the matter of screening healthcare staff with a medical director and chief executive officer of two private hospitals.
The former said that this matter was under consideration and the latter stated that current assessment methods, i.e. temperature and symptom screening were adequate.
There has been no further action since then.
It is time the Government takes the lead in implementing the screening of asymptomatic healthcare staff for Covid-19, prioritising those in high-risk areas like intensive care units (ICUs), operating theatres, and accident and emergency departments.
With increasing laboratory capacity, this can be extended to all healthcare staff.
Although how often screening should be done has not been worked out, a weekly interval is suggested for those in high-risk areas.
A healthy workforce that is not burnt out with work and anxiety is needed in the marathon response to Covid-19.
In the final analysis, the health of healthcare staff and other frontliners is critical as staff depletion would impact negatively on service delivery.
Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email email@example.com. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
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