|Year : 2021 | Volume
| Issue : 3 | Page : 264-271
|COVID-19 and healthcare worker: What we need to know
Deepak Jakhar1, Chander Grover2, Ishmeet Kaur3, Anupam Das4, Subuhi Kaul5
1 From the Consultant Dermatologist, Dermosphere Clinic, University College of Medical Sciences and GTB Hospital, New Delhi, India
2 Department of Dermatology and STD, University College of Medical Sciences and GTB Hospital, New Delhi, India
3 Department of Dermatology, North Delhi Municipal Corporation Medical College and Hindu Rao Hospital, New Delhi, India
4 Department of Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal, India
5 Department of Internal Medicine, John H Stroger Hospital of Cook County, Chicago, Illinois, USA
|Date of Web Publication||13-Jul-2021|
Consultant Dermatologist, Dermosphere Clinic, New Delhi - 110 075
Source of Support: None, Conflict of Interest: None
| Abstract|| |
COVID-19 pandemic has challenged and overwhelmed most healthcare institutions and healthcare workers, across the world. Despite being unprepared for this pandemic, frontline workers have worked relentlessly to provide the much-needed care to these patients. Doctors from different branches of medicine, including dermatologists, came forward and played a substantial role in mitigating the impact of this pandemic on the general population. Sadly, in the process, these healthcare workers faced many personal, social, psychological, economic, and health-related issues. The psychological burden and health-related issues received due attention in the main-stream news as well as scientific research papers. With most frontline workers isolated from their families, social media became the new platform to reduce the sense of isolation and share their anxiety, insomnia, and fatigue. This article is aimed at highlighting various challenges faced by healthcare workers during the ongoing COVID-19 pandemic.
Keywords: COVID-19, SARS-CoV-2, healthcare workers, dermatologists
|How to cite this article:|
Jakhar D, Grover C, Kaur I, Das A, Kaul S. COVID-19 and healthcare worker: What we need to know. Indian J Dermatol 2021;66:264-71
| Introduction|| |
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified as the causative novel coronavirus for the cluster of patients suffering from pneumonia in China. The disease was named coronavirus disease of 2019 (COVID-19) and was declared a pandemic by the World Health Organization on March 11, 2020. Since then, healthcare institutions across the world have been fighting this onslaught. COVID-19 has set forth an array of challenges—medical, ethical, social, economic, and organizational. Healthcare workers (HCWs) are bound by ethics to provide support to patients even in the face of adversity. Adhering to medical ethics, HCWs are doing their best to save lives across the world. Uniquely placed at the center of this pandemic, HCWs have faced several challenges including increased risk of infection, shortage of personal protective equipment (PPE), psychosocial trauma, economic issues, occupational dermatosis, etc. Physicians from all branches of medicine including dermatology have contributed and continue to contribute their best efforts towards containing this pandemic.
Addressing the needs of front-line HCWs during the COVID-19 pandemic should be, and is a high priority. This article provides a narrative review of various factors bearing upon HCWs during the current COVID-19 pandemic.
| Higher Risk of Exposure and Infection|| |
Being on the front line, HCWs are at the highest risk of getting infected with SARS-CoV-2. Several studies published globally outline the exposure and infection of COVID-19 among HCWs. Compared to the general population, front-line HCWs have been found to have at least a threefold increased risk of acquiring COVID-19. The identified high-risk factors include poor availability or improper use of PPE, typical workplace setting, and specialty determining the risk of exposure, contacts, and testing strategies. Reused or inadequate PPE is associated with an increased risk of exposure and infection.[4–6] Inadequate availability of PPE in countries like India had been a major concern during the initial phase of this pandemic. Evidence suggests that sufficient availability of PPE and high quality of PPE do reduce the risk of COVID-19. In addition, suboptimal hand hygiene before-and-after consulting patients and inadequate use of face masks have also been linked to increased risk of infection., HCWs working in an inpatient setting are at the highest risk of getting exposed. Physicians at highest risk were those involved in interventional or surgical procedures that generated respiratory aerosols, including within pulmonology departments, infection control departments, intensive care units (ICU), and surgical departments. Prolonged daily work hours (>10 h) and sharing the work environment contribute further toward increasing the risk., Professionally, physicians posted in direct care of patients are at a higher risk as compared to the nurses and general service employees.
In an Indian study, HCWs reported an inability to follow social distancing within wards and duty rooms. They cited lack of adequate space and difficulty in communication as the possible explanation for not being able to follow social distancing. It also reported widespread use of mobile phones in healthcare settings (a potential fomite), however, the majority of HCWs sanitized them at the end of the duty. Cling film wrap has been advocated as a simple protective covering for mobile phones during COVID-19 duty hours, though now, specially designed covers are also available.
During the pandemic, dermatologists, especially in institutions, have been deployed for the care of COVID-19 infected patients. They have been working in ICU, high dependency units, participating in triage, and also establishing diagnosis and treatment of these patients., Working at the forefront, up to half of these dermatologists are known to have become infected with SARS-CoV-2 in various departments. An Italian study found that around 23.1% were either PCR positive or showed clinical symptoms of COVID-19.
Mortality among the COVID-19 infected HCWs has been worrisome and many doctors, including many senior dermatologists, have lost their lives during this pandemic. The overall global magnitude of COVID-19 in HCWs (from 37 countries) was recently documented by the Infectious Diseases International Research Initiative (ID-IRI). The report documented 2736 HCW deaths with a mortality rate of 0–0.90/100,000 in the reporting countries. India lost 108 medical doctors according to this survey. The official count from the Indian Medical Association registry is much higher, with 864 physician deaths recorded till May 2021.
| Personal Protective Equipment: Usage and Disposal|| |
The availability of PPE is a crucial factor for the management of COVID-19 [Figure 1]. The guidelines issued by the Government of India on rational use of PPE, based on risk assessment, include the usage of gloves, coverall or gowns, goggles, N95 mask, shoe cover, headcover, and triple-layered medical masks. During the pandemic, the requirement for PPE exponentially increased, creating a temporary shortage of PPE in many countries, including India. The sudden surge in demand forced many HCWs to use helmets, plastic bags, and raincoats as protective gear amid PPE shortage. The shortage was overcome through the collective efforts of various government and healthcare institutions across the globe. Appropriate use of PPE has been shown to decrease the risk of infection and therefore HCWs should be meticulously trained in their proper use and disposal. Proper donning and doffing while preventing the risk of contamination is a skill that needs to be acquired by all HCWs.
|Figure 1: A frontline healthcare workers with gloves, gown, headcover, shoe cover, N95 mask, and face shield|
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A study observed that dermatologists during work-hours used masks (97.9%), hydro-alcoholic gel (95.4%), soap (87.0%), gloves (83.5%), white coats (64.4%), and, less frequently, glasses (44.1%), mobcaps (14.1%), or overshoes (5.4%). Interestingly 10.7% indicated that they had created their personal protective kit.
In tropical countries like India, donning PPE is a challenge for HCWs. Even in centrally air-conditioned institutions, HCWs reported increased perspiration with the use of PPE [Figure 2] and [Figure 3]. Heat stress due to PPE impairs the cognitive and physical performance of HCWs. Restricted body movement and difficulty in communication through PPE make routine bedside work difficult. Frequent headache is one of the most common adverse effects reported by HCW with PPE usage.
|Figure 2: Excessive perspiration due to PPE on the back of a healthcare worker|
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|Figure 3: Wrinkling of the hands due to sweat after prolonged wearing of gloves|
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Disposal of PPE is equally important in the containment of infection. Under biomedical waste (BMW) rules, PPE items should be disposed of, in yellow, non-chlorinated plastic bags and be considered as infectious waste. The BMW guidelines suggest the use of double-layered bags for ensuring leak-proof collection and transportation. These bags or containers should be adequately labeled as COVID-19 waste.
| Occupational Dermatoses|| |
Due to an increased frequency of donning PPE, handwashing, and use of sanitizers, the COVID-19 pandemic also saw an increase in cases with occupational dermatosis [Table 1]. Initial studies from China reported up to 97% of HCWs experiencing skin changes secondary to newly adopted infection control practices., Mushtaq et al. reported prevalence of cutaneous adverse effects of PPE to be similar in HCWs and the general population. Wearing PPE for a longer duration was found to be significantly associated with cutaneous adverse effects. A study from United Kingdom (UK) reported irritant contact dermatitis among 97.1% HCWs with a high incidence of pressure-related facial dermatitis due to masks and goggles. Mask-induced contact dermatitis and contact urticaria can occur due to adhesives, rubber straps, free formaldehyde released from the non-woven polypropylene, and metallic clips., In addition, mask-induced acne, rosacea, and seborrheic dermatitis have also been reported and can occur due to the occlusive/frictional effect of the mask, sebum dysregulation, and microenvironment changes.,, Proposed diagnostic criteria for “maskne” include: (a) de novo acne occurring 6 weeks after regular mask wear or (b) worsening of pre‐existing acne in mask covered by areas after regular mask-wearing, (c) exclusion of the main differential diagnoses ensured [Figure 4]. Koebnerization of facial psoriasis associated with frequent mask usage has also been reported. A combined study from UK and Ireland reported occupational dermatoses in 93.5% of HCWs. Around 16.6% HCWs developed mask-related acne or rosacea, however, no significant association with mask type was found. Pressure injuries were found to be associated with the prolonged wearing of PPE (91% HCWs developed pressure injuries who wore PPE for greater than 5 h per shift). The study also highlighted that significant work hours are lost due to occupational dermatoses. HCWs with the previous history of dermatitis have significantly higher chances of developing irritant contact dermatitis due to PPE.
Guertler et al. observed an increased frequency of hand washing and disinfection among HCWs, and reported acute hand dermatitis in up to 90.4% HCWs. Altunisik et al. reported a statistically significant increase in hand dermatoses during the pandemic as compared to prepandemic time. The authors also observed a higher frequency of hand dermatoses [Figure 5] among female HCWs as compared to male HCWs. HCWs attributed their hand dermatoses to alcohol-based hand antiseptics (71.4%), soap (48.6%), and gloves (24.3%). The rate of hypersensitivity to latex gloves among HCWs has been reported to be 32.6%.
An Indian study on facial dermatoses secondary to PPE found irritant contact dermatitis (39.5%), pressure/frictional marks (25.6%), sweat dermatitis (16.3%), facial acne (11.6%), allergic dermatitis (6.9%), and lip-lick dermatitis (9.3%) among HCWs. The most common sites of involvement were: nasal bridge, eyelids, and forehead. The authors also reported that 21% HCWs suffered from work absenteeism due to occupational dermatoses. Lip cheilitis and angular cheilitis has also been reported in few studies and can also result due to prolonged mask-wearing and anxiety., Increasing incidence of hand dermatitis secondary to hand hygiene practices during COVID-19 was also reported by Kar et al.
| Psychological Impact|| |
COVID-19 had a major psychological impact on the general population as well as HCWs during this pandemic. Among the HCWs, those involved directly in patient care, diagnosis, and treatment had to face greater psychological consequences, even though the impact on others cannot be underestimated. The reasons attributed ranged from excessive workload/work hours, inadequate PPE, over-enthusiastic media coverage, feeling inadequately supported, infection among peers and family members, administrative pressures, and fear of getting infected.[42–44] Research shows that a substantial number of HCWs suffered from anxiety, depression, distress, and insomnia amidst this pandemic., Lai et al. reported depression (50.4%), anxiety (44.6%), insomnia (34.0%), and distress (71.5%) among 1257 HCWs. Female HCWs were found to be more symptomatic than males. One of the meta-analyses calculated the pooled prevalence of anxiety (23.2%), depression (22.8%), and insomnia (34.3%). The values are significant as one out of every three HCWs experiences some sort of psychological disturbance. The situation remained bleak even with the subsidence of a wave. Studies have shown that HCWs have a high tendency to develop post-traumatic stress disorders (PTSD).,, The tendency to develop PTSD is higher in the female gender and younger HCWs. Social isolation, quarantine, and separation from family are found to be associated with higher rates of PTSD. Sadly, suicides have also been reported, as healthcare professionals are faced with accumulated psychological pressure and intense fear of dying., [Table 2] shows various factors associated with an increased risk of psychological issues. Younger HCWs have lower job satisfaction as compared to older HCWs when it comes to the increased working hours. Emotional exhaustion, depression, burnout, and anxiety among HCWs is known to correlate with the risk of medical errors, lack of empathy towards patients, and lower productivity.
|Table 2: Factors associated with increased risk of psychological disturbances among healthcare workers|
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Dermatologists also faced psychological distress during COVID-19. Podder et al. conducted an online survey to compare the psychological stress among dermatologists and non-dermatologists. Stress score of dermatologists was found to be comparable to the non-dermatologists. Significantly higher stress levels were found in female gender and unmarried dermatologists. The risk of self-infection was a more significant risk factor in dermatologists compared to uncertain availability of food, transport, and lack of protective gear at workplace in nondermatologists. Sil et al. conducted a survey on frontline dermatologists and found depression and stress in 26.8% and 29.2% of responders. Higher perceived stress scores were reported by females, those having long working hours, those working in COVID wards, and participants staying away from family. Bhargava et al. found stress (73.9%), irritability (33.7%), insomnia (30%), and depression (27.6%) among dermatologists. The distress was noted more among dermatologists practicing in North America and Asia than in Central/South America and Europe. Among Italian dermatologists, stress more than usual was reported by 50.4% responders. Other personal feelings during the pandemic included: increased anxiety (41.1%), feeling of worthlessness (39.8%), feeling of anger (23.5%), feeling of loneliness (16.4%), depression (8%), and suicidal ideation (0.6%). Some responders also reported positive feelings like: pride in the capacity of being a dermatologist (28.2%), feeling of purpose (16.1%), and less stress than usual (18%).
The increased stress during the pandemic also brought an increase in psychodermatological disorders. Kutlu et al. reported an increase in cases of alopecia areata 2 months after the emergence of COVID-19, suggesting a link between stressors related to COVID-19 and alopecia areata. Shen et al. reported increased disease activity in chronic urticaria, with perceived stress assessed by a visual analog scale. Authors correlated increased stress to income loss. Kuang et al. observed an association between exacerbation of psoriasis, income loss, outdoor activity restriction, perceived stress, and symptoms of anxiety and depression. The authors also reported a higher prevalence of nonadherence to treatment.
| Dermatology Practice and Economic Impact|| |
Most of the attention during the pandemic has been diverted towards the management of COVID-19 patients. Healthcare facilities had to face challenges like healthcare rationing, setting clinical priorities, and working within a severely restricted diktat. Most hospitals and medical colleges across India resorted to limiting the dermatology out-patient and in-patient departments to contain the spread of infection, but this was primarily to free up manpower and resources for the massive number of COVID-19 patients. As dermatologists, we were aware of the significant collateral damage, which may arise due to delays in diagnosis and treatment of acute and chronic dermatological conditions; however, the pandemic and massive societal suffering expectedly took precedence.
The dermatology training opportunities and academic curricula also suffered across institutions., Qualifying exams were delayed and conducted on novel patterns, which lead to higher anxiety levels in the exam-going candidates. For the trainee dermatologists, skill acquisition and day-to-day training in their chosen specialty suffered and continues to do so. Most of the private healthcare and individual practices moved from physical consultation mode to teledermatology platforms., Bhargava et al. reported that around 66.9% of dermatologists in India used teledermatology during the pandemic. The dermatology practices saw a marked reduction in the number of patients and procedures. To aid in the clinical practice, several suggestions and recommendations were put forward.,,,,,,,,, Many dermatologists, especially during the second nationwide wave moved on to contribute teleservices towards COVID care and post COVID care as well, due to the felt needs of the society.
In Italy, very high numbers of canceled or rescheduled appointments were reported by dermatologists. Two-thirds of dermatologists practiced telemedicine. During teleconsultations, 45.3% of dermatologists felt the patient–physician relationship was worse, 31.9% felt it was much worse, 19.5% felt it was unchanged, 4.1% felt it was better, and 0.8% thought it was much better. In a survey by International Dermoscopy Society, around 49.3% dermatologists experienced a 75% reduction in daily work activity.
The reduction in dermatology practices also brought a decrease in revenue generation. Loss of revenue was huge for dermatologists in private practice, especially because of continuing overheads, EMI's, and staff salaries. On the other hand, there was no significant impact for dermatologists working in government institutions who were contributing towards COVID care in their institutions. In Italy, 16.2% of dermatologists decided to take out a loan, whereas 17.6% did not know what they would do in this crisis.
| Stigmatization and Misbehavior|| |
Violence against healthcare professionals has been a frustrating phenomenon and is not restricted to India alone. It is reflective of the overall negative mindset of the society at large towards HCW and even the COVID-19 pandemic witnessed many unfortunate incidents. HCWs working in COVID facilities were asked to vacate rented accommodation, abused, and physically assaulted. Such actions probably result from the lack of understanding among the general public regarding the kind of efforts put in by doctors to deliver healthcare services. Among dermatologists in Italy, 75.1% felt no stigmatization. Stigmatization appeared to be expressed by patients (14.4%); neighbours (6.5%); family (5.7%); friends (4.2%); shopkeepers (4.0%); and household members (3.1%). The psychological impact of such behavior on doctors is unimaginable. COVID-19 highlighted the fact that we need to have stricter laws, and even stricter implementation in letter and spirit to protect our HCWs from such unsolicited behavior.
| Conclusion|| |
At the heart of this once-in-a-lifetime pandemic, HCWs have strived to give their best despite facing many challenges. It is true that HCWs are not immune to the psychological, social, and economic impact of this pandemic. As a vulnerable section of society, they have borne the brunt of the pandemic. This does not mean taking away credit from other frontline workers or humanity at large; however, to support HCWs, the general population and healthcare institutions must understand their challenges and needs. We sincerely hope that the COVID-19 pandemic will prompt a redefinition of work ethics and work behavior, with due recognition of the contribution of all HCWs who have risen to their responsibility time and again. That will be the silver lining of this dark cloud!
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]