Oman study reveals hurdles in COVID-19 treatment

Muscat: The spread of COVID-19 to 46 people who were in close contact with a patient who tested positive for the virus at the Royal Hospital has demonstrated the challenges medical workers face when trying to contain the virus.

A case study conducted by four medical practitioners in Oman shows that on 2 July 2020, an investigation was opened when a patient who had been admitted to the hospital was diagnosed with COVID-19.

The patient had been receiving non-invasive ventilation (NIV) in the two days prior to testing positive, having been in the same high dependency medical unit (HDU) cubicle with four other patients.

The study, which was done by Adil Al Lawati and Faryal Khamis of the hospital’s Department of Medicine, and Samiha Al Habsi and Khazina Al Dalhami from the Department of Nursing, revealed that the patient in question had chronic kidney disease, with symptoms suggestive of pulmonary oedema.

“A total of 22 healthcare workers were assigned to the HDU, but were unaware of the index case COVID-19 status at the time of contact and, as a result, were only wearing surgical masks as per hospital policy,” said the study, published in the Oman Medical Journal.

“All exposed cases were screened by SARS-CoV-2 real-time polymerase chain reaction. Positive cases were thoroughly investigated to determine demographic data, occupation, acquisition risk, and clinical outcomes.”

The study, however, revealed that COVID-19 poses unique challenges for infection prevention and control within health facilities. COVID-19 and other diseases such as SARS and MERS put healthcare workers at increased risk of exposure to viruses in the workplace, because they are in increased contact with respiratory droplets and aerosols that transmit the disease between people.

“During the COVID-19 outbreak, healthcare workers were at high risk of developing COVID-19, even when infection prevention measures at hospitals were in place, including using personal protective equipment, hand hygiene, and patient placement in negative pressure isolation rooms,” explained the report. “Most of these acquisitions were related to community exposures.

“In some reports, the risk of acquisition within healthcare settings was highest among healthcare workers exposed to COVID-19 patients with low clinical suspicion and, therefore, were unlikely to adhere to strict infection control measures such as wearing the appropriate PPE or performing hand hygiene.”

The report added that asymptomatic infected front-line workers could contribute to transmission to their colleagues or patients. Compared to the general population, studies from the UK and USA suggest that front-line workers account for 10 to 20 percent of all COVID-19 positive cases. Locally, the study shows 4.3 percent acquisition of the virus among medical workers.

A total of 38 healthcare workers and 28 patients were screened after exposure to the infected patient. 46 of them tested positive for COVID-19. Among them were 26 nurses, seven doctors, one paramedical personnel, and 12 patients. 22 staff and four patients, or over half of those who tested positive, were in the same cubicle as the patient in question, and were identified as close contacts with significant exposure.

“Knowledge gaps on the potential role of NIV in airborne transmission of COVID-19 may result in serious outbreaks among health care workers if appropriate protective measures are not taken, and could deprive patients of lifesaving procedures due to safety concerns,” the study added.

“Following this incident, the hospital issued more regulations to prevent similar acquisition, including wearing N95 masks when dealing with patients on NIV regardless of their COVID-19 status, restricting NIV use to predetermined areas, and screening all patients requiring NIV for COVID-19.”

An additional seven patients and 13 staff were exposed indirectly through contact with other healthcare workers or patients in the same ward. Out of the 12 exposed patients, three died from their original disease: two had advanced malignancies and one had terminal cardiomyopathy, while none of the medical personnel required hospitalisation. Sore throat, fever, and myalgia were the commonest symptoms.

The study concluded that early recognition and screening of patients for COVID-19, and strict adherence to infection control measures, including appropriate PPE, should be encouraged at all times when healthcare workers deal with patients.