Jaipur: Rashmi (name changed), a nurse at Mumbai’s King Edward Memorial (KEM) Hospital, tested positive for COVID-19 on May 21. She had no symptoms necessary for a test under India’s testing guidelines. But she had had contact with a colleague who had tested positive five days prior.

Rashmi continued to work for five days before her samples were collected on May 20. “Some nurses had been immediately quarantined but not all as there is a shortage of staff at hospitals,” she told IndiaSpend. She was finally isolated on May 21.

Healthcare workers are more susceptible to SARS-CoV-2, the virus that causes COVID-19, but India has no policy on regularly testing its healthcare workers, including doctors, nurses and support staff working in COVID-19 hospitals, quarantine or isolation centres or non-COVID medical facilities. This lack of testing of healthcare workers puts their colleagues, patients and the community at a higher risk, research has shown.

Despite this, India’s Ministry of Health and Family Welfare (MOHFW) on May 15 had said that there was no need to quarantine healthcare workers unless they had been exposed to COVID-19 either by mistake or because of a lack of personal protective equipment (PPE). On June 19, in response to a petition to the Supreme Court filed by a nurses' union, the Centre said it had directed state governments to provide a mandatory seven-day quarantine to nurses on COVID-19 duty, a lawyer representing the nurses union told IndiaSpend.

Initially, several hospitals sent their workers into a 14-day quarantine between two 14- to 15-day-long rotations in COVID-19 wards. But when increasing caseload caused a shortage of staff, especially in urban centres such as Delhi and Mumbai, the quarantine period was compressed to as little as three days, nurses and nurses’ unions told IndiaSpend.

States make their own rules when it comes to health and health workers, sometimes based on guidelines from the Centre. In most states with high rates of COVID-19, there are no strict rules on quarantining or testing healthcare workers, the unions said.

“The implementation of these [central government] guidelines varies from state to state and hospital to hospital,” said Swati Rani, an independent researcher and founder of Seva Shakti, an organisation that provides training to healthcare workers. The experiences of nurses also vary based on which city and which hospital they work at or are admitted to for COVID-19 care, nurses’ unions said.

Poor support, low morale

The uncertain quarantine period, no regular testing strategy and no designated quarantine facility so that the health workers do not expose their families, who often share small houses, has resulted in low morale and a loss of trust in the system, nurses said. “All the staff are frustrated,” said Joldin Francis of United Nurses Association, a nurses’ union.

“Healthcare workers, unlike ventilators or wards, cannot be urgently manufactured or run at 100% occupancy for long periods. It is vital that governments see workers not simply as pawns to be deployed, but as human individuals,” noted an editorial in the medical journal The Lancet in March.

Since the start of the pandemic, India’s healthcare workers have protested the shortfall in PPEs, delayed salary payments, ever-changing quarantine rules, poor to non-existent quarantine facilities, long working hours and disregard for their safety, nurses unions told IndiaSpend.

“The healthcare industry culture is not employee-oriented and wellness of employees is not a priority,” said Rani of Seva Shakti.

On June 14, healthcare workers, represented by the United Nurses Association, asked for COVID-19 protection kits for all those who work in COVID-19 wards or with those suspected of COVID-19, accommodation for those who work in COVID wards and nutritious meals and transport facilities for them to reach work, through an intervention application in an ongoing Supreme Court case on the dignified treatment of dead bodies.

They demanded that hospitals screen all patients and test suspected patients without delay, train healthcare workers on infection control and PPE disposal, and provide separate, hygienic washrooms for staff, along with free testing and treatment for those who get infected while on the job. They also asked for timely and full payment of salaries, and no deduction in salary if a healthcare worker contracts COVID-19 while working.

In response to this petition, the central government said it had asked all state governments to implement mandatory seven-day quarantine for those on COVID-19 duty and had passed an order that non-payment of salaries to healthcare workers would be a criminal offence, a lawyer representing the union told IndiaSpend.

Why healthcare worker testing is important

There have been outbreaks of COVID-19 in several health facilities across India with over 190 healthcare workers at the All India Institute of Medical Sciences contracting the virus. In Mumbai alone, about 4% of the 5,000 nurses at Brihanmumbai Municipal Corporation hospitals contracted COVID-19 either at healthcare facilities or in the community, said Ranjana Athwale of the Brihanmumbai Municipal Corporation Nursing and Para Medical Staff Union. “Many of these cases are coming from non-COVID wards and hospitals, but there are no city-wide or country-wide numbers available,” added Rani.

These experiences are in line with other countries where healthcare workers have been disproportionately infected by SARS-CoV-2. They made up between 4% and 19% of COVID-19 cases in China and Europe (3.8% in China, 4.6% in Germany, 9% in Italy and 19% in Spain) by April 23, according to a report by the Imperial College COVID-19 Response team.

Administering weekly RT-PCR tests on healthcare workers and ensuring results are made available within 24 hours would reduce transmission of COVID-19 by 16-23% more than only self-isolation based on symptoms, noted the report, citing academic research.

Further, in previous epidemics, screening programmes for healthcare workers had “boosted morale, decreased absenteeism and potentially reduced long-term psychological impacts”, wrote authors of a study on COVID-19 in healthcare workers in a National Health System hospital in the UK. Screening protects vulnerable patients from an infectious workforce and COVID-19 outbreaks in healthcare staff while also increasing patient confidence and willingness to access healthcare services, the study added.

“Regular tests will improve our healthcare workers’ confidence levels,” said Francis of United Nurses Association.

But there are no guidelines on regular quarantining or testing of healthcare workers in COVID-19 hospitals in India, nurses and public health experts told IndiaSpend.

India and healthcare worker screenings

India does not have separate COVID-19 testing guidelines for healthcare workers, other than those exposed to COVID-19 without protective equipment. In its latest COVID-19 testing strategy announced on May 18, the Indian Council of Medical Research said only those frontline workers who work in containment or mitigation of COVID-19 and have symptoms of influenza-like illnesses (acute respiratory infection with fever ≥ 38°C and cough) could be tested. Direct and high-risk contacts of COVID-19 patients could be tested once between the fifth and tenth day of being exposed to a confirmed case.

Moreover, the Ministry of Health and Family Welfare recommends hydroxychloroquine, stress management routines, protective equipment and training in infection prevention control. Their guidelines mention that all healthcare workers and support staff who have been exposed to a confirmed COVID-19 case should be quarantined and followed-up with for 14 days. In addition, they should be put on hydroxychloroquine (HCQ) for seven weeks. (Read our story on how using HCQ as a preventive for COVID-19 is based on scant evidence).

Even after completing a 14-day shift in a COVID ward or after recovering from COVID-19, not all nurses might be tested before they return to work or home. After about 16 days of treatment in a COVID-19 medical facility, Rashmi was asked to return home for an approximately 12-day home quarantine. “They did not do a second test [to find whether she was negative for COVID-19] on me even after I asked them for it. I have two young children at home but they said that they did not have a policy of testing a second time for patients who had been asymptomatic at that facility,” she said.

In May, the health ministry had revised its discharge policy to allow mild and moderately-ill patients to be discharged from hospital 10 days after onset of symptoms, if there is no fever and no need for oxygen therapy for three days, without testing them before discharge. Patients have to isolate themselves at home for seven days thereafter.

Meanwhile, the government has also announced an insurance cover of Rs 50 lakh for 221,200 health workers who might be pressed into service in India’s fight against COVID-19.

Testing asymptomatic healthcare workers

Not testing health workers regularly is dangerous as asymptomatic and presymptomatic healthcare workers continue to commute to places of work where they might not have quality PPE, wrote authors from Cancer Evolution and Genome Instability Laboratory in London, in an article titled ‘The case for health-care worker screening to prevent hospital transmission’, published in The Lancet in April. These workers could spread the disease to others within and outside of hospitals. Even during a lockdown, asymptomatic COVID-19 among hospital staff could “act as a potent source of ongoing transmission”, the article added.

In India, several hospital facilities are inadequate. Often, healthcare staff do not even have a designated room to put on and take off PPEs and they are not given fitting N95 masks, which leaves them exposed to the virus, nurses and doctors from COVID-19 wards told IndiaSpend. “We are not fit-testing staff for N95 masks, increasing the risk of infection,” said a doctor who works at a government hospital in Maharashtra.

“To reach the room where we wear the PPE we have to pass through the COVID ward,” said Rashmi, the nurse who tested positive. “In the emergency ward, the designated area to put on our PPE is next to the patient bathroom,” Rashmi added.

The lack of such basics makes regular screening and testing of health workers even more important, especially as many could be asymptomatic.

How Daegu in South Korea Protected Healthcare Workers

The South Korean city of Daegu (population 2.4 million) had the first large outbreak of COVID-19 outside of China. Despite facing similar challenges as other large cities--shortages of personal protective equipment, in-patient beds and healthcare workers--the rate of COVID-19 infections among healthcare workers in Daegu remained lower than in other cities.

A month into the epidemic, 121 healthcare workers were COVID-19 positive, including 14 doctors, 56 nurses and 51 nurse aides--1.8% of the 6,620 confirmed cases at the time. This is lower than other countries such as Italy where 9% of all confirmed cases were of healthcare workers. The study found that nurses were more susceptible to catching the virus: 2.4 per 1,000 doctors were infected compared to 5 per 1,000 for nurses and nurse aides.

This is what Daegu did: Closely monitored shift durations to minimise fatigue that could cause errors in basic infection control, such as hand hygiene and PPE donning and doffing. They limited shifts to two weeks for public sector workers and one month for private sector workers, with 40 hours per week.

They followed a policy of aggressive use of PPE, N95 respirators along with eye protection, shoe covers and coveralls at screening clinics and for the care of all suspected or confirmed COVID-19 patients.

Staff working with COVID-19 patients were screened twice a day for symptoms. Each hospital adapted screening protocols for employees. Anybody who reported symptoms was tested, with results provided within hours, and could work only if they tested negative. If there was a potential cluster outbreak, all staff were tested regardless of symptoms.

All healthcare professionals completing their rotation in a COVID-19 facility were tested regardless of symptoms, and asked to self-quarantine if they had had close contact with a patient without proper PPE, if they had traveled internationally, or if they were part of a specific religious group known to have a high incidence of infection. On the 13th day of quarantine after exposure, healthcare workers were tested and could return to work only on Day 15 if they tested negative.

Source: How South Korea Responded to the Covid-19 Outbreak in Daegu

(Khaitan is a writer/editor with IndiaSpend. Surbhi Bharadwaj, an intern with IndiaSpend, contributed to this article.)

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.

Shreya Khaitan

    Shreya is a writer and editor at IndiaSpend. She is a graduate of the Global Human Development program at Georgetown University, Washington D.C. and has previously worked with the Mumbai bureau of The Wall Street Journal. There she researched for a series on drug resistant tuberculosis and wrote on a number of topics, ranging from reservation for women in Indian politics to the black and yellow taxis plying the city’s roads. Her report on a pilot TB care programme in Gujarat's Mehsana district won the 2017 REACH Media Award for excellence in reporting on TB. She has also worked in education and early childhood development with organizations in Washington D.C., India and Jordan.