|Year : 2020 | Volume
| Issue : 1 | Page : 3-7
Factors leading to delayed testing from the time of symptom onset for COVID-19 by health-care personnel: A study from all india institute of medical sciences, New Delhi
JS Anuvindha1, Vishwajeet Singh2, Radhika Sarda3, Vishal Kumar Vishwakarma4, Aishee Pal5, Bharathi Arunan3, Shivam Goel3, Piyush Ranjan3, Arvind Kumar3, Naveet Wig3
1 Department of Oral and Maxillofacial Surgery, All India Institute of Medical Sciences, New Delhi, India
2 Department of Biostatics, All India Institute of Medical Sciences, New Delhi, India
3 Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
4 Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, India
5 Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||06-Dec-2020|
|Date of Decision||11-Dec-2020|
|Date of Acceptance||16-Dec-2020|
|Date of Web Publication||31-Dec-2020|
Dr. Arvind Kumar
Department of Medicine, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Background and Objectives: Early testing and diagnosis of COVID-19 infection can help decrease the spread of the virus. Undoubtedly, health-care workers (HCWs) have been the frontline warriors in the COVID-19 pandemic and are at maximum risk of acquiring the infection. We thereby conducted this study to assess the factors that lead to delayed testing after symptom onset in health-care personnel. Methodology: This single-center, cross-sectional study was conducted at a dedicated COVID-19 Employee Health Services Outpatient Department at a tertiary care center, New Delhi, in July 2020. HCWs who were suspected COVID and presented for testing were included in the study. The duration between symptom onset and date of testing was noted. Delayed testing was defined as testing after 24 h from symptom onset. Results: A total of 653 HCWs were included in the study, and 55.9% were males. Female workers presented after a mean (standard deviation [SD]) of 3.43 days (1.91) from symptom onset as compared to male counterparts 3.16 days (1.84). Frontline HCWs who managed patients directly had delayed testing when compared to others at mean (SD) days of 3.46 (1.96) versus 3.13 (1.79), P = 0.04. Conclusion: In the ongoing COVID-19 pandemic, prevention and mitigation of the disease are still the mainstays of combating the disease, for the given fact that treatment and immunization still remain largely unanswered. All HCWs, irrespective of sex, age, and place of working, should be routinely reiterated, motivated, and reinforced for early testing in case of COVID-19-related symptoms.
Keywords: COVID-19, delayed testing, factors, health-care workers
|How to cite this article:|
Anuvindha J S, Singh V, Sarda R, Vishwakarma VK, Pal A, Arunan B, Goel S, Ranjan P, Kumar A, Wig N. Factors leading to delayed testing from the time of symptom onset for COVID-19 by health-care personnel: A study from all india institute of medical sciences, New Delhi. J Prim Care Spec 2020;1:3-7
|How to cite this URL:|
Anuvindha J S, Singh V, Sarda R, Vishwakarma VK, Pal A, Arunan B, Goel S, Ranjan P, Kumar A, Wig N. Factors leading to delayed testing from the time of symptom onset for COVID-19 by health-care personnel: A study from all india institute of medical sciences, New Delhi. J Prim Care Spec [serial online] 2020 [cited 2021 Mar 4];1:3-7. Available from: http://www.jpcs.com/text.asp?2020/1/1/3/305884
| Introduction|| |
The spread of COVID-19 caused by SARS-CoV-2 has been very rapid, and the overall burden has been immense. The major mode of transmission has been close exposure to an infected patient, irrespective of one being symptomatic or asymptomatic. The most effective diagnostic method has been reverse transcription-polymerase chain reaction-based SARS-CoV-2 RNA detection from the nasopharynx.
Despite incessant research and trials, we are still far from vaccine or any approved treatment for COVID-19. However, there are enough evidences to support that interventions, such as appropriate isolation in a center or home, COVID-19-related cautions, and behavior after one gets infected, are the most effective ways of reducing the transmission of this rapidly growing pandemic.,, Kretzschmar et al. published a modeling study which estimated and concluded bad effects on the contact-tracing strategies for COVID-19 if the diagnostics are delayed. Timely testing (the delay in the said study by Kretzschmar et al. was taken as more than 1 day) leads to timely contact tracing which is needed to keep R0 effective reproduction rate below 1. Timely testing and timely contact tracing both are very closely interlinked. Keeping R0 values below 1 in a given situation where testing is delayed by 3 or more days seems not feasible even if all available measures are taken. As of November 16, 2020, worldwide, 54.81 million cases were reported as COVID-19 positive with 1.32 million deaths, with most cases reported in the USA, India, and Brazil, respectively. Frontline health-care workers (HCWs) have a mortality rate of 1.4%, but in countries like Italy, it has been reported to be as high as 9%. HCWs are affected in this crisis despite following the guidelines strictly recommended by the CDC and the WHO to manage the patients.
Infection among the HCWs is one of the greatest risks to the health-care system for the obvious reasons of their direct or indirect involvement in COVID-related care. Early recognition of suspected or confirmed cases leading to appropriate COVID behavior (quarantining, isolation, decontamination, etc.) with involvement of all the stakeholders in an institute or a state cannot be substituted at this point in time. Early HCW COVID diagnostics could reduce inhospital transmission and spread to others as well. In a single-center retrospective study in Wuhan, 41% of 138 patients were thought to have acquired infection in a hospital.
The doctor–population ratio in India is 1:1456 against the WHO recommendation of 1:1000. With HCWs getting infected, it will strain the already overworked health-care system. Delay in diagnosis can increase exposure and lead to unnecessary isolation of others who are exposed. In one small study, only one in seven self-isolating HCWs were found to have the virus. Early diagnosis of COVID-19 in HCWs followed by isolation can reduce the risk of transmission to patients as well as others working in the hospital setting. We thereby conducted this study to evaluate if there is a delay in time to testing from symptom onset and the factors associated with it.
| Methodology|| |
This is a single-center, cross-sectional observational study conducted at the All India Institute of Medical Sciences (AIIMS), New Delhi, a tertiary care hospital in the month of July 2020. AIIMS has more than 10,000 employees and Employee Health Services to cater the health-care needs of its employees. During the pandemic, a dedicated COVID-19 Employee Health Services Outpatient Department (OPD) was established where HCWs and their family could get tested for COVID-19. All HCWs reported for sampling were offered participation in the study, and data were collected which included detailed clinical history, relevant demographic details, and particular focus on date of symptom onset to date of testing. Delay in testing is defined as the time between symptom onset and the testing of COVID-19. We have defined delayed testing for COVID-19 as testing done after 24 h from symptom onset. Ethical clearance was obtained from the Institutional Ethics Committee before commencing the study.
The duration between day of symptom onset and testing was compared with all other factors, and it was correlated and analyzed to see the factors leading to delayed testing. Statistical software, STATA/SE version 14.2, was used for the analysis. All the categorical variables were described using absolute/relative frequency distribution and quantitative variables using mean (standard deviation)/median (quartile range). The association between qualitative independent variables was assessed using Chi-square test/Fisher's exact test, and a correlation between two quantitative variables was assessed using Pearson/Spearman's correlation coefficient. To see the difference of quantitative variables between two groups, t-test/Wilcoxon's test was used. P < 0.05 was considered statistically significant.
| Results|| |
A total of 758 patients present to the OPD in July 2020, and 653 HCWs gave consent to participation. The mean (standard deviation [SD]) age of the study population was 33.8 years (12.6), and 424 (55.9%) were males. The average time between symptom onset and COVID-19 testing was 3.25 days (±1.87). No significant correlation of time was observed with age (r = −0.04, P = 0.30), however, patients with age more than 35 years went for testing earlier as compared to patients with age less than equal to 35 years, however, it was not statistically significant [Table 1]. Females had delayed testing as compared to males (3.43 days [±1.91] vs. 3.16 days [±1.84] [P = 0.04]) [Figure 1]. Further, frontline HCWs who were managing patients directly went for testing significantly late (3.46 [1.96] vs. 3.13 [1.79], P = 0.04) [Figure 2]. When analysis was done in symptoms at presentation, patients with complaints of fever, productive sputum, nasal discharge, breathlessness, and diarrhea got tested comparatively earlier, however, the difference was not statistically significant with any of the known symptoms [Table 2].
|Figure 1: Comparison of mean time to testing for COVID-19 after symptom onset in health-care workers managing patients directly and indirectly|
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|Figure 2: Comparison of mean time to testing after symptom onset in males and females|
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|Table 1: Duration in relation to demographic characteristics and health-care workers' status of working environment|
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| Discussion|| |
Protecting HCWs in this pandemic is of paramount importance to safeguard their health and to maintain patient care. Delayed testing can cause unnecessary isolation of those who are exposed, and it also increases the risk of further spread to others. A study done in the National Health Service (NHS) found that 340,900 full-time equivalent days were lost, equating to 18.9% of all absences recorded compared to 30.6% in April 2020 and 15.9% in March 2020. Testing should be made easily accessible for health-care personnel to reduce quarantine period and early isolation. NHS Providers chief executive Chris Hopson had suggested that centers with adequate testing facility for HCWs would avoid unnecessary absence or leave of the health staffs and lack of the same will draw apprehensions to be available on hospital duty. Our institute where testing is easily available for its doctors and other HCWs is contrary to the study by lobby group Doctors' Association UK, so behavior should not limit the access of these facilities. A prospective cohort study done on HCW and non-HCWs (NHCWs) in the US showed a high prevalence of SARS-CoV2 in HCWs compared to NHCWs.
In this study, we evaluated the factors leading to delayed testing from the time of symptom onset by health-care personals. We found out that female workers presented after 3.43 days (1.91) than male counterparts 3.16 days (1.84) of symptom onset. Age <35 years presented later compared to those > 35 years and personal managing patients present late. The reasons attributed for this are family responsibilities, fear of coronavirus exposure from others while attending OPD, to name a few.
Currently, there is a vast volume of information on COVID-19 available on the Internet which may or may not be authentic. Keeping this in mind, the health authorities and scientists have warned that this widespread misinformation about COVID-19 can cause a serious concern leading to xenophobia worldwide.,,, A cross-sectional study conducted globally among HCWs to assess the knowledge and perception of prevention and control of COVID-19 showed a poor level of knowledge, a significant gap in information source, and discrepancy in perception of COVID-19. These studies point toward the need of constant monitoring of HCWs to present for diagnosis at an early stage and, in turn, reduce the transmission of infection. Studies have proven that HCWs who are mildly symptomatic or asymptomatic are likely to have gone untested., In our study, the participants with mild symptoms are also reported for testing, but there was a mean (SD) gap of 3.25 (±1.87) days between onset of symptom and the day of testing. Viral loads are generally high soon after the onset of mild illness or asymptomatic cases. A study from The Netherlands showed that 63% of HCWs continued to work despite mild symptoms. The estimated sensitivity of COVID testing was 33% 4 days after exposure, 62% on the day of symptom onset, and 80% 3 days after onset of symptom as found by recent studies.,, Reviewing all the available studies and concerns, it seems most prudent to test at the earliest in case of HCWs and be safe.
The significant delay in testing as shown by the results of our study, especially among the HCWs who are managing patients directly and it highlights the increase in risk of spreading infection among colleagues, patients, and even family members. That indicates the need of early testing of HCWs can be useful for curtailing the pandemic in an effective way.
| Conclusion|| |
By the study, we want to emphasize the need for further educating health-care personals to report immediately when symptoms develop and not to neglect. Human behavior related to standard precaution during this pandemic has always been discussed and focused. Testing facilities by the government and private agencies have been immensely built upon which is clearly visible by the number of tests done in India from the date of the first case of the pandemic in the country to the present date. However, studies and data regarding appropriateness of consuming these testing facilities timely have been scarce. Early testing followed by isolation in patients having COVID-related symptoms is the cornerstone of reducing transmission of virus presently. Any delay can add to the ongoing surge of cases and make the situation grave and that too if by HCWs can never be justified. In the ongoing COVID-19 pandemic, prevention and mitigation of the disease are still the mainstays of combating the disease, for the given fact that treatment and immunization still remain largely unanswered. In our study conducted at a tertiary hospital with adequate testing facilities, we found delayed testing among HCWs of age < 35 years, female HCWs, and personal managing patients. From our findings, we emphasize that all HCWs, irrespective of sex, age, and place of working, should be routinely reiterated, motivated, and reinforced for early testing in case of COVID-related symptoms.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]