Taking proper care of frontline healthworkers

This is war; and we need to protect our fighters

In a wartime situation; if a country needs to win the war; priority must be given to every soldiers life. Yet, we have somehow already failed our first responders. We have seen more than 50 health care workers getting infected of COVID-19 and in cases like Bhilwara and Mumbai this led to significant increase in the number of cases.

Health workers (from Doctors to ASHA workers) will tend to have extensive and close contact with vulnerable individuals in healthcare settings. Hence we need to take a conservative approach to HCW monitoring and general guidelines must be broader than those described when assessing exposures for individuals not working in healthcare. We need to have low threshold for defining a symptomatic individual in case of healthcare workers and also very closely monitor and assess their risk to exposure.

There is news of nurses in Jhansi who haven't been paid for last 7 months but are being forced to work and cases of 83 junior doctors in Nalanda Medical College; Bihar who are being forced to treat patients despite being symptomatic. In a country where we have less than 1 doctor and less than 2 nurses for every 1000 people. HCW infections can very quickly crumble under the patient overload that coronavirus will bring with it. We can't let this be the source of failure!

UNDERSTAND RISK CLASSIFICATION OF EXPOSURES

High-risk exposures refer to HCW who have had prolonged close contact with patients with COVID-19 who were not wearing a facemask while HCW nose and mouth were exposed to material potentially infectious with the virus causing COVID-19. Being present in the room for procedures that generate aerosols or during which respiratory secretions are likely to be poorly controlled (e.g., cardiopulmonary resuscitation, intubation, extubation, bronchoscopy, nebulizer therapy, sputum induction) on patients with COVID-19 when the healthcare providers’ eyes, nose, or mouth were not protected, is also considered High-Risk.

Medium-risk exposures generally include HCW who had prolonged close contact with patients with COVID-19 who were wearing a facemask while HCW nose and mouth were exposed to material potentially infectious with the virus causing COVID-19. Some low-risk exposures are considered medium-risk depending on the type of care activity performed. For example, HCP who were wearing a gown, gloves, eye protection and a facemask (instead of a respirator) during an aerosol-generating procedure would be considered to have a medium-risk exposure. If an aerosol-generating procedure had not been performed, they would have been considered low-risk.

Low-risk exposures generally refer to brief interactions with patients with COVID-19 or prolonged close contact with patients who were wearing a facemask for source control while HCW were wearing a facemask or respirator. Use of eye protection, in addition to a facemask or respirator would further lower the risk of exposure.

(Guidance for assessing risk of infection for health workers as per CDC)

RESTRICT WORK INTERACTIONS BASED ON RISK CATEGORY

Work restrictions based on the risk category need to be imposed on all HCW. While in the Indian scenario we have a shortage of healthcare workers; having infected doctors and nurses in the hospital will do more harm than good.

For every medium and high risk exposure that is identified; the healthcare worker must be restricted from work for atleast 14 days.

Work restrictions need to be imposed on symptomatic as well as asymptomatic HCWs.

Asymptomatic HCWs must also continue self-monitoring of symptoms over the next 14 days of isolation. Symptomatic HCWs must have the option for active monitoring in a hospital setting.

A health care worker may return to work only after two negative confirmed PCR test results have been obtained (if the healthcare worker was confirmed positive case). In case the health care worker was a suspected case; and in lack of testing kits or infrastructure; a healthcare worker must return only after a minimum of 3 days after fever has subsided. Post return to work, a suspected HCW must strictly follow all PPE compliance and must be kept away from immunocompromised patients such as patients above 65 years of age.

Criteria for return to work post-infection for a health worker as per CDC

COMPENSATE DURING WORK RESTRICTION PERIOD

Most HCWs would be working round the clock and there are at severe risk of financial, mental and socio-psychological stress. At this point in time it is important to compensate the health workers for their additional risk and for any economic loss which may come with imposing work restrictions and for management of their infection.

  1. The work restriction periods hence must be fully paid with all benefits as per the health workers category.

  2. Health insurance packages have been announced by the Finance Minister and also some state governments. These must be made broader to also cover for non-COVID related illnesses; so that we can address all-cause mortality among healthworkers. Also, the insurance packages will be difficult to claim if the HCW isn't a confirmed case due to lack of testing or due to hospital misreporting.

  3. In lack of the health insurance coverage; costs of testing; active monitoring and treatment for the healthcare worker should be borne by the hospital at which the HCW got infected.

  4. In lack of the health insurance coverage; in case of ASHA workers; rapid-response teams, 108 ambulance drivers and other door-to-door healthcare workers the cost for testing; active monitoring and treatment must be borne by the District Health Services department.

  5. A number of state govts compensate ASHAs or HWs (M) based on number of home visits or number of cases identified rather than a fixed salary. During the COVID-19 crisis; we would urge state governments to change this model to a fixed salary model so that there is no loss of income during the mandatory work restriction period.

  6. Clear backlog payments and salaries. We cannot emphasize this enough. Doctors and nurses should not be paying for this crisis that we are in. Assess the district-wise corpus that would be required to clear backlog payments for doctors, nurses and ASHAs and get it cleared asap either through philanthropy money; through PM CARES fund or through CSR support.

  7. Set up mental health counselling channels for HCWs: The fear, concern and sense of betrayal that health workers are facing are valid. Forcing doctors and nurses to work in such high-risk situation is being seen as inhumane by many and health workers shouldn't be forced to do their job. A better way of resolving these disputes while also putting the HCWs first is by ensuring proper counselling; assuring them that they and their family will be taken care of and giving them a sense of hope that the nation is with them.

Unfortunately, all our efforts of appreciating frontline workers and boosting their morale by ringing bells and lighting candles will not really be of any use if we cannot meet these very basic needs.