key: cord-343845-suoy3ojr authors: Martín, Vicente; Fernández-Villa, Tania; de Gomez, María Lamuedra Gil; Mencía, Oscar; Rodríguez, Ana Rivero; Celada, Sofía Reguero; Gomez, Marina Montoro; Guisado, María Teresa Nuevo; Ruiz, Cristina Villa; Flecha, Cristina Díez; Carvajal, Ana; Vázquez, Jose Pedro Fernández title: Prevalencia de la Infección por SARS-CoV-2 en médicos y enfermeras de Atención Primaria y Residencias de Ancianos del Área de Salud de León y Factores asociados date: 2020-06-06 journal: Semergen DOI: 10.1016/j.semerg.2020.05.014 sha: doc_id: 343845 cord_uid: suoy3ojr ABSTRACT Objective: To evaluate the prevalence and associated factors with SARS-CoV-2 infection in general practitioners and nurses of primary care centers and nursing homes in the health area of León (Spain). Materials and methods: Cross-sectional study in a convenience sample of professionals from 30 health centers and 30 nursing homes from the primary care management division of the Healthcare Area of Leon. The work center, type of profession, COVID-19 infection, level of exposure, compliance with preventive measures, isolation (if required) and diagnostic tests carried out were collected. The determination of infection was made by differentiated rapid diagnostic test (dRDT), using a finger-stick whole-blood sample. The association of variables with infection was assessed by multivariable non-conditional logistic regression. The true prevalence of SARS-CoV-2 infection was calculated according to two scenarios for RDT (Sensitivity=0.6 and Specificity=0.985; Sensitivity=0.8 and Specificity=1). Results: The true prevalence of SARS-CoV-2 infection was between 4.9% - 11.0%. The observed prevalence was 5.9%, being higher in nursing home compared to primary care centers (9.5% vs. 5.5%). No statistically significant differences were observed by sex, type of professional, level of exposure or compliance with preventive measures. Conclusions: The prevalence of SARS-CoV-2 infection in this group is low. A high number of professionals remain susceptible to SARS-CoV-2 infection and therefore protective measures should be taken, especially in nursing home professionals. RESUMEN Objetivo: Evaluar la prevalencia y los factores asociados a la infección por SARS-CoV-2 en médicos y enfermeras de centros de atención primaria y residencias de ancianos del área de salud de León (España). Material y métodos: Estudio observacional realizado en una muestra de conveniencia de profesionales de 30 centros de salud y 30 residencias de ancianos, de la Gerencia de Atención Primaria del área de salud de León. Se recogió información del centro de trabajo, tipo de profesión, infección por COVID-19, nivel de exposición, cumplimiento de medidas preventivas, aislamiento (si fue requerido) y test diagnósticos realizados. La determinación de infección fue llevada a cabo mediante prueba de diagnóstico rápido diferenciado (PDRd), usando muestra de sangre capilar. La asociación de las variables con la infección se evaluó mediante regresión logística multivariable no condicional. La prevalencia real de infección por SARS-CoV-2 fue calculada de acuerdo a dos escenarios para el PDRd (Sensibilidad=0,6 y Especificidad=0,985; Sensibilidad=0,8 y Especificidad=1). Resultados: La prevalencia real de infección por SARS-CoV-2 se encontró entre 4,9%-11,0%. La prevalencia observada fue de 5,9%, siendo mayor en trabajadores de residencias de ancianos que de centros de salud de atención primaria (9,5% vs 5,5%). No hubo diferencias estadísticamente significativas por sexo, tipo de profesional, nivel de exposición o cumplimiento de medidas preventivas. Conclusiones: La prevalencia de la infección por el SARS-CoV-2 en este grupo es baja. Un gran número de profesionales siguen siendo susceptibles a la infección por el SARS-CoV-2 y, por lo tanto, medidas de protección deben ser adoptadas, especialmente en los profesionales de las residencias de ancianos. J o u r n a l P r e -p r o o f RESUMEN Objetivo: Evaluar la prevalencia y los factores asociados a la infección por SARS-CoV-2 en médicos y enfermeras de centros de atención primaria y residencias de ancianos del área de salud de León (España). Material y métodos: Estudio observacional realizado en una muestra de conveniencia de profesionales de 30 centros de salud y 30 residencias de ancianos, de la Gerencia de Atención Primaria del área de salud de León. Se recogió información del centro de trabajo, tipo de profesión, infección por COVID-19, nivel de exposición, cumplimiento de medidas preventivas, aislamiento (si fue requerido) y test diagnósticos realizados. La determinación de infección fue llevada a cabo mediante prueba de diagnóstico rápido diferenciado (PDRd), usando muestra de sangre capilar. La asociación de las variables con la infección se evaluó mediante regresión logística multivariable no condicional. La prevalencia real de infección por SARS-CoV-2 fue calculada de acuerdo a dos escenarios para el PDRd (Sensibilidad=0,6 y Especificidad=0,985; Sensibilidad=0,8 y Especificidad=1). Resultados: La prevalencia real de infección por SARS-CoV-2 se encontró entre 4,9%-11,0%. La prevalencia observada fue de 5,9%, siendo mayor en trabajadores de residencias de ancianos que de centros de salud de atención primaria (9,5% vs 5,5%). No hubo diferencias estadísticamente significativas por sexo, tipo de profesional, nivel de exposición o cumplimiento de medidas preventivas. Conclusiones: La prevalencia de la infección por el SARS-CoV-2 en este grupo es baja. Un gran número de profesionales siguen siendo susceptibles a la infección por el SARS-CoV-2 y, por lo tanto, medidas de protección deben ser adoptadas, especialmente en los profesionales de las residencias de ancianos. Palabras clave: SARS-CoV-2, prevalencia, médicos, enfermeras, residencias de ancianos, atención primaria The new disease known as COVID-19 was detected for the first time in December 2019 in Wuhan, China 1 . This is a disease caused by a virus from the Coronaviridae family, SARS-CoV-2 (Severe Acute Respiratory Syndrome-Coronavirus-2) 2,3 , which affects most severely elderly people 4 . Healthcare workers, due to their work in the diagnosis, treatment and care of patients with COVID-19, are particularly exposed to sources of SARS-CoV-2 infection. In the pandemic earlier stages, ignorance of the real significance of the problem, the lack of personal protective equipment or its misuse could lead to significant exposure of healthcare workers to SARS-CoV-2. Altogether, these facts would explain to a large extent that of the total of 250,287 cases of COVID-19 reported in Spain (on May 21, 2020) to the Spanish Network for Epidemiological Surveillance (RENAVE), 16,3% corresponded to healthcare workers 5 . The Spanish primary care has been especially affected by all these problems and has been the first wall in front of the COVID-19 6 . The aim of this study is to evaluate the prevalence and factors associated with SARS-CoV-2 infection in General Practitioners and Nurses of primary care centers and nursing homes in the health area of León. Observational, descriptive, cross-sectional study. General practitioner (GP) and Nurses of Primary Care of the Health Area of León, who worked in health centers or Nursing homes. The convenience sample obtained in this study was constituted by professionals from 30 health centers and 30 nursing homes who wanted to participate in the study. By means of a registration sheet, socio-demographic information was collected, as well as information on the work center, type of profession, previous diagnosis or suspected of COVID-19, level of exposure, compliance with preventive measures, isolation (if required) and diagnostic tests carried out. The level of exposure to coronavirus and the degree of compliance with preventive measures were recorded using a Likert scale of 0-10, with 0 being the lowest degree of exposure or compliance and 10 the highest. Infection status determination: Using a fingerstick whole blood sample, the COVID-19 infection was evaluated with a differentiated rapid diagnostic test (RDT), which classifies IgG and IgM separately (All Test® 2019-nCoV IgG/IgM Rapid Test Casette of HANGZHOU ALL TEST BIOTECH CO LTD). The result was read 10-15 minutes after the test was carried out 7 . The determination was made during the first two weeks of April, 2020. We calculate central and dispersion measures of quantitative variables (mean and standard deviation (SD)) and frequencies with their 95% confidence intervals in qualitative variables. The dependent variable, COVID-19 infection, was considered when the IgG or IgM were positive. The relationship with the collected variables was evaluated by unconditional logistic regression adjusted for all factors analyzed, and the odds ratio (OR) and its 95% confidence intervals were calculated. All analyses were performed with the Stata 14 statistical package 8 . Also, the true prevalence was calculated according to two internal validity scenarios for RDP, one with a sensitivity of 60% and specificity of 98.5% and the other with a sensitivity of 80% and specificity of 100%, as described by Rogan and Gladen 9 using the application EPITOOLS available on the Internet 10 . Approximately 1000 nurses and doctors were the target population and 676 have participated in the study, i.e. two thirds. The average age of the participants was 47.7 ±12.4 years and 74% were females. Half of the sample were nurses and 88% of the workers were from primary care centers. In relation to exposure and compliance with preventive measures, 44% of the respondents reported high exposure to COVID-19 and 31% high compliance with preventive measures (10 points in the survey). Out of 615 participants who answered the question, 5 (0.8%) had been diagnosed with COVID-19 and out of 628, 44 (7.0%) had been isolated due to contact with sick or suspected COVID-19 patients. The overall prevalence of positive RDT was 5.9% (40/676), with no statistically significant differences observed by sex, type of professional, level of exposure or compliance with preventive measures. However, the higher prevalence of positive RDTs in nursing home workers compared to those working in health centers is noteworthy (Table 1) . On the other hand, 38.5% of the cases of COVID-19 and 18.2% of the people who required isolation were positive in RDTs (Table 1) . The true prevalence, under the scenario of RDT sensitivity and specificity of 0.6 and 0.985, respectively, is 7.6% (95% CI= 4.9%-11.0%) and under the scenario of sensitivity of 0.8 and specificity of 1 it is 7.4% (95% CI= 5.5%-10.0%). The true prevalence of SARS-CoV-2 infection in the sample studied is between 4.9% and 11.0% according to the scenarios described. The most relevant results of this study indicate that the observed prevalence of SARS-CoV-2 infection in the health workers analyzed is 5.9% (CI95% 4.4%-8.0%), being higher in nursing home workers compared to primary care centers (9.5% vs. 5.5%). The prevalence of infection found in our results is in line with the 5% reported in a preliminary report of the seroprevalence results in the general Spanish population of the ENE-COVID study. The results obtained in this study for León, indicate a prevalence of 7.0% (CI95% 4.8%-10.0%), slightly higher in women than in men (7.8% vs. 6.2% respectively), data that differ with our results (5.8% women vs. 6.3% men). Despite this, the ENE-COVID refers seroprevalence data with RDTs, their participation rate was also two thirds as in our study, and if we observe the confidence intervals obtained, there is overlap, as there would be no significant differences between both studies 11 . Our result is also lower than the 11.2% found in another recent seroprevalence study carried out on health professionals at Hospital Clinic of Barcelona 12 . These differences may be due to the sample studied, given that our study focused on primary care workers and not on hospital workers, and only on doctors and nurses without including other professionals. The observed prevalence in our study is surprisingly low, for what was originally expected, and can be explained by several reasons: 1) the non-participation of those workers on leave from COVID-19 (The estimated staff of doctors and nurses at the centers studied is about 500 doctors and 500 nurses which means that two thirds of the possible staff have participated in the study); 2) the implementation of preventive measures, social isolation and confinement had already been initiated before the sample was obtained; and 3) the care measures implemented in Primary Care. It is worrying the there is a high number of respondents who are susceptible to infection in future waves. CoV-2 infection in health professionals, including: late recognition or suspicion of patients with COVID-19, working in a high-risk area, longer duty hours, lack or low use of personal protective equipment (PPE), and inadequate hand hygiene 13 . In our results, 44% of the respondents indicated that they had had a high exposure to COVID-19. However, there was no statistically significant association between the level of self-perceived exposure and the prevalence of SARS-CoV-2 infection in our sample (aOR=1.45 CI95%=0.59-3.55). This could be explained by a possible selection bias, given that there is a third of nonparticipants in the study who could be on sick leave as a result of the COVID as well. According to the preventive measures, it is important to note that 31% of those surveyed reported a high level of compliance of these measures in our study, not found significant association with In relation to the workplace, our study shows a higher infection rate among workers in nursing homes (9.5%) compared to those working in health centers (5.5%). This difference can be explained by the conditions of the nursing homes themselves and the special incidence that the COVID19 has had on them 14 . Finally, our results reflect a higher risk of positive RDT in those respondents with a previous diagnosis of COVID-19 (aOR=5.38) or those who had been isolated through contact with a confirmed or suspected case (aOR=3.29). These results could be due to a combination of effects: 1) the sensitivity of the tests (between 20 and 40% of false negatives 15 , and 2) to be included as cases, those suspects with non-specific clinical manifestations that may not be COVID-19. For these reasons, in the study we have analyzed the true prevalence in different sensitivity and specificity scenarios of RDT, obtaining a range of 4.9 to 11%. Although these data are nearly double the observed prevalence, they still highlight the high percentage of health professionals who will be vulnerable to infection in the next waves, and therefore their protection should be increased. J o u r n a l P r e -p r o o f However, our results need to be analyzed with caution, as there are certain limitations. 1) The descriptive nature of the study and the low rate of infection may influence the statistical power of the findings. 2) the study was conducted at the same time as the confinement and preventive measures were put in place, so the infection may be underestimated. 3) The RDTs have obtained different certifications for their clinical use but they also have sensitivity problems. Despite these limitations, this study highlights the prevalence in primary care and nursing home doctors and nurses, as well as the associated factors, generating evidence that is so important in the fight against COVID-19. The prevalence of SARS-CoV-2 infection in tested health workers is low, similar to other national studies. Our results indicate that a high number of professionals remain susceptible to SARS-CoV-2 infection and therefore protective measures should be taken, not only in primary care, as the main contact with the health system, but also in nursing homes. The authors declare no conflict of interest. World Health Organization (WHO) China Novel Coronavirus Investigating and Research Team. A Novel Coronavirus from Patients with Pneumonia in China Novel coronavirus: From discovery to clinical diagnostics Assessing risk factors for severe COVID-19 illness Informe sobre la situación de COVID-19 en personal sanitario en España -21-05-2020 La maldita pandemia: una oportunidad para la Atención Primaria de Salud Informe sobre estrategia de diagnóstico microbiológico del COVID-19 (Actualización) Madrid 19 de abril de 2020 StataCorp. 2015. Stata Statistical Software: Release 14 Estimating prevalence from the results of a screening test Estudio ENE-COVID19: Primera ronda. Estudio nacional de sero-epidemiología de la infección por SARS-CoV-2 en España Seroprevalence of antibodies against SARS-CoV-2 among health care workers in a large Spanish reference hospital. medRxiv World Health Organization (WHO) Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility Informe sobre estrategia de diagnóstico microbiológico del COVID-19 (Actualización) Madrid 19 de abril de 2020 The authors would like to thank all the workers for their participation in this study. And of course, thank you to the primary care management division of the Healthcare Area of Leon and the University of Leon also, because their collaboration has been crucial in developing this study. This research has not received specific support from public sector agencies, the commercial sector or non-profit organizations.