The burnout and workload impact on recurrent COVID-19: Analysis of two healthcare professionals.

Abstract

Coronavirus disease 2019 (COVID-19) pandemic continues to spread across the world since early December 2019. To date, the number of confirmed COVID-19 cases has exceeded 68 million according to the WHO data.1 Recurrent COVID-19 has been described for the patients who have positive reverse transcriptase-polymerase chain reaction (RT-PCR) results after recovering from COVID-19. Recovery criteria include the resolution of clinical symptoms and radiological abnormalities with two consecutive negative RT-PCR test results. Given these criteria, a previous study reported 7.78% recurrent COVID-19.2 To the best of our knowledge, there are only a few reports available on the recurrent COVID-19.2-4 Herein, we would like to present two health care professionals who had recurrent COVID-19 that can be evaluated in the context of work-related stress and increased exposure to viral load. A 26-year-old emergency physician had complaints of fever, cough, and myalgia a week after close contact with a COVID-19 patient in the emergency room. RT-PCR was performed on nasopharyngeal swab specimens and he had a positive RT-PCR test result. Based on the clinical manifestations and positive test result, he was diagnosed with COVID-19. At the time of the diagnosis, he was working intensively both in the COVID-19 outpatient clinic and in the emergency room. The patient received 2x200 mg oral hydroxychloroquine for 5 days and remained in quarantine at home for 15 days. After returning to work, the patient had a 24-hour shift at the hospital every other day for 14 days. At the end of the 2 weeks, he had still had complaints of dry cough without fever; thus, a control RT-PCR test was performed again on the nasopharyngeal swab and was found positive. The routine complete blood count and biochemical tests were within normal limits except high d-dimer level (1001 ng/ml). The condition of the patient was considered as a prolonged infection and he was followed up without medication. After a week, RT-PCR test was negative. The patient started to work intensively again in the COVID-19 outpatient clinic. Twenty-five days later, the patient developed anosmia and dysgeusia along with a sudden-onset fever, fatigue and cough complaints. The RT-PCR test was positive again, while there was no abnormality in the chest computer tomography (CT) scan. The patient was followed up only with paracetamol, 9 days later the RT-PCR test turned into negative. A 32-year-old dentist was actively working in the field for identification and follow-up of the contacts/co-exposed individuals. While he was obtaining nasopharyngeal swabs and initiating treatment protocol for patients, he had a positive RT-PCR test 2 months ago. He had diarrhoea, fatigue and myalgia. He received oral favipiravir 2 × 1600 mg on the first day following 2 × 600 mg for 4 days and was quarantined at home. After recovery, he continued to work intensely in the field again. The patient had positive IgG serology on the 40th day after the onset of the symptoms. The RT-PCR was negative three times after 2 months from the first positivity. After 67 days, patient's wife had COVID-19 symptoms and a positive RT-PCR test and the patient developed fatigue and myalgia again. Thus, RT-PCR was performed to the patient and the result was positive. The routine complete blood count and biochemical tests were within normal limits, while there was no abnormality in the chest CT scan. The patient was followed up without medications and 7 days later the RT-PCR test turned into negative. It has been reported that even after the virus is cleared by the indivudial's immune system, and the affected patient is no longer contagious, the RT-PCR test remains to be positive for several weeks because of the presence of circulating viral RNA transcripts, which takes longer time to be cleared.5 The first case had positive RT-PCR results over 30 days that can be addressed in the context of prolonged COVID-19. However, both cases had at least two consecutive negative RT-PCR result before the last positive RT-PCR result. In addition, they both had characteristic symptoms of the COVID-19, thus the diagnosis of recurrent COVID-19 was considered. A previous study from China reported that four healthcare professionals who had fever, cough, or both still had positive RT-PCR 5-13 days after recovery. These patients were asymptomatic in the recurrent infection.3 Both of our cases had recurrent COVID-19 approximately 2 months after the first positive RT-PCR test result. Moreover, these cases were symptomatic. Although there were mild to moderate symptoms, the chest CT scans of the patients were normal. Both patients were working intensively in positions dealing with COVID-19 patients after their first recovery. In this regard, work-related burnout and stress in healthcare professionals might cause a decrease in the immune system that results in secondary serious diseases. It should be also noted that healthcare professionals are exposed to increased viral load when they work intensely. Therefore, it can be speculated that decreasing the risk of recurrent infections can be possible by reducing the workload of healthcare professionals. Governments are more focused on the social measures to prevent the spread of the virus, but they neglect healthcare professionals. The decrease in the number of actively working healthcare professionals because of recurrent infections may also contribute to the collapse of the health system. Occurrence of these recurrent infections emphasises once again that the idea of herd immunity is not reasonable because the healthcare system can collapse for many reasons (increased number of patients and decreased number of healthcare professionals) if the capacity is exceeded. In conclusion, we would like to increase the awareness of the burnout and work-related stress burden associated with COVID-19. Necessary measures should be taken in order to protect both healthcare professionals and healthcare system. The authors have no conflict of interest to declare.