COVID-19 Surveillance of Patients and Healthcare Workers in a Hospital Department

At present the COVID-19 pandemic is evolving, and numbers of cases admitted to hospital and
case fatalities are on the rise in Denmark.

The epidemic of SARS-CoV-2 can pose a great burden on all healthcare systems at both national
and local level.Data from the SARS epidemic (2002-2003) showed that the countries with the
largest number of cases were China (including administrative regions), Canada and
Singapore.Healthcare workers accounted for 20%,43% and 41%, respectively of the total number
of cases.

In the initial stages of the current pandemic, Wuhan ear-nose and throat (ENT) doctors were
affected at higher rates than other doctors at the hospital (personal message from Stanford
University, confirmed in media). This has been acknowledged by the Confederation of European
Otorhinolaryngology - Head and Neck Surgery (CEORL HNS). A possible explanation is the close
contact with the patient's airway mucosa during routine ENT examinations, the risk of
inducing sneezing and coughing during these examinations and the use of nasal endoscopic
procedures among other airway procedures,at both examination and during surgery. Compared to
SARS, the new SARS-CoV-2 seems to have a higher viral load in the nasopharynx, posing
increased risk for ENT doctors.

Persons who experience symptoms from the airways are in Denmark advised to stay at home, as
they may have COVID-19, and only contact the health care system if the situation
deteriorates. However, unspecific symptoms or complications in the upper airways, the oral
cavity, pharynx and neck can lead to contact with an ENT department, e.g. in case of symptoms
potentially related to cancer. Bacterial super infections as complications to viral airway
infections is seen during e.g. influenza epidemics. Acute bacterial middle ear infections is
one of the most common infections among children and is associated with virus in 80 % of
cases. Complications include acute mastoiditis, ethmoiditis and peritonsillar abscess,which
are potentially life-threatening conditions which need to be treated at a hospital ENT
department. It is not known if the incidence of these bacterial super infections will
increase during the SARS-CoV-2 pandemic or if such an increase will lead to a concurrent
increase in the exposure of virus to the healthcare workers within the ENT departments.

COVID-19 has a broad spectrum of clinical presentations from asymptomatic, to complicated
pneumonias, to multi-organ failure and death. Studies have shown that 2/3 of patients with
SARS-CoV-2 will have debut of symptoms from the upper airways.

Protecting and monitoring healthcare workers and patients The mode of human transmission for
SARS-Cov-2 is not fully understood, but expected to be through direct contact and partly by
aerosol transmission, which is the reason for the health authorities' current advice of
keeping distance.

SARS-Cov-2 can remain viable as aerosols for more than three hours, with a half-life of 1.1
hours and on plastic surfaces for up to 72 hours with a half-life of 6.8 hours.

Virus has shown to be present in the oropharynx the first week after symptom onset with a
subsequent decline, but viral RNA has been detected up to 25 days after.

The use of personal protection including mask and gloves are essential for healthcare workers
treating patients with COVID-19.

However, on March 3rd 2020 The World Health Organization announced global shortage of
personal protection supplies. In Denmark, there is also a current shortage of adequate
protection, which increases the risk for healthcare workers as the epidemic intensifies in
the population.

Large scale population testing in Iceland indicates that half of individuals carrying
SARS-CoV-2 are asymptomatic. With a concurrent lack of personal protection in a department
with a high risk of SARS-CoV-2 exposure, it is important to identify infected patients and
infected healthcare workers at an early stage,in order to prevent a COVID-19 outbreak within
the department.

As the Danish healthcare system was not prepared for an epidemic of this nature, detailed
guidelines to reduce transmission to healthcare workers at department level are deficient.
The department will progressively implement infection disease control measures based on
monitored real time data from the patient and healthcare worker surveillance. Control
measures will follow local guidelines and be inspired by recommendations from departments who
managed the SARS epidemic.