Corresponding Author:
Alberto Modenese, Post-Doc researcher in Occupational Medicine
Affiliation: Chair of Occupational Medicine, Dept. of Biomedical,
Metabolic and Neural Sciences, University of Modena & Reggio Emilia
Address: via G. Campi 287, 41125 Modena (Italy)
Health care workers (HCW) are generally recognized as having a high
occupational risk related to SARS-CoV-2 infection 1:
in Italy it is currently estimated that 10,5% of all the diagnosed
COVID-19 cases (20,618 out of 197,096 diagnoses) occurred in HCW2. This high risk is not unexpected, and was also
observed during the SARS and MERS outbreaks, respectively in 2003 and
2015.
Specific procedures for the protection of HCW have been proposed, and
updated, by authoritative organizations, such as the World Health
Organization (WHO)3, the European Centre for Disease
Prevention and Control 4 and the Centre for Disease
Control and Prevention (CDC) 5, but data clearly
support the need for further development of preventive measures,
possibly more tailored to the specific activities performed. In this
context, an aspect likely to provide useful insight is the knowledge on
variations in disease occurrence among physicians practicing specific
medical specialties, as significant differences are likely for example
in relation to the type of contact with patients, the procedures applied
and also the environment where contacts occur. A group with various
specific peculiarities are family physicians/general practitioners
(GPs), representing one of the front lines of the war against COVID-19,
visiting an overwhelming number of patients, often directly at their
homes, with scarce possibilities, if any, to control the work
environment and, especially during the first phases of the outbreak,
with an incomplete knowledge of the risk, and of adequate procedures
and, possibly, also insufficient/inadequate personal protective
equipment (PPE) availability 6. Data available from
studies on specific COVID-19 contagion among GPs is currently scant, but
in Italy, one of the Countries with the highest number of COVID-19 cases
and mortality, at least some mortality data are available. In fact, the
official web-page of the Italian Federation of the Colleges of
Physicians (FNOMCEO) is publishing and updating daily a list of the
Italian physicians died as a consequence of SARS-CoV-2 infection, also
reporting their medical specialty 7. At the date of
26th April 2020 the number of physicians died was of
151 cases. All physicians died due to COVID-19 are reported in this
list, including both active and retired physicians; accordingly, in
order to have a more reliable overview of the situation, we have
excluded all cases of deaths occurred in physicians over 75 years old
(private practice is common for some years after the formal retirement,
that usually happens between 67 and 70 years). After this exclusion, the
number of physicians’ death cases due to COVID-19 occurred in Italy at
the 26th April 2020 lowers to 118. GPs were 51 (43%),
i.e. by large the most represented medical specialty. The mean age of
death cases is similar in GPs and other medical specialties (66,5 vs
66,2 y/o) and is lower compared to the mean age of the death cases in
the general population: 79,5 years 8 , supporting the
specificity of the contagion in these groups. The first Italian case of
COVID-19 in Italy was diagnosed in Lombardy region on February
21th, and the first cases of death were reported on
the FNOMCEO website on the 11th March 2020 in two GPs
practicing in the same region, even if it should not be excluded that
some cases may have occurred even before that date. It has to be noted
that the national lock-down officially started only from the second week
of March, so that we have currently overcome the seventh week of
lock-down. In Figure 1, showing the daily cumulative increase of the
death cases among physicians since the first case reported, the trend of
the 118 death cases in these seven weeks of national lock-down can be
observed. It should be noted that up to the 26th of
March, GPs’ death cases were higher than the cases reported in other
medical specialties, reaching a proportion of the 50% by the end of
March, and since the beginning of April the proportion of the cases
between GPs and others stayed at the level of 45%, while since the
second half of April the proportion has been established at the current
estimate of the 43% (Figure 1). However, even if decreasing, this
proportion is still relevantly higher, approximately three times,
compared to the ratio between the number of GPs and physicians
practicing other medical specialties operating in Italy, which can be
estimated around the 15% according to the Italian national Institute of
statistics (ISTAT) 9, suggesting the persistence of a
higher risk.
This difference in the proportion of GPs vs other physicians between the
currently available occupational data and the death cases related to
COVID-19 indicates a relevantly high occupational risk for GPs, and
according to the trend of death cases, the work-related contagion of the
GPs was more critical during the first weeks of the epidemic in Italy,
with a slight decrease in more recent days, even if the proportion is
still very high for GPs. The relatively high number of death cases among
GPs, in particular during the first weeks of the epidemic suggests that,
according to the SARS-CoV-2 incubation period and the period elapsed
between symptoms’ onset and death, many of GPs’ infections have occurred
in February/first week of March, when in Italy there was still a scant
awareness of the risk related to COVID-19 and, in general, the
perception was largely lower compared to the weeks after the national
lock-down. Moreover, February/early March in Italy is a period of the
year when GPs use to perform a lot of medical examinations of patients
with influence-like symptoms. Recent data have confirmed that SARS-CoV-2
salivary viral load is particularly high during the first week after
symptoms onset 10 , and viral RNA has been documented
in throat swabs for more than 40 days, with high titers in the saliva11. Furthermore, especially at the beginning of the
epidemic the exponential increase of the cases in a few days did not let
GPs have enough time to adopt adequate safety procedures to visit the
patients, to be appropriately informed on the most effective ways to
prevent COVID-19 transmission and, finally, the availability of personal
protective equipment (PPE) was insufficient to allow the high number of
visits requested, as recently reported in a survey from one of the
Italian region with the highest incidence of SARS-CoV-2 infections,
Lombardy 12. It should also be noted that several
studies documented SARS-CoV-2 infections in asymptomatic patients, i.e
persons not manifesting any symptoms inducing the suspect of infection
and, consequently, in no need of specific measures 13.
These persons may have contributed to the transmission of the infection
to GPs, especially during the first weeks of the epidemic in Italy. In
addition, it has to be considered that a medical examination usually
implies a short distance between the patient and the doctor, but, also
in case of reduced direct contacts and extensive use of protections,
there are other additional problems, as: a) the documented persistence
of the pathogen on the surfaces of the clinic up to several hours/few
days, depending on the type of materials 14; and b)
recent evidence suggesting the possibility of transmission of the virus
also at distances higher than 2 meters, and the detection in the air up
to three hours after aerosolization 15 .
In conclusion, according to the abovementioned observations, and
especially considering the extremely relevant tribute in terms of lives
among Italian GPs, as recently underlined also in other countries,
Covid-19 pandemic will probably revolutionize the approach to the
patient in the general practice of family physicians6,16. The refining of adequate strategies and
procedures to prevent COVID-19 infections among Italian GPs, as well as
in the rest of the world, is crucial, and clear and effective guidelines
are absolutely and urgently needed. It is not clear, up to now, whether
the slight decrease in the proportion of GPs died during the latest
weeks of the epidemic in Italy may be attributed to some kind of
improvements in targeted prevention, as e.g. the availability of
indications for the execution of the medical examinations with adequate
individual protections and organizational measures, including an
activation of procedures of telemedicine 17-19, or
possibly it is only a reflection of the attenuation of the epidemic in
Italy as a consequence of the lock-down. Another point to be stressed is
the progressive activation, since the second half of March, in many
Italian regions of special medical units for the assistance of COVID-19
patients at home, called ”USCA” (Unità Speciali di Continuità
Assistenziale ), as prescribed by a national decree20: this may have reduced the impact on the GPs’
workload for the assistance of patients with active infections or
recovering after hospitalization. Nevertheless, the high proportion of
death cases among GPs compared to other medical specialties, still
persisting, clearly indicates the need of further development of
effective and, possibly, more tailored preventive measures.