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      Intranational differences in the case fatality rates for COVID-19 among Peruvian physicians

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          Sir, Peru is one of the most currently affected countries in Latin America and worldwide because of COVID-19 pandemic in terms of the number of infections and deceased people (Ministry of Health of Peru, 2020, Johns Hopkins University of Medicine, 2020). Unfortunately, physicians and other health care workers (HCW) have been significantly affected since the beginning of the pandemic (Ollarves-Carrero et al, 2020). Herein, we analyzed and discussed the impact of COVID-19 among Peruvian physicians in terms of infected and deaths professionals. Up to August 27th, 2020, 3586 physicians, out of 73375, in Peru, have been confirmed with COVID-19 by RT-PCR and/or serological tests (Table 1 ). From them, 148 physicians have died (4.13%, case fatality rate, CFR%) (Table 1). The mean average of them was 58.66 years old (±15.27). One hundred and forty-two (95.3%) were male. Sixty-eight (45.6%) were general practitioners, 41 (27.5%) worked in surgical specialities, 32 (21.4%) in clinical specialities, and 3 (2.15%) in specialities related to diagnostic procedures. Moreover, it was reported that the death of 5 physicians recently graduated (3.55%). Table 1 Number of infected and decease physicians due to COVID-19 by Department, Peru (Ministry of Health of Peru, 2020, Medical College of Peru, 2020). Table 1 Physicians Department Registered* Infected % Infected Deaths CFR% Arequipa 5220 217 4.15 19 8.75 Loreto 957 285 29.78 18 6.32 Lima 39851 1048 2.62 62 5.91 Piura 2296 192 8.36 9 4.68 Puno 1663 116 6.97 5 4.31 Ucayali 585 142 24.27 6 4.22 Huánuco 806 98 12.15 4 4.08 Huancavelica 300 84 28 3 3.57 Amazonas 246 60 24.39 2 3.33 Ica 2044 125 6.11 4 3.2 Tumbes 213 50 23.47 1 2.0 Moquegua 303 50 16.5 0 2.0 Madre de Dios 176 51 28.97 1 1.96 La Libertad 5683 218 3.83 4 1.83 Ancash 1513 113 7.46 2 1.76 Lambayeque 2925 194 6.63 3 1.54 Junin 2082 70 3.36 1 1.42 Cuzco 2723 91 3.34 1 1.09 Ayacucho 457 98 21.44 1 1.02 Cajamarca 931 106 11.38 1 0.94 San Martin 546 113 20.69 1 0.88 Cerro de Pasco 266 24 9.02 0 0.0 Apurimac 467 30 6.42 0 0.0 Tacna 1122 11 0.98 0 0.0 Total 73375 3586 4.89 148 4.13 CFR%, case fatality rate. *Number of physicians at the department. In some departments such as Loreto, Ucayali, Madre de Dios, Amazonas, San Martin (all of them from the Jungle Region), and Tumbes, Huancavelica, and Ayacucho, there is a significant lack of attention in terms of infrastructure of health services, number of physicians and well-standardized processes for health attention, the percentage of infected physicians considering the total number of registered physicians was above 20%. On the other hand, CFR% among physicians was higher than the entire population (4.59%), being higher in Arequipa (8.75%), Loreto, Lima, and Piura (Table 1). As of 19 August 2020, according to available information from 19 countries in the Region of the Americas, a total of 569,304 cases of COVID-19, including 2,506 deaths, have been reported among HCW, with 268,954 from Brazil (241 deaths, 0.09%), 143,100 from USA (660 deaths, 0.46%), 97,632 from Mexico (1,320 deaths, 1.36%), 16,194 from Argentina, 7,692 from Colombia (52 deaths, 0.67%), among other countries (PAHO, 2020, CIDRAP, 2020). Although the number of physicians infected in Peru may be considered lower, compared to other countries in the region, the CFR% of physicians in Peru due to COVID-19 seems to be higher (∼5%), reaching even higher values in some areas of the country, as discussed. Especially in developing countries, lack of personal protective equipment (PPE) and its inappropriate use are risk factors to acquire the infection for COVID-19 among physicians (Ing et al., 2020, Mhango et al., 2020). Moreover, overexposure to infected patients with an excessive workload in regions with scarce physicians and inferior systems of infection controls could be associated factors (Mhango et al, 2020). In Peru, the lack of mechanical ventilators, well-equipped intensive care units, and oxygen, in most of the departments, with the higher levels of lethality among physicians was reported (Diario Gestion Peru, 2020). For this situation, we consider as significant measures to provide for physicians and other health care practitioners, adequate PPE, and increased attention in health services. At the end of August 2020, the number of infected nurses in Peru is ∼5,000, and the number of deceased nurses is 71 (1.42%) (Diario Co Latino, 2020). Still, especially to prioritize physicians' attention, taking into account they accomplish a critical mission in the first line of defence during the pandemic. Authors' Contributions GVR and AJRM conceived the review, developed the preliminary search strategy, and drafted the manuscript. All authors critically reviewed the manuscript for relevant intellectual content. All authors have read and approved the final version of the paper. Funding Source Universidad Tecnológica de Pereira. From the Facultad de Ciencias Médicas (FCM) (2-03-01-01), National Autonomous University of Honduras, Tegucigalpa, MDC, Honduras, Central America, for funding this article. L.I.Z. was the recipient of the UNAH (CU-0-041-05-2014/03-2014 Scholarship). Study sponsors had no role in the study design, in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication. Ethical Approval Approval was not required. Conflicts of interest All authors report no potential conflicts. Uncited references Diario Gestión Perú (2020)

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          Anosmia in a healthcare worker with COVID-19 in Madrid, Spain

          Dear Editor During the course of the Coronavirus Disease 2019 (COVID-19) pandemic, and its international spreading [1], multiple countries have also raised the concerns of this emerging condition as an occupational disease. As cases increased and required healthcare, healthcare workers (HCWs) have been recognized as a high-risk group to acquire the infection due to the Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [2], that may lead to a broad and changing spectrum of clinical disease, recently including olfactory and taste disorders. Despite this, there are few reports in healthcare workers [3,4], also about the occurrence of anosmia and dysgeusia [5]. The patient, a 40-year-old Venezuelan woman, works as a radiologist, attending patients in different areas of one service of nuclear medicine in a 900-bed hospital of Madrid, Spain. Between March 1 and March 14, 2020, she provided care in the hospital, at the X-ray room, to multiple symptomatic patients, who tested positive by rRT-PCR to the SARS-CoV-2 and who had suggestive COVID-19 imaging alterations (Fig. 1 ). Those days, healthcare workers were not yet using personal protective equipment (PPE), a measure implemented in her hospital a week later. Fig. 1 Clinical evolution of the patient. Temperature, mean value per day, she measured it three times per day. *Generalized, with moderate to severe intensity, predominantly at the shoulder girdle. **Holocranial, oppressive, with moderate intensity. ***Predominantly at mesogastrium and hypogastrium, of slight intensity. ****Watery stools, with no blood or mucus, reaching the first days, from four to five per day episodes. *****Mostly dry, with a white appearance. S1, Sample 1°; S2, Sample 2°. +, positive. –, negative. <14 pd, 14 previous days. The number at the end of each horizontal color bar represents the total number of days with the clinical finding. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.) Fig. 1 On March 14, 2020, the physician presented with myalgias, headache, chills, abdominal pain, and diarrhea, persisting for five days, but with no fever, she took her temperature three times per day (Fig. 1). She self-medicated with paracetamol. On March 16, she additionally presented with cough and anosmia. That day, she reported her clinical condition to the hospital but remained working until March 20, when a nasopharyngeal swab was collected, and she was on leave, at home (Fig. 1). From March 16 to March 18, her initial symptoms improved and resolved. However, the dry cough persisted and lasted 21 days, improving gradually, although interminttently, and her anosmia gradually improved and resolved after 14 days (Fig. 1). On March 24, her rRT-PCR test confirmed the viral RNA of SARS-CoV-2. She remained at home till March 31, when her rRT-PCR was repeated and reported negative on April 1, and she returned to work at the hospital (Fig. 1). She lives with her husband, non-HCW, a 38-year-old man, and her son, 11 months old. The husband presented slight myalgia and asthenia during three days. Her son did not have symptoms. Both always had a normal temperature, and remained asymptomatic at home. Neither were tested for SARS-CoV-2. For April 13, 2020 she continues well, as also her husband and son. For March 1, 2020, only 85 cases of COVID-19 were reported in Spain, but as of March 14, when her symptoms began, the country reported more than 6391 cumulated cases. All the HCW then needed to use the contact and respiratory precautions when attending patients with respiratory symptoms or/and flu-like illnesses in all areas with presumed ongoing community transmission of COVID-19 in most countries [4]. In a case series of 138 patients treated in a Wuhan hospital, 40 patients (29% of cases) were HCWs [3]. Among the affected HCWs, 31 (77.5%) worked on general wards, 7 (17.5%) in the emergency department, and 2 (5%) in the intensive care unit (ICU), then in any area HCWs would be exposed and infected. Our case also presented with, a still considered novel, the clinical manifestation of COVID-19, the anosmia persisting for more than two weeks, and more prominent than other common clinical findings reported in this infection (e.g., fever, cough) [5]. Olfactory and taste disorders are well known to be related to a wide range of viral infections, although not a high proportion of patients. Multiple viruses can use the olfactory nerve as a shortcut into the central nervous systems, including the influenza virus, and cause even long-term olfactory disorders in some cases [6]. Hypogeusia, dysgeusia, hyposmia, and dysosmia associated with COVID-19 require more detailed studies in order to understand their pathophysiology, but especially their clinical course and implications. As the pandemic increases, early detection and suspicion of cases, based on broader clinical findings, would be useful, to aid diagnosis, in addition to the confirmation by the rRT-PCR. Anosmia is not frequent in the context of common cold and flu, then, an increase in this finding, in the COVID-19 context, make this case relevant. Credit MFOC, Writing - review & editing. AGRM, Writing - review & editing. DKBA, Writing - review & editing. AJRM, Conceptualization; Writing - original draft; Writing - review & editing. Funding source None. Declaration of competing interest We declare that we have no competing interests. MFOC is the physician case reported in this article.
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            COVID-19 Risk Factors Among Health Workers: A Rapid Review

            Coronavirus disease 2019 (Covid-19) poses an important occupational health risk to health workers (HWs) that has attracted global scrutiny. To date, several thousand HWs globally have been reported as infected with the severe acute respiratory syndrome coronavirus 2 virus that causes the disease. It is therefore a public health priority for policymakers to understand risk factors for this vulnerable group to avert occupational transmission. A rapid review was carried out on 20 April 2020 on Covid-19 risk factors among HWs in PubMed, Google Scholar, and EBSCOHost Web (Academic Search Complete, CINAHL Complete, MEDLINE with Full Text, CINAHL with Full Text, APA PsycInfo, Health Source—Consumer Edition, Health Source: Nursing/Academic Edition) and WHO Global Database. We also searched for preprints on the medRxiv database. We searched for reports, reviews, and primary observational studies (case control, case cross-over, cross-sectional, and cohort). The review included studies conducted among HWs with Covid-19 that reported risk factors irrespective of their sample size. Eleven studies met the inclusion criteria. Lack of personal protective equipment, exposure to infected patients, work overload, poor infection control, and preexisting medical conditions were identified as risk factors for Covid-19 among HWs. In the context of Covid-19, HWs face an unprecedented occupational risk of morbidity and mortality. There is need for rapid development of sustainable measures that protect HWs from the pandemic.

              Author and article information

              Int J Infect Dis
              Int. J. Infect. Dis
              International Journal of Infectious Diseases
              The Author(s). Published by Elsevier Ltd on behalf of International Society for Infectious Diseases.
              13 September 2020
              13 September 2020
              [a ]Clinica Delgado, Grupo AUNA, Lima, Perú
              [b ]Facultad de Medicina Humana, Universidad Nacional Mayor de San Marcos, Lima, Peru
              [c ]Departments of Physiological and Morphological Sciences, School of Medical Sciences, Universidad Nacional Autónoma de Honduras (UNAH), Tegucigalpa, Honduras
              [a ]Department of Internal Medicine, Faculty of Medical Sciences, Universidad Nacional Autónoma de Honduras (UNAH), Tegucigalpa, Honduras
              [b ]Department de Internal Medicine, Hospital Escuela, Tegucigalpa, Honduras
              [a ]Pneumology Service, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
              [b ]Master in Clinical Epidemiology and Biostatistics, Universidad Cientifica del Sur, Lima, Peru
              [a ]Master in Clinical Epidemiology and Biostatistics, Universidad Cientifica del Sur, Lima, Peru
              [b ]Faculty of Medicine, Universidad Nacional Hermilio Valdizán, Huánuco, Peru
              [a ]Master in Clinical Epidemiology and Biostatistics, Universidad Cientifica del Sur, Lima, Peru
              [b ]Public Health and infection Research Group, Faculty of Health Sciences, Universidad Tecnologica de Pereira, Pereira, Risaralda, Colombia
              [c ]Grupo de Investigación Biomedicina, Faculty of Medicine, Fundacion Universitaria Autonoma de las Americas, Pereira, Risaralda, Colombia
              Author notes
              [* ]Corresponding author at: Master in Clinical Epidemiology and Biostatistics, Universidad Cientifica del Sur, Lima, Peru.
              © 2020 The Author(s). Published by Elsevier Ltd on behalf of International Society for Infectious Diseases.

              Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

              Letter to the Editor

              Infectious disease & Microbiology


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