**4. Discussion**

In many countries, especially China, which is the country where the COVID-19 epidemic was first seen, the healthcare professionals became the "frontline" occupational group struggling against COVID-19 [13–15]. According to the first date of February 11, 2020, 1716 Chinese HCWs have been reported to have COVID-19 infection when the first 15 affected cases were reported in Wuhan [13]. On February 17, 2020, the CDC weekly report reported that a total of 3,019 Chinese HCWs were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and 1,716 of them were confirmed with COVID-19. As of February 20, ten health workers died [16]. Reasons why healthcare professionals get an increasing number of infections were the following; 1) People who are unaware of the disease and epidemic are transmitted to HCWs who do not have protective clothing when they return to their place of residence, 2) Inadequate protective equipment supply especially for primary HCWs in primary care, and 3) Computed tomography (CT) scan results before COVID-19 case definition criteria are not specified and then it was later seen as sudden changes in the criteria [13, 14].

After the first case reported in Turkey and the Ministry of Health have published the management and treatment algorithm guides. The possible case and the definite case definitions were made by them and HCWs were informed. The use of protective equipment was recommended by the Governments [17, 18]. In the Rize province, which was 1150 km away since the first cases originated from Istanbul, 16 (59.3%) of the HCWs did not have awareness about index cases. The use of surgical masks was widespread among the staff, but the mask use of the patient and accompanying people to patients weremissing, and the highly protective respiratory mask

#### **Figure 3.**

*(a-d) 44 year old male patient, it was noteworthy that in the first examination (a), the GGOs observed in the lower lobe of the left lung expanded in the control examination on iv non-contrasted axial CT images obtained with an interval of 4 days (b). In the control evaluation in the ground glass area (c) located in the left lobe lower lobe posterobasal segment, fibrous bands developed (d).*

was used in case of intubation. While 63% of the cases (n = 17) had a mild clinical level, 29.6% (n = 8) were moderate and 7.4% (n = 2) were severe. Index 2 case had comorbidities and died but there was no severe clinical condition such as ARDS or death among the medical staff which were in contact with her.

In our study, the mean age of the total 27 HCW was 33.2 ± 6.9 years. The median age was 39 (IQR: 32–48.5 years) in studies conducted in health workers in China [19] the age ranges of 72 HCWs, 33 of whom were at high-risk Section 39 and general departments were 21–66 years [13]. It was similar to the report showing the age of 41 (IQR: 32–52 years) from Zhejiang province in the first studies [20]. The average age in the local study of Wuhan, the starting place of the outbreak, was 56 (IQR: 42–68 years) [21]. In another study conducted in Wuhan, the average age was 49.0 (IQR 41.0–58.0) [22]. In our study, 63% (n = 17) of the 27 health personnel were

*Demographic, Clinical and Radiological Features of Healthcare Workers and Two Index Cases… DOI: http://dx.doi.org/10.5772/intechopen.99148*

#### **Figure 4.**

*(a-d) 41 year old female patient, in the CT images of 31.03.2020 (a) and 5.05.2020 (b), the minimum-intensityprojection coronal cross-sectional CT images show different areas of involvement. Right lung lower lobe findings (a) declined in control, but consolidation developed with a reverse halo sign in posterobasal (b).*

#### **Figure 5.**

*(a, b) 34-year-old female patient, peripheral small-sized GGOs are observed in the iv non-contrasted axial CT images obtained every 10 days apart (a). The GGOswere diminished but new ground glass areas developed (b).*

female and 37% (n = 10) were male and Wang et al. reported that female patients constituted the majority of all cases (61.25%), the male ratio was (38.75%) [19]. Ran et al. showed that the genders were similar (χ2 = 2.243, p = 0.134) [13]. In other studies conducted in Wuhan, most of the infected patients were men 30/41 (73%), and (54.3%) were male [15, 21], respectively. Most of our HCW cases were highrisk departments workers, such as coronary intensive care. It was found similar to the study conducted in Wuhan [13]. In our study, 51.9% (n = 14) of the infected profession group were female nurses and 13 (76.5%) were among the nurses. It was similar to the work of Wang et al. [19] the ratio as 41/80 (51.25%). In the comparison between doctors in our study, male doctors were found to be significantly

higher than female doctors (70% vs. 5.9%, p < .001). It was observed that thorax CT findings were normal in the female gender.

In our study, none of the healthcare professionals had comorbidity. The clinic of 63% (n = 17) of the cases was followed up with outpatient home isolation. Wang D et al., also constituted a significant number of HCWs in the majority of non-intensive care patients (p < .001) [21]. However, having a non-intensive care follow-up suggested that they were clinically mild. In previous studies, it was shown that this infection may cause severe clinical picture in non-comorbid patients, however hypertension, diabetes, cardiovascular, chronic obstructive pulmonary diseases, liver, and kidney failure are risk-causing comorbidities [15, 19–21].

The most common clinical symptoms in our study were present in 55.6% (n = 15) of fever and 40.7% (n = 11) of cough, respectively, less than the signs of fever and cough in previous studies [15, 19–21]. Chinese cases showed more severe clinical. Fever was seen at a relatively low rate in the European studies which were more extensive studies and they included mild to moderate COVID-19 (45.7% and 48%) [23, 24]. The cough was reported at high rates in European studies (63.2 and 80%) [22, 23]. Shortness of breath was present in 14.8% of the cases (n = 4), which was less than the previous study results [15, 21–23]. In our study, the complaint of malaise was present in 44.4% of the cases (n = 12) and myalgia in 33.3% (n = 9), this rate was higher than that of the health workers in Wuhan-China [19] compared to other studies [15, 20–23] was less. The low levels of these findings may be since most of the clinical conditions are good-moderate or the number of cases was limited. According to clinical studies in Asia [15, 19–21], the most common symptoms were fever, cough, shortness of breath, muscle pain, arthralgia, headache, diarrhea. With the spread of COVID-19 in Europe, he emphasized a new atypical presentation of the disease: smell and taste dysfunction [22–27].

In our study, anosmia was detected in 18.5% of the cases (n = 5) and complaints about the sense of taste in 22.2% of the cases (n = 6). Taste and smell tests were not performed, only the presence of symptoms was said by the staff themselves, similar to the previous studies [24]. The rate of anosmia in Europe was shown to be in 201 patients (14.2%) [22]. Even in a more comprehensive study of 2428 patient series, 74% of the 80 subjects tested were positive despite limited access. Cases; only 51% reported their symptoms as cough or fever, while 16% reported it as isolated anosmia as an isolated symptom [25]. Another recent study reported that anosmia was recorded in 73% of patients and the first symptom in 26.6% before the diagnosis of COVID-19 [26]. In the European study (54.2%) there was a taste impairment [22]. In a study of 417 mild to moderate COVID-19 patients in European hospitals, 85.6% and 88.0% of the patients reported smell and taste impairment and a significant relationship between both disorders (p < 0.001) [23]. It has been argued that the reason for sensory loss may be due to neurotropic and neuroinvasive coronaviruses [27]. In our study, headache complaints were found in 37% of the cases (n = 10), and headache rates in female HCWs infected with COVID-19 were found to be significantly higher than men (52.9% vs. 10%, p = .042, Fisher's exact test). All other complaints except for headaches were found in male and female workers at similar rates (p > .05 for all).

While it was 21/62 (34%) (2021) close to our study in Zhejiang provincial, it was lower in studies from Wuhan; The most comprehensive study on 138 patients Wang D et all. Headache was 6.5% in 9 people in total (15, 19–21). But in the more extensive European mild to moderate Coronavirus Disease 2019 study, this rate was much higher. The most common symptom was reported asheadache (70.3%) [22]. Diarrhea, another symptom in our study, was in 22.2% (n = 6) of the cases. In two studies [19, 21] involving health workers in China (80 and 138 cases), it was 18.75% and 10.1%, respectively, in other studies, the rate was reported to be much (3–8%)

*Demographic, Clinical and Radiological Features of Healthcare Workers and Two Index Cases… DOI: http://dx.doi.org/10.5772/intechopen.99148*

less [15, 20]. In European studies, it was 473/1420 (38.1%) [22] and 50% [23]. In our study, vomiting was reported in 14.8% of the cases (n = 4), less in Chinese studies [21, 22], and in European studies at a similar rate [22, 23].

As laboratory parameters; WBC, neutrophil, and lymphocyte levels were normal. However, the decrease in PLT, MPV, hemoglobin levels in the first and last measurements in hospital admission was found significant.

From the place where the outbreak and clinical findings were severe, for instance, Huang C. et al. reported 25% leukopenia and 63% lymphopenia [15]. In the Chinese HCWs study, 19 of 80 patients (23.75%) had leukopenia and 38 (47.5%) had lymphopenia [19]. In the Zhejiang province study, there was leukopenia and 42% lymphopenia at 31% at the time of admission [20]. Wang et al. showed that although the total of 138 patients was within normal limits, white blood cell and neutrophil counts were significantly higher in intensive care patients [21]. In our study, neutrophil/lymphocyte rate (NLR) was normal, as the clinical well-being ratio of HCWs was high. In the study in which they compared mild type and severe-critical patient groups in China, NLR was the most useful prognostic factor affecting prognosis in patients with a severe disease with COVID-19 pneumonia. In the severe group, the blood neutrophil count was higher than in the mild group, the blood lymphocyte count was significantly lower, and the bacterial infection rate increased significantly [28]. When the results of many studies in China were evaluated, high NLR was argued to be an independent prognostic biomarker for COVID-19 patients [29, 30]. Studies were reporting that MPV was elevated during the active period of some viral infection [31, 32]. In our study, it was noteworthy that the HCW was higher than the values of the first measurement MPV levels were higher than that of recovery period measurement (10.0 vs. 9.5; z = −2.161, p = .031).

In our study, mild elevation was found in two patients with moderate to severe pneumonia signs, and total D-dimer measurements were in the normal range and were similar to some Chinese studies [19, 20], but were high in intensive care patients in China [15, 21, 33]. Tang N et al. [34] showed that abnormal coagulation results, especially markedly elevated D-dimer and fibrin degradation product FDP, are common in deaths with new coronavirus pneumonia NCP (34).PLT levels were within normal limits in all studies, including intensive care patients [15, 19–21, 33]. Lippi G and Plebani M [33], reported that the country where the epidemic spread, increased C-reactive protein (CRP) and lactate dehydrogenase (LDH) in their letters, which summarize abnormal laboratory parameters, which are prognostic biomarkers in studies in most Wuhan studies in China, were shown as negative prognoses. In our study, a significant difference was found between the median value of the first and second CRP (g/dL) levels (2.9 vs. 1). Another significant difference was found between the mean first and second LDH (U/L) levels (91.1 vs. 47.2). A significant difference was found between the mean values of first and second albumin (g/L) levels in our cases (43.8 vs. 44.4). The value of troponin levels in the second measurement was found to be <3.2 in all cases. Although our cases showed clinically good to moderate clinics [34], they were consistent with the study. We found a significant difference between the first and second median CK (U/L) levels (77 vs. 60). A significant difference was found between the first CK-MB (mg/mL) of the cases and the second CK-MB (0.8 vs. 0.5). There was a significant difference between the mean values of the first ferritin (ng/mL) and the second ferritin (151.7 vs. 95).

Computed Tomography (CT) can help in diagnosis and differential diagnosis in patients with COVID-19 [35] and is particularly high when evaluated with serial CT images. RT-PCR provides a chance to catch 93% of negative patients earlier [36] history of contact, clinical findings, and imaging findings were considered more sensitive in the diagnosis of COVID-19 [36]. Typical radiological findings of COVID-19 pneumonia have been reported as interstitial inflammation, ground-glass opacities, crazy

paving appearance, and bilateral or multiple lobular or subsegmental widespread consolidation [19–21, 35–37]. In our study, pneumonia findings and CT findings were seen in 7 persons (25.9%) and in 20 subjects (74.1%), there was no CT involvement. The clinical progresses was good in HCWs at the beginning of the outbreak.

While not being aware of the cases initially caused contamination by contact, it may be related to the aerosol contact formed later by intubation. Nevertheless, the timely implementation of protective measures prevented negative consequences. The clinical reflection severity of the contamination was low, the radiological reflection was moderate, and the laboratory reflections were partly significant in HCWs. Acute respiratory distress syndrome (ARDS) was not seen in any healthcare worker.

In conclusion, HCWs are a respected professional group that must be at the forefront of the epidemic and the center of the risk. The risk decreases when the virus load is reduced using PPE. It would be also crucial to ensure that complete PPE, including the electrical air purification device, is fitted, providing a negative pressure isolation ward environment that prevents patients from spreading to the rest of the infectious pathogen.
