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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 5  |  Page : 38-42

Hydroxychloroquine prophylaxis against coronavirus disease-19: Knowledge and practice among health-care professionals


1 Department of General Medicine, JSS Medical College, JSS AHER, Mysore, Karnataka, India
2 Department of Community Medicine, JSS Medical College, JSS AHER, Mysore, Karnataka, India

Date of Submission05-May-2020
Date of Decision06-May-2020
Date of Acceptance11-May-2020
Date of Web Publication04-Jun-2020

Correspondence Address:
Dr. C R Venkatesh
#345, 23rd Cross, Vijayanagar Railway Layout, Mysore - 570 016, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_95_20

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  Abstract 


INTRODUCTION: The Indian Council of Medical Research recommended chemoprophylaxis with hydroxychloroquine (HCQ) for asymptomatic health-care professionals (HCPs) treating coronavirus disease-19 (COVID-19). This questionnaire study was aimed at assessing the knowledge and the practice of HCPs on the use of HCQ for prophylaxis of COVID-19.
OBJECTIVE: The objective was to assess the knowledge and practice of HCQ prophylaxis among HCPs.
MATERIALS AND METHODS: This was a cross-sectional study targeting HCPs involved in the management of suspected/confirmed COVID-19. The data were obtained by convenience sampling, collected by a structured tested online questionnaire. Descriptive statistics and inferential statistics such as Chi-square analysis and Fisher's exact analysis and Mann–Whitney U-test were used.
RESULTS: Among 135 study participants, about 76% were male and 26% were female, and the mean age was 37 years (standard deviation: 10.35). About 64.5% of the participants took HCQ prophylaxis, and 67.8% among them got an electrocardiogram. Thirty-two percent were using proper personal protective equipments (PPEs) and 11% were unaware of the use of appropriate PPEs. Apprehension associated with HCQ adverse effects in those who were suggested (70%) (P = 0.002) and made mandatory (33.3%) (P < 0.001) by their institutions (P < 0.001) was statistically significant. About 67.8% did not experience side effects. Gastrointestinal side effects were most common. Majority of the study participants who took HCQ prophylaxis were consultant doctors directly involved in patient care (71.2%) (P = 0.018).
CONCLUSIONS: Knowledge and practice with HCQ prophylaxis for COVID-19 was not adequate among the HCPs, and appraisal on proper HCQ dose and need for adequate PPEs and provision of the same could mitigate the false sense of security with HCQ prophylaxis alone.

Keywords: Chemoprophylaxis, COVID-19, health-care professionals, hydroxychloroquine, questionnaire study


How to cite this article:
Ashoka H G, Venkatesh C R, Smitha M C, Nandhini S H. Hydroxychloroquine prophylaxis against coronavirus disease-19: Knowledge and practice among health-care professionals. Int J Health Allied Sci 2020;9, Suppl S1:38-42

How to cite this URL:
Ashoka H G, Venkatesh C R, Smitha M C, Nandhini S H. Hydroxychloroquine prophylaxis against coronavirus disease-19: Knowledge and practice among health-care professionals. Int J Health Allied Sci [serial online] 2020 [cited 2020 Jul 13];9, Suppl S1:38-42. Available from: http://www.ijhas.in/text.asp?2020/9/5/38/285978




  Introduction Top


Coronavirus disease-19 (COVID-19), being a global pandemic, has overwhelmed the world's health-care system. This disease is hardly 4 months old, and, unfortunately, a standard treatment protocol is yet to emerge. Hence, the emphasis is on prevention in the form of lockdowns, social distancing, hand hygiene, and use of personal protective equipments (PPEs) to name a few. Person-to-person spread occurs among close contacts mainly through respiratory droplets through contact with mucous membranes of the mouth, nose, and possibly eyes.[1] The etiologic agent, severe acute respiratory syndrome coronavirus-2 belongs to subgenus Sarbecovirus of the genus Betacoronavirus, family Coronaviridae. Viruses of the family Coronaviridae possess a single-strand, positive-sense RNA genome.[2] The Indian Council of Medical Research (ICMR), under the Ministry of Health and Family Welfare, Government of India, has recommended chemoprophylaxis with hydroxychloroquine (HCQ) for asymptomatic health-care professionals (HCPs) treating patients with suspected or confirmed COVID-19, the proposed regimen for health-care workers being 400 mg twice on day 1, followed by 400 mg once a week thereafter for 7 weeks, to be taken with meals.[3] Clinical trials are underway in various parts of the globe to evaluate the efficacy of HCQ chemoprophylaxis in COVID-19 among HCPs.[4],[5] However, HCQ could have serious adverse effects, and the HCPs should be aware of the same. The ICMR has also reiterated that the intake of HCQ should not instill a false sense of security and that all the prescribed public health measures have to be followed in addition to chemoprophylaxis and judicious use of PPEs. A detailed study on the awareness and opinion of the HCPs on this less-known topic would facilitate an overall understanding of the common misconceptions, a general opinion, and the number of health-care workers who have conformed to the use of this drug. It would also help to orient, reorient, and remove the misconceptions. This would also give an overall clarity and perspective of the health-care workers, which is the need of the hour. Hence, this questionnaire-based study aimed at assessing the knowledge and the practice of the HCPs on the use of HCQ for prophylaxis of COVID-19 was conducted.

Objective

The objective was to assess the knowledge and practice of HCQ prophylaxis among HCPs.


  Materials and Methods Top


It was a cross-sectional study targeting HCPs involved in the treatment of suspected/confirmed cases of COVID-19 patients which included doctors (consultants and postgraduates), nursing staff, and laboratory technicians. The data were obtained by convenience sampling, collected by a structured pretested online questionnaire through Google Forms that was circulated through social media platform WhatsApp to the HCPs. The questionnaire was validated by face validation before the start of the study. The contents of the questionnaire were validated by face validation after circulating the questionnaire among peers. The questionnaire included two components which include (1) questions on basic demographic parameters which included age, sex, designation, and years of experience and (2) questions related to knowledge and practice of HCPs on HCQ chemoprophylaxis. Questions related to knowledge included questions regarding awareness on dosage and adverse effects of HCQ prophylaxis and if receiving HCQ prophylaxis is a replacement for the use of PPEs. Questions related to practice included questions related to taking of chemoprophylaxis, getting electrocardiogram (ECG) done before starting of chemoprophylaxis, information on any other drugs taken for associated comorbidities, side effects of the drug experienced, and system which was involved. Information was also collected on the role of their respective home institutions with respect to HCQ prophylaxis in control of disease transmission. Participants had to select responses from the options provided. For those questions, where the responses were thought to be nonexhaustive, open-ended questions were constructed. HCPs involved in the management of suspected/confirmed COVID-19 patients who were willing to participate in an online study were included in the study, and there were no exclusion criteria.

Ethical consideration

Ethical approval was obtained from the institutional ethics committee.

Statistical analysis

Data obtained were entered in Microsoft Excel 2016 software and analyzed using SPSS (SPSS Statistics for Windows, Version 23.0, IBM Corp, Armonk, NY) (licensed to the institution). Descriptive statistics were employed to determine mean, standard deviation, and proportions, and inferential statistics such as Chi-square analysis and Fisher's exact analysis and Mann–Whitney U-test were used to determine the association between sociodemographic variables and the knowledge and practice in relation to HCQ chemoprophylaxis among the HCPs.


  Results Top


Among the 135 study participants, about 76% were male and 26% were female. Their ages ranged between 22 years and 75 years with the mean age of 37 years (±10.35). Their professional experience ranged between 1 and 50 years, with a median of 11 years (interquartile range 3–20). About 34%, 59.3%, 1.5%, and 5.2% of the participants responded that they were involved in patient care as residents/postgraduates, as doctors, in taking samples as technician/doctor, and in screening patients, respectively. About 64.5% of the participants took HCQ prophylaxis [Figure 1] and 67.8% among them got an ECG before starting the prophylaxis. Only 32% of the study participants reported that they were using proper PPE's according to the World Health Organization guidelines, and 57% reported not using PPEs adequately and 11% were not aware about the use of appropriate PPEs. Majority of the HCPs (70%) reported that it was suggested or was made mandatory (33%) by their respective institutions to take HCQ prophylaxis. It was also reported that 0.7% of the participants were already on HCQ therapy for other health conditions. Other drugs that were taken by the participants who took chemoprophylaxis included antidiabetics, antihypertensives, levothyroxine, multivitamins, and bronchodilators. While 67.8% did not experience any side effect subsequent to the prophylaxis, among those who experienced side effects included symptoms such as gastric irritation, nausea, vomiting, headache, dyspepsia, hair loss, dizziness, and skin rashes with majority of them experiencing gastrointestinal side effects [Figure 2].
Figure 1: Proportion of health-care professionals taking hydroxychloroquine chemoprophylaxis

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Figure 2: Side effects seen among the participants who took hydroxychloroquine prophylaxis

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With respect to the knowledge in relation to HCQ chemoprophylaxis, only 33% were aware of the proper dosage, 97% were aware of its adverse effects, 3.7% responded that they believe that HCQ prophylaxis is a substitute for the use of proper PPEs, and 20.7% of them expressed apprehension related to the adverse effects of the drug.

There was a significant statistical association seen between the kind of patient care and the practice related to chemoprophylaxis. Those who were directly involved in patient care constituted major portion of the study participants who took HCQ prophylaxis with consultant doctors being the majority among them (71.2%). There was also a statistically significant association seen between institutions suggesting (P = 0.002) or mandating (P< 0.001) chemoprophylaxis to the health-care staff and apprehension associated with adverse effects of HCQ (P< 0.001) with HCPs taking the drug. However, there was no association seen in respect of the gender, age, and years of professional experience [Table 1].
Table 1: Association of various factors with study participants taking chemoprophylaxis

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  Discussion Top


Given the substantial risk of morbidity and mortality,[6] and the absence of specific effective pharmacological treatment against the agent, chloroquine and chloroquine-related formulations have been tentatively included among the drugs for use in limiting the total burden of COVID-19.[7],[8] Currently, no human study results supporting the role of HCQ for chemoprophylaxis of COVID-19 are available. Few trials exploring the use of HCQ for chemoprophylaxis of COVID-19 are underway.[7],[9] Despite the absence of human data, the ICMR-national task force for COVID-19 has recommended chemoprophylaxis for preexposure prophylaxis for frontline health-care workers having “high risk” contact with patients with suspected or confirmed COVID-19 infection. These recommendations are based on in vivo efficacy of HCQ for the treatment of COVID 19, and the prophylactic efficacy is inferred from therapeutic efficacy.[8],[10] HCQ has well documented adverse effect profiles including but not limited to gastrointestinal upset and headache.[11] More serious adverse effects such as QTc interval prolongation on ECG, cardiac arrhythmias, and retinopathy[12] are associated with chronic therapy. However, in general, HCQ is considered to be safe, and side effects are generally mild and transitory, despite the margin between the therapeutic and toxic dose being narrow. The use of this drug should, therefore, be subject to strict restrictions, and self treatment is not to be recommended. About 67.8% of our study participants did not experience any side effect subsequent to the prophylaxis, and the drug was more or less well tolerated. In those who experienced side effects, gastrointestinal symptoms such as gastric irritation, nausea, vomiting, and dyspepsia were the most common ones. Few also reported headaches and dizziness. Although HCQ is generally well tolerated, dermatologic side effects involving the skin, hair, or nails are a frequent and significant complication.[13] Dermatological side effects such as hair loss and skin rashes were experienced by some of the participants in our study also. are known to cause QTc prolongation, routine ECG is essential before starting these drugs. Coadministration of other drugs known to cause QTc prolongation should be avoided.[14] Our study respondents responded that an ECG was done in only 67.8% of the individuals before receiving HCQ chemoprophylaxis. This could have serious concerns as a blanket treatment of all the individuals might expose at risk individuals to serious cardiac side effects of the drug. This would necessitate national guidelines to modify to include a mandatory ECG before the administration of HCQ chemoprophylaxis. Although majority of the HCPs who responded were either consultant doctors or resident postgraduates, totally 126 out of 134 (94.03%), only 32% of the study respondents reported to be using proper PPEs every time according to the World Health Organization guidelines,[15] and 57% reported not using PPEs adequately and 11% were not aware about the use of appropriate PPEs. Given this, 3.7% responded that they believe that HCQ prophylaxis is a substitute for the use of proper PPEs, which raises serious concerns over the safety of the HCPs involved in the care of confirmed or suspected COVID patients. However, this is to be strengthened by repeated education and re-education by conducting orientation programs to reiterate the need for appropriate PPEs in COVID management. Similar studies which looked into these aspects were not to be found in literature.

It was also seen that those HCPs who belonged to the institutions where the prophylaxis was either suggested or made mandatory to the frontline workers and those involved in the management of suspected or COVID-positive cases had greater uptake of prophylaxis proving the influence of institutions in advocating such measures.

Twenty-eight participants, 14 (50%) each of the ones who actually took the chemoprophylaxis and an equal number of HCPs who did not receive the chemoprophylaxis expressed that they had concerns over developing adverse effects with the drug and 33 participants, 16 (42%) of those who took the chemoprophylaxis and 22 (58%) of those who did not receive the chemoprophylaxis were also possibly concerned over developing adverse effects with the drug. However, the rest 69 participants admitted to be not concerned about the adverse effects of the drug.


  Conclusions Top


It was noticed that knowledge and practice with HCQ prophylaxis for COVID-19 was not adequate among the HCPs and appraisal on proper HCQ dose and need for adequate PPEs and provision of the same could mitigate the false sense of security with HCQ prophylaxis alone.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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The PATCH Trial (Prevention and Treatment of Covid 19 with Hydroxychloroquine) Full Text View ClinicalTrials.gov; 2020. Available from: https://clinicaltrials.gov/ct2/show/ NCT04329923. [Last accessed on 2020 Apr 23].  Back to cited text no. 5
    
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Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet 2020;395:1054-62.  Back to cited text no. 6
    
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Cortegiani A, Ingoglia G, Ippolito M, Giarratano A, Einav S. A systematic review on the efficacy and safety of chloroquine for the treatment of COVID-19. J Crit Care 2020. pii: S0883-9441(20) 30390-7.  Back to cited text no. 7
    
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Yao X, Ye F, Zhang M, Cui C, Huang B, Niu P, et al. In vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Clin Infect Dis 2020. pii: ciaa237.  Back to cited text no. 8
    
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Mitjà O, Clotet B. Use of antiviral drugs to reduce COVID-19 transmission. Lancet Glob Health 2020;8:e639-40.  Back to cited text no. 9
    
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Indian Council of Medical Research – National Taskforce for Covid 19. Recommendation on the use of Hydroxy chloroquine as Prophylaxis for SARS CoV 2 Infection; 22 March, 2020. Available from: https://icmr.nic.in/sites/default/files/upl oad_documents/HCQ_Recommendation_22M arch_final_MM_ V2.pdf. [Last accessed on 2020 Apr 23].  Back to cited text no. 10
    
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Fiehn C, Ness T, Weseloh C, Specker C, Hadjiski D, Detert J, et al. Safety management in treatment with antimalarials in rheumatology. Interdisciplinary recommendations on the basis of a systematic literature review. Z Rheumatol 2020. Online ahead of print.  Back to cited text no. 12
    
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Sharma AN, Mesinkovska NA, Paravar T. Characterizing the adverse dermatologic effects of hydroxychloroquine: A systematic review. J Am Acad Dermatol 2020. pii: S0190-9622(20)30564-8.  Back to cited text no. 13
    
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