COVID-19 prevalence and infection control practices among dentists in Andhra Pradesh State, India

1Introduction

Coronaviruses belong to a group of RNA viruses that can cause severe respiratory infections. The virus is highly infectious, and it spreads through droplets produced by speaking, coughing, and sneezing [1]. Since the occurrence of a Spanish flu pandemic in the 1900 s, many outbreaks have occurred globally which include severe acute respiratory syndrome coronavirus (SARS-CoV-1 in 2003), the Middle East respiratory syndrome coronavirus (MERS-CoV in 2012), Ebola and Zika viruses in 2014, and recently, the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19 in 2019) [2]. SARS-CoV-2 was first reported from Wuhan, China and was said to be one of the most swiftly spreading pandemics affecting more than 82 million people of all age groups worldwide [3, 4]. To contain the pandemic, many countries implemented remote working and strict lockdown measures and emphasized social distancing, hand hygiene and personal protection measures [5].

As more information appeared on the mode of transmission, it is now proven that SARS-CoV-2 is air borne and spreads through infected aerosols (≤5 mm) and droplets (5-12 micrometers) from symptomatic and asymptomatic individuals [5, 6]. The infected aerosol can remain airborne for few hours and on the contaminated surfaces for up to 72 hours (about 3 days) [5–7]. Indirect spread or transmission of SARS-CoV-2 can occur from the contaminated surfaces through the mucous membranes of ear, nose, and mouth by self-innoculation [8].

Health workers are most vulnerable groups for coronavirus 2019 (COVID-19) cross infection [9]. Dental operatory has been considered as one of the potential areas for the spread of this dreadful disease. Standard dental procedures such as using high-speed hand piece, ultrasonic scalars, air-water-pressure (3-in-1) syringes and hard tissue LASERS are aerosol-generating procedures (AGPs) [10]. These aerosols in enormous quantities remain splattered in the air for at least 30 minutes before settling on the surrounding surfaces and will invariably contaminate them [6, 11]. Dentists and their auxiliaries are at considerable risk of being exposed to SARS-CoV-2 [10, 12]. Considering the above consequences, many countries suspended regular dental services during the initial stages of the SARS-CoV-2 outbreak and all AGPs in particular [6, 13, 14].

The World Health Organization has laid down the interim guidelines for the clinical management of COVID-19 in health services [14]. Besides, several health services governing bodies like Centre for Disease Control and Prevention (CDC), Indian Council of Medical Research (ICMR), Dental Council of India (DCI) and other dental associations across the globe have endorsed the infection control guidelines for hospitals rendering medical and dental services. One such recommendation is the usage of PPE (Personal protective equipment) for all health care workers involved during the procedure [14, 15].

With new mutant strains of the virus appearing in different countries, it is evident that COVID-19 is going to stay for a long time. As dental practices pose a potential area of cross-infection and the role of dentists in containing the spread of COVID-19 is critically important [14, 16]. The need to assess the risk and follow all infection control protocols is justified. Therefore, the present study was aimed to estimate the prevalence, its associated factors and infection control practices of COVID-19 among the dentists in Andhra Pradesh State, India.

2Materials and methods

The data was collected between January 30, 2021 and February 21, 2021 through an online survey using Google Forms. Participants were initially selected from the DCI Indian Dentists Register [17], as this is the most comprehensive official list available having name of each dentist and their registration numbers. The selected dentists’ e-mail addresses were obtained from the directory of the Andhra Pradesh State Indian Dental Association (AP state IDA) and members of the AP state IDA that represents 91% of the total practicing dentists in this state. The questionnaire and a brief description of the survey’s purpose have been sent to the dentists’ emails on January 30, 2021 and reminder email to fill the questionnaire were sent on February 11, 2021. The participating dentists were asked to declare that they have read the data privacy policy and voluntarily agreed to fill the questionnaire.

3Results

Among the 3700 dentists who were invited for this study, 1887 dentists agreed and filled the questionnaire with response rate of 51%. Incomplete data or missing data was observed in 11 responses therefore we eliminated them from analysis and the final analysis included responses from 1876 dentists.

4Discussion

This study was conducted during the period of peak diffusion of COVID-19 cases in India, with 8,869,576 cases reported until December 20, 2020. Andhra Pradesh is in the Southern part of India and is reported to be one of the three states with the highest number of COVID-19 cases reported since the outbreak of the pandemic [23].

In the literature search, most of the studies from India involving dentists or dental settings reported either knowledge, attitudes, and practices related to COVID-19 [24] or reported on dentist’s perceptions about stress, vulnerability, etc. [25], but the prevalence of COVID-19 among dentists and its associated factors were not reported until date (Jan. 30, 2021). However, a study from the United States reported that COVID-19 prevalence among the dentists was 0.9% [5], and study from the Northern part of Italy described that the COVID-19 prevalence among the dentists was 0.86% [19].

In the present survey, the percentage of dentists diagnosed with COVID-19 was 9%, which is much greater than the prevalence reported in the inhabitant population in that area (0.73%) [26]. COVID-19 prevalence reported in this study was also much higher (9% vs 1.8%) than other health workers in India [21]. This data suggests that there is a greater COVID-19 infection diffusion among dentists. All dentists who were reported as COVID-19 positive were tested through RT-PCR technique (nasal swabs) as no other tests were available at that period.

In the present study, 70% of the COVID-19 positive cases were reported in male dentists. Similar findings were reported in the National Serosurvey for COVID-19 in which the seropositivity in males was 1.5 times more than females [26] and in contrast to the study reported from Wuhan, China in which females are more affected than males [27]. The probable reason behind this could be that more male dentists work full-time compared to female counter parts [28] and high-risk activities were more common in males than females [29].

Nearly one-third of the COVID-19 positive dentists in this study could not identify the source of infection through currently followed contact-tracing mechanism and 60.5% participants mentioned that patients are the source of infection. The statements given by them could be duly supported because many dental procedures involve high-speed hand pieces that emit aerosols, which serve as a vehicle for virus transmission. In addition to these findings, two-thirds of the dentists performed ultrasonic scaling or used a high-speed hand piece to treat such patients who were tested positive immediately after dental treatment. A logistic regression model also identified dental practice as the single most statistically significant factor and had a 2.8 times more risk of being COVID-19 positive. High prevalence and being involved in active dental practice during the pandemic as a risk indicator for COVID-19 is alarming for the future of the dental profession, as the survey in Slovakia reported that 40% of the dentists have the intention to leave the profession due to fear of COVID-19 [30].

COVID-19 prevalence rate found in this study are in contrast to the study reported Manzar et al., only one dentist was COVID-19 positive out of forty dentists who performed Aerosol producing dental procedures during the pandemic [31]. The dentists in this study, however, were worked under different settings, i.e., part of testing new COVID-19 infection control protocol and working under supervision may positively influence adherence to infection control protocols [31].

Among the infection control practices, two-third of the dentists used protective full-face shield and N 95 or equivalent masks while performing dental care, which is similar to the study reported by Banaee et al. [32] among dentists in the US, where 56% of them wear N95 or equivalent masks. The frequency of changing the mouth masks in between the patients varies among the dentists, where few changed it for every patient and others changed between multiple patients or once in a day. Only a few dentists used pre-procedural mouthwash, which is an effective measure to reduce viral load in the patient’s oral cavity. Such differences in practices among dentists call a need to develop evidence-based guidelines and specific protocols in the dental practice.

The present study was the first large-scale study reporting about the prevalence of COVID-19 among dentists from India to the best of our knowledge. The sample was representative of Indian Dentists as the participants were selected from the Indian Dentists Register, which allows comparison among the subgroups. However, this study had few limitations. Dentists represent a highly motivated group who would have undergone COVID-19 testing upon any obvious symptom or perceived risk more than the public, which could increase the reported prevalence rate among dentists compared to the public. Moreover, COVID-19 testing was not mandatory in India for the public unless they were demanded or were identified by the health workers as vulnerable groups through contact tracing [18].

The response rate (51%) in the present study was more compared to other similar studies, such as 40.1% among the US Dentists [5] and 41.60% in another study reported from Italy [19]. Also, non-participating dentists may differ from participants, which lower the validity and generalization of findings. Although the response rate of our study met with optimal response rate (50-60%) suggested by Duagalis [33] and it was suggested that survey findings with a response rate of less than 65% should be applied with caution [33]. In addition, there are chances of under reporting COVID-19 prevalence and symptoms among dentists because some of the non-respondents would have succumbed to COVID-19 infection or were unable to participate due to hospitalization.

Another limitation of the study could be the recall bias, as participants had to answer several questions based on the past few months’ experiences; but the chances of recall bias may be less as all study participants were professionals. The nature of questions enquired were about COVID-19 symptoms, testing, test result (positive/negative), etc. are not related to day-to-day activities and certainly, there should not be an inadequate answer, and the participant dentists would not have serious difficulty in recollecting.

Due to the cross-sectional nature of the data, the association between infection control practices and COVID-19 infection among the dentists was not tested. Future studies should include assessment of COVID-19 incidence among the same cohorts and identification of risk factors for COVID-19 cross infection among the dentists.

5Conclusion

The estimated prevalence of COVID-19 among dentists in Andhra Pradesh state is 9%, which is alarming. Such high prevalence rate demands strict adherence to ICMR standard operating procedures for the dental operatory and dentists need to be further educated about infection control protocols for implementation and maintenance of safe practices.