The therapeutic itinerary of health workers diagnosed with COVID-19

Objective: to analyze the therapeutic itinerary of health workers diagnosed with COVID-19. Method: qualitative study conducted with 132 health workers diagnosed with COVID-19. Data were collected using a semi-structured form sent through the social media and processed with the Interface de R pour Analyses Multidimensionnelles de Textes et de Questionnaires, according to the Descending Hierarchical Classification. Results: the participants included 116 women and 16 men with 14 different professions within the health field. Five classes of excerpts emerged from the text, revealing the therapeutic itinerary from the onset of symptoms, up to referrals for testing and confirming COVID-19. Additionally, the aspects that facilitated or hindered access to testing in healthcare units were identified, in addition to misinformation and the need for workers to pay for the tests to obtain a diagnosis. Conclusion: this study’s results show the difficulties health workers experienced to access the tests and related information and the delay in accessing the results and obtaining a sick leave to remain in isolation at home. The health workers who did not get support in terms of management and monitoring from the facilities where they worked adopted an active search.


Introduction
In December 2019, the SARS-CoV-2 coronavirus, which causes the Coronavirus disease (COVID-19), was identified in the city of Wuhan (China) after a series of pneumonia cases. In February 2020, the virus had already spread to various countries, after which the World Health Organization (WHO) declared the pandemic (1)(2) .
Currently, contamination by the SARS-CoV-2 is a very severe and challenging public health problem in many countries, including Brazil, with important consequences in the health, social, economic and political spheres. More than 7,600,000 cases and 427,000 deaths had been confirmed up to June 14 th , 2020 worldwide and the numbers keep growing, with almost all countries reporting new cases daily (2) .
In Brazil, the first case was reported on February 26 th , 2020 and the numbers are ascending ever since, reaching 828,810 confirmed cases and 41,828 deaths up to June 14 th , 2020 (2) . The first case was reported in Rio There is no complete information regarding the natural history of the virus or effective measures to clinical manage cases of human infection caused by the SARS-CoV-2 coronavirus. It is known, however, that the virus is highly transmissible and causes acute respiratory syndrome, ranging from mild to severe cases, with respiratory failure. Transmission mainly occurs through contact with respiratory droplets released by sick and symptomatic individuals (2) .
Transmission by asymptomatic individuals is still unclear (5)(6) . On average, the period of incubation is 5-6 days, ranging from 0 to 14. The main signs and symptoms include fever, dry cough, dyspnea, myalgia or fatigue, upper respiratory symptoms and, more rarely, gastrointestinal symptoms (7) .
The diagnosis and isolation of infected individuals are important measures to prevent the dissemination of the virus and the contamination of new individuals. In terms of clinical management, mild cases need to receive supportive measures, such as stay isolated at home and monitoring up to the end of the isolation measures. Severe cases, however, require clinical stabilization, referral and transportation to referral centers, emergency services or hospital facilities (8) .
The increased demand for health services to treat infected individuals has overburdened the health systems in the countries more severely affected by the pandemic.
In Brazil, the number of hospitalizations has followed an ascending curve (9) , with severe consequences such as overcrowded facilities and exhausted professionals working on the front lines. Hence, many of these professionals, in addition to fighting the COVID-19, are also experiencing a humanitarian crisis, compounded by the scarcity of protective materials, which puts their lives at risk (10) .
Health workers providing direct care to COVID-19 patients at the different levels of care are directly and continuously exposed and, therefore, more vulnerable than most of the population. A Chinese study revealed that geographical proximity to the outbreak epicenter directly influenced the severity of COVID-19 cases among these professionals (11) .
From the onset of symptoms and signs until the confirmation of the diagnosis, individuals, even health workers, have to follow a path, a journey in which they seek treatment. This journey, which is associated with individual and socio-cultural practices and is intended to solve healthcare problems, is called the therapeutic itinerary (12) .
Studies addressing therapeutic itineraries support the understanding of how health services work and behave and how they are used, i.e. the path chosen and its multiple repercussions. A late diagnosis may result when patients are not properly referred (12) . This is of concern when such a situation occurs with health workers, that is, people who provide care to other people within the context of health care.
Additionally, because COVID-19 is a disease caused by a highly transmissible virus, having an infected health professional working in a healthcare unit, without having a confirmed diagnosis, may entail consequences, especially because it increases the exposure of other workers and the population seeking health services (13) .
Considering these aspects, studying the therapeutic itinerary of health workers diagnosed with COVID-19 is vital. The identification of this itinerary and the difficulties found may help to devise strategies to correct gaps and problems in this itinerary. Hence, this study's objective was to analyze the therapeutic itinerary of health workers diagnosed with COVID-19.

Method
This descriptive and exploratory study with a qualitative approach was conducted using an electronic form with health workers diagnosed with the COVID-19, living in the state of Rio de Janeiro, Brazil and working at different levels of care, in public or private healthcare facilities, these being the study inclusion criteria.
Individuals with professional training in the health field but not active during the pandemic were excluded. www.eerp.usp.br/rlae were granted access to a free and informed consent form and the semi-structured questionnaire. Criteria to cease the interviews were theoretical saturation of data (14) and utilization rate index (15) . What were the aspects that facilitated this path? What were the aspects that hindered it? The participants took approximately 10 minutes to complete the form.
The responses obtained composed the textual corpus, which was submitted to lexicographic analysis in Interface de R pour Analyses Multidimensionnelles de Textes et de Questionnaires (IRAMuTeQ) (15) , via Descending Hierarchical

Classification.
The active forms of each class of excerpts were used in the interpretation of data, including nouns, adjectives and unrecognized forms, such as acronyms, with emphasis on the forms that scored ≥3.84 in the Chi-square test (χ 2 ), which indicates the associative strength between the words in their respective classes.
The Institutional Review Board approved the study (CAAE 31201420.6.0000.5243 and opinion report 4.012.631). The participants were ensured that their identities would remain confidential. A free and informed consent form was available online. The participants confirmed their consent by checking the option "I read and agree to participate in this survey". An alphanumerical code was used according to the order in which the participant entered the survey, followed by a code that identified the participant's profession.
The letter P was used, followed by the number that

Results
In total, 132 health workers from 14 different professions participated in this study: health agents (4), nursing aids (1), biologists (2), dentists (2) In the dendrogram, the textual corpus was divided into two subcorpus. The first was composed of Class 1, which appears in red, (20.4%) and a second subgroup with Classes 4 in blue (19.7%) and 3 in green (16.2%).
The second subcorpus was composed of Classes 2 in gray  Three days after I went to a primary health care unit and they prescribed mandatory isolation (P108, TE).
The need to confirm the diagnosis and take a sick leave from work led workers to go to different services.
Additionally, some highlighted that they were unable to test their families while others obtained a confirmation of the diagnosis after their condition worsened:

Discussion
The results show that the therapeutic itinerary of the workers participating in this study to access the COVID-19 test is marked by having to go to different health facilities, not only to confirm the disease but also to obtain a medical certificate, which extends the time between the suspicion and confirmation of the condition.
Due to the risk of infection and the possibility to spread COVID-19 to other people, including family members, ensuring that care is provided to health workers and rapidly performing the tests among individuals with symptoms are essential (16) . Therefore, recommendations that should not be neglected during the pandemic include giving priority to health professionals working on the front line (17)(18) .
The results, however, reveal a lack of protocols or failure to follow institutional protocols to guide and ensure health workers with a suspicion of being infected with the disease receive proper care, as well as to manage exposure to the virus, actively monitoring respiratory signs and symptoms and notifying health governmental and the institutions' health occupational authorities.
The WHO provides guidelines, among which taking sick leave and ensuring that all workers with suspicion of being infected with COVID-19 are tested stand out.  (8) .
When referred to testing sites, the workers had to queue, long waiting times, had difficulties to schedule the test, while in some cases, the services were located far away from their homes. These aspects concerning organizational accessibility were also reported in a study addressing the patients' satisfaction with a primary health care service (20) .
Considering the different difficulties perceived in the itinerary of this study's participants, working in facilities that provide tests to their employees promotes a faster diagnosis of COVID-19, resulting in greater safety for them, their families and patients. Additionally, it helps to control the disease better and is one of the main elements that facilitate the therapeutic itinerary. patients. Even though little specific, it is sensitive to show the diseases' most frequent findings in the lung (21) , such as bilateral lung lesions, ground-glass opacity and air bronchogram (22) . This exam, however, was restricted to those who had access to hospital facilities, that is, it was not available to all the workers.
In addition to the little availability of tests in the public system, which was reported as an aspect that hindered the therapeutic itinerary, the participants  (23) . Even though the RT-PCR remains detectable in some individuals from 2 to 6 weeks, most cases represent inactive genetic material, not presenting the risk of transmission (16) .
The serological tests detect levels of IgM, IgA and IgG antibodies as part of the individuals' immune response against the SARS-CoV-2 virus, that is, indicate a previous or ongoing contact (23) . These tests are performed using different techniques, such as automated chemiluminescence immunoassay, immunoenzymatic assay, and immunochromatography, that is, a rapid, less sensitive test. In general, these tests present between 60% and 70% sensitivity around the 7 th day and around 90%, 10 days after the onset of symptoms. Hence, a serological negative result during the first seven days of the disease cannot be used as a criterion to rule out a case (16) . when in contact with suspected or confirmed cases (16) .
In this Brazilian context, given the insufficient number of molecular tests to meet the demand, a fact that is reinforced by this study's participants, many workers had to pay for the tests performed in private laboratories. The Brazilian Ministry of Health (MH) established criteria for performing rapid serological tests, determining that health workers and public security workers had priority because these are the most frequently exposed to the coronavirus in addition to their contacts at home. Hence, the MH asked that the states and cities tested symptomatic active workers as well as those living in the same household with the flu syndrome. A blood sample is used for the rapid test and the result is released in approximately 20 minutes (8) .
As previously mentioned, the problem of this type of test is that greater sensitivity is obtained only 10 days after the onset of symptoms (16) .
Despite the MH's recommendations, workers still faced difficulties to take the test in the public system due to various reasons, such as lack of inputs or because they did not present a severe condition. Additionally, some participants reported doubts and divergences between the results obtained with the RT-PCR and rapid tests, a fact that may be explained by the need to perform the tests within the period in which sensibility is greater. Additionally, even though the rapid tests to detect antibodies are widely produced and sold, the quality of these tests varies, as they do not reveal the nature of the antigens used. These are qualitative tests and, only, indicate the presence or absence of SARS-CoV-2 antibodies (24) .
The doubts the workers reported regarding the type of test, ideal period to take it, among others, indicate a need to providing training not only to address diagnostic tests but, also, to decrease the risk of infection, considering the vulnerability of these individuals to COVID-19. Therefore, topics such as how to properly wear PPE, hand hygiene, health waste management, sterilization of patient care devices and management of occupational exposure (25) should be addressed.

Conclusion
Regarding the therapeutic itinerary of the health workers diagnosed with COVID-19, the results show the difficulties health workers faced to access tests, obtain information regarding tests, to access the results and to obtain a medical certificate to stay isolated at home. The study shows an active search on the part of professionals who worked in a facility that did not manage or monitor such cases.
Hence, this study revealed a therapeutic itinerary marked by difficulties that included delayed diagnoses, lack of precise information, uncertainties and having to pay for the tests. These results indicate the urgent need to reorganize the services and institutions to manage and monitor cases of occupational exposure. Despite restricted resources in institutional contexts and the growing demand for diagnostic tests and monitoring of the entire population, there is a need to protect and improve the therapeutic itinerary of health workers, considering that they are essential to fight the pandemic.