Letter: Outpatient Consultation and Silent Transmission of COVID-19: Risk for the Neurosurgeon?

To the Editor: The COVID-19 pandemic has been terrifying for our world. In this situation, problems are confronting healthcare professionals worldwide, particularly neurosurgeons. This is of great concern that healthcare professionals with inadequate personal protective equipment are getting more infected during face-toface identification or due to aerosol production when sitting in the waiting room in the hospital. The cases of infection rise during ambulatory treatment due to silent transmission from a mixture of presymptomatic and asymptomatic infections. The distribution of services for both COVID-19 and non-COVID-19 patients in the COVID-19 period should be based on a few needful concepts. Global neurosurgical initiatives need to be taken that could rise to the cause of providing essential and uniform neurosurgical treatment in order to avoid infection due to silent transmission. Global leaders are continuously providing comprehensive literature to help us all manage neurosurgical patients with safety and produce good outcomes. The whole world is trying to cope with the current global pandemic of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and reduce infection spread not only among patients but also among treating neurosurgeons.1 In lowand middle-income countries, the patient flow management in hospitals is modified by local guidelines and resource allocation in outpatient departments. It is of great concern that the healthcare professionals with inadequate personal protective equipment are getting more infected during face-to-face registration or due to aerosol generation in the hospital waiting room.2 Neurosurgical patients undergo proper documentation of their medical history, very close clinical examination, evaluation of previous documents, and allocation of a new treatment plan, which increases exposure time. Exposure time may further increase for physically challenged patients. In the case of physically challenged patients, social distancing of about 2 m and exposure time of less than 10 min cannot be adequately maintained.3 The identification of asymptomatic carriers is done by reverse transcription polymerase chain reaction (RT-PCR), and the success rate is almost 56% to 80%.4 Such estimates using a targeted population provide an important insight into evaluating the prevalence of asymptomatic viral shedding.5 It is not always possible to run all the screening methods for the asymptomatic patient in the outpatient department, especially in low-resource countries. Allocating resources in the COVID19 era should be based on six principles: maximizing health benefits; prioritizing healthcare workers; not allocating in the manner of the first-come-first-served basis; being responsive to evidence-based medicine; recognizing research participation; and applying the same strategy to all COVID-19 and non-COVID19 patients.6 There is a lot of controversy regarding the spread of COVID19 from asymptomatic carriers. In one study, it was suggested that in China there is a 5.8% prevalence rate of silent infection of COVID-19,7 while another Japanese study found a total asymptomatic proportion of 17.9% out of all COVID-19 cases found in a ship.8 COVID-19 also spreads through air, which might play an important role in COVID-19 infection during outpatient management. Proper ventilation systems, proper air conditioning, adequate room space, availability of quality PPE, adequate hand sanitizer, and proper disposal management systems also play a major role in preventing COVID-19 infection. Studies have found that the majority of incidences may be due to silent transmission from a combination of presymptomatic and asymptomatic infections.9 Symptom screening, thermal scanning, and taking recent history of contact with COVID-19 patients are essential, but when community transmission occurs, it is very difficult to assume the actual number of asymptomatic patients without testing.10 To avoid silent infection, the following steps can be taken: