Healthcare workers and their families account for a sixth (17%) of hospital admissions for COVID-19 in the working age population (18-65 years), finds a study from Scotland published by The BMJ today.
Although hospital admission with COVID-19 in this age group was very low overall, the risk for healthcare workers and their families was higher compared with other working age adults, especially for those in “front door” patient facing roles such as paramedics and A&E department staff, say the researchers.
As such, they say these findings have implications for the safety and wellbeing of healthcare workers, and their households.
Many healthcare staff work in high-risk settings for contracting COVID-19 and transmitting it to their household, workplace contacts, or both. Yet the extent of these risks are not well understood, as studies are lacking or have been beset by quality issues.
To address this evidence gap, a team of UK researchers set out to assess the risk of hospital admission for COVID-19 among patient facing and non-patient facing healthcare workers and their household members.
Their findings are based on Scottish workforce data for 158,445 healthcare workers (aged 18-65 years), 229,905 household members, and other members of the general population during the peak period for COVID-19 infection in Scotland (1 March to 6 June 2020).
The researchers found that admission to hospital with COVID-19 was uncommon, with an overall risk of less than 0.5%.
However compared with other adults of working age, healthcare workers and their households accounted for 17% of all COVID-19 related hospital admissions, even though they represent only 11% of the working age population.
After adjusting for factors such as age, sex, ethnicity and underlying health conditions (comorbidities), the risk of hospital admission for COVID-19 in non-patient facing healthcare workers and their household members was similar to the risk in the general population.
However, patient-facing healthcare workers were three times more likely to be admitted to hospital for COVID-19, while members of their households were nearly twice as likely to be admitted to hospital for COVID-19 than other working age adults.
Those working in “front door” roles, such as paramedics and A&E department staff, were at the highest risk of hospital admission for COVID-19.
Among healthcare workers who were admitted, 1 in 8 were admitted into critical care and six (2.5%) died. To put this into context, this corresponds to just 0.004% of deaths as a proportion of all healthcare workers. In admitted household members, 1 in 5 were admitted to critical care and 18 (13%) died.
This is an observational study, so can’t establish cause, and the researchers acknowledge that some misclassification is likely to have occurred. What’s more, the study included predominantly white healthcare workers, so results may not apply to ethnic minority groups.
Nevertheless, the researchers say these findings from the “first wave” in Scotland show that healthcare workers in patient facing roles – especially those in “front door” roles – are, along with their households, at particular risk.
And they call on governments, healthcare managers and occupational health specialists to consider how best to protect healthcare workers and their families in the event of a resurgent pandemic.
These findings should inform decisions about the organisation of health services, the use of personal protective equipment (PPE), and redeployment, they conclude.
In a linked editorial, researchers at Skane University Hospital in Sweden welcome these findings and say reasons for the observed increase in risk “need to be explored to help to guide safety improvements in healthcare settings.”
They call for high quality studies evaluating new prevention and control practices “to guide improvements in our approach to protecting health care workers and their families, including those from ethnic minority communities who have the highest risks of infection and poor outcomes, widening workplace inequality.”
They also call on the international community to support efforts by the World Health Organization to secure adequate supplies of PPE and COVID-19 tests for low and middle income countries, and say an effective vaccine, if and when available, “must be distributed fairly and healthcare workers must be prioritised globally.”
In accordance with United Nations Sustainable Development Goals, “we must ensure the protection and security of all health workers in all settings,” they conclude.
Between March 24 and April 23, 2020, we enrolled 2 810 103 consecutive users of the COVID Symptom Study app to our study. 2 627 695 participants in the UK and 182 408 in the USA provided baseline information about feeling physically normal or having symptoms (appendix p 14). 134 885 (4·8%) participants reported being a front-line health-care worker.
The prevalence of COVID-19 was 2747 cases per 100 000 front-line health-care workers compared with 242 cases per 100 000 people in the general community (figure). The highest infection rates were reported in the US states New York, New Jersey, and Louisiana and in areas around London and the Midlands in the UK.
After excluding 670 298 participants with less than 24 h of follow-up and 4615 individuals who reported a positive COVID-19 test at baseline, we included 2 135 190 participants in our prospective inception cohort, of whom 99 795 (4·7%) identified as front-line health-care workers (appendix p 14).
Based on this cohort, we had 80% power to detect a minimum HR of 1·16 for risk of reporting a positive COVID-19 test between health-care workers and the general community. In this cohort, we recorded 24·4 million entries, or 11·5 logs per participant, with median follow-up of 18·9 days (IQR 5·1–26·1).
Median age was 44 years (IQR 32–57). Compared with the general community, front-line health-care workers were more frequently female, had a slightly higher prevalence of body-mass index 30·0 kg/m2 or higher, were slightly more likely to smoke (particularly in the UK), and were more likely to use non-steroidal anti-inflammatory drugs (table 1; appendix pp 9–10).
At baseline, 20·2% of front-line health-care workers reported at least one symptom associated with SARS-CoV-2 infection compared with 14·4% of the general population; fatigue, loss of smell or taste, and hoarse voice were especially frequent (appendix p 11).
When comparing health-care workers who were asked about PPE use with those who were not asked, no difference was noted in baseline factors including age (median 45 years vs 40 years), female sex (81% vs 82%), or body-mass index (median 25·9 kg/m2 vs 25·7 kg/m2).
Table 1Baseline characteristics of front-line health-care workers compared with the general community
|Front-line health-care workers (n=99 795)||General community (n=2 035 395)|
|Age, years||42 (33–53)||44 (33–56)|
|Missing data for age||1·1%||5·7%|
|Race or ethnic origin*|
|Hispanic or Latinx||1·1%||0·5%|
|More than one or other||2·4%||2·9%|
|Missing data for race or ethnic origin, or prefer not to say||2·7%||1·3%|
|Body-mass index (kg/m2)||25·8 (22·8–30·2)||25·3 (22·5–29·1)|
|Missing data for body-mass index||0·5%||0·5%|
|Missing data for cancer||0·3%||0·3%|
|Pregnant (% of females)||0·9%||1·0%|
|Non-steroidal anti-inflammatory drugs||8·2%||6·1%|
|Chemotherapy or immunotherapy||0·1%||0·3%|
|Angiotensin-converting enzyme inhibitor||5·0%||4·9%|
|Missing data for angiotensin-converting enzyme inhibitor||10·1%||4·3%|
|Missing data for smoking status||0·2%||0·1%|
Data are % or median (IQR). % are calculated based on the total number of participants with available data. Polytomous variables might not add up to 100% because of rounding. Questions about history of cancer, angiotensin-converting enzyme inhibitor use, and smoking status have been asked since launch in the USA and March 29, 2020, in the UK; questions about race and ethnic origin were asked since April 17, 2020, in both the UK and the USA. Percentages within each category are based on the total population responding when the question was first asked.* Non-Hispanic white defined as UK White, US White, and no designation of other race or ethnic origin. Hispanic or Latinx designated as Hispanic and Latino. Black defined as UK Black, Black British, US Black, and African American. White defined as UK White and US White. Asian defined as UK Asian, Asian British, UK Chinese, Chinese British, US Asian, and US Native Hawaiian or other Pacific Islander. More than one or other defined as UK mixed race White and Black or Black British UK, mixed race other, UK Middle Eastern or Middle Eastern British, US American Indian or Alaska Native, other, and denoted more than one race.
We recorded 5545 incident reports of positive COVID-19 testing over 34 435 272 person-days. In the UK, 1·1% of health-care workers reported being tested compared with 0·2% of the general community (health-care workers to community testing ratio 5·5), whereas 4·1% of US health-care workers were tested versus 1·1% of the general community (testing ratio 3·7). Compared with the general community, front-line health-care workers had a twelvefold increase in risk of a positive test after multivariable adjustment (adjusted HR 11·61, 95% CI 10·93–12·33; table 2; appendix p 15). The association seemed stronger in the UK (adjusted HR 12·52, 95% CI 11·77–13·31) compared with the USA (2·80, 2·09–3·75; pdifference<0·0001; appendix p 12).
able 2Risk of reporting a positive test for COVID-19 among front-line health-care workers compared with the general community
|Event/person-days||Incidence (30-day)||Age-adjusted hazard ratio (95% CI)||Multivariate-adjusted hazard ratio (95% CI)||Inverse probability-weighted hazard ratio (95% CI)|
|Overall (primary analysis)|
|General community||3623/32 980 571||0·33%||1 (ref)||1 (ref)||1 (ref)|
|Front-line health-care worker||1922/1 454 701||3·96%||11·68 (10·99–12·40)||11·61 (10·93–12·33)||3·40 (3·37–3·43)|
|According to race or ethnic origin (post-hoc analysis)|
|Non-Hispanic white, general community||1498/23 941 092||0·19%||1 (ref)||1 (ref)||1 (ref)|
|Black, Asian, and minority ethnic, general community||227/1 362 956||0·50%||2·49 (2·16–2·86)||2·51 (2·18–2·89)||1·74 (1·71–1·77)|
|Non-Hispanic white, front-line health-care worker||726/935 860||2·33%||12·47 (11·33–13·72)||12·58 (11·42–13·86)||3·52 (3·48–3·56)|
|Black, Asian, and minority ethnic, front-line health-care worker||98/72 556||4·05%||21·68 (17·61–26·68)||21·88 (17·78–26·94)||4·88 (4·76–5·01)|
All models were stratified by 5-year age group, calendar date at study entry, and country. Multivariate risk factor models were adjusted for sex (male or female), history of diabetes (yes or no), heart disease (yes or no), lung disease (yes or no), kidney disease (yes or no), current smoking (yes or no), and body-mass index (17·0–19·9 kg/m2, 20·0–24·9 kg/m2, 25·0–29·9 kg/m2, and ≥30 kg/m2). Black, Asian, and minority ethnic was defined among individuals who had race or ethnicity information and did not identify as non-Hispanic white.
We considered the possibility that noted differences could be related to testing eligibility. A multivariable-adjusted Cox proportional hazards model with inverse probability weighting for predictors of testing also showed a higher risk of infection among front-line health-care workers (adjusted HR 3·40, 95% CI 3·37–3·43; table 2), which was higher in the UK (3·43, 3·18–3·69) than in the USA (1·97, 1·36–2·85; pdifference<0·0001; appendix p 12). In a prespecified secondary analysis, a validated model was used based on a combination of symptoms predictive of COVID-19 infection.16
Compared with the general community, health-care workers initially free of symptoms had an increased risk of predicted COVID-19 (adjusted HR 2·05, 95% CI 1·99–2·10), which was higher in the UK (2·09, 2·02–2·15) than in the USA (1·31, 1·14–1·51; pdifference<0·0001).In a post-hoc analysis, compared with individuals in the general community from a non-Hispanic white ethnic background, the risk for a positive COVID-19 test was increased for individuals from Black, Asian, and minority ethnic backgrounds in the general community (adjusted HR 2·51, 95% CI 2·18–2·89), for Black, Asian, and minority ethnic health-care workers (21·88, 17·78–26·94), and for non-Hispanic white health-care workers (12·58, 11·42–13·86; table 2).
In post-hoc analyses, the association of race and health-care worker status with risk of COVID-19 was assessed. Black, Asian, and minority ethnic health-care workers had an increased risk of COVID-19 (adjusted HR 1·81, 95% CI 1·45–2·24) compared with non-Hispanic white health-care workers. Risk estimates were similar among male (adjusted HR 14·02, 95% CI 12·38–15·82) compared with female (11·27, 10·53–12·14) front-line health-care workers.Among front-line health-care workers, availability and use of PPE, COVID-19 patient exposures, and subsequent risk for testing positive were assessed in prespecified analyses.
Compared with health-care workers who reported adequate PPE, front-line health-care workers reporting PPE reuse had an increased risk of a positive COVID-19 test (adjusted HR 1·46, 95% CI 1·21–1·76), with inadequate PPE associated with a comparable increase in risk after multivariable adjustment (1·31, 1·10–1·56; table 3).Table 3Risk of reporting a positive test for COVID-19, according to availability of PPE and exposure to patients with COVID-19 among front-line health-care workers (prespecified secondary analysis)
|Adequate PPE||Reused PPE||Inadequate PPE|
|Event/person-days||592/332 901||146/80 728||157/60 916|
|Unadjusted hazard ratio (95% CI)||1 (ref)||1·46 (1·21–1·76)||1·32 (1·10–1·57)|
|Multivariate-adjusted hazard ratio (95% CI)||1 (ref)||1·46 (1·21–1·76)||1·31 (1·10–1·56)|
|No exposure to patients with COVID-19|
|Event/person-days||186/227 654||19/37 599||48/35 159|
|Unadjusted hazard ratio (95% CI)||1 (ref)||0·96 (0·60–1·55)||1·53 (1·11–2·11)|
|Multivariate-adjusted hazard ratio (95% CI)||1 (ref)||0·95 (0·59–1·54)||1·52 (1·10–2·09)|
|Exposure to patients with suspected COVID-19|
|Event/person-days||126/54 676||36/19 378||26/14 083|
|Unadjusted hazard ratio (95% CI)||2·40 (1·91–3·02)||3·23 (2·24–4·66)||1·87 (1·24–2·83)|
|Multivariate-adjusted hazard ratio (95% CI)||2·39 (1·90–3·00)||3·20 (2·22–4·61)||1·83 (1·21–2·78)|
|Exposure to patients with documented COVID-19|
|Event/person-days||280/50 571||91/23 751||83/11 675|
|Unadjusted hazard ratio (95% CI)||4·93 (4·07–5·97)||5·12 (3·94–6·64)||5·95 (4·57–7·76)|
|Multivariate-adjusted hazard ratio (95% CI)||4·83 (3·99–5·85)||5·06 (3·90–6·57)||5·91 (4·53–7·71)|
All models were stratified by 5-year age group, calendar date at study entry, and country. Multivariate risk factor models were adjusted for sex (male or female), history of diabetes (yes or no), heart disease (yes or no), lung disease (yes or no), kidney disease (yes or no), current smoking (yes or no), and body-mass index (17·0–19·9 kg/m2, 20·0–24·9 kg/m2, 25·0–29·9 kg/m2, and ≥30·0 kg/m2). PPE=personal protective equipment.
In a prespecified secondary analysis, front-line health-care workers with inadequate PPE caring for patients with documented COVID-19 had an increased risk for COVID-19 after multivariable adjustment (adjusted HR 5·91, 95% CI 4·53–7·71) compared with those with adequate PPE not caring for patients with suspected or documented COVID-19 (table 3).
Risk for front-line health-care workers reusing PPE and exposed to patients with documented COVID-19 was also increased (adjusted HR 5·06, 95% CI 3·90–6·57). Notably, even among front-line health-care workers reporting adequate PPE, the risk for COVID-19 was increased for those caring for patients with suspected COVID-19 (adjusted HR 2·39, 95% CI 1·90–3·00) and for those caring for patients with documented COVID-19 (4·83, 3·99–5·85), compared with health-care workers who did not care for either group (table 3).
In a post-hoc analysis, differences were noted in PPE adequacy according to race and ethnicity, with non-white health-care workers more frequently reporting reuse of or inadequate access to PPE, even after adjusting for exposure to patients with COVID-19 (adjusted OR 1·49, 95% CI 1·36–1·63; table 4).Table 4Risk of reporting PPE inadequacy or reuse among front-line health-care workers, according to race or ethnic origin (post-hoc analysis)
|Health-care workers reporting reuse of or inadequate PPE||Multivariate-adjusted odds ratio (95% CI)|
|Non-Hispanic white, front-line health-care worker||27·7%||1 (ref)|
|Black, Asian, and minority ethnic, front-line health-care worker||36·7%||1·49 (1·36–1·63)|
|According to racial or ethnic subgroup*|
|Non-Hispanic white’||27·7%||1 (ref)|
|Hispanic or Latinx||49·6%||2·64 (2·03–3·45)|
|More than one race or other race||34·7%||1·33 (1·12–1·57)|
Multivariate risk factor models were adjusted for 5-year age group, sex, and exposure to patients with COVID-19 (none, suspected, and documented). Black, Asian, and minority ethnic was defined among individuals who had race or ethnicity information and did not identify as non-Hispanic white. PPE=personal protective equipment.* Non-Hispanic white defined as UK White, US White, and no designation of other race or ethnic origin. Hispanic or Latinx designated as Hispanic and Latino.
Black defined as UK Black, Black British, US Black, and African American. White defined as UK White and US White. Asian defined as UK Asian, Asian British, UK Chinese, Chinese British, US Asian, and US Native Hawaiian or other Pacific Islander. More than one or other defined as UK mixed race White and Black or Black British UK, mixed race other, UK Middle Eastern or Middle Eastern British, US American Indian or Alaska Native, other, and denoted more than one race.
In a prespecified secondary analysis, risk of COVID-19 by practice location was assessed. Compared with risk for the general community, risk for front-line health-care workers was increased in all health-care settings, but was highest for those working in inpatient settings (adjusted HR 24·30, 95% CI 21·83–27·06) and nursing homes (16·24, 13·39–19·70; table 5).
Notably, health-care workers in nursing homes most frequently (16·9%) reported inadequate PPE, whereas inpatient providers reported reuse of PPE most often (23·7%; table 5).
In a post-hoc analysis, compared with non-Hispanic white health-care workers, Black, Asian, and minority ethnic health-care workers were more likely to work in higher risk clinical settings, including inpatient hospital or nursing homes (adjusted OR 1·13, 95% CI 1·03–1·23) and to care for patients with suspected or documented COVID-19 (1·20, 1·09–1·30).
These noted differences were most pronounced among Black health-care workers (appendix p 13).Table 5Front-line health-care workers and risk of testing positive for COVID-19, by site of care delivery (prespecified secondary analysis)
|Event/person-days||Incidence (30-day)||Age-adjusted hazard ratio (95% CI)||Multivariate-adjusted hazard ratio (95% CI)||Health-care workers reporting reuse of PPE||Health-care workers reporting inadequate PPE|
|General community||3623/32 980 571||0·33%||1 (ref)||1 (ref)||..||..|
|Front-line health-care worker|
|Inpatient||564/184 293||9·18%||23·58 (21·20–26·25)||24·30 (21·83–27·06)||23·7%||11·9%|
|Nursing homes||118/52 901||6·69%||16·48 (13·60–19·97)||16·24 (13·39–19·70)||15·4%||16·9%|
|Outpatient hospital clinics||51/45 217||3·38%||10·75 (8·10–14·27)||11·21 (8·44–14·89)||16·3%||12·2%|
|Home health sites||36/38 642||2·79%||7·79 (5·58–10·87)||7·86 (5·63–10·98)||14·7%||15·9%|
|Ambulatory clinics||44/66 408||1·99%||6·64 (4·90–9·01)||6·94 (5·12–9·41)||19·3%||11·8%|
|Other||73/64 310||3·41%||9·42 (7·42–11·96)||9·52 (7·49–12·08)||12·0%||13·8%|
Model was stratified by 5-year age group, calendar date at study entry, and country and adjusted for sex (male or female), history of diabetes (yes or no), heart disease (yes or no), lung disease (yes or no), kidney disease (yes or no), current smoking (yes or no), and body-mass index (17·0–19·9 kg/m2, 20·0–24·9 kg/m2, 25·0–29·9 kg/m2, and ≥30·0 kg/m2). Ambulatory clinics include free-standing (non-hospital) primary care or specialty clinics and school-based clinics. PPE=personal protective equipment.
reference link : https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(20)30164-X/fulltext
More information: Risk of hospital admission with coronavirus disease 2019 in healthcare workers and their households: nationwide linkage cohort study, BMJ (2020). DOI: 10.1136/bmj.m3582