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Coronavirus Infection in Health Care Workers
Quick Takes
- Data from China suggest that health care workers (HCWs) are at higher risk of developing COVID-19 than the general population.
- In several studies, a majority (>60%) of HCWs diagnosed with COVID-19 were women.
- Use of full PPE, including N95 respirators, is protective against coronavirus infection in HCWs.
Study Questions:
What is the burden of risk for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2; the virus causing COVID-19), SARS-CoV-1, and Middle Eastern respiratory syndrome (MERS)-CoV among health care workers (HCWs)? And, what are the risk factors for HCW infection and for household transmission from HCWs?
Methods:
For the sake of expediency, a living rapid review rather than a systematic review was conducted. A medical librarian searched PubMed, MEDLINE, Embase, the World Health Organization (WHO) Database on Coronavirus Disease, and the medRxiv preprint server for relevant manuscripts from 2003 to April 24, 2020. A single investigator reviewed each full-text article for inclusion and performed data extraction, with data verification by a second investigator. For all three coronaviruses, cohort and cross-sectional studies were included, and for SARS-CoV-2, case series and non–peer-reviewed articles were also included. Given the heterogeneity of study design and methods, quantitative synthesis and formal risk for bias assessment were not performed. Surveillance for new studies is ongoing, and results will be updated regularly.
Results:
In China as of mid-February 2020, HCWs accounted for 3.8% of PCR-confirmed COVID-19 cases; 15% of these cases were severe or critical, and the case fatality rate was 0.3% (5/1,716). HCWs accounted for 5.1% (1,316/25,961) cases of COVID-19 in Wuhan, China as of mid-February, and the incidence among HCWs was 144.7/106 people as compared with 41.7/106 people in the general population. By comparison, HCWs accounted for 21% (1,706/8,096) of all SARS-CoV-1 cases reported to WHO (1,706/8,096), and among HCWs infected with SARS-CoV-1 in Hong Kong, the case fatality rate was 2.0% (8/405). HCWs accounted for 19.1% (402/2,106) of laboratory-confirmed cases of MERS-CoV in Saudi Arabia. The case fatality rate of MERS-CoV in HCWs based on all cases reported to WHO was 5.8% (24/415), as compared with an overall MERS-CoV case fatality rate of 34.4%.
In several studies, a majority of HCWs infected with SARS-CoV-2 were women. In the state of Washington, a case series in a long-term care facility found that 29% (50/167) of cases of COVID-19 occurred in HCWs; the median age of the HCWs was 43.5 years, and 76% were female. In two case series in Wuhan, China, the average age of affected HCWs was 35 years, and approximately 65% were women. In one of these studies, 1/3 of affected HCWs were physicians and 2/3 were nurses; the proportions were reversed in the other study. Several cross-sectional studies identified female gender as a risk factor for mental health problems in the context of the COVID-19 outbreak in China.
In a cohort study from China, risk factors for development of COVID-19 in exposed HCWs included suboptimal handwashing, improper use of personal protective equipment (PPE), longer work hours, and assignment to a high-risk department. In multiple studies, there was no consistent difference in risk for COVID-19 between nurses and physicians. SARS-CoV-1 infection in HCWs was strongly associated with exposure during endotracheal intubation in six studies. In two studies each, electrocardiography and chest compressions were associated with increased HCW risk of SARS-CoV-1 infection. Use of N95 respirators versus surgical masks and full versus partial PPE were protective against SARS-CoV-1.
No study evaluated the incidence of or risk factors for transmission of SARS-CoV-2 from HCWs to household contacts.
Conclusions:
HCWs may be at higher risk of COVID-19 than the general population. Use of full PPE, including N95 respirators, is protective against coronavirus infection. Risks of coronavirus transmission from HCWs to household contacts have not been reported.
Perspective:
Notable methodologic limitations of this review are lack of formal study quality rating and inclusion of non–peer-reviewed articles. Possible reasons that female HCWs are disproportionately affected by COVID-19 include female predominance in the field of nursing, as well as prolonged patient contact required for good-quality nursing care. However, further study is needed to clarify the true magnitude of risk among female HCWs and to understand how this risk can be mitigated. Fear of infection transmission to loved ones can be a source of great psychological stress to HCWs, and studies employing systematic contact tracing methods are needed to ascertain this risk.
Clinical Topics: Cardiovascular Care Team, COVID-19 Hub, Prevention
Keywords: Contact Tracing, Coronavirus, Coronavirus Infections, COVID-19, Electrocardiography, Hand Disinfection, Health Personnel, Nurses, Personal Protective Equipment, Primary Prevention, Risk Factors, SARS Virus
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