Risk of Hospital Admission for COVID-19 in Healthcare Workers and Their Households

Healthcare Workers and COVID-19 Hospitalization

We are rapidly approaching the first deployments of vaccines for SARS-CoV-2.  Over the first few months of availability, vaccine supplies will be very limited, and allocation of this scarce resource will be necessary.  The multitude of state-based prioritization plans across the U.S. all designate healthcare workers (HCWs), who have direct or indirect exposure to COVID-19 patients or infectious materials, for the first tier of vaccination.  A recent paper by Shah and colleagues [1] helps in our understanding of this approach.

Through an evaluation of nearly 160,000 HCWs in Scotland, along with 229,000 household members of these workers, the study team was able to assess risks for hospital admission for “patient facing” and “non-patient facing” HCWs (along with their household contacts) as compared to the general population.  Scottish HCWs and their household members make up 11.2% of the working age population, but contributed 17.2% of COVID-19 hospitalizations.  With more detailed analysis, however, there were no differences in the hospitalization rate for non-patient facing HCWs and their families (hazard ratio = 0.81; 95% CI: 0.52—1.26; 0.86: 0.49—1.51, respectively) compared to the general population.  On the other hand, patient facing HCWs experienced a threefold increase in risk for hospitalization (hazard ratio = 3.30: 2.13—5.13) and their household members registered a twofold increase (hazard ratio = 2.09; 1.49—2.94).

In the act of caring for our patients, we who work in patient-facing healthcare expose ourselves to infection with SARS-CoV-2.  Accordingly, availability and appropriate use of personal protective equipment is essential for patient care, but sadly, it is not always enough.  We are now more hopeful for the arrival of safe and effective vaccines for SARS-CoV-2.  Due to the increase burden of hospitalization suffered by HCWs, the essential nature of their role in countering this pandemic, and the ability to serve as role models for countering hesitancy, initial vaccination of HCWs with SARS-CoV-2 vaccines is a wise and ethical approach.

References

1. Shah ASV, Wood R, Gribben C, Caldwell D, Bishop J, Weir A et al. Risk of hospital admission with coronavirus disease 2019 in healthcare workers and their households: nationwide linkage cohort study.  BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m3582 (Published 28 October 2020).

As cases of SARS-CoV-2 surge in the United States, concerns regarding the safety of healthcare workers (HCWs) persist, despite the arrival of vaccinations, which will take months to implement. This nationwide linkage study evaluated rates of hospitalization among 158,445 HCWs and their household members during the first wave of the pandemic in Scotland, finding that 17.2% of all hospital admissions were in this population, with significantly increased risk among HCWs with patient-facing roles. Also notable was the finding of a twofold risk of COVID-19 in household members compared with the general population, highlighting that occupationally infected HCWs can spread COVID-19 to their families.

Of note, the data were obtained early in the pandemic when infection and hospitalization rates were much lower than current estimates, highlighting the ongoing urgent need to adequately protect HCWs, especially given the current understanding that SARS-CoV-2 can be transmitted by airborne particles. Many HCWs still lack adequate respiratory PPE, such as N95 respirators. In addition to risk from patients, maintaining social distancing among HCWs is challenging in both inpatient and outpatient settings, contributing to additional risk from coworkers. Although most hospitals are testing all patients for COVID-19 before admission, most are not performing routine surveillance testing on hospital staff, and surveillance testing in most outpatient settings is even more limited.

Thus, until HCWs are fully vaccinated, this study highlights the importance of protecting all HCWs in patient care settings against airborne SARS-CoV-2 exposure (including proper respirator, fit testing, and training) and not just those considered at highest risk (eg, in ICUs). Engineering controls (eg, improved ventilation, source control) and administrative controls (eg, limiting number of staff, use of televisits, and greater social distancing among HCWs) must also be aggressively pursued in order to keep HCWs, their families, and their patients safe.